Health systems are tasked with managing increasingly complex and tightly regulated clinical programs and payer pressures, as well as strategizing new ways to compete for patients and organ donors.
This article first appeared in the June 2016 issue of HealthLeaders magazine.
Just a few decades ago, organ transplantation was still a relatively new frontier in medicine. In recent years, however, much has changed. Clinical advances, greater numbers of organ donors, changing reimbursement structures, sophisticated administrative models, and ever-tightening government regulations have led to improved healthcare outcomes, more individuals receiving transplants, and the introduction of new transplant procedures.
In 2015, there were 30,973 organ transplants in the United States, surpassing the 30,000 mark annually for the first time, according to the Organ Procurement and Transplantation Network. What's more, there has been an increase in donors "upon cardiovascular death as opposed to brain death," and African American and Hispanic deceased donors increased over the last year, according to the OPTN.
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"I've seen the field of transplantation evolve from one that was absolutely new and, as a result, almost entirely unregulated, to a field that is arguably the most regulated in the field of healthcare," says Steven Colquhoun, MD, FACS, director of the Abdominal Multi-organ Transplant Center at the Keck School of Medicine at the University of Southern California in Los Angeles.
Increasing oversight from the United Network for Organ Sharing, the Centers for Medicare & Medicaid Services, and The Joint Commission, which provide outcomes information for each transplant program in the United States, not only ensures the quality of transplant programs but is leading to greater innovation, better organ donor matches, and a lessening of racial and other disparities when it comes to determining who receives an organ.
In December 2014, UNOS changed kidney allocations rules, factoring in considerations other than a person's place on the wait list. Among other changes, the new system is priority matching patients and donor kidneys with the highest life expectancies and "increasing priority for candidates whose immune system is not compatible with most donor kidneys," according to the OPTN.
For Colquhoun and other transplant leaders, as the world of transplantation evolves, they are tasked with managing increasingly complex and tightly regulated clinical programs and payer pressures, as well as strategizing new ways to compete for patients and organ donors.
Success key No. 1: Create a high-performing matrix
At the Bronx, New York–based Montefiore Einstein Center for Transplantation, which performs liver, kidney, and pancreas transplants, Milan Kinkhabwala, MD, chief of the division of transplantation at the center and director of abdominal transplantation, stresses that successful programs must have administrative structures that can accommodate the potential for strong revenue, while at the same time handling regulatory oversight and risk.
Transplant administrative structures have changed a lot over 20 years, he says. "It used to be driven by surgeons who were part of surgical departments. They performed the surgery, administered all of the things in the program." There was no standardization, minimal regulatory oversight, and payment was largely fee-for-service.
Now, "most hospital systems that are doing transplants on a large scale have organized their transplant programs into some kind of matrix center," says Kinkhabwala, who oversees 100 employees. By matrix he means a tightly coordinated center with a physician and an administrative leader who work together tending to everything from business planning and regulations to quality and outreach.
"Transplant physician leaders need to be matrix leaders, interacting with a lot of different departments and division leaders," says Kinkhabwala. "They have to be bridge builders to some degree and develop agreements and relationships with everybody from radiologists and other surgeons to operating room personnel. I'm a busy transplant surgeon, but I spend 80% of my time in program administration."
Montefiore has designated transplantation as one of five centers of excellence within the health system. The transplant center has dedicated administrative leadership from the hospital, and separate budgets, marketing resources, and quality oversight. Since Kinkhabwala joined Montefiore eight years ago, kidney transplants have gone from a low of 109 in 2011 to 168 in 2015. "We had a very successful year in kidney transplants. It was a record year," he says.
"When I came to Montefiore, we set out to organize the center of excellence and build on an existing kidney program," says Kinkhabwala. "I knew what I needed in terms of floor capacity, nursing, clinical protocols, and faculty development, but I needed a hospital partner to help me execute that vision." He stresses that the physician leader's vision must be in sync with hospital goals.
