The AJT Report
The AJT Report: News and issues that affect organ and tissue transplantation
With implementation of the Affordable Care Act, accountable care organizations and a possible new kidney allocation policy around the corner, what's in store for renal wait list management? This month, we review what these policies may mean for pre-operative testing guidelines, and how transplant centers may need to reevaluate their approach to managing their wait list patients. Additionally, we'll review the key features of the newly proposed kidney allocation policy.
What's Ahead for Renal Wait List Management
It's the goal of every transplant center to maintain a healthy, transplant-ready wait list (WL), but the way centers go about this can vary. If, in June, the board of the United Network for Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN) approves a new kidney allocation system, will WL management need to change? Will data-driven standardization be required with the possibility of reimbursement tied to capitation (a lump sum for all tests during a waiting period) rather than fee-for-service?
Currently, transplant evaluation is not conducted