WV HEALTH CARE AUTHORITY

TRANSPLANTS

CON STANDARDS MEETING

10/08/2008 - 1:00 P.M.

 

 

On the conference phone: 

Ted Cheatham - PEIA

Phil Wright – The Health Plan

Gary Murdock - WVUH

Marilyn White – Health Care Authority

David Jarrett - CAMC

Raymona Kinneberg – Bill J. Crouch Associates

 

Sonia Chambers:  All right.  Why don't we go around the room here, and have everybody identify themselves, that's here in the room.  Let's start with Ed.

 

Ed Hamilton:  Mountain State Blue Cross and Blue Shield.

 

Bob O'Neil:  From Dinsmore & Shohl.

 

Sonia Chambers:  Health Care Authority.

 

Sam Kapourales:  Health Care Authority.

 

Dayle Stepp:  CON.

 

Jill McDaniel:  Hospital Association.

 

Nora McQuain:  BMS.

 

Kay Myers:  Health Care Authority.

 

Tim Adkins:  Health Care Authority.

 

Cindy Dellinger:  Health Care Authority.

 

Marianne Kapinos:  Health Care Authority.

 

Sonia Chambers:  For those of you who have not participated, you know, almost everybody has.  I guess, maybe, Nora and Gary, and David have not participated in the prior meetings.  The goal of these meetings is to get input from interested parties on the question of whether Certificate of Need should continue to exist for certain services.  We're going through the whole list of them, just 'cause we love to meet.  We've done a couple, and today's issue is transplant.  So I'm going to have Dayle go through the very long Certificate of Need Standards, related to transplants, and then we will open it up for discussion.  Let me also say that folks are more than welcome to make their comments, verbally, today, and they certainly also can submit written comments.  We'd ask that you'd submit those within 30-days of today's meeting.  This call is being recorded—there will be a transcript.  So before you speak, please identify yourself so that will be clear in the transcript.  Unless you don’t want your comments attributed to yourself.  We’ll go ahead and let Dayle do this.

 

Dayle Stepp:  Okay.  The Standards now say transplants of the heart, lungs, liver, pancreas, and bone marrow, shall be considered emerging technology.  That’s all of the Standards.

 

Sonia Chambers:  That’s the sum total of the Standards.  And in terms of emerged, Dayle, why don’t you explain the process for emerging technology, then.

 

Dayle Stepp:  If we declare the emerging technology, we can then place the 180-day moratorium on to developed Standards.

 

Sonia Chambers:  So if somebody were to come through and, say they wanted to do a heart transplant, in West Virginia.  We could either accept their application as it was presented…

 

Dayle Stepp:  Right.

 

Sonia Chambers:  And they could come up with their own need methodology and put whatever they wanted in their application.  We could accept that as their application.

 

Dayle Stepp:  Right.

 

Sonia Chambers:  Or we could place 180-day moratorium on any new development of any type, any—that application or any other application for those services—and develop Standards to which to apply to that application.

 

Dayle Stepp:  Correct.

 

Sonia Chambers:  Ed, does that answer your question you were going to ask?

 

Ed Hamilton:  Yeah.  The question I had is since it references the emergent CON, they’re going to want two CONs rather than one.  - - the guidelines, rather than one.

 

Sonia Chambers:  I guess, for the emerging technology, it just references a process we can go through.  Which means we can just say, okay, we’ve gotten your application, but we have to develop Standards before we will even accept your application.  Preference is a process, not really a set of CON Standards.

 

Phil Wright:  Sonia, a question.

 

Sonia Chambers:  Yes, Phil.

 

Phil Wright:  For each one of these, how many are done in West Virginia?  For the heart, lung, liver, pancreas; we know bone marrow, but how many hospitals do the heart?

 

Dayle Stepp:  None.

 

Sonia Chambers:  None.  In West Virginia.

 

Dayle Stepp:  The only transplants being done, I think, are kidney, at WVUH, and at CAMC.  And WVUH has not done any since January.

 

Sonia Chambers:  And then bone marrow; WVU does bone marrow.  Is that correct?

 

Dayle Stepp:  That’s correct.

 

Sonia Chambers:  So those are the only transplants being done.

 

Phil Wright:  Okay.

 

Sonia Chambers:  In West Virginia.  Is that correct, Gary and David?

 

Gary Murdock:  Yes, that’s correct.  Kidneys are done at CAMC and we’re doing bone marrow—is the only activity.  And I think both programs are doing, between 60 and 90.  I can’t speak for CAMC, but CAMC is doing good many kidney transplants, and we’re doing 60, or so, this year, at WVUH; 60 to 70, I think.

