Chal­leng­ing the al­ter­na­tive

Rule tar­gets ad­van­tage of some transplant sys­tems

Modern Healthcare - - THE WEEK IN HEALTHCARE - Beth Kutscher

The me­dian wait for a liver transplant na­tion­wide is about a year, as or­gans are as­signed based on a com­plex al­go­rithm that takes into ac­count med­i­cal need as well as a pa­tient’s ge­o­graphic re­gion.

But at Methodist Univer­sity Hospi­tal Transplant In­sti­tute, Mem­phis, Tenn., the wait is sig­nif­i­cantly shorter—a me­dian of two months. The shorter wait is thanks to “al­ter­na­tive al­lo­ca­tion sys­tems” cur­rently in place in Ten­nessee, Florida and Ohio that have al­lowed livers to be matched pref­er­en­tially in-state be­fore they’re of­fered to pa­tients throughout their re­spec­tive re­gions.

But that ad­van­tage is be­ing chal­lenged. A rule change from the United Net­work for Or­gan Shar­ing, a Rich­mond, Va.-based not-for-profit or­ga­ni­za­tion con­tracted by the fed­eral gov­ern­ment to man­age the na­tional transplant wait­ing list, will dis­con­tinue the al­ter­na­tive al­lo­ca­tion sys­tems at the end of the year. In a 2008 rec­om­men­da­tion to end the pro­gram, a UNOS com­mit­tee wrote that Florida’s sys­tem, for ex­am­ple, “es­sen­tially cre­ates a sys­tem where no Florida donor livers leave the state of Florida.”

Crit­ics of the sys­tem say that shorter wait­ing lists have been a busi­ness boon to sys­tems such as Mem­phis-based Methodist Le Bon­heur Health­care, which have at­tracted out-of­s­tate pa­tients able to get to the transplant hospi­tal quickly. In 2009, Ap­ple co-founder Steve Jobs re­ceived a liver transplant at Methodist Univer­sity Hospi­tal Transplant In­sti­tute.

Un­der the UNOS’ new pol­icy, the 1,305-bed hospi­tal, which runs its transplant pro­gram in part­ner­ship with the Univer­sity of Ten­nessee Health Sci­ence Cen­ter, also in Mem­phis, would be re­stricted to trans­plant­ing livers ob­tained by the lo­cal or­gan pro­cure­ment or­ga­ni­za­tion, Mid-South Transplant Foun­da­tion, Cordova, Tenn. This could re­sult in longer waits at Methodist for avail­able livers.

Methodist—one of only two med­i­cal cen­ters in the state to per­form liver trans­plants— has ap­plied to the CMS for a waiver that would ex­empt it from the UNOS’ rule change.

Methodist also has sug­gested a merger of Mid-South, which serves western Ten­nessee, eastern Arkansas and north­ern Mis­sis­sippi, and Ten­nessee Donor Ser­vices, Nashville, which serves the rest of the state as well as parts of Ge­or­gia and Vir­ginia.

There is no time­line for when the CMS might rule on the pe­ti­tion. A spokes­woman for UNOS said she was not aware of any other waiver re­quests from hos­pi­tals in Florida or Ohio.

Dr. James Ea­son, di­rec­tor of the Methodist Univer­sity Hospi­tal Transplant In­sti­tute, noted that Ten­nessee Donor Ser­vices, which serves 75% of the state’s pop­u­la­tion, pro­duced 220 donors last year. Mid-South pro­duced only 62.

He added that Methodist has a large pro­gram that serves a community with high poverty, a large mi­nor­ity pop­u­la­tion and a high in­ci­dence of re­nal dis­ease. Those chal­lenges also com­pound the prob­lem of find­ing us­able or­gans, even af­ter do­na­tion.

“The fun­da­men­tal dif­fer­ence is the pop­u­la­tion served,” he said. “Even if (Mid-South is) the best (or­gan pro­cure­ment or­ga­ni­za­tion) in the coun­try, they’re not big enough to meet the need.”

Van­der­bilt Univer­sity Med­i­cal Cen­ter, the only other Ten­nessee fa­cil­ity per­form­ing liver trans­plants, de­clined to com­ment. But in a let­ter to the CMS op­pos­ing Methodist’s waiver, the Nashville-based med­i­cal cen­ter ar­gued that in 2011, about half of Methodist’s liver transplant pa­tients came from out­side its ser­vice area.

It cited un­pub­lished data from the Ten­nessee Hospi­tal As­so­ci­a­tion that showed a 60% in­crease in the num­ber of out-of-state pa­tients be­tween 2008 and 2011. It also noted that Methodist’s liver transplant pa­tients had lower MELD scores—a marker of med­i­cal need, with higher scores in­di­cat­ing sicker pa­tients—than the na­tional av­er­age, cit­ing the Sci­en­tific Reg­istry of Transplant Re­cip­i­ents.

Ea­son coun­tered that 90% of Methodist’s pa­tients are from the mid-South re­gion, in­clud­ing bor­der states Mis­sis­sippi, which doesn’t have its own liver transplant pro­gram, and Arkansas.

Al­ter­na­tive shar­ing agree­ments re­ceived ap­proval in the early 1990s, ac­cord­ing to Kim Van Frank, ex­ec­u­tive di­rec­tor of the Mid-South Transplant Foun­da­tion. But in 2008, a re-eval­u­a­tion of the sys­tem found that they cre­ated an ad­van­tage for cer­tain pro­grams and couldn’t be du­pli­cated across the coun­try.

Van Frank said dis­par­i­ties be­tween or­gan-pro­cure­ment or­ga­ni­za­tions can be ad­dressed by in­creas­ing do­na­tions, which MidSouth has done by more than 50% over the past five years. “Those lo­cal ef­forts have re­ally made an im­pact,” she said.

Bill Vaughan, chief oper­at­ing of­fi­cer at transplant con­sult­ing firm Guidry & East, noted that as UNOS moves to end al­ter­na­tive al­lo­ca­tion agree­ments across the coun­try, transplant cen­ters have been dis­cussing the ef­fects on their pro­grams.

“They are profit-driv­ers, es­pe­cially with heart and liver,” he said. “When they get rid of those method­olo­gies, some hos­pi­tals win and some hos­pi­tals lose.”

Ste­fanos Ze­nios, a pro­fes­sor of health­care man­age­ment at Stan­ford Univer­sity’s Grad­u­ate School of Busi­ness, noted that be­yond prof­itabil­ity, a suc­cess­ful transplant pro­gram “has huge eth­i­cal and so­cial value.”

“Trans­plants are the top of the hi­er­ar­chy for sur­gi­cal pro­ce­dures,” he noted, adding that they can pro­duce the high­est gains in pa­tient out­comes and have the feel-good value of turn­ing dev­as­tat­ing tragedies into life-sav­ing events.

And the ear­lier the transplant, the bet­ter the out­come. “That en­hances the rep­u­ta­tion (of the transplant cen­ter),” he said.

Vaughan noted that con­tract­ing with pay­ers as a pre­ferred, in-net­work transplant cen­ter can be lu­cra­tive for a med­i­cal cen­ter. More­over, transplant cen­ters are a “huge, huge mar­ket­ing tool” for hos­pi­tals, he said.

“The other kind of busi­ness it draws can be very prof­itable,” he said. “You’re mak­ing your money on the end-stage or­gan dis­ease part.”

The me­dian wait for a liver transplant at Methodist, above, is two months.

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