Archaic Billing Systems Interfere With Treatment of Hospitalized Patients With Lymphoid Malignancies Free

The scenario is all too familiar. A patient with relapsed/refractory lymphoma or another hematologic malignancy such as multiple myeloma requires urgent hospitalization due to the burden of their disease. This could involve a range of symptoms, such as spinal cord compression from bulky lymphadenopathy, visceral organ dysfunction from tumor involvement, or skeletal fracture from lytic lesions. Historically, such patients were often deemed too frail and of advanced stage to benefit from traditional cytotoxic chemotherapy due to its inherent risk and low likelihood of clinical benefit in the relapse setting.

However, there has been a sea change in the management of patients with diseases such as diffuse large B-cell lymphoma, chronic lymphocytic leukemia, follicular lymphoma, Hodgkin lymphoma, and multiple myeloma over the past decade. As shown in the accompanying table, there have been 15 newly approved, parenterally administered agents in the past 10 years, with many more to come. These include monoclonal antibodies, antibody drug conjugates, checkpoint inhibitors, and bispecific T-cell engagers.

The availability of these agents has led to a major shift in discussions regarding the utility of urgent inpatient treatment. Many recently approved therapeutics often have rapid onset of action and sufficient safety profiles, with their net risk/benefit favoring a trial of treatment in clinical scenarios that previously would have been considered futile. Often, inpatient systemic treatment is the only viable way to relieve the burden of disease to achieve hospital discharge.

The vast majority of hospitals in the U.S. are reimbursed for the care of oncology patients, including those with lymphoid malignancies, under a Diagnosis Related Group (DRG) code — a billing construct used by the Centers for Medicare and Medicaid Services (CMS) to pay hospitals for their services.¹  However, the DRG is a capped sum of money that does not include the cost of traditional chemotherapy or novel, parenterally administered, targeted treatments, which are often very expensive. Therefore, most newer oncology treatments are restricted to outpatient use only, as their acquisition cost can be exorbitant and there is no anticipated insurance reimbursement when these agents are delivered on an inpatient basis.

This leaves patients and hematologist-oncologists in a difficult position, as hospital policies vary regarding what processes are in place, if any, to approve inpatient treatment, which can often be time-sensitive due to high patient acuity. However, while the cumulative acquisition cost of these medications can be significant for hospital systems, withholding approved medications that are safe and likely effective is not a desired state for patients.

Going forward, a modification of the CMS rules regarding reimbursement for inpatient medications to treat life-threatening diseases such as hematologic malignancies should be considered. Whether there is an appetite for constructive reform in the current political climate is unclear, even though the burden of cancer and challenges of its treatment affect patients of all groups and backgrounds.