 

Sonia Chambers:  Okay.  So you both do kidney and only WVU does bone?

 

Gary Murdock:  Yeah.

 

Sonia Chambers:  Although - - has expressed an interest in having the opportunity to do bone marrow, down the road.

 

Gary Murdock:  And Sonia—this is Gary.  We had a handful of meetings, I think, earlier this year, regarding bone marrow, and I think many of the same people were on this call were at that.  I don’t know if our position up here is the same as there.  I don’t know if we need to - - or not.  I assume all that information is still available and relevant, that we talked about then.

 

Sonia Chambers:  I think it is available.  However, I would encourage you to perhaps summarize all of that in written comments for this process.

 

Gary Murdock:  Um-hm.

 

Bob O’Neil:  If I might.  This is Bob O’Neil.  Tom Jones called me up yesterday and asked me to speak on behalf of WVU, and I don’t know if he coordinated with Gary, or not.  But Tom asked me to say today that WVU would like CON to remain in place, for all the needs.  But really, his focus is on bone marrow.  And WVU’s position with respect, primarily to this, there’s really only enough utilization in West Virginia, to justify one.  And his rationale for that is that in words of the - - by many insurance companies, and in order to be a participant in many registries, you have to do 50 bone marrow procedures per year.  And WVU does 55 a year.  So they barely make it - - reimbursed into being a registry.  There apparently is one registry that requires 60 a year to participate and they’ve gotten a break from that registry, that they’re allowed to participate.  And according to information Tom gave me yesterday, there are not 100 bone marrow patients in West Virginia, to divide it in half and come up with two programs.  And if there were more patients in the state, and the situation were different, he would—WVU would understand the need for two programs.  With the situation the way it is right now, WVU believes there’s only a need for one.  So he asked me if I would come here today and make that statement on WVU’s behalf.

 

Sonia Chambers:  Okay.  Gary, do you want to add anything to that, while…?

 

Gary Murdock:  No, that’s pretty much the exact data that I was talking about in our meetings we had, in I think they were, January and February.  There’s about - - data, which would show there’s 70 to 90 in the state, maybe more, and I think last year we did in the high 40s; this year we’re going to be around 60, plus.  And we - - network on a handful of things; if we get below 50, and we’re right on the edge of that.  So we think there is a need for CON review of these types of things.  In general, I think, whether it’s emerging technology or transplants, I think it’s good policy—the state only produces, probably, ten heart transplant patients a year, from - - .  Maybe 100 or so, kidney transplants.  There needs to be some sort of oversight that we don’t dilute programs.  I think that’s the policy issue that this hearing’s trying to address, that I would go on record, on saying.

 

Sonia Chambers:  Okay.

 

Phil Wright:  Sonia, this is Phil Wright.  My position has not changed, or Health Plan’s position has not changed since the meetings with Gary Murdock, in the summertime.  We still feel exactly the same way.

 

Sonia Chambers:  Which is?

 

Phil Wright:  Well, leave it alone.  I normally don’t agree with Tom Jones, but on this, with the volume the way it is, I’d say, leave it alone.

 

Sonia Chambers:  Okay.  So CON should remain in place?

 

Phil Wright:  Yes.

 

Sonia Chambers:  And there should only be…

 

Phil Wright:  Well, right now, with the numbers, there’s only one program.  You dilute that program, you dilute the quality of that program, and we are not for that, at all.

 

Sonia Chambers:  Okay.  All right.  So this is where you think there should be CON in place, for transplants?

 

Phil Wright:  Absolutely.

 

Sonia Chambers:  Okay.  Ed?  Do you have an official position?

 

Ed Hamilton:  The official position is that we’re not going pay one unless it’s case managed and it’s through a qualified provider that meets the registry standards, that we bought into with Blue Cross Blue Shield Association, which at this point, means that potentially, we don’t pay for any of these inside the state of West Virginia.  The question I have, though, is if you’ve got a provider that comes in from out of state, with Cleveland Clinic, and they decide they want to run an intake program; in order to gather transplants that might exist in the state and direct them in to their facility, versus WVU or Pittsburgh, or somewhere else, where does that fall under this standard?

 

Sonia Chambers:  It would depend on—now I’m practicing law, here—it would depend on how that was structured.  If they opened it as a private physician office practice and patients were seen, and they just happened to be referred to Cleveland, then it would not be reviewable.  However, if Cleveland Clinic, itself, set up a facility or office, then it would be subject to review.  Correct?  I’m looking at all the CON lawyers.  Although…

 

Male Voice:  I’m not sure that’s 100% right.

