Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
NATIONAL  MARROW  DONOR  PROGRAM

GEOGRAPHIC  OVERLAP  AMONG  DONOR  CENTERS 
# 0EI-01-95-O0122
 OFFICE  OF  INSPECTOR  GENERAL 
The mission  of the Office of Inspector General (OIG), as mandated by Public Law 95-452,  is to 
protect the integrity of the Department of Health and Human Services programs  as well as the 
health and welfare of beneficiaries  served by them.  This statutory mission is carried out through  a 
nationwide program  of audits,  investigations,  evaluations,  sanctions,  and fraud alerts.  The 
Inspector  General informs the Secretary of program  and management problems  and recommends 
legislative,  regulatory,  and operational approaches to correct them. 
OFFICE  OF  EVALUATION  AND  INSPECTIONS 
The OIGS Office of Evaluation  and Inspections (OEI) conducts short-term  management  and

program  evaluations  (called inspections) that focus on issues of concern to the Department,  the

Congress,  and the public.  The inspection reports provide findings and recommendations  on the

efficiency,  vulnerability,  and effectiveness of departmental programs.

OEIS Boston Regional Office prepared this report under the direction of Mark R. Yessian,  Ph. D.,

Regional Inspector  General.  Principal OEI staff included:

Boston Region  Headquarters

Russell W. Hereford,  Ph. D.,  Project Leader  Alan Levine, Program Specialist

Elizabeth Robboy,  Program Analyst

To obtain a copy of this report,  contact the Boston Regional Office by telephone at

(617) 565-1050 or by fax at (617) 565-3751.
 Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
NATIONAL  MARROW  DONOR  PROGRAM

GEOGRAPHIC  OVERLAP  AMONG  DONOR  CENTERS 
# OEI-01-95-00122
 EXECUTIVE  SUMMARY

PURPOSE 
To provide  a preliminary  assessment  of the extent of overlap  among donor centers 
participating  in the National  Marrow  Donor Program. 
BACKGROUND 
Bone marrow  transplantation  is a treatment  for blood borne diseases  such as leukemia  and 
Iymphoma.  For  a transplant  to be successful,  the patients  and donors  blood cell 
proteins,  or human  leukocyte  antigens  (HLA), must match as closely  as possible. 
The National  Marrow  Donor Program  (NMDP) is a nonprofit  organization  based  in 
Minneapolis,  Minnesota  that finds matching  donors for patients  seeking a transplant.  The 
NMDPoperates  the congressionally  authorized  marrow  donor registry  under  contract  with 
the Health  Resources  and Services  Administration  (HRSA).  The NMDPaccredits  donor 
centers  that recruit  volunteers  to join  the registry,  which contains  almost  1.5 million 
potential  donors  in 97 domestic  donor centers. 
Staff at HRSAasked us to assess the extent to which donor center  service areas  overlap. 
This report  responds  to that request. 
This report  is based  on 88 responses  to a mail survey  of the domestic  centers;  analysis  of 
service  area  information  provided  in the NMDPSDonor  Center Access  Directory  and U.S. 
census data;  and site visits to nine donors centers  across the country. 
FINDINGS 
Fifty-seven  of the  88 donor  centers  responding  to our  survey  report  that  more than 
one donor center  operates  in their  area. 
Forty-eight  of these 57 centers  say that their geographic  service  areas overlap. 
Forty-three  centers  say that their target populations  overlap. 
Our  population-based  analysis  of all donor  centers  descriptions  of their  service  areas 
reveals  even  greater  geographic  overlap  than  donor  centers  reported  in responses  to 
our survey. 
The service  areas of 24 of 96 donor centers  are covered  in full by at least 
1 other center. 
For 54 donor centers,  more than half of their population  live in an area served by 
at least one other center. 
i  The extent  of service  area overlap  appears to have little,  if any, impact on donor 
centers  performance  as measured  by: 
Rate of growth  in donor  list. 
Cost per new donor  on the list. 
Donor  retention  at fwst stage followup  (DR)testing. 
Donor  retention  at second stage followup  (CT) testing. 
CONCLUSION 
Our report  identifies  a substantial  degree  of overlap  among donor centers.  However,  our 
analysis  does not reveal  any negative  impact on center  performance  arising from that 
overlap.  To be sure,  there  appears  to be some competition  between  donor centers  serving 
the same area.  Such competition,  however,  may be beneficial. 
On the other  hand,  some of our respondents  raised concerns  about inefficiencies  and 
COnfUSiOIIIIX.dthg  frOIII OVdZtp.  The NMDP, WOdChIjjWith HRSA, k  100kkg at options 
for restructuring  the contlguration  of the donor center  network,  including consolidation  of 
donor  centers  at the local level as one way of reducing  overhead  costs.  The substantial 
degree  of geographic  overlap  that we found among donor centers  indicates that such a 
restructuring  could be accomplished  without disrupting  the geographic  service  areas that 
are currently  covered  in most regions  of the country. 
COMMENTS  ON THE DRAFI REPORT 
We received  comments  from HRSA and the NMDP.  They offer the general  comment  that 
this report  oversimplifies  a complicated  issue.  We agree that this is a complex  issue, but 
we also note this report  is intended  only as a first look at the issue of overlap.  Our 
analysis  is based  on county-level  depictions  of each donor centers  semice  area,  as 
provided  by NMDP. By any definition,  the county is a broad unit of amlysis.  We agree 
that,  should HRSA and NMDPproceed  to consider  these issues in their evaluation  of the 
donor  center  network,  a more precise  targeting  of each centers  true service  area would be 
needed. 
ii  TABLE  OF  CONTENTS

EXECUTIVE  SUMMARY 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..1

FINDINGS

 
Multiple  centersinsarne  area  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

.  Population-based  analysis  shows even greater  overlap  . . . . . . . . . . . . . . . . . .  3

 
Impact ofservice  area overlap  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4

CONCLUSIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...8

CONfMENTS  ON THE  D~REPORT  . . . . . . . . . . . . . . . . . . . . . . . ...9

APPENDICES

A:  Extent ofservice  area overlap  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  A-1

B:  Methodology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. B-l

C:  Textofcomments  onthe  draft report  . . . . . . . . . . . . . . . . . . . . . . . . . .. C-l 
D:  Endnotes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  D-l  INTRODUCTION

PURPOSE: 
To provide  a preliminary  assessment  of the extent of overlap  among donor centers

participating  in the National  Marrow  Donor Program.

