Economic Implications of Inpatient versus Outpatient Autologous Transplant for Patients with Multiple Myeloma

January/February 2019, Vol 10, No 1 | Payers’ Perspectives In Oncology: ASH 2018 Highlights

San Diego, CA—Analysis of healthcare utilization among Medicare beneficiaries with multiple myeloma suggests that the setting of autologous hema­topoietic stem-cell transplantation (HSCT) has a significant impact on provider reimbursement and out-of-pocket expenses for patients, according to data presented at ASH 2018.

The total reimbursement for 100 days posttransplant was $27,659 higher for inpatient than for outpatient transplant after adjusting for patient and HSCT-related characteristics. The adjusted total out-of-pocket patient responsibility, however, was $2805 higher for outpatient HSCT.

Although the overall survival (OS) was equally high for both groups, patients undergoing outpatient transplant were nearly twice as likely to require subsequent hospitalization than recipients of inpatient transplant, the investigators noted.

“The setting of transplant seems to matter for hospital reimbursement and for out-of-pocket expenses for patients,” said Neil Dunavin, MD, MHS, Assistant Professor, Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Westwood.

“For transplanters, there are many factors that go into the decision to have an inpatient or outpatient autologous transplant, including center experience, severity of disease, patient comorbidities, access to care, and proximity of lodging, but this study defines the economic considerations when choosing the setting of care,” said Dr Dunavin.

The number of Medicare beneficiaries who receive autologous HSCT is increasing, driven in part by the effectiveness of the procedure in older patients with multiple myeloma, Dr Dunavin suggested. Although the vast majority of these procedures have been conducted in the inpatient setting in the past, centers across the country have started to establish outpatient transplant programs, where patients come daily for supportive care in the 2 weeks after transplant rather than remain in the hospital.

“Single center studies have shown that outpatient transplant may cost less and have comparable outcomes to inpatient transplant, so we wanted it to examine this in greater detail,” Dr Dunavin explained.

For this multicenter retrospective cohort study, Dr Dunavin and colleagues identified 11,358 HSCT recipients between 2010 and 2012 in the Centers for Medicare & Medicaid Services database. The researchers linked 9055 (80%) of these patients with the Center for International Blood & Marrow Transplant Research data. Selection criteria included first HSCT for multiple myeloma, diagnosis-to-HSCT time between 0 and 18 months, and continuous enrollment for 30 days pre-index date and 100 days post-HSCT or until death.

Reimbursement Higher for Inpatient Transplant

Of the 1640 patients included in the final cohort, 1445 (88%) received inpatient HSCT (in 126 centers) and 195 (12%) patients received outpatient HSCT (in 24 centers). The data showed a significant difference between cohorts in the utilization of hospital services. The median number of inpatient days was 19 for patients receiving inpatient transplant versus 4 days for patients receiving outpatient transplant (P <.0001). Outpatient services were used a median of 16 days for inpatient transplant versus 33 days for outpatient transplant (P <.0001).

The adjusted total mean reimbursement for the inpatient transplant group was $83,380 versus $55,721 for the outpatient transplant group. According to the investigators, transplant setting, age, sex, comorbidity index, diagnosis-­to-transplant time, and melphalan dose were all factors associated with total reimbursement. The majority of the reimbursement came from Medicare, Dr Dunavin said, with a small amount coming from secondary payers and patient responsibility (ie, copays and deductibles).

The adjusted total patient responsibility for the inpatient transplant group, however, was significantly lower than the outpatient HSCT group ($4567 vs $7372, respectively), meaning that patients undergoing outpatient transplant had approximately 60% higher out-of-pocket expenses for their outpatient procedures.


Analysis of subsequent readmissions also showed a difference between cohorts. After the transplant index period, approximately 1 in 4 inpatient transplant recipients required rehospitalization within 100 days compared with 1 in 2 outpatient transplant recipients. Despite the increased likelihood of hospital re­admission, the findings demonstrated no difference in OS between the cohorts up to 100 days posttransplant. The OS at 100 days was high for the inpatient (98%) and the outpatient (99%) settings.

Although many factors influence the decision between inpatient and outpatient autologous HSCT, cancer center experience is the biggest one, Dr Dunavin concluded.

Moderator of the session, Navneet S. Majhail, MD, MS, Director, Blood & Marrow Transplant Program, Cleveland Clinic, OH, highlighted the apparent tradeoff between increased center reimbursement and out-of-pocket expenses for patients.

“Patients shouldn’t be penalized financially for outpatient transplant because it’s a nice way to use resources,” Dr Dunavin responded. “That is something that should be brought up and hopefully change.”

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