Life Sciences

Medicare & Reimbursement Advisor Weekly, July 8th, 2009

Medicare & Reimbursement Advisor Weekly, July 8, 2009


Readmission data can inform formulary decisions

Commercial policies, economy affect site of care

Readmission data can inform formulary decisions

by Bryan Cote

I’m toiling away in the field this week on a tracking study regarding readmissions involving plans, hospitals, primary care practices, and skilled nursing facilities, so this is an abbreviated issue of MRAW. I thought I’d share some of the initial data from a participating hospital because Medicare is now reducing reimbursement for preventable readmissions, which means hospitals are trying to track the data and create solutions before, at, and post discharge.

There are opportunities for support, particularly for the case management, admissions, and discharge staff members, who are key influencers in the process and closest to seeing the impact of medication-related problems (reimbursement or clinical).

St. Joseph’s Hospital of Atlanta requires an assessment of every patient readmitted within 30 days. “[We] assume that a 30-day readmission suggests something happened bad or wrong at the discharge planning stage of the previous admission,” says Anne Pedersen, RN, MSN, director of care management.

The numbers in this data are small since they come from just one institution; they are also focused only on certain diagnosis groups.

However, they give you a sense of the type of data hospitals are tracking and using to make decisions that affect everything from discharge plans to formularies.

Editor’s note: To access similar data or discuss these issues, feel free to drop me a line anytime. –BC (860/712-8960)


Commercial policies, economy affect site of care

How drug cost, climate affect myelodysplastic syndrome patients

by Bryan Cote

Urban medical and academic centers are concerned that the economy and/or job loss has forced people to delay doctor visits and hold off reporting symptoms. Susan Buchanan, MS, PA-C, adult leukemia physician assistant at the Dana-Farber Cancer Institute in Boston, says a 5%–10% drop in new patient consults for adult leukemia is being noticed, as well as fewer second opinion consults (perhaps due to travel expenses), and an increase in Medicaid patients from New Hampshire and Maine—two states severely hit with unemployment since December.

“Leukemia symptoms like bruising don’t always show up so with [primary care physician] visits down due to the economy, there have been fewer physicals, which means fewer CBCs ordered—reducing the likelihood that a physician could catch an abnormal blood count,” Buchanan says.

Buchanan and her physician colleague are used to seeing four new patients per week, about half for myelodysplastic syndrome (MDS). “These numbers have remained relatively steady since patients often request my MD but, overall, for the four physicians in our group, visits were down,” she says.

Interestingly, Dana-Farber is seeing growth in the number of complex cases for rare leukemia and bone marrow transplants—the result of commercial payers’ policies to encourage physicians to refer these types of cases to institutions with larger volumes and more developed infrastructure and expertise. This growth at Dana-Farber has offset some of the dip on less complex cases. “It tells me that our new patient volume would be much lower without these cases,” Buchanan says.

In some ways, treating patients with MDS has become more difficult in the economic downturn since patients, and some doctors, are either uneducated about the disease or are faced with a difficult financial decision, says Buchanan.

According to the American Cancer Society, about 40% of patients with MDS convert to full-blown leukemia and of all newly diagnosed MDS patients annually (approximately 14,000 in the United States), about 10%–15% have deletion 5q cytogenetic abnormality, which essentially means they are missing the long arm on the fifth chromosome. If the 5q is their only abnormality, Buchanan says Revlimid (lenalidomide; Celgene) has worked well in about 50% of cases to either eliminate the abnormality or improve blood count so much that the patient no longer needs transfusions.

The cost to use Revlimid (lenalidomide; Celgene) per month is significant (The Wall Street Journal, July 1, 2006, “Celgene to Price Cancer Medicine at $6,195 a Month”), so seniors with Part D benefits hit the catastrophic cap almost immediately and, unless they can get patient assistance, are forced to pay a large portion out of pocket. “This is a lot financially to bear for a treatment that is not guaranteed to provide a patient benefit,” says Buchanan, adding that Celgene has been generous with patients who can’t afford the drug. Sometimes, underinsured patients make too much to qualify, however, and have elected to halt treatment.

Alternatively, Vidaza (azacitidine; Celgene) and Dacogen (decitabine; Eisai) are two other treatment options indicated for those with MDS, but some community physicians have not given Vidaza enough time for proper trial efficacy, says Buchanan. “Based on the CALGB clinical trial data presented by L. Silverman in 2006, and in our experience, patients need four cycles, one per month, before we compare bone marrow results to baseline. Unfortunately, some oncologists who don’t see blood count improvement after two cycles stop the course and try something else,” she says. Many oncologists are now educated on the four-cycle benefit since the FDA approved the drug in 2004. Buchanan thinks patients are less likely to stop Vidaza or Dacogen treatment for financial reasons since these injectables are delivered under a hospital Medicare Part A or in-office Medicare Part B benefit. n

Editor’s note: The full story will appear in the July Oncology Business Review.


Here’s a new resource to quickly search for Medicare rules, regulations, and CMS documents. Check it out at If you’d like me to arrange a Web-based tutorial to walk you through it, e-mail