BACKGROUND:

Bone  Marrow  Transplantation

Bone marrow  transplantation  is a treatment  for blood borne diseases  such as Ieukemias

and lymphomas.  About  16,000 people are diagnosed  each year with leukemia  and other

fatal blood  diseases. 1  Many of these people could benefit  from a bone marrow

transplant,  a procedure  in which the patients  diseased bone marrow  is destroyed  and

marrow  from  a healthy  donor  is infused into the patients  blood stream.  Bone marrow

produces  platelets,  red blood cells,  and white blood cells,  the agents of the bodys immune

system.  For  a bone marrow  transplant  to be successful,  the patients  and donors  antigens

must match  as closely as possible.  About thirty percent  of the time the patient  has a

sibling with matching  antigens.  In the other  seventy percent  of cases the patient  must seek

an unrelated  donor.

Three  pairs  of blood  cell proteins,  known as the Human  Leukocyte  Antigen  (HLA)-A,

-B and -DR, are important  in deterrnining whether  a match will be successful.  One antigen

in each pair  is inherited  from an individuals  mother,  the other from the father.  Because

there  are numerous  antigens  at each HLA-A, -B, -DR locus,  more than 600 million

combinations  are theoretically  possible.2

The  National  Marrow  Donor  program

The National  Marrow  Donor  Program  (NMDP)is a nonprofit  organization  based  in

Minneapolis,  Minnesota.  The NMDP operates  the Congressionally  authorized  marrow

donor  registry  under  contract  with the Health Resources  and Services Administration

(HRSA). The contract  is funded at $40,471,000,  from July  1994 through  April  1997.

The NMDPbegan  operations  in September  1987 as a non-profit  organization  funded

through  a contract  from  Office of Naval Research.  The NMDPwas created  through  a

cooperative  effort  of the American  Association  of Blood Banks, American  Red Cross,  and

Council  of Community  Blood Centers.  The NMDP began search operations  with  10

transplant  centers,  49 donor centers  and 8,000 donors  listed on the registry.  As bone

marrow  transplantation  came to be seen as viable technique,  the U.S.  Navy recognized

that it was inappropriate  for the military  to maintain  a civilian  registry.  In  1989,

responsibility  for the contract  was transferred  to the National  Heart,  Lung,  and Blood

Institute  in the National  Institutes  of Health.  Contract  oversight  for the NMDPwas again

1
 transferred  in 1994 to HRSAin recognition  that NMDPwas a service delivery  program, 
rather  than a basic research  initiative. 
The NMDPaccredits  donor centers  that recruit  volunteers  to join  the registry.  As of 
October  1995, the registry  contained  almost  1.5 million  donors in 97 domestic  donor 
centers,  and an additioml  450,000  donors from 6 foreign centers.  Eighty-one  of the 
domestic  centers  are blood centers,  either  Red Cross-affiliated  or part of community  blood 
centers;  13 centers  are departments  of hospitals,  and 3 are free standing centers.  Six of 
the domestic  centers  have more than 50,000  donors on their list; another  35 centers  have 
between  10,000  and 50,000  donors each.  The remaining  56 centers  have fewer than 
10,000 donors. 
In some areas  of the country  several donor centers  cover  similar territory.  Staff at HRSA 
asked us to assess the extent  of overlaps  in these service areas.  This report  responds  to 
that request. 
SCOPE  and METHODOLOGY 
This report  addresses  the domestic  donor centers  only.  The report  is one of four 
companion  reports  addressing  the Natioml  Marrow  Donor Program.  The other three 
reports  are:  National  Marrow Donor  Program:  Progress in Minority  Recruitment  (OEI-
01-95-00120);  National  Marrow  Donor Program:  Effectiveness  in Retaining  Donors  (OEI-
01-95-00121);  and National  Marrow Donor  Program:  Financing Donor  Centers (OEI-Ol-
95-00123). 
This report  is based  on four primary  data sources: 
1)  A mail  survey  of the 97 domestic  donor centers.  We received  88 responses,  a 
response  rate  of 91 percent. 
2) 1990 U.S.  Census  Data at a county  level. 
3)  The NMDPSDonor  Center  Access Directory,  in which each donor center  displays  a 
map of the geographic  area that it covers. 
4)	 Site visits to donors  centers  in California,  Massachusetts,  Minnesota,  New Jersey, 
North  Carolim,  and South Carolina. 
Appendix  B provides  a more detailed  description  of our methodology. 
We conducted  this study in accordance  with the QualiQ Standards for  Inspections  issued 
by the Presidents  Council  on Integrity  and Efficiency. 
2
 FINDINGS

