James Gajewski

James L. Gajewski

Professor at Oregon Health & Science University

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3181 S.W. Sam Jackson Park Rd, Portland, Oregon, United States
HQ Phone:
(503) 494-7800

General Information


A.B.Notre Dame


medical degreeTemple University


Medical Advisory Board Member - American Organ Transplant Association

Board Member - American Society for Blood and Marrow Transplantation

Board of Trustees Member - Oregon Society of Medical Oncology

Member - Fox Chase Cancer Center

Board Member - ELECTED

Medical Advisory Board Member - The Give Life Foundation

Board Member - Existing

Recent News  

Leadership | ASBMT

James Gajewski, MD, At Large 2016-2019
Oregon Health & Science University

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However, application of bundled payments is not without risk, according to James L. Gajewski, MD, professor and hematologist at Oregon Health & Science University.
"We have to have outlier clauses [with bundled payments], because our worst patients can use 10 to 100 times as many resources as the average patient," Dr. Gajewski explained. "I may have a bone marrow transplant patient with congestive heart failure, liver dysfunction, or chronic obstructive pulmonary disease. Caring for these comorbidities alone can cause as much resource use as the pathway for the transplant." Because of these unknowns, institutions using bundled payments often have to negotiate the existence of outlier or stop-loss clauses in order to minimize risk. Even for patients without higher comorbidity burdens, Dr. Gajewski said that stem cell and bone marrow transplants are becoming much more complex. "The Centers for Medicare & Medicaid Services (CMS) would love to treat all hematologic malignancies the same and establish one fixed rate for transplant, but that's simply not possible," Dr. Gajewski said. "If a patient is undergoing an autologous transplant, immunosuppression is not required and there is less risk for infection. Resource use in this setting, then, is different than for matched sibling allogeneic transplant, which is different from resource use for a patient undergoing an unrelated donor transplant. The list goes on." Dr. Gajewski gained experience with bundled payments at the University of Texas MD Anderson Cancer Center, where he was involved in writing contracts for bundled payments with a now-defunct payer. At the time, they established that management of any comorbidities a patient presented to transplant with would be excluded from the bundled payment. "We thought this was a great idea, but the practical application was much different," he said. "For example, some of the drugs used in transplant patients can cause hypertension, like cyclosporine. Well, if the patient already had hypertension, was it made worse because of cyclosporine or should it be considered a primary disease? If the patient's serum creatinine goes up because I am giving cyclosporine, but the patient also already had hypertension, how do we bill that? How do we pull out individual labs to identify as not being part of the bundled payment when there have been 20 to 30 labs performed each day for four straight days?" Widespread use of these bundled payment models could also create access issues for patients who are sicker or less compliant with preventive health care, or the "tail end" of the bell curve, Dr. Gajewski noted. Not every provider takes care of patients representing the full bell-shaped curve, he added. "When this model was introduced, we brought up the issue of patients who might require adjuvant chemotherapy," Dr. Gajewski said.

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