Rocky Billups, RN, MSAdministrator, Sarah Cannon Cancer Center

The Workshop for Financial CoordinatorsThe Transplant Financial Coordinators AssociationOctober 1-3, 2008Nashville, Tennessee

Stem Cell Transplant: Making it all Work

The Sarah Cannon Cancer Center Experience

Presentation Outline

Review the Challenges Experienced with Starting a New BMT Program in the 21st Century.

• Sarah Cannon Blood and Marrow Transplant Program

• Managed Care Challenges

• FACT Accreditation

• The Transplant Financial Coordinator in a new Program

• Next Steps

Why would anyone start a BMT Program in today’s competitive

Managed Care Environment

Why would anyone start a BMT Program in today’s competitive

Managed Care Environment

Sarah Cannon Blood and MarrowTransplant Program

A Collaborative Program Between

Sarah Cannon Blood and MarrowTransplant Program

A Collaborative Program Between

SCBMTP Timeline

• Transferred from Denver in August 2005

• August 2006 - Dr. Flinn recruited from Johns Hopkins

• December 2006 - Autologous BMT Program launched

• January 2007 - 1st Autologous Transplant completed

• Spring 2007 - SCBMTP Inpt Unit and Outpt Clinic Open

• July 2007 - Dr. Couriel recruited from MD Anderson

• March 2008 – Dr. Berdeja recruited from Loma Linda

• April 2008 – 1st Allogeneic Transplant completed

• Sept 5, 2008 - FACT Survey completed and awaiting results

• Through the work of The Sarah Cannon Cancer Center and its network of more than 100 medical oncologists, gynecological oncologists, surgeons, pathologists, and radiation oncologists in 2 states, more patients are benefiting from life-saving cancer diagnosis and treatment.

• In 2007 The Sarah Cannon Cancer Center Network diagnosed and/or treated over 4000 new cases of cancer

• Through its affiliation with Sarah Cannon Research Institute, SCCC helps patients gain access to research studies and oncology clinical trial programs.

The Sarah Cannon Cancer Center Network

7

Tennessee Oncology

HCA Blood and Marrow Transplant Programs

• Centennial Medical Center, Nashville Sarah Cannon Blood and Marrow Transplant Program

• Harley Street Clinic, London England

• Medical City of Dallas, Dallas Stem Cell Transplantation and Research Program

• Oklahoma University Medical Center, Oklahoma City

• Presbyterian/St. Luke’s Medical Center, Denver Rocky Mountain Blood & Marrow Transplant Program

• Southwest Texas Methodist Hospital, San Antonio Texas Transplant Institute

• Tulane University Medical Center, New Orleans

Since 1982, we have performed over 5,000 TransplantsSince 1982, we have performed over 5,000 Transplants

SCBMTP Patient VolumeSCBMTP Patient Volume

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Jan07

Feb07

Mar07

Apr07

May07

Jun07

Jul07

Aug07

Sep07

Oct07

Nov07

Dec07

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Feb08

Mar08

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Oct08

Nov08

Dec08

Tran

spla

nts Projected

# Total txp

# Txp 2008

# Txp/month

# Auto Txp/month

# Allo Txp/month

Staff Challenges for a New BMT Program

• Recruitment of experienced BMT staff for all disciplines of the team is very difficult.

• A lot of time was needed to develop an educational program for inexperienced clinical staff

• General BMT Education was needed for the Hospital and Tennessee Oncology

Managed Care Challenges of starting a BMT Program

Managed Care Challenges for a New BMT Program

The Toughest requirement for a New BMT Program to achieve status as a Payor’s Center of Excellence Within their Transplant Network.

Volume, Volume, Volume

Its difficult to obtain the volume needed to meet the requirements when Payors deny you the approval to transplant their patient.

Negotiating with Managed Care as a New BMT Program

• Payors did not welcome us with open arms and a friendly smile

• Certain Payors were only willing to negotiate one time contracts per patient (Letters of Agreement)

• The Payors already had a BMT program in Nashville, why did they need a second one

Negotiating with Managed Care as a New BMT Program

• Tennessee Oncology holds 80% of the market share of Medical Oncology in Middle Tennessee

• HCA has 10 Hospitals in Middle Tennessee and 160 throughout the United States

• Combined, one would think our leverage to negotiate BMT contracts would be strong.

Negotiating with Managed Care as a New BMT Program

• Medicare patients were not a challenge for getting approval

• We had to negotiate contracts with TennCare (Medicaid)

• Spring 2007 we were able to get a local contract with BCBS of Tennessee.

Negotiating with Managed Care as a New BMT Program

• Spring 2007 we were able to start negotiating Global LOAs with HealthSpring

• Fall 2007 we negotiated our first Global LOA with Interlink

• Since HCA is self insured through Humana, we were able to start transplanting HCA employees in the Spring of 2007.

