Evaluation of payment reimbursement models for teclistamab administration and monitoring in the community hospital setting

Abstract Background T-cell engaging bispecific antibodies (BsAbs) have emerged as an important class of immunotherapy for the management of hematologic cancers. The high-costs associated with BsAbs, complexity of monitoring, and toxicity management for cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) serve as barriers in restricting the integration of BsAbs into widespread clinical use. Site of care is an important consideration with the use of BsAbs; there are financial incentives for healthcare organizations to defer the use of costly medications to the outpatient setting where there is greater opportunity for substantial cost-savings. The aim of this study was to evaluate the total cost of care and payment reimbursement associated with two different site of care models for teclistamab administration. Methods This was a multicenter, retrospective analysis of patients with relapsed/refractory multiple myeloma who received teclistamab during the step-up dosing phase under two different site of care models (model 1 as outpatient at Henry Ford St. John Hospital or model 2 as inpatient at Henry Ford Providence Southfield Hospital) between December 1, 2022 to December 31, 2023. Baseline demographics, teclistamab-associated toxicities, toxicity treatment, hospital diagnosis related group (DRG) classification, total inpatient and outpatient expenditure and payment reimbursement, and net profit margins associated with teclistamab administration were collected. Descriptive statistics were used to summarize cost and reimbursement data, and the Mann-Whitney U test and two-sample t-test were used to compare values between the two models. Results A total of 14 patients were included in the analysis, of which 8 were in model 1 and 6 were in model 2. In model 1, 5 (62.5%) were female and 7 (87.5%) identified as white; 5 (62.5%) had Medicare, 2 (25%) had Medicaid, and 1 (12.5%) had private insurance. Median number of lines of therapy including teclistamab was 5 (interquartile range [IQR] 4.75-7). Two (25%) patients had a prior autologous stem cell transplant (ASCT), and 1 (12.5%) had prior chimeric antigen receptor T-cell therapy. Median time between the first and second ramp-up dose was 4 (IQR 4-4) days. Median time between the second ramp-up dose and first full-dose was 4 (IQR 4-4.25) days. Median time between the first full-dose and discharge was 3 (IQR 3-3) days. In model 2, 6 patients (100%) were female and 3 (50%) identified as white; 6 (100%) had Medicare insurance. Median number of lines of therapy including teclistamab was 4 (IQR 4-5.5), and 2 patients (33.3%) had a previous ASCT. Median time between the first and second ramp-up dose was 2 (IQR 2-2.75) days. Median time between the second ramp-up dose and first full-dose was 3 (IQR 2.25-3) days. Median time between the first full-dose and discharge was 3 (IQR 2.25-7.5) days. Median total hospital length of stay for model 1 was 11 (IQR 11-11.25) days and 8 (IQR 7.25-14) days for model 2 (p = 0.23). CRS was observed in 4 patients (2 with grade 1, 2 with grade 2) and ICANS was observed in 2 patients (all grade 1) in model 1. One patient required CRS management in the intensive care unit. In model 2, CRS was observed in 4 patients (all grade 1) and ICANS was observed in 2 patients (all grade 2). Five doses of tocilizumab were given in model 1 and 0 doses were given in model 2 (p=0.26). Eight doses of supplemental dexamethasone were given in model 1 and 7 doses were given in model 2 (p=0.88). Median DRG payment for model 1 was $33,713.94 (IQR $22,656.69-$51,306.50) and $38,107.38 (IQR $32,269.60-$52,059.75) for model 2 (p=0.66). Median total expenses for model 1 was $26,343.08 (IQR $21,700.83-$35,681.33) and $23,277.23 (IQR $22,613.48-$29,834.48) for model 2 (p=0.49). Median payment reimbursement for model 1 was $26,490.35 (IQR $19,443.57-$34,922.03) and $12,316.54 (IQR $9,931.17-$17,859.52) for model 2 (p=0.01). Median net profit margin for model 1 was -$3,894.14 (IQR -$13,726.72-$9,991.69) and -$12,916.99 (IQR -$18,699.53- -$9,649.71) for model 2 (p=0.03). Total net profit margin was -16.5% for model 1 and -94.9% for model 2. Conclusion Outpatient model 1 had significantly higher payment reimbursement and net profit margins compared to inpatient model 2. Our study showed that site of care is an important consideration with BsAbs to optimize revenue and minimize costs, in addition to enhancing access among community-based practices.