Cost of Thrombolysis Outpaces Reimbursement in Stroke

Megan Brooks

February 23, 2016

LOS ANGELES — The cost of tissue plasminogen activator (tPA; alteplase, Genentech) has more than doubled over the past decade, but Medicare/Medicaid reimbursement has not kept pace, new research shows.

Between 2005 and 2014, the cost of tPA jumped by 111%, but reimbursement from Medicare/Medicaid rose by only 8%, according to the study presented here at the International Stroke Conference (ISC) 2016.

"The reason the cost has gone up so much is unclear," Dawn Kleindorfer, MD, lead researcher and professor, Department of Neurology and Rehabilitation, University of Cincinnati, Ohio, said in a conference statement.

"The reason that reimbursement has not kept up with the cost is complicated but has to do with the way it's calculated and the fact that Medicare/Medicaid is cutting hospital reimbursements across the board," she said. "What we need to do is ensure that the reimbursement covers the cost of caring for these patients so that hospitals don't lose money while providing this proven beneficial treatment," she noted.

A "Clear Disconnect"

Using publicly available data, the researchers evaluated the average sales price of tPA since 2006 and compared it to the base payment from the Centers for Medicare & Medicaid Services (CMS).

The cost of tPA was "relatively stable from 2005 to about 2009, when it began to increase over time," Dr Kleindorfer reported. In 2005, 1 mg of tPA cost $30.50, compared with $64.30 in 2014, meaning the standard 100-mg vial of tPA cost about $6400 in 2014, she explained.

"Over the study period, we found an 111% increase in the cost of the medication," she said. During that same time frame, the consumer price index for all drugs increased by 30.2%, she noted.

At the same time, CMS reimbursement to hospitals for tPA-treated patients increased by just 8%, from $11,173 in 2006 to $12,064 in 2013. More than half (53%) of the total CMS hospital reimbursement amount now goes to pay for tPA, up from 27% in 2006, Dr Kleindorfer noted.

A limitation of the study is that it relies on the drug manufacturer's average sales price, which may vary between different hospitals. The reimbursement amount from private insurers also varies.

Commenting on the study results, Ralph Sacco, MD, chairman of neurology and executive director of the Evelyn McKnight Brain Institute at the Miller School of Medicine, University of Miami, Florida, said, "There's a disconnect here. A drug that is really amazingly productive for acute stroke has risen greatly over time in price, while the reimbursement for acute stroke has not risen at the same rate."

Dr Kleindorfer noted during her presentation that tPA is still cost-effective to society, even at a cost of $6500 per dose.

From a policy perspective, 39 years of quality-adjusted life-years would be gained and over 2.5 million US dollars saved in medical costs for every 100 patients treated with tPA within 0 to 3 hours of acute ischemic stroke onset. The savings would come from reduced long-term rehabilitation and nursing home costs, but this does not address the hospital costs, she said.

Dr Kleindorfer said healthcare providers caring for stroke patients need to be aware of the increased cost of tPA as they are managing their stroke centers' finances. She called on stroke physicians to lobby CMS to increase payments to hospitals for tPA-treated patients.

Dr Sacco agrees. Taking care of stroke patients "takes a whole team and does cost money," he said, "and it's important for all of us to lobby Medicare and the other reimbursers…to make sure that stroke is adequately covered.

"Using tPA is cost-saving," he added, "but that cost savings actually goes down if the cost of the drug goes up too high and we don't get the proper reimbursement."

The study had no funding. Dr Kleindorfer is on the speaker's bureau for Genentech.

International Stroke Conference (ISC) 2016. Abstract 78. Presented February 17, 2016.

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