59%

7%

7%

20%

7%

BCBS Humana PHCS Medicare Medicaid

SCBMTP’s 2007 Payor Mix

Negotiating with Managed Care as a New BMT Program

• Spring 2008 we were able to start negotiating LOAs with Aetna

• Summer 2008 we negotiated our first LOA with Mailhandlers

• We negotiated our first Cigna LOA during the Summer of 2008

• Continue to work on each individual case to determine the need for an LOA.

4%8%

8%

4%

44%

32%

BCBS Humana PHCS Medicare Aetna Cigna

SCBMTP’s 2008 Payor Mix

Current Payors we have negotiated with for BMT

• BCBS of TN

• BCBS of MI

• BCBS of AL

• BCBS of KS

• BCBS of SC

• BCBS of NJ

• BCBS of KY

• BCBS of W. PA

• BCBS Blue Advantage (Medicare)

• Aetna• HealthSpring• Humana• PHCS• Medicare• Medicaid• Cigna

Managed Care Challenges related to

BMT Centers of Excellence and their Request for Information

BMT and Centers of Excellence

• In healthcare, Centers of Excellence are preferred places of care. They have better outcomes, good operational standings and the best patient care.

• One of the keys to developing a Center of Excellence is patient volume. The more patients with the same type of illness or requiring the same procedure, the better physicians and staff become at diagnosing and treating that illness or performing that procedure.

Centers of Excellence for BMTCigna’s LIFESOURCE Transplant Network

Each facility in our network is carefully chosen and must continue to meet our stringent quality standards. We assess several factors, including:

-patient outcomes;

-staff training and experience;

-number of transplants performed;

-waiting periods;

-availability of housing arrangements and transportation;

-geographic location and accessibility

Centers of Excellence for BMTUnited Resource Network “Our BMT programs are selected through a process of quality

measurement and value-driven contracting that are unique in the health care industry.”

“TRS contracts address 100% of the total transplant risk (similar services control only 60%). We cover all phases of patient health care from evaluation, pre-transplant, transplant, post-transplant and 12-month follow-up health care.”

“Because blood/marrow data is not tracked by the Federal Government, U.R.N. is arguably the only institution with enough data to manage the quality, selection criteria conformance and cost of this expensive (more than $300,000 average billed charges) and complex clinical event.”

Managed Care’s Request For Information

An RFI is required annually by all Payors.

It reports the transplant center’s information and

treatment outcomes. 

The standardized RFI form in three parts:

1. Administrative Survey

2. Program Information

3. Outcomes Data

Managed Care’s Request For Information

• New version released every February by the American Society for Blood and Marrow Transplantation’s RFI Committee

• Several Payors participate in the development of the ASBMT RFI.

• Every BMT Program must complete the RFI and submit it to Payors when requested.

FACT Accreditation

FACT Accreditation

Foundation for Accreditation of Cellular Therapy

-Payors require BMT Programs to be Accredited

-Requirements for Accreditation

1. Volume of Autologous and Allogeneic BMTs

2. Structured Quality Management Program

3. Meet all standards within 3 sections of Survey

FACT Accreditation

-162 Facilities in the United States and Canada

are FACT Accredited

-Payors want to know if a program is accredited, if not where are they in the process

-Payors consider FACT accreditation as a stamp of quality approval

FACT Accreditation

-We structured our program based on the FACT standards

-It took us 1 year to write SOPs and implement the FACT standards into our program prior to performing our first BMT

-We were surveyed on Sept 5, 2008

The Role of the Transplant Financial Coordinator

in a New BMT Program

BMT Financial Coordinator

The financial coordinator role may vary from

program to program.

Typically the Financial Coordinator works with BMT patients to ensure smooth coordination with their health insurance provider as well as assisting patients with any financial needs they may have.

BMT Financial Coordinator

In a new BMT program the financial coordinator needs to work with the Administrator, Physicians and other members of the team to develop

1. A List of Insurance companies and their contact

information

2. Process for communicating Approval Status

3. A process for Patient Financial Counseling

(cont.)

BMT Financial Coordinator

In a new BMT program the financial coordinator needs to work with the Administrator, Physicians and other members of the team to develop (cont.)

4. Process for informing all members of the team

the inclusion and exclusions of each Payor’s

contract.

5. Process for tracking all charges associated with

each patient’s transplant.

BMT Financial Coordinator

The Financial Coordinator has been the first line of defense to determine if we are eligible to transplant our patients

When a patient is referred to the program, the Financial Coordinator checked the insurance benefits to determine if the patient should be referred to another program.

As a new program we did not want to place more work on our referring physicians.

BMT Financial Coordinator

Due to our Program Structure we have 2

Financial Coordinators.

They work closely together to ensure the continuum of care for each patient as they navigate the program

The Financial Coordinators meet frequently to discuss insurance issues and review these issues with the BMT Coordinators

Next Steps

• Continue to educate and market our program to referring physicians and Payors

• Work 1:1 with Payors to negotiate LOAs until we reach the volume threshold required for COEs

• Continue to provide quality care to our patients and their family.

Questions

Thanks for everything you do for our BMT programs!

Rocky Billups, RN, MS Administrator, Sarah Cannon Cancer Center Rocky.Billups@HCAHealthcare.com