FIFTY-SEVEN (65 PERCENT)OF THE 88 DONORCENTERS RESPONDING TO OUR SURVEY 
REPORTTHATMORETHANONEDONORCENTEROPERATESIN THEIRAREA. 
	 Forty-eight  (84 percent)  of these  57 centers  say that their geographic  service 
areas overlap. 
  Fozty-three  (75 percent)  say that their target populations  overlap. 
In their  responses  to our survey: 
Twelve  donor centers  indicated  that four other centers  operate  in their area.  Three 
F	
of these centers  are affiliated  with the American  Red Cross,  five with independent 
blood banks,  two are hospital based programs,  and two are free-standing  centers-
one private  and one the U.S.  Navys Bill Young Marrow  Donor  Center.  Two of 
these donor  centers  characterized  their relationship  as competitive  with two of the 
four other centers  operating  in their  area,  and two centers  said it was competitive 
with one other center. 
E	 Twelve  centers  said that three  other donor centers  operate  in their area.  Three  are 
afilliated  with the Red Cross,  five with blood banks,  three  are hospital-based,  and 
one is free standing.  Two of these centers  said that their relationship  was 
competitive  with all three;  two said it was competitive  with two of the centers,  and 
three  said it was competitive  with one center. 
	 Fourteen  centers  reported  that two other centers  operate  in their area.  Four centers 
said relationship  was competitive  with both,  and five said it was competitive  with 
one. 
	 Nineteen  centers  reported  that one other center  operates  in their  service  area. 
Seven centers  said the relationship  was competitive. 
OUR  POPULATION-BASED ANALYSIS OF ALL DONOR CENTERS DESCRIPTIONS OF THEIR 
SERVICE AREAS REVEALS EVEN GREATER GEOGRAPHIC OVERLAP THAN DONOR 
CENTERS REPORTED IN RESPONSES TO OUR SURVEY. 
	 The service  areas of 24 of 96 donor centers are covered  in full  by at least one 
other center. 
	 For 54 donor  centers,  more than half of their population  lives in an area served 
by at least one other center. 
3
 We matched  county-level  census data from  1990 with donor centers  self-defined  service 
areas.  This provides  an objective  measure  of the  Service Area Overlap,  which we 
define  as: 
The percentage  of the population  in a donor centers service  area that is also 
served  by at least one other center. 
An overlapping  service  area does not mean that the service  areas of two centers  are 
identical.  Rather,  it means that a particular  donor center  might overlap  in one part  of is 
service  area with one center,  in another part of its area with a second center,  and perhaps 
in another  part  of its service area with yet a third center. 
Appendix  A provides  a center-by-center  breakdown  of the extent of service area overlap. 
Service  area overlap  is most extensive  in a few States: 
  California,  where  8 of 11 centers  overlap  100 percent,  and 1 center  overlaps  more 
than 90 percent; 
  Texas,	 where 4 of 9 donor centers  overlap  100 percent,  and 1 more  overlaps  more 
than 90 percent; 
Maryland/Washington  D. C.,  where 2 of 4 donor centers  overlap  100 percent,  and 
F 
2 others  overlap  more than 90 percent; 
  New England,  where  all 4 donor centers  serving the 6 states (Connecticut,  Maine, 
Massachusetts,  New Hampshire,  Rhode Island,  Vermont)  overlap  100 
percent; 
  Idaho,	 where  2 donor centers  based there  and others from Utah and Washington 
lead to 100 percent  overlap  for the Idaho centers. 
Illinois,  where  two of four donor centers  have  100 percent  overlap,  and another 
b 
two more have greater  than 75 percent  overlap. 
~  EXTENT  OF SERVICE AREA OVERLAP APPEARS TO HAVE LITTLE,  IF ANY,  IMPAC1 
ON CENTERS  DONOR RECRUITMENT OR DONOR RETENTION PERFORMANCE. 
We examined  four effectiveness  measures  to make an assessment  of the impact  associated 
with geographic  overlap.  Two effectiveness  measures  relate to recruitment  of new 
donors,  and two measures  address donor retention.  We grouped centers  into 6 categories, 
defined  by the extent  of geographic  overlap.  We created  groups comprised  of the centers 
at either  extreme--100  percent  overlap  and no overlap.  We then assigned the other centers 
to quartiles  based on the degree  of overlap. 
4
 Recruitment  Effectiveness  Measures: 
Rate of growth in donor list.  If competition  among donor centers  operating  in the same 
area were  a concern,  it would manifest  itself in donor recruitment.  Between October  1, 
1994 and September  30,  1995, the domestic  registry3 grew from  1,069,144  to  1,340,941 
donors.  As Table  1 shows, the increases  within each group of centers  cluster  around the 
overall  mean of 25 percent.  The smallest  increase--2O percent--occurred  among  centers 
with overlap  between  75 and 99.9 percent.  At the extremes,  those centers  with no 
overlapping  service  areas had a 27 percent  growth,  while those whose service  areas 
overlapped  completely  averaged  28 percent  growth. 
10Q%  13  10  28%  $52.28 
[4-50%]  [$20.38-$226.08] 
75%-99.9%  9  4  20%  $75.06 
[8-64%]  [21.73-$164.93] 
50%-74.9%  11  5  29%  $44.12 
[7-78%]  [$22.48-$87.98] 
25%-49.9%  12  4  29%  $50.75 
[1349%]  [$22.68-$73.83] 
0.1%-24.9%  11  I  9  I  23%  I  $55.53 
[0-40%]  [$19.69-$134.05] 
o%  4  1  27%  $39.59 
[10-71%]  [31.78-$63.45] 
All Centers  60  33  25%  $54.41 
Excludes U.S. Navys Bill Young Marrow Donor Center because of that centers unique focus on military personnel worldwide; 
also excludes 1 contract center that was extreme outlier in mean cost per new donor. 
List size: n=  1,340,941 (September 30, 1995) 
n=  1,069,144 (September 30, 1994) 
cost per new donor calculated fmm May 1, 1994 through April 30, 1995 
Data source:  NMDP Registry Statistics, October 1995 and October 1994  Analysis:  OIG/OEI 
Cost per new donor.  We present  the mean cost per new donor added to the list for the 
year ending  April  30,  1995, to provide  a preliminary  assessment of the cost impact  of 
service  area  overlap.  As Table  1 shows, five of the groups are quite close in the mean 
cost per  donor,  between  $39 and $56.  One group,  however--those  with overlap  between 
75 and 99 percent--show  higher  mean costs.  These cost data should be treated  with some 
caution.  In our companion  report,  National  Marrow Donor  Program:  Financing  Donor 
Centers  (OEI-01-95-00123),  we find that centers paid on contract  receive  higher  payments 
5
 from the NMDPthan do those paid on a fee-for-service  basis.  The current  amlysis  does 
not factor  in this important  difference  payment  mechanism;  table  1, however,  does present 
data on the number  of centers  paid under  each mechanism. 
Retention  Effectiveness  Measures:  The NMDP identifies  four reasons that an individual 
may not come forward  for further testing at either fiist  level  followup  testing (DR) or 
second level followup  testing  (CT):  unable to contact  donor,  donor not interested,  donor 
medically  deferred,  donor  temporarily  unavailable.  Our companion  report,  National 
Marrow  Donor  Program:  Effectiveness  in Retaining  Donors  (OEI-01-95-00121),  provides 
an assessment  of the overall  effectiveness  of the program  in retaining  donors  at both the 
DR and CT stages. 
Retention  at DR testing.  Donor centers  received  over  17,000 requests  for DR testing  in 
the 6-month  period  between  April  1 and September  30,  1995, of which they filled  12,503 
(72 percent).  The lowest DR retention  rates--63  percent--occurred  in those centers  where 
there  is no service  area overlap,  and the highest rate--78  percent--in  the centers  with less 
than 25 percent  overlap. 
Retention  at  CT testing.  Donor centers  received  over 4,500  requests  for CT testing  in the 
six-month period between April  1 and September 30, 1995, of w-hich they filled  3,422 
(76 percent).  The CT retention rates within each group of centers cluster closely  around 
that mean, ranging from 71 to 80 percent. 
Table 2

