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 OIG’S 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.


OEI’S 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 patient’s and donor’s 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 NMDP’SDonor 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 

COnfUSiOI’IIIX.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 center’s 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 center’s 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 patient’s diseased bone marrow is destroyed and


marrow from a healthy donor is infused into the patient’s blood stream. Bone marrow


produces platelets, red blood cells, and white blood cells, the agents of the body’s immune


system. For a bone marrow transplant to be successful, the patient’s and donor’s 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 individual’s 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 (OEI01-95-00120); National Marrow Donor Program: Effectiveness in Retaining Donors (OEI01-95-00121); and National Marrow Donor Program: Financing Donor Centers (OEI-Ol95-00123). 

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 NMDP’SDonor 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 President’s 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: 

F	 Twelve donor centers indicated that four other centers operate in their area. Three 

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. Navy’s 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 center’s 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; 

F Maryland/Washington D. C., where 2 of 4 donor centers overlap 100 percent, and 

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. 

b Illinois, where two of four donor centers have 100 percent overlap, and another 

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% 

75%-99.9% 

50%-74.9% 

25%-49.9% 

0.1%-24.9% 

o% 

All Centers 

13 10 28% $52.28 

[4-50%] [$20.38-$226.08] 

9 4 20% $75.06 

[8-64%] [21.73-$164.93] 

11 5 29% $44.12 

[7-78%] [$22.48-$87.98] 

12 4 29% $50.75 

[1349%] [$22.68-$73.83] 

11 I 9 I 23% 

[0-40%] I $55.53 

[$19.69-$134.05] 

4 1 27% $39.59 

[10-71%] [31.78-$63.45] 

60 33 25% $54.41 

Excludes U.S. Navy’s Bill Young Marrow Donor Center because of that center’s 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 

Centers @ange] 

100 % 23 72 % 

[49-100%] 

75 % -99.9 % 13 65 %

I I [53-100%] 

50 % -74.9 % 18 75 % 

[61-98%] 

25 % -49.9 % 16 75 % 

[61-100%] 

0.1 % - 24.9% 20 78% 

[58-93%] 

o% 6 63 % 

[47-85 %] 

All Centers 96 72 % 

Mean Retention atCT Testing 

~ge] 

74 % 

[43-100%] 

I 71 % 

[54-100%] 

78 % 

[54-100%] 

80 % 

[68-100%] 

78% 

[67-100%] 

78 % 

[59-100%] 

76 % 

Excludes U.S. Navy’s Bill Young Marrow Donor Center because of that center’s 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 center’s 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 center’s 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

I I ! 

1 I 

APPENDIX A


EXTENT OF SERVICE AREA OVERLAP


Thefollowing 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 NMDP’SDonor 

Center Access Directo~, published in October, 1995. 

The number of donors on each center’s list was obtained from the NMDP’SMonthly 

Registry Statistics for October, 1995. 

Donors on 

lCenter I I I ] ServieeAreal Percentl Center’s List 

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 

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 

17 ARC Fort Wayne Fort Wayne IN 2,628,1811 88% 4,916 

A-1


I 
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 

Center 

I 57/United Blood Services /Scottsdale 

581Colorado Marrow Donor Denver 

Program 

591University Medical Center Tucson 

[- ~/New York Blood Center lNew York 

62 United Blood Services Albuquerque 

63 LlfeSource Glenview 

64 Central Florida Blood Orlando 

Bank 

66 Alameda-ContraCosta Oakland 

Medical Association 

67 City of Hope National Duarte r ‘IMedical Center 

68 Peninsuia Blood Bank Burlingame 

70 Heart of America Registry Kansas City 

74 HLA Registry Foundation River Edge 

75 Methodist Hospital Houston 

76 Community Blood Center Dayton 

78 Virginia Blood Services Richmond 

79 St. AlphonsusRegional Boise I Medical Center

81 Puget Sound Blood Center Seattle 

~ 

83 IntermountainMarrow Salt Lake City I ‘1Donor

I 851University of Louisville ]Louisville 

1 86 Stewart Regional Blood Tyler 

Center 

87 Bill Young Donor Center Bethesda 

88 Assoc. of Independent West PaIm 

Blood Centers Beach 

89 Mountain States Marrow Boise 

Donor Center 

90 Rhode Island Blood Center Providence 

91 GuJf Coast Regional Blood Houston 

Center 

92 United Blood Services Las Vegas 

1 

93 Mississippi Marrow Donor Jackson 

Program 

94 Baylor Research Institute Dallas 

97 Community Blood Center Appleton 

KY 1,896,480 33% 7,271 

AZ 2,742,989 12% 15,105 

co 3,747,982 23% 34,325 

AZ 1,092,2321 24%1 3,216 

NY I 18,765,8691 39%1 65,982] 

NM / 1,362,241 9% 4,630 

IL ~ 7,039,960 84% 21,355 

FL 2,862,030 51% 5,224 

1 

CA I 2,082,914 100% 12,279 

CA I 14,901,137 100% 23,512 

CA 649,623 100% 3,976 

MO 38,476,844 65% 88,909 

NJ 29,964,435 95% 109,099 

TX 5,030,783 100% 4,623 

OH 1,573,020 28% 7,007 

VA I i ,763,405/ 54%/ 9,046/ 

ID 841,200 100% 1,593 I 

PA 4,022,386 43% 6,308 

WA 4,218,015 9% 27,593 

WI I 1,735,364 0% 22,643 

UT 1,912,791 9% 3,572 

KY 2,098,501 17% 7,555 

TX 895,293 100% 5,040 

MD not applicable 83,873 

FL 4,858,161 89% 990 

ID 1,053,517 100% 3,011 

I 1 I 

RI 1,003,4641 100%1 11,778 

TX I 4,504,753 100% 17,151 

NV 2,419,238 63% 2,518 

MS 2,919,679 42% 5,764 

I I I 

TX 6,201,3331 92%[ 8,262 

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 Children’s 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 center’s service area by using the NMDP’sDonor 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 center’s service area. 