 

Sonia Chambers:  Right.

 

Phil Wright:  An office or a facility, for transplants?

 

Sonia Chambers:  If they set up a facility…

 

Phil Wright:  That would be CON.

 

Sonia Chambers:  Although it would depend on the capital expenditure.  That would be an issue I think we would have to look at.

 

Male Voice:  It could potentially exist out there already, in the form of doctors’ office.

 

Phil Wright:  Well, we’re doing that every day.  I mean when the physician refers someone to Cleveland Clinic with a health plan for these kinds of transplants, we approve.  They are a contract, they are approved for transplants in our program, and they would go forward without a CON.  Happens every day.

 

Cindy Dellinger:  This is Cindy Dellinger.  I mean if I was a resident of West Virginia and I wanted to go to Cleveland to get a procedure, and my health plan approved it, I wouldn’t need a CON for that.  I’d be getting the procedure done out of state.

 

Sonia Chambers:  I guess the only question would be, depending on what would be set up in West Virginia.

 

Raymona Kinneberg:  The question’s whether they’d be doing any health procedure here, or just taking names and processing them.  Right?

 

Sonia Chambers:  Right.

 

Cindy Dellinger:  Okay.

 

Sonia Chambers:  Other—Ed, anything else?

 

Female Voice:  I have a question for Ed.  The way he said, you don’t pay for any providers in West Virginia.  Blue Cross doesn’t take transplants in West Virginia because…

 

Ed Hamilton:  Essentially, no.

 

Female Voice:  Okay.  And you mentioned something about a registry.  So it’s important that these providers that do transplants participate in a registry.  Is that right?

 

Ed Hamilton:  Yeah.  The way we got started in our transplant program was actually when heart transplants came out of the experimental status.  The Blue Cross Blue Shield Association immediately put together reinsurance.  And one of the conditions that applies to the reinsurance is that you have to follow specific guidelines, which means, we’ve got a panel of providers in a pre-approved program.  So in essence, most of these kind of things—except for, like, the bone marrow and perhaps the liver—no, I think liver is under the transplant guidelines, too.  But most of these transplants like this, heart, heart/lung, those kinds of things; they have to be managed, otherwise, they won’t be covered.

 

Cindy Dellinger:  Right.  So when Gary, at WVU, mentioned earlier—and Bob referenced earlier—they have to participate, they have to have a certain volume to participate in a registry.  And if they fall under a certain volume then they can’t participate in the registry.  And I heard you mention that they have to participate through a registry.  So if, you know, we’re talking about, you know, are we going to allow other people to come in for procedures, and if that would happen, the volume could be split, and they could drop under what a registry would allow.

 

Ed Hamilton:  And that may be why their volume in some procedures, is suppressed already.

 

Cindy Dellinger:  I guess my question is you’re saying it’s Blue Cross who require people to participate in a registry as part of your payment.  Is that—that’s what I’m getting at.

 

Ed Hamilton:  The patient needs to go through the management program in order to have that procedure covered.  And that procedure needs to be done through the panel of approved providers.  And, you know, the registry approval process is pretty complicated.  It goes to the number of years it’s been done, success rate, follow-up, all those kinds of things.  And essentially, what it comes down to in our area, is UNC, Pittsburgh, and Cleveland—maybe some things in Columbus, but that’s, you know…

 

Cindy Dellinger:  The track [phonetic] that the hospital participates in a registry, or something like that, doesn’t matter, for your approval process, or anything like that?

 

Ed Hamilton:  Not to us, it doesn’t.  Because we don’t run the panel.

 

Cindy Dellinger:  Okay.

 

Marilyn White:  This is Marilyn.  Can I ask a question of Ed, please?

 

Ed Hamilton:  Go.

 

Marilyn White:  All right.  Just for clarification, here.  I think probably what you’re saying—and tell me if I’m wrong, here—is that yes, Blue Cross requires that the facility belongs to the registry, but on top of that, they must be a participating—you have to have a contract with that facility.  So there could be a lot of facilities, perhaps that belong to the registry but unless Blue Cross has a contract with them, you still would not allow.

 

Ed Hamilton:  Well, part of the program is an agreed payment rate.

 

Marilyn White:  Yeah.  That’s what I’m getting at, is that you’re only going to send your members to a facility that you have a contract with.

 

Ed Hamilton:  Right.