Service Area Overlap and Donor Retention

Extent  of Service  Area Overlap  Number  of  Mean Retention  at DR Testing  Mean Retention  atCT Testing 
Centers  @ange]  ~ge] 
100 %  23  72 %  74 % 
[49-100%]  [43-100%] 
I I  I 
75 % -99.9  %  13  65 % 71 % 
[53-100%]  [54-100%] 
50 % -74.9  %  18  75 %  78 % 
[61-98%]  [54-100%] 
25 % -49.9  %  16  75 %  80 % 
[61-100%]  [68-100%] 
0.1  % - 24.9%  20  78%  78% 
[58-9%3]  [67-100%] 
o%  6  63 %  78 % 
[47-85 %]  [59-100%] 
All Centers  96  72 %  76 % 
Excludes U.S. Navys Bill Young Marrow Donor Center because of that centers unique focus on military persomel worldwide. 
DR Requests Resolved between April 1- September 30, 1995 = 17,333

CT Requests Resolved between April 1- September 30, 1995 =  4,515

Data source:  NMDP Registry Statistics, October 1995 and October 1994  Asudysis: OIG/OEI

6
 Donor  centers  operating  in the same area frequently  collaborate  in their work.  For 
example,  51 percent  of centers  in overlapping  areas report  that they routinely  share 
information  about recruitment  drives  with other local centers,  and 38 percent  report  that 
they hold drives  in conjunction  with these other centers.  Although 70 percent  of these 
centers  report  informal  understandings  with the other donor centers,  however,  only 5 
percent  report  any written  agreements  with other donor centers  about how to focus their 
efforts. 
Importantly,  the reimbursement  system may have a significant effect on the extent to 
which donor  centers  would hold drives  together.  Sixty-two donor centers  are reimbursed 
by NMDPon a fee-for-service  basis. 4  These centers  receive  a fued  amount  for each 
donor they recruit  ($10 for each Caucasian,  $28 for each person  from a racial  or ethnic 
minority).  Because these recruitment  fees are the fimncial  base of any fee-for-service 
donor center,  the incentive  to be the sole sponsor of a drive is very strong. 
In our survey  and site visits,  some donor center  staff did identify potential  inefficiencies 
and confusion  that can arise from multiple  donor centers  in the same area.  Donor  centers 
raised  two types of concerns  that can arise from multiple  donor centers  in the same 
geographic  area:  duplication  of costs and confusion  among donors.  The director  of one 
donor center  captured  this concern  when she told us,  A hospital here has a marrow  donor 
center,  but it is also our chief customer  for whole blood.  We serve identical  patient 
populations--we  even have a blood center  facility inside that hospital.  Having  two donor 
centers  that  service  the same patients  is an expensive  duplication  of effort  and creates 
extensive  confusion  in the community.  
Concerns  about duplication  were most evident  where a new center  has been established  in 
an area  served  by an existing  center.  At several donor centers  we saw evidence  of 
possessiveness  (e. g.,  comments  about our donors).  The comments  from the director  of 
one donor  center  is illustrative  of how strongly these feelings run.  The NMDPrecently 
approved  a new program  where  we already  have a satellite office.  The new one is very 
small--less  than  1,000 donors.  So that center  thinks that we should hand them all our 
donors  in that area--not just  new ones,  but those that we already  recruited.  
7
 CONCLUSIONS

Our report  identifies  a substantial  degree  of overlap  among donor centers.  Responses  to 
our survey  of donor  centers,  as well as our separate population-based  analysis,  reveal 
geographic  overlap;  our survey responses  also show that donor center  directors  believe 
that their  target  populations  overlap. 
However,  our analysis  does not reveal  any negative  impact on center  performance  arising 
from that overlap.  To be sure,  there appears to be some competition  between  donor 
centers  serving  the same area.  Competition  in itself may be beneficial,  as it may spur 
donor  centers  to work even more diligently  to expand their lists.  In addition,  in many 
overlapping  areas,  we found donor center  staff who reported  a generally  cooperative 
attitude  toward  their colleagues,  and they frequently  share information  about recruitment 
activities. 
On the other hand, some of our respondents raised concerns about potential inefficiencies 
and confusion  resulting from overlap.  Certainly,  where two or more donor centers serve 
the same area or target the same population,  the potential exists for duplication of services 
and subsequent duplication of costs.  These costs could include administrative overhead 
expenses,  persomel  costs, and recruitment expenses, such as publicity,  travel,  and on-site 
expenses of conducting drives. 
We do not make  any recommendations  regarding  the optimal confQuration  of the donor 
center  network.  We understand  that the NMDP,working  with HRSA,is looking  at options 
for changing  the structure  of that network.  The substantial  degree  of geographic  overlap 
that our analysis  found among donor centers  indicates that restructuring  could well be 
accomplished  without disrupting  the geographic  service  areas that currently  are covered  in 
most regions  of the country. 
8  COMMENTS  ON  THE  DRAFT  REPORT 
We sought comments  on the draft report  from the Health Resources  and Services

Admini&ation  (HRSA),the Assistant  Secretary  for Planning  and Evaluation  (ASPE),and

the Assistant  Secretary  for Health  (ASH). In addition,  HRSArequested  comments  on the

report  from the National  Marrow  Donor Program.