� The numerator is the population in that donor center’s 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 center’s 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 
�

# ,,,1 m, 

A+ 4 

DEPARTMENT OF HEAL’1= & HUMAN” SERVICES Public kleekh Service g 

: 

~i “%m;~ \

&

Health Resources and 

TO:


FROM: 

SUBJECT : 

OCT ~ 3 Pgt Services Administration 

Rockville MD 20857 

Inspector General, DHHS 

Deputy Administrator 

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 Overl”ap Among Donor Centers


OEI-01-95-00122


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


Attached is HRSA’S responsetoyour 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 AD irdre Walsh on x35181. ‘


Attachment


c-2 
OIG Report: Geographic Overlap Amona Donor Centers


0EI-01-95-O0122


No specific recommendations.


GENERAL COMMENTS 

HRSA notes that theconclusions 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.


Bidding for territory needs further evaluation. A difference of 

opinion was expressed regarding the potential effects of the 

bidding process, particularly because of the concern that the

phrase, “service area overlap, “isnot well defined and the


analysis is an oversimplification. Modeling
 ofvarious donor


center configurations should take into consideration the


complicated issues ofgeographic
 overlap.


c-3 
National MmTOW 

Donor FrugmTI 

N~tioIM Coomlinsting Ccnkr 

3433 Emadwuy Stxaf N.E. 

Suirc ~ 

Mhmmpdis. MN 55411 

6 L2-627-58rx) , 

I I -tUxJ-sz&7twJ 

FAX: 61>6274W 

Seard ofmfwdo~ 

HcrbaK A. Pcfkim, M.D., (%uar I 

Jnndwn R bong, P& (%uir 

clam Psdilla A*s 

Richmd H A$w. M.D. 

h~ncc D. AtlX’, J.IJ. 

Jn~h “t BdL M.D. 

80 Dupont, .M.D.,0..%. 

Ro&r W. P.vww *D. 

Ban S. tishcr. I.D.. Ph.D. 

Dnvid B. Fmhnmsvcf. J.IJ. 

J. Cunynn (lordon. J.D. 

JohnA. lLmerL M.~. 

-e&rick J. Hams. M.S.F.&. M.B.A. 

. MW M. Hnmwicz M. D.. M.S. 

ErnstR. J.W. M.D. 

Nancy A. Kcmsn M.U. 

sos kitmnm MD. 

{ichola* J. NaIhnusd. J.D.. k4SLM. 

R&1. Plq?eM-U. 

Gsrlcs A. (CAP) Pdicf 

rm pcetwm, M. P.. Ph.D. 

U. Gcn. F-k E. Pcterm. Jr. 

Kobtsl K. Ruu. M.D. 

E&d P.sam. M.D. 

12avid F.StronaL MD. 

J&II S. ‘130topsxI. MJY. 

CIWICS H. Walk. M.D. 

SIewm N. WulIToM.D. 

wmmeuc K- YaOCCY.M. D.. M. J’.HAdmiml E- R. ZurnwdL Jr. 

f.3a@ W. S. HnWA M. D.. PtLD. 

Chkfizzmulwr OLTW 

Cluirs Rnacritan: 

IZ(imt c.oruves. D.V.M.

Admiml E. R. Zumwah. Jr. 

LRgm Grows Awwd: 

llu HnnnrmbtcU. W. Y3il~ yUUOg 

John A. Han.=%M.~­

(nswic bkML MD. 

A cdldmrwf’c effoff of tie 

Amcncon Association 

tinki~ 

Amcricm) RedCr06S 

Co.ncii d CO!OfIlti@ 

BlootiCen@~ 

With fwdmg (rum: 

Health Resuttes and Scwiccs 

Admintwwwn and 

Naval Medical Rcwtrch nnd 

~kymen[ Ct)mmd 

September 4, I!& 

Judith Braslow


Director, Division of Organ Transplantation


Health Ilesources and Services Administration


Park Lawn Building 

5600 ~SkfS Lane - Room 729 

Roclwiflc, MD 20857 

kr Ms. BraS~OW: 

Thank you very much for providing the National Marrow Donor 

Program@ (NMDP) with an opportunity to review the draft reports of the 

Office of Imp=tor GmemJ (OIG), Depa~ent of H~ti and Human 

Services. The draft reports were sent to members of the Minority Affairs, 

Membership and Process Improvement, Donor Recmit.ment and Executive 

Committees as well as the NMDP’s Network EYahzationAdvisory Panel 

and sckmrcd members of the staff. 

The comments received have been collati and a synthesis of the 

responses is presented below. The intent of the J’?MDP is
not to criticize 

the draft reports, but rather toadd information fkom a varie~ of 

respondents, all of whom have been involvai with aspects of donor center 

operations andlor donor recruirmenf. As you know the NMDP is well 

along in its own analysis of donor center timetions,the findings of which 

should provide fiwthcruseful recommendations. 

Following the summaryof cmnments on each draft RPOrt we Mve . 

provided our own list of recommendations for modification of the OIG 

document. 
Geographic Overlap 

One respondent feIt that continuing the geographic overlap 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: 

c
 We agree with the OIGreport that geographic overlap per se does not have to 

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 

Advisory Panel and by several committ=. Minority recruitment approaches and donor 

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. 

&~ / 

. Herbert A. Perkins. M.D. 

NMDPBoardChair


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