state health plan request for review of donor coverage benefits presented by: s. elizabeth sharf...
TRANSCRIPT
STATE HEALTH PLAN REQUEST FOR REVIEW OF DONOR COVERAGE BENEFITS
Presented by: S. Elizabeth Sharf August 2015
Background Hematopoietic stem cell transplantation or HCT
(historically called a “bone marrow transplant” or BMT) remains the only curative treatment option for a wide range of diseases that evolve out of the hematopoietic (blood) system such as: Leukemias
Acute Lymphoblastic Leukemia (ALL) Acute Myelogenous Leukemia (AML)
Myelodysplastic syndromes (MDS) Aplastic Anemia
These patients must undergo a BMT in order to destroy their own blood forming system and replace it with a donor’s.
This type of transplant is called an allogeneic BMT. An allogeneic transplant is when cells from a family member,
unrelated donor or umbilical cord blood unit are used for transplant. This is also called a related donor transplant if the donor is a family
member or an unrelated donor transplant if the donor is not a family member.
Solid Organ Donors vs. Bone Marrow Donors
Solid organ donors (heart, kidney, lung, etc.) must be a compatible match with the recipient’s blood type: A, B, O or AB
Hematopoietic cell transplant (BMT) donors need to be as closely matched as possible to the recipient’s Human Leukocyte Antigens (HLAs) for the best transplant outcomes.1
This is not the same as ABO blood typing. HLAs are proteins on almost all cells in the human
body. Found on the surface of white blood cells Help the immune system tell the difference between body
tissue and substances that are not from your own body
HLA and Ethnicity
A patient’s likelihood of finding a match within an unrelated donor registry ranges from 66% to 97%, depending on race and ethnicity.
Many people have very complex HLA tissue types, due to human migration over time. This is especially true for individuals of diverse racial and ethnic heritage.
When it comes to matching human leukocyte antigen (HLA) types, a person is more likely to find a donor from the same racial or ethnic background. This is because HLA markers used in matching are inherited.
BMT Benefit Language
For patients who need an allogeneic transplant, the State Health Plan has benefit coverage for: the work-up of the selected donor, the procurement of the donor cells the coverage of the transplant event.
BMT Donor Search Restrictions
The current donor search coverage provided through the
NC State Health Plan has a
maximum benefit of
$10,000
Finding a Donor
NC TRANSPLANT
CENTERS
Duke University
UNC Hospitals
Wake Forest Baptist Health
Carolinas Medical Center
About 70%, or 7 out of 10 patients, who need a transplant do not have a suitable HLA donor match within their family.
Buccal Swab Blood Sample
Father Mother A 01:01 A 68:02 A 02:01 A 11:01 B 08:01 B 14:02 B 18:01 B 40:01DRB1 03:01 DRB1 13:03 DRB1 03:01 DRB1 13:02
Patient
A 01:01 A 11:01
B 08:01 B 40:01
DRB1 03:01 DRB1 13:02
EXAMPLE of FAMILY HLA TYPING
Child 1 Child 2 Child 3
A 01:01 A 02:01 A 68:02 A 11:01 A 68:02 A 02:01
B 08:01 B 18:01 B 14:02 B 40:01 B 14:02 B 18:01
DR 03:01 DR 03:01 DR 03:01 DR13:02 DR 13:03 DR 03:01
Child 4 PATIENT – Child 5
A 23:01 A 11:01 A 01:01 A 11:01
B 44:03 B 40:01 B 08:01 B 40:01
DR 15:03 DR13:02 DR 03:01 DR 13:02
Father MotherA 01:01 A 68:02 A 02:01 A 11:01B 08:01 B 14:02 B 18:01 B 40:01DRB1 03:01 DRB1 13:03 DRB1 03:01 DRB1 13:02
Finding an Unrelated Donor
When no family members are a match, an unrelated donor is required and searches are
performed through donor registries such as Be The Match Registry or DKMS.
Costs
Approximate cost to have HLA typing performed at a large university hospital can be $3,000/donor.
If HLA typing must be performed on an unrelated donor, additional registry charges* will be incurred: One time formal activation fee = $1095 Sample obtained from domestic donor = $ 530 Infectious Disease Results = $ 425 Sample obtained from international donor = $
400-$2300* = approximate
Potential Cost of Unrelated Domestic Donor HLA Typing
$955 to obtain the blood sample, send to the transplant center for typing and infectious disease markers performed
$3000 to perform HLA typing at a large university hospital
__________________________________________
$4,000 total cost/unrelated domestic donor typing
Cost and Timing
$10,000 Donor Search Benefit
This amount can be quickly exceeded and create a barrier to a successful outcome for the transplant recipient.
Strategies to stay within the $10K benefit
While these strategies may protect the patient financially, it may also cause an unnecessary delay in securing an allogeneic donor.
Counsel patients regarding donor search limitations and obtain their permission to potentially exceed $10K in order to find a donor in a timely fashion
Seek financial assistance for the patient through the donor registry grants prior to activating a formal search – may not qualify
Utilize search strategy analysis to select best donors
BMT Statistics - State of NC
The current population of NC is 9.9M
In 2013, 256 allogeneic transplants were performed in NC (Source: HRSA website)
SHP members comprise 7% of NC population 700,000 members (Source: SHP website)
Using 7% SHP/NC population, 18 of those 256 transplants would be for SHP members
Approximate additional Costs to the SHP
If donor search coverage benefits were raised from $10K to $50K: 18 transplants x $40K (additional
donor coverage) = $720K
FY14 SHP expenses = 2.83B (SHP website)
$720K additional benefit coverage represents an increase of 0.025%
This hypothetical projection does not include those patients who have donor searches performed but will never get to transplant.
The need to find a donor can happen to anyone…
Orange County Judge Carl Fox
…when we least expect it.
An increase in the donor search coverage benefit maximum would allow the employees of the state of North Carolina to
be able to search for the best possible donor in the most timely fashion which should be the goal for SHP members.
In Conclusion
