Shouts & Mumblings: A Transplant in Every Kitchen

Mikkael Sekeres, MD, MS
Director of the Leukemia Program at the Cleveland Clinic in Cleveland, Ohio

Patients with various blood-related cancers … receive transplants of bone marrow and peripheral blood stem cells to restore stem cells that were destroyed by high doses of chemotherapy or radiation therapy or both. After being treated with anti-cancer drugs or radiation, the patient receives the harvested stem cells, which travel to the bone marrow and begin to produce new blood cells. Stem cell transplantation is not on the Centers for Medicare & Medicaid Services’ (CMS) list of inpatient-only procedures, and according to an independent medical review contractor, stem cell transplantation is routinely performed as an outpatient procedure.”

—2016 report from the U.S. Department of Health and Human Services’ (HHS) Office of Inspector General, “Medicare Did Not Pay Selected Inpatient Claims for Bone Marrow and Stem Cell Transplant Procedures in Accordance with Medicare Requirements (A-09-14-02037)”; HHS and Centers for Medicare & Medicaid Services, MLN Matters Number SE1624, May 1, 2017.

CMS has gone on a hiring rampage of late, seeking independent medical review contractors who can identify interventions that have been performed unnecessarily within the highly technical and sterile confines of large, tertiary-care hospitals. These medical review contractors – for whom a health-care background is optional – have been applauded for their innovative approaches to deconstructing medical procedures into their elemental components. They make these procedures sound safer and, thus, better-suited to the outpatient or medical home setting.

Here are their recommendations for health-care practices that are expected to routinely relocate to home-care environments in the near future.

Allogeneic Hematopoietic Cell Transplantation
Here’s what you’ll need: Some bone marrow cells, which are basically like soupy Kool-Aid and can be delivered to the home using a service such as UberRUSH; an intravenous line, which even an emergency medical services worker can place in a variety of settings (such as a community soccer field when a parent feels faint after his 8-year-old has a nice assist); and some breath mints to mitigate that “not-so-fresh” preservative taste as the cells infuse. The procedure can be performed by a visiting nurse as the patient sits in a chair near the kitchen table, followed by instructions for the patient to call the general home health-care number in the event of a fever within 48 hours, but only between the hours of 8 a.m. and 4 p.m., Monday through Friday. One follow-up visit from the nurse and one visit from a physical therapist, to be scheduled as needed. Free “You, Too, Can Diagnose Graft-Versus-Host Disease!” pamphlet to be provided.

Cardiac Transplantation
The heart is basically a muscle, and a New York Heart Association class IV heart failure is like having a slight muscle pull, as might occur when running down the soccer field for an assist, except you have to replace the muscle. This can be performed in a patient’s living room, on a couch or La-Z-Boy recliner, using a 3-inch paring knife, a clean washcloth, and a sewing kit (which can be obtained at no cost from the bathroom of a moderately priced hotel within the Fairmont or Hilton hotel chains). The donor heart should be transported to the recipient’s house via UPS 3-Day Select shipping, so the patient will need a companion who can sign for the package. The box will also include a manual with aesthetically pleasing diagrams that indicate how to remove and replace the impaired organ (similar to the assembly instructions for the Ikea Godmorgon bathroom sink cabinet with 4 drawers) – along with an Allen wrench.

Hip, Knee, Joint NOS Repair/Replacement, Right or Left
Similar to the previously mentioned procedure for cardiac transplantation, but following assembly instructions for the Ikea Förhöja wall cabinet/writing board.

Separation of Conjoined Twins
Home births are ubiquitous, particularly in underserved parts of the world without basic health care. We project that these will become widespread in the United States within 6 months of adoption of our mind-numbingly obvious recommendations. In the rare case of complicated births of identical twins joined in utero, we recommend laying the twins in their crib and applying gentle pressure to each twin simultaneously, if separation is desired.

Therapeutic Plasma Exchange for Thrombotic Thrombocytopenic Purpura
This one is a doozy to even say, so we considered removing it altogether from coverage. But, in response to decades of complaints from hematology fellows being called to the hospital in the middle of the night to evaluate patients for suspected thrombotic thrombocytopenic purpura (TTP) – when those patients had platelet counts of 148,000/µL and were able to correctly answer only two out of three “orientation” questions – we now provide an easy, at-home alternative. After the patient is diagnosed with TTP by a qualified emergency room physician, he or she should be discharged to his or her place of residence, with planned follow-up by a visiting nurse within 48 hours. In the meantime, a family member can obtain a refrigerator water supply line and rent a 6,500-watt Honda power generator (model number: EG6500CLAT) from their local Home Depot for groin line and plasma exchange purposes, respectively. The intervention can be performed in the patient’s bathtub, with 1-month follow-up scheduled with the patient’s primary-care doctor, as needed.

Patients insisting on having any of the above medical procedures completed in a hospital setting may have to pay out-of-pocket expenses for any and all components, even with supplemental insurance coverage, and will incur additional facility fees.