How can health plans manage unpredictable transplant costs?

While overall health care costs have been rising in the last decade, transplant costs have surged, becoming an unpredictable and volatile expense for payers. Financial projections are often hard to make in transplant episodes, which occur unexpectedly with costs varying widely based on organ type, clinical complexity, transplant facility and geography.

Transplant providers themselves vary in their facilities’ capabilities, case volume, treatment protocols and the expertise of the surgeons, doctors and supporting clinical staff.

Health plans employ various strategies to manage risk and contain costs, including:

● Developing or buying access to a network of specialized transplant centers to improve outcomes and lower costs
● Enlisting case managers to educate, support and guide members through the transplant decision process
● Relying on reinsurance to protect them from transplant risk

Each of these strategies provides some protection against transplant costs. But they don’t fully address cost variability and related financial uncertainty — critical concerns for health plans. Further, for a health plan to do this on its own requires an in-house transplant team of medical directors, transplant nurse case managers, pricing analysts and contract specialists. This team requires:

● Contracting experience with networks
● Clinical knowledge
● Expertise in best practices and emerging therapies
● Deep understanding of regulatory and compliance issues

This skill, knowledge and experience can be costly. That’s why health plans may want to partner with a health care organization that already has the clinical expertise, network professionals, relevant skills, experience and scale to address the broad transplant spectrum. This approach can meet the needs of both the payer and its members.

A recently published white paper provides a framework for evaluating a transplant partner organization and explores strategies for managing the risk and unpredictable costs of transplant.

Read “Managing the risk and unpredictable costs of transplants” to learn more.


About the Author:

Anthony Bonagura, MD
National Medical Director, Transplantation and Congenital Heart Disease, Optum

Before joining Optum in 2013, Dr. Bonagura held medical director positions at Aetna Insurance, where he worked for 13 years, administering the transplant benefit. He served as Aetna’s liaison to the Pennsylvania Medical Society and has chaired the Mid- Atlantic Quality Review Committee.  He maintains Board Certification in Internal Medicine and maintains licensure in Pennsylvania and New Jersey. He is a fellow of the American College of Physicians, and is a member of the American Society of Blood and Marrow Transplantation and the American Society of Transplantation. Dr Bonagura completed a residency in Internal Medicine in 1993. He graduated from SUNY Stony Brook School of Medicine in 1990.

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