How Payers Can Prepare for Coverage Challenges Among Patients With COVID, Hematologic Malignancies

Edmund Pezalla, MD, MPH, CEO, Enlightenment Bioconsult LLC, discusses how payers can prepare for billing and coverage challenges for COVID treatments in the patient populations experiencing hematologic malignancies, and provides insight on how costs can be estimated in the future.

There have been a number of hematologic malignancies in patients with COVID, complicating care even further. How can payers prepare for billing and coverage challenges for COVID treatments in the patient populations experiencing hematologic malignancies?

In Western Countries there is an increasing number of people with compromised immune systems due to shifting population demographics towards groups with higher incidence of cancer and need for cancer therapies as well as increasing use of immune modulating drugs for auto-immune and other disorders. Immune compromise is listed by the CDC as a risk factor for more severe COVID-19 disease course. One group of patients with immune compromise is that with hematologic malignancy. Recent studies in China and now in Italy confirm that patients with hematologic malignancies are at much higher risk of dying from COVID-19 than the general population. The implication for payers will be to recognize the impact of COVID-19 on this group of patients and prepare for coverage of prolonged and complex therapy. This preparation should include estimates of the cost of treating more severe COVID-19 cases, information that is now known, and of the numbers of vulnerable patients in treatment for hematologic malignancy.

Many patients with cancer and COVID are receiving investigational COVID therapies. Because there is no cost-related data, how do you think this will impact payers? Do you think anything can be done to help estimate costs and prepare for this in the future?

Estimating costs in a novel situation is difficult but there are already some data that can help.

1) We can assume that patients with hematologic malignancy will have more severe cases of COVID-19 and will be at the higher end of the cost spectrum, 2) We are now paying for remdesivir and other therapy, the cost of which can be added to the known baseline cost for severe disease, 3) The most difficult part is predicting how many patients will fall in.

The literature does not yet address this issue, but we can assume that the rate of infection, and therefore severe infection, will be much higher in the hematologic malignancy population.

The majority of data that we have on this is from a number of countries other than the US. How can we use this data to help inform treatment decisions within the US? 

Date from outside the US can help in several respects. First, it is directly useful and provides a starting point for estimates of resource utilization. Although costs vary widely across countries human biology does not. Therefore, the course of the disease is less dependent on the country if treatments are similar (e.g. range of available resources is about the same for most OECD countries). More variable is the date when a patient was treated as treatment outcomes have improve steadily over the past several months.

As a health care professional yourself, how do you or your peers feel about making clinical treatment decisions based upon constantly changing data? 

Physicians are called upon to make treatment decisions, often under conditions of uncertainty. In this case we have uncertainty as to which patients should receive which therapy. The best approach is to arm yourself with the latest information and frequently compare notes with colleagues. Review of recent cases can help provide some information as well. The goal should be to make the best decision based on the information available at the time, not to look into a crystal ball and try to predict what the future will bring. In my own experience as a physician I was one of the first in the US to treat a child with Kawasaki Syndrome with high dose IVIG. We based this treatment decision on a paper from a center in Canada and direct phone communication with the author of that paper.