HRSAand NMDPoffer the general  comment  that this report,  which did not contain

recommendations  for action,  oversimplifies  a complicated  issue.  We agree that this is a

complex  issue,  but we also note that this report  is intended only as a first look at the issue

of overlapping  service  areas.

HRSAand NMDPcite concerns  that the term  service  area overlap  was not well-defined.

We based this term  on county-level  depictions  of each donor centers  service  area,  as

provided  by NMDP. We recognize  that this is broad unit of analysis by any definition.

Should HRSAand NMDPproceed  to consider  these issues in their evaluation  of the network

configuration,  a much more precise  targeting  of each centers  true service  area would be

worthwhile.  This targeting  could be based,  for example,  on ZIP codes of donors on the

list of each center.  That information  was not available  to us for this analysis.

NMDPalso states that the fact that some counties are served by more than one donor

center  is ignored  in reaching  conclusions  about the percentage  of population  served.  Our

report  nowhere  makes  a statement  about the percentage  of population  served,  but our

analysis  directly  addresses  the issues of counties  in which more than one donor center

operates.

The ASPEand ASHresponded  that they had no comments  on this report.

9
 APPENDIX  A

EXTENT OF SERVICE AREA OVERLAP

The
following  table presents  the service  area overlap  for each donor center. 
The acronym  ARC stands for American  Red Cross. 
~eci~provided  istieheadquafiers  office ofeach  donor center.  Some centers  have 
additional  satellite  offices  in other cities. 
The Service  Area  Population  was obtained using county-level  U.S.  Census data from 
1990, combined  with the service  area defined by each donor center  in the NMDPSDonor 
Center Access  Directo~,  published  in October,  1995. 
The number  of donors  on each centers  list was obtained  from the NMDPSMonthly 
Registry  Statistics  for October,  1995. 
Donorson 
lCenter  I  I I  ] ServieeAreal Percentl  Centers List  I 
Number Center  City  State  Population Overlap  (October, 1995) 
1 ARC St. Paul  St. Paul  MN  5,105,798  11%  18,716 
2 ARC Los Angeles  Los Angeles  CA  12,529,506  98%  79,823 
3 ARC South Carolina  Columbia  Sc  3,486,703  33%  11.737 
I  I  ! 
41Stanford University Blood  \Palo Alto  CA  2,147,2WI  100%  8,524 
Bank 
5 Sacramento Medical  Sacramento  CA  4,709,359  100%  22,496 
Foundation 
6 Blood Bank of San  San Bernardino  CA  2,588,793  100%  9,566 
Bemzwdino 
7 San Diego Blood Bank  San Diego  CA  3,777,732  31%  24,060 
8 Irwin Memorial Blood  San Francisco  CA  1,618,549  100%  9,031 
Center 
9 ARC Northern California  San Jose  CA  2,119,668  100%  14,330 
10 ARC Connecticut  Farmington  CT  12,326,600  100%  48.748 
11 Civitan Blood Center  Gainesville  FL  554,759  58%  2,428 
12 Fox-Ft. Lauderdale Labs  Lauderhill  FL  4,469,237  100%  15,296 
13 ARC South Florida  Miami  FL  3,270,606  100%  16.109 
14 Florida Blood Services  St. Petersburg  FL  2,480,192  11%  13,351 
15 ARC Atlanta  Atlanta  GA  10,518,803  52%  28,045 
16 ARC Heart of Illinois  Peoria  IL  3,946,270  61%  3.979 
1  I 
17 ARC Fort Wayne  Fort Wayne  IN  2,628,1811  88%  4,916 
A-1
 18 Central Indiana Blood  Indianapolis  IN  5,544,159  42%  16,043 
Center 
19 Poudre Valley Hospital  Fort Collins  co  798,030  94%  2,554 
22 Memorial Blood Center  Mimeapolis  MN  1,676,784  19%  4,248 
23 Johns Hopkins MedicaJ  Baltimore  MD  4,270,760  92%  4,755 
Center 
24 ARC Central Maryland  Baltimore  MD  3,260,823  97%  9,583 
25 NIH Marrow Donor  Rockville  MD  4,125,640  100%  35,979 
Center 
26 Dana Farber Cancer  Boston  MA  8,353,605  100%  11,180 
Institute 
28 ARC Southeastern  Detroit  MI  4,341,223  0%  21,706 
Michigan 
29 Grand Valley Blood  Grand Rapids  MI  1,981,642  55%  13,963 
Program 
30 ARC Great Lakes Region  Lansing  MI  3,651,886  30%  28,384 
31 Oklahoma Blood Institute  OklahomaCity  OK  1,383,650  77%  3,265 
32 University of Iowa  Iowa City  IA  3,233,026  58%  8,774 
Hospitals 
33 ARC Midwest Region  Omaha  NE  1,991,505  26%  7,868 
34 ARC Greater Upstate New Albany  NY  1,942,024  11%  7,552 
York 
35 ARC Rochester  Rochester  NY  1,729,762  2%  7,516 
36 ARC Syracuse  Syracuse  NY  1,563,868  0%  4,480 
37 ARC Carolinas Region  Charlotte  NC  6,894,642  19%  62,780 
38 Hoxworth Blood Center  Cincinnati  OH  1,680,402  36%  5,259 
39 ARC Northern Ohio  Cleveland  OH  4,706,151  24%  16,221 
40 ARC Central Ohio  Columbus  OH  3,074,462  22%  9,588 
41 ARC Northwest Ohio  Toledo  OH  1,060,170  o%  2,076 
42 ARC Oklahoma Region  Tulsa  OK  2,770,330  38%  5,340 
43 ARC Pacific Northwest  Portland  OR  3,937,645  11%  14,719 
44 ARC Johnstown  Johnstown  PA  3,410,233  56%  3,885 
45 ARC Penn-Jersey Region  Philadelphia  PA  10,110,990  100%  17,544 
46 Wadley Cancer Center  Dallas  TX  2,561,371  100%  23,623 
48 ARC Mid-Atlantic  Norfolk  VA  3,349,752  23%  9,119 
49 Spokane-InlandEmpire  Spokane  WA  1,474,738  37%  5,727 
Blood Bank 
50 ARC Badger Region  Madison  WI  3,631,770  31%  11,664 
51 ARC Washington DC  Washington  DC  3,917,108  100%  10,098 
52 Saginaw Valley Blood  Saginaw  MI  1,981,642  55%  3,560 
Program 
53 Life BIood  Memphis  TN  8,485,325  64%  14,895 
54 Hawaii Marrow Donor  Honolulu  HI  1,108,229  o%  12,617 
Registry 
55 Jacksonville Donor  Jacksonville  FL  1,020,450  12%  2,674 
Registry 
A-2  1  56 Central Kentucky Blood  Lexington  KY  1,896,480  33%  7,271 
Center 
I  57/United Blood Services  /Scottsdale  AZ  2,742,989  12%  15,105 
581Colorado Marrow Donor  Denver  co  3,747,982  23%  34,325 
Program 
591University Medical Center  Tucson  AZ  1,092,2321  24%1  3,216 
[- ~/New  York Blood Center  lNew York  NY I  18,765,8691  39%1  65,982] 
62 United Blood Services  Albuquerque  NM /  1,362,241  9%  4,630 
63 LlfeSource  Glenview  IL  ~  7,039,960  84%  21,355 
64 Central Florida Blood  Orlando  FL  2,862,030  51%  5,224 
Bank  1 
66 Alameda-ContraCosta  Oakland  CA  I  2,082,914  100%  12,279 
MedicalAssociation 
r 
67I City of Hope National  Duarte CA  I  14,901,137  100%  23,512 
Medical Center 
68 Peninsuia Blood Bank  Burlingame  CA  649,623  100%  3,976 
70 Heart of America Registry  Kansas City  MO  38,476,844  65%  88,909 
74 HLA Registry Foundation  River Edge  NJ  29,964,435  95%  109,099 
75 Methodist Hospital  Houston  TX  5,030,783  100%  4,623 
76 Community Blood Center  Dayton  OH  1,573,020  28%  7,007 
78 Virginia Blood Services  Richmond  VA I  i ,763,405/  54%/  9,046/ 
I  79 St. AlphonsusRegional  Boise  ID  I  841,200  100%  1,593
MedicalCenter
PA  4,022,386  43%  6,308 
81 Puget Sound Blood Center  Seattle  WA  4,218,015  9%  27,593 
WI I  1,735,364  0%  22,643 
~ 
I  831 IntermountainMarrow  Salt Lake City  UT  1,912,791  9%  3,572 
Donor
I  851University of Louisville  ]Louisville  KY  2,098,501  17%  7,555 
1  86 Stewart Regional Blood  Tyler  TX  895,293  100%  5,040 
Center 
87 Bill Young Donor Center  Bethesda  MD  not applicable  83,873 
88 Assoc. of Independent  West PaIm  FL  4,858,161  89%  990 
Blood Centers  Beach 
89 Mountain States Marrow  Boise  ID  1,053,517  100%  3,011 
Donor Center 
I  1 I 
90 Rhode Island Blood Center Providence  RI  1,003,4641  100%1  11,778 
1  91 GuJf Coast Regional Blood Houston  TX  I  4,504,753  100%  17,151 
Center 
92 United Blood Services  Las Vegas  NV  2,419,238  63%  2,518 
93 Mississippi Marrow Donor Jackson  MS  2,919,679  42%  5,764 
Program 
I  I I 
94 Baylor Research Institute  Dallas  TX  6,201,3331  92%[  8,262 
97 Community Blood Center  Appleton  WI I  280,830  49.966  1,066 
%, 
A-3
 98]Leon County Blood Bank  ]Tallahassee  FL  1,272,857]  51%1  1,451[ 
99 Northern Illinois Blood  Rockford  IL  655,706  100%  1,637 
Bank 
100 North Jersey Blood Center  East Orange  NJ  6,217,506  100%  7,819 
101 Cook-Ft. Worth Childrens Fort Worth  TX  3,877,589  56%  20,137 
Medical Center 
102 South Texas Regional  San Antonio  TX  3,193,622  5%  19,091 
Blood Bank 
103 United Blood Services  Chicago  IL  5,621,485  100!%  8,492 
105 Champaign County Blood  Urbana  IL  1,446,262  77%  1,634 
Bank 
108 Central Texas Regional  Austin  TX  874,238  21%  4,122 
Blood 
109 ARC Puerto Rico  San Juan  PR  3,522,037  o%  1,460 
111 ARC AppalachianRegional Roanoke  VA  3,336,493  54%  1,191 
Blood Service 
112 Cooperative Appalachian  Johnson City  TN  1,624,276  80%  918 
Marrow Program 
115 Blood Assurance, Inc  Chattanooga  TN  625,787  48%  1,130 
116 Scott & White Clinic  Temple  Tx  832,775  63%  2,004 
118 ARC Blood Services  Savannah  GA  2,924,744  86%  1,568 
Southeast 
A-4
 APPENDIX  B