Kinkhabwala says the transplant center must operate like a well-oiled machine because of the type of patients it sees. "If there's a problem in one part of the assembly line, the whole thing kind of falls apart. If your flow of patients, for example, is dependent on a financial counselor getting insurance clearance for patients and you have a financial counselor that's not working out well, or you don't have enough of them, then your whole assembly line could stop because of one person, and that could affect hundreds of people."
Success key No. 2: Redefine each patient's experience
USC's Abdominal Multi-organ Transplant Center performed 125 liver transplants and 152 kidney transplants in 2015 as well as six pancreas-only transplants in 2015, according to OPTN. Transplant surgeon Colquhoun, who specializes in liver transplantation and hepatobiliary surgery, has been on the job there for less than a year, but already his top goal will be to take patient experience to a new level in the transplantation world.
"While we don't really have an issue with our outcomes and things are generally running pretty smoothly, I think one of the themes in healthcare, in general, is always continuously circling back and trying to make things better."
For Colquhoun—who founded a new liver transplant program at the University of California, Davis, and served as the director of Los Angeles–based Cedars-Sinai Medical Center's liver transplant program for 20 years—patient experience goes beyond convenience, since patients receiving a transplant are critically ill. "Making things go faster and efficiently, optimizing ongoing communication, and managing patient and family expectations is critical, since anyone needing a transplant is by definition facing a more or less life-threatening disease condition," he says. "All of these factors are of paramount and often urgent in importance."
One area Colquhoun is zeroing in on is streamlining the exhaustive testing process patients must endure prior to surgery. "As one might imagine, the process for evaluating an individual's candidacy for a transplant is extremely complex and requires not only an exceptional number of tests and studies, but also input from a surprising number of healthcare specialists," he says. "For the sickest patients, these tests and encounters happen in the hospital with some efficiency. However, for the 80% or so of patients who are not hospitalized, the sheer volume of tests and visits can be onerous," he says.
The logistics of coordinating all of this typically takes weeks for most large programs, given that patients who are sick with life-threatening diseases, are not feeling well, have to take days off of work and may have to travel great distances and rely on family members for transportation, says Colquhoun.
Colquhoun and his team want to reduce this process to a single day. It may sound like an insurmountable challenge, given that patients require everything from lab tests to MRIs as well as input from a dozen or more specialists and clinicians, but Colquhoun says he has done it before at other organizations and insists it can be done at USC. The plan will involve tight coordination with other clinicians and labs.
For example, he says, it may mean that the echocardio lab clears its schedule one day a week to accommodate several patients. "A lot of times just talking with all the various parties, getting things mapped out in advance and planned is what's required," he says. Also, Colquhoun says the organization will be starting an ambassador program, in which previous patients will interact with new candidates and their families, and physically guide them to tests and visits.
Success key No. 3: Be a strategic list manager
List management innovation is essential to maintaining high-quality rankings. "If you think about the transplant as a business, what we're really involved in is the business of list management," says Montefiore's Kinkhabwala.
"We're in the business of getting people with organ failure and evaluating them to be put on a waiting list, and then maintaining their health on the waiting list until they get in a surgical operation, and then provide their aftercare." Because donors are allocated based on an organization's wait list, it's important to always be working on maximizing your list number, stresses Kinkhabwala. But, it's not merely as simple as having a larger wait list than other transplant centers. List management strategy involves a deep understanding of how organ allocation works.
In the not so distant past, some organizations would list every patient who came through the door regardless of of how sick they were or how long they would have to wait for a transplant, explains Kinkhabwala. The downside to this strategy, he notes, is that your list size balloons up, resulting in low transplant rates.
Also, kidney allocation has changed recently, he says. "In the past, your clock started ticking when you were referred to the transplant center and they put you on the list. Now, your clock starts from when you started on dialysis." A better list-management strategy for kidney is to evaluate the patients, manage the condition, and defer listing them until they are closer to requiring transplantation. "That makes the list size smaller, your transplant rate higher, and your costs go down because you're not spending as much on testing people who are not going to be transplanted right away." The same strategy can be applied to liver transplants, adds Kinkhabwala.
