Challenging the alternative
Rule targets advantage of some transplant systems
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.”