METHODOLOGY

Determination  of Service  Area Overlap 
Redetermined  each donor centers  service  area by using the NMDPsDonor  Center 
Access  Directory,  published  in October  1995.  In that directory,  each donor center 
provided  amapdelfieating  its service  area. 
We used  1990 U.S.  Census DaWthe  most recent  available,  atthe  county level.  We 
matched  these data with the counties  that each center  described  as its service  area. 
If two or more  centers  covered  a particular  county,  we defined the service areas  as 
overlapping. 
We calculated  the percentage  of service  area overlap  as a ratio: 
.  The denominator  is the entire population  in each donor centers  service  area. 
(cid:1) The numerator  is the population  in that donor centers  service  area that reside  in 
counties  served by one or more  other donor centers. 
We excluded  the Bill Young Marrow  Donor Center  from this amlysis  because  it is part  of 
the U.S.  Navy.  This center  has a unique  focus on recruitment  of U.S.  Military  Personnel 
worldwide.  Consequently,  we consider  issues related  to overlap  and donor recruitment  to 
be substantially  different  from the other centers  in the program. 
Mail  Survey 
In July  1995 we mailed  a survey to each of the 98 donor centers  then in operation.  We 
received  responses  from  89, a 91 percent  response  rate.  Because one of those centers  has 
since merged  with another  center,  we chose to omit the responses  of that center  from  our 
analysis.  In this report,  we draw on the questions described  on the following  page. 
B-1
 :::::::::::::.:.:.:.:.:.:.:.::...:::..::...::....:.:......:.:....... .:......:......:.......:...... . ............
Are there  other  NMDP  accredited  donor centers  operating  in the  56  32 
same area  that you serve? 
(Zf you  answered  yes, please  answer the rest of the questions  (64%)  (36%) 
on this page;  if you  answered  no please  go to the next page.) 
Do you feel that your donor centers  geographic  service area  47  8

overlaps  with that of another  donor center(s)?  (85%)  (15%)

Do you feel that the populations  your center  targets  for donor  43

recruitment  overlap  with those targeted  by another donor  (78%)

center(s)?