Success key No. 4: Have an innovative donor strategy
Despite the advances in transplantation, the reality is more than 77,000 people are active waiting list candidates for an organ transplant, according to UNOS. One way to reduce this list is by expanding organ procurement methods, including expanding living donor programs.
Tim Taber, MD, a transplant nephrologist and medical director of kidney and pancreas transplantation for Indiana University Health and the chief medical officer for Indiana Donor Network, says IU Health Transplant has deployed several strategies to bring in more donors. To start, he says, it is critical to be willing to travel.
"We have built a reputation for having physicians who are willing to travel to hospitals across the country at any time of the day or night to take a closer look at donor organs to see if they could be suitable for a transplant back in Indiana," says Taber. "Doing so gives our doctors access to more organs to consider for patients."
IU Health Transplant performed 145 liver transplants, 177 kidney transplants, and 26 pancreas transplants in 2015, according to the OPTN. Taber, who works with a team of nearly 100 clinicians and specialists, says that it is important to examine every organ. "IU transplant surgeons review each organ individually, which means we are able to use more organs and significantly reduce wait times."
His top goal this year is to expand the kidney living donor program at IU Health Transplant. He says about one-third of all kidney donors at IU Health Transplant are living. To increase this percentage, he says, IU Health Transplant has also been doing paired donations for several years. The paired donation process works to procure a living donor for individuals who have a living donor who isn't a match.
IU has also started a donor champion program that helps potential recipients find a donor and teaches them how to talk to people about donations. "The other thing we're doing is trying to do a better job using kidneys that are on the margin of what we've used before and trying to push the boundaries of the quality of kidneys we've taken in the past," says Taber. "Nationally, we just haven't done a good enough job of that. A lot of kidneys are turned away that are procured that probably could be used in the appropriate circumstances."
Montefiore's Kinkhabwala is looking to make improvements to the transplant program by growing its number of living donors. "We want a higher ratio of living donors, because recipients of live donors generally have better outcomes," he says. "We can transplant them quickly and the outcomes are more reliable."
Kinkhabwala says national benchmarks show that about 50% of kidney donations nationally are living donors. "At our program, it's only about 20%, so we have a long way to go to get to at least the national average for living donation, and part of that is our demographic." One way Montefiore is addressing this issue is by going outside of its service area to other parts of the state to attract patients who may have more living donors, he says.
Success key No. 5: Focus on long-term, coordinated care
Montefiore performed 39 liver transplants in 2015 and 46 the year before, according to OPTN data. Kinkhabwala notes that liver transplant volumes need to be between 50 and 70 to maintain a high-quality ranking. Growing the program is a challenge given the competition in New York for transplant services as well as clinical advancements.
"In the downstate area, there are four or five doing liver transplants, so there are a lot of hospitals that are competing for the same patients," says Kinkhabwala. He adds that better treatments for hepatitis C also make it less likely that liver transplantation will be a growth area down the road.
Still, the plan is to grow the program by taking a more expansive approach to the service line, explains Kinkhabwala. "It's more accurate to call it an organ failure service line." With that approach in mind, Montefiore is developing a model of care similar to an ACO for its liver programs, treating all liver conditions, regardless of transplant need, including hepatitis and liver cancer.
"We want to provide all of the services in the health system that eventually, like a pyramid, may lead to transplant." This broader approach also helps other service lines, such as oncology. Regardless of disease stage, "we're taking care of them holistically for life, and we'll actively manage everything in their care, whether that's a psychiatric problem, or if someone with cirrhosis is an alcoholic, then it's our job to get them intervention for alcohol dependency. That is very unique in healthcare," says Kinkhabwala.
Still, despite these efforts, he says there is pressure on revenue in heavy managed care regions because larger insurers demand transplant centers to become centers of excellence. "Those centers of excellence are really vehicles to negotiate lower rates," Kinkhabwala adds. Ultimately, he says, "there's a tremendous halo effect, and there's an elevation of the case mix index for the hospital as a result of the transplant program, which is important for overall reimbursement."