 

Phil Wright:  If you have contract with WVU, you just don’t have it for their transplant program.

 

Ed Hamilton:  Right.

 

Phil Wright:  What disqualified Wave’s bone marrow transplant program with Blue Cross?

 

Ed Hamilton:  I don’t know.  I can’t speak to that.  I haven’t studied up on it.

 

Phil Wright:  Okay.  Our reinsure has approved it.  You know, we have the registry; we go through all that, also.  But they have approved the BMT for Morgantown.  So I don’t know what—different reinsurers do different things.  I know that they all have their own networks and rates get involved, and everything else.  But I mean the bottom line is once they cross that quality program within a certain parameter of rates, they’ll sign off, and ours has signed off.

 

Gary Murdock:  This is Gary, up in Morgantown.  My understanding is similar.  We had to meet some minimum thresholds.  There is a national registry of bone marrow, and a national—not accrediting body—but it’s survey.  You have to submit data to that national body and then each insurance company, before they’ll even negotiate you, will make sure you meet minimum thresholds.

 

Phil Wright:  Right.

 

Gary Murdock:  I think we have had some Blue Cross patients in the past, but it was primarily because they’re employed by us and Blue Cross is the administrator of our insurance, or some affiliate.  But up until recently, I don’t think we’ve reached those minimum thresholds, because that was one of the higher ones, 50 or 60, before we could even get to the table to negotiate a price, is where I—

 

Phil Wright:  [Interposing].  Yeah, but that’s because you’re self-funded.  You were directing your own people to your own program, that’s all.

 

Gary Murdock:  Yeah.  They were just—that’s the only thing about that, ‘cause that—I’ve already looked at that, but that’s why that number was so low, I guess.  But the conversation about registry, there is—each insurance company doesn’t have its own registry—there’s a national registry.  And once you have a program you submit to it and you maintain your certification in it.  It’s not an accreditation but it’s a certification program, and that’s sort of the minimum threshold, and then you have to do a certain amount of volume, to get “into the game.”  And that’s why the state—whether it—not just bone marrow.  When we looked at open heart a handful of years ago, there’s only five or six, or ten individuals a year, in the entire 1.8 million people in West Virginia, that probably need a heart transplant.  And can you have a quality program with six, eight, ten, twelve people.  I mean it doesn’t make sense.  And there probably should be some review of that.

 

Phil Wright:  What worries us is the fact that you have such a low number now; you’re just over the threshold.  And to deteriorate that any more would be, you know, it’d probably take you out of doing the transplants.

 

Gary Murdock:  Yeah.

 

Sonia Chambers:  All right.

 

Female Voice:  Sonia, I’ve got one more question.  In the number 50, that the registry requires, is there any differentiation between the allogenic [phonetic] or the onlogis [phonetic], or does it matter?

 

Gary Murdock:  This is Gary.  I’ll take a—to the registry, you report the two types, and then each plan might have different minimum thresholds.  I believe there’s some guidelines, whether it’s 15 and 35, but I’m not sure whether that’s the registry or whether that’s the payer A or payer Y, type decision.  You report both those and that’s out there for public consumption, and then every payer decides, just like they decide whether they want to contract with people.  About 50 or 60—the breakdown of what that 50 or 60 should be, somewhat varies depending on the payer.  That’s my understanding of it.

 

Female Voice:  Okay.  Thank you.

 

Sonia Chambers:  All right.  Raymona?

 

Raymona Kinneberg:  Yes.

Sonia Chambers:  Any comments?

 

Raymona Kinneberg:  No.  It all makes sense to me.  I don’t think you’d want a low volume program for transplants.

 

Sonia Chambers:  Nora, do you have any comments or are you just here to listen?

 

Nora McQuain :  I’m just here to listen and learn.  Thanks.

 

Sonia Chambers:  Jill?

 

Jill McDaniel:  Here to listen.

 

Sonia Chambers:  Anybody else?  All right.  If not, I appreciate everybody’s time and attendance.  And let’s see, we have two more meetings next week; one on rehabilitation and one on lithotripsy.

 

Female Voice:  The rehab one got changed.  It’s not next week.

 

Sonia Chambers:  Okay.  Okay.

 

Phil Wright:  Lithotripsy is next week, isn’t it?

 

Sonia Chambers:  Yes.

 

Phil Wright:  Yeah.  That’s the only one.

 

Sonia Chambers:  I don’t know if we have—I was just talking to Amy Toliver, and we hope we have collective physician participation since there were a lot of questions about that, last time.  All right.  Thank you all.  I appreciate your time.