Does your center  routinely  share information  about recruitment  28  27

drives  with other centers?  (51%)  (49%)

Does your center  hold recruitment  drives  in conjunction  with  21  35

other donor  centers  in your area?  (38%)  (63 %)

Does your center  have informal  understandings  with other donor  39

centers  about how each center  focus its efforts?  (70%)  ::0%)

Does your center  have written  agreements  with other donor  3  53

centers  about how each center  focus its efforts?  (5%)  (95 %)

Cooperative  Neutral  Competitive 
5  4  3 2 1 
Donor  Center  1  22  4  10  4  17 
Donor  Center  2  19  3  4  3  8 
Donor  Center  3  12  3  4  1  3 
Donor  Center  4  4  3  2  1  2 
We also draw  on open ended responses  to the survey and on discussions  and observations 
made during  our site visits for qualitative  interpretation  of the data 
B-2
 APPENDIX  C

TEXT OF COMMENTS  ON THE DRAFT REPORT

Health Resources  and Services Administration  . . . . . . . . . . . . . . . . . . . . . . . .C-2 
National Marrow Donor Program..  . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..CA 
Note:  The Health  Resources  and Services  Administration  and the Natioml  Marrow  Donor 
Program  provided  combined  comments  on four draft reports  that examined  the National 
Marrow  Donor  Program.  This appendix  includes only those portions  of their  comments 
that are relevant  to the report  entitled  National Marrow  Donor Program:  Geographic 
Overlap  Among  Donor  Centers.  
c-1  # 
A+ &,,,1  m,  4 
Public kleekh Service 
DEPARTMENT  OF HEAL1= & HUMAN SERVICES 
g 
: 
~i \%m;~ 
Health Resources and 
OCT  ~ 3  Pgt  Services Administration 
Rockville  MD  20857 
TO:
 Inspector  General,  DHHS 
FROM:  Deputy  Administrator 
SUBJECT  :  office  of  Inspector  General  (OIG)  Draft  Repo-rtsf 
IiNational  Marrow  Donor Program  (NMDP) : 
1) Financing  Donor  Centers OEI-01-95-00123

2) Progress  in Minority  Recruitment  OEI-01-95-00120  

3) Geographic  Overlap Among  Donor  Centers

OEI-01-95-00122

4) Effectiveness  in Retaining  Donors  0EI-01-95-00121~C  .

respontsoe
Attached  is HRSAS  your memorandum  requesting 
comments  on  the  four  subject  draft reports. 
We appreciate  the OIG conducting  the review,  Bone  Marrow  Program

inspection.    The  draft  reports  were  forwarded  to  the  NMDP  for

comment.  Their  comments  have  been  incorporated  into our

response.  HRSA and NMDP will  be performing  further  analysis  and

examination  regarding  some issues,  such as restructuring  of donor

centers,  implementation  of  performance  indicators,  and

specification  of  retention  rates,  before  specific  changes  are

made.  HRSA plans  to utilize  the findings  and recommendations

contained  in these  reports  as an integral  part  of the development

of the contract.

Questions  may  be referred  to D irdre Walsh  on x35181.  

A
Attachment

c-2  OIG Report:  Geographic  Overlap Amona  Donor  Centers

0EI-01-95-O0122

No specific recommendations.

GENERAL  COMMENTS 
the
HRSA  notes  that  conclusions  state  that  service  area overlap, 
though substantial,  appeared  to have  little,  if anyl impact on 
donor centers  performance  as measured  in  this  report.  The 
report lacks an assessment  of the relationship  between geographic 
overlap  and  cost-efficiency  of donor  center  operations. 
Geographic  overlap  does nor have to be a problem,  provided 
competition  is not counterproductive.  HRSA raised  concerns  in an 
earlier draft about  inefficiencies  and confusion  resulting  from 
geographic  overlap  among donor  centers.

A difference  of 
Bidding  for territory  needs  further  evaluation. 
opinion was expressed  regarding  the potential  effects of the 
bidding process,  particularly  because  of the concern  that the
overlapi,s 
phrase,  service  area  not well  defined  and the

oversimplificaMtoidoenl.i nogf
 donor

analysis  is an  various 
center configurations  should  take  into consideration  the

ofgeographic

complicated  issues  overlap.

c-3  September  4,  I!& 
National  MmTOW 
Donor  FrugmTI 
N~tioIM  Coomlinsting Ccnkr 
3433 Emadwuy Stxaf N.E. 
Suirc ~ 
Mhmmpdis.  MN 55411 
6 L2-627-58rx)  ,  Judith Braslow

I-tUxJ-sz&7twJ  I Director,  Division  of Organ Transplantation

FAX: 61>6274W 
Health Ilesources  and Services Administration

of Park Lawn Building 
Seard  mfwdo~ 
HcrbaK A. Pcfkim, M.D.,  (%uar  5600 ~SkfS  Lane  - Room  729 
I 
Jnndwn R bong,  P&  (%uir  Roclwiflc,  MD 20857 
clam Psdilla A*s 
Richmd H A$w. M.D. 
h~ncc  D. AtlX, J.IJ. 
kr  Ms. BraS~OW: 
Jn~h  t BdL M.D. 
80 Dupont, .M.D.,0..%. 
Ro&r  W. P.vww *D. 
Ban S. tishcr. I.D.. Ph.D.  Thank you very much for providing  the National  Marrow  Donor 
Dnvid B. Fmhnmsvcf. J.IJ.  Program@ (NMDP)  with an opportunity  to review  the draft  reports  of the 
J. Cunynn (lordon. J.D. 
Office of Imp=tor  GmemJ  (OIG), Depa~ent  of H~ti  and Human 
JohnA. lLmerL M.~. 
-e&rick J. Hams. M.S.F.&. M.B.A.  Services.  The draft reports  were sent to members  of the Minority  Affairs, 
.  MW  M. Hnmwicz M. D.. M.S.  Membership  and Process  Improvement,  Donor  Recmit.ment  and Executive 
ErnstR. J.W.  M.D. 
Nancy A. Kcmsn M.U.  Committees  as well as the NMDPs Network  EYahzationAdvisory  Panel 
sos  kitmnm  MD.  and sckmrcd members of the staff. 
{ichola* J. NaIhnusd. J.D.. k4SLM. 
R&1.  Plq?eM-U. 
Gsrlcs  A. (CAP) Pdicf  The comments received have been collati  and a synthesis of the 
J?MiDsP

rm  pcetwm,  M. P.. Ph.D.  responses is presented below.  The intent of the  not to criticize 
U. Gcn. F-k  E. Pcterm.  Jr.  rather
Kobtsl K. Ruu. M.D.  the draft reports, but  toadd information fkom a varie~  of 
E&d  P.sam. M.D.  respondents, all of whom  have been involvai with  aspects of donor center 
12avid F.StronaL MD. 
operations andlor donor recruirmenf.  As you know the NMDP is well 
J&II S. 130topsxI. MJY. 
CIWICS H. Walk.  M.D.  along in its own analysis of donor center timetions,the findings  of which 
SIewm N. WulIToM.D.  should provide fiwthcruseful recommendations. 
wmmeuc K-YaOCCYM. . D.. M. J.H-
Admiml E-R. ZurnwdL  Jr. 
Following the summaryof cmnments on each draft RPOrt we Mve  . 
f.3a@ W. S. HnWA M. D.. PtLD. 
Chkfizzmulwr  OLTW  provided  our own list of recommendations  for modification  of the OIG 
document. 
Cluirs  Rnacritan: 
IZ(imct. oruvesD..V .M.
Admiml E. R. Zumwah. Jr. 
LRgm Grows  Awwd: 
llu  HnnnrmbtUc. W. Y3il~ yUUOg 
John A. Han.=%M.~
(nswic bkML  MD. 
A cdldmrwfc  effoff  of tie 
Amcncon  Association 
tinki~ 
Amcricm)  RedCr06S 
Co.ncii  d  CO!OfIlti@ 
BlootCien@~ 
With fwdmg  (rum: 
Health Resuttes  and Scwiccs 
Admintwwwn  and 
Naval Medical  Rcwtrch  nnd 
~kymen[  Ct)mmd  Geographic  Overlap 
overlap
One respondent  feIt that continuing the geographic  of donor centers would 
make it difficult IOestablish minority recruitment goals reflective of the population 
served by the competing centers.  While possibly mahg  centers more efficient, 
competition  for a donor  could well be munterproductivc  as has already been

demonstrated  for blood  donors.

There  was  a differe~  of opinion regarding a bidding process to establish defti

NMDP  service areas.  It wls  thought to be the prefimb]e  approach by one individual,

but another  felt that it ~tid  FXXCMY  alienate donor centers and ultimately disrupt  the

program.  An alternative  suggestion was tlult of a huh and spoke model of

recruitment  and donor management.

Servicz area overlap w% not well defined in the draft report.  For example,  in

Caiifomia  it could be sati  that every donor center is overlapped by the Hem  of

America  (HOA) donor centi  when in fact there are areas of the state not sewed  by

HOA.  *other  oversi.mplfx=tion  is found jn Appendix B where the fact that sow

counties  are send  by mom b  00Cdonor center is ignored in reaching conclusions

about the percentage  of population served.

Recommended  Modifications  to the Drafl  Report: 
OIG
We agree with the  report that geographic overlap per se does not have to 
c

be a problem,  bw this ckpends on whether the overlapping centers cQopcrate or 
compete.  Blood bank experiences have shown clearly that compeation f~ 
donors is um.nkrproduetive. 
	 Bidding for tirTitorY needs fkther  evaluation &fore giving it serious 
consideration.  It ~uld  crtatc much ill will for the program from groups  whose 
support wend. 
	 TIE NMDP feels  tit  modeling of variousdorm center, recruitment  group and 
distant donor  satelli~  con.@urations,  as a part of the Network Evaluation,  will 
be helpful  in sornng  Wt  h  compiicmti  issu=  of geographic  ovcdap. 
c-5  ,. 
we  ~  ~dy  embarked  upon  continuing  the effo~  begun  with  these OIG  d.mfc reports.  Our 
own  detailed  evaluation  of costs  to recrwt  donors  and rerneve  them  for donation  is well under 
way.  The effects  of geographic overlap =  being evaluated by our Network Evaluation 
Minority recruitment  approaches and donor 
Advisory  Panel and by several committ=. 
retention are areas  of high concern,  being addressed by our Mimrity  Affairs  Committee,  the 
Donor Recruitment  Committee,  and the Mmbe@Lip and Process Improvement  Committee. 
These are all high priority  items for our Board of Directors,  which will be reviewing  these 
documents at its regular mating  in several weeks. 
We hope that you find these comments helpfil.  The NMDP thanks you for sharing these draft 
reports and looks forward  to a continuing collaboration in improving all aspects of donor 
center and recruitment  group operations. 
&~ 
/ 
. 
M.D. 
Herbert A. Perkins. 
NMDPBoarCdhair

. 
C-6
 APPENDIX  D

ENDNOTES

1. Natioml  Marrow  Donor  Program,  The Living  Gij  of Life,  October,  1994. 
2. Bone Marrow  Transplants  - A Book of Basics for  Patients  (reprinted by NYSERnet, 
Inc. with permission from  BMT  newsletter),  chapter 4, pp. 35-36. 
3.  Excluding  the Bill Young  Donor  Center. 
4.  The remaining centers are paid through a cost-based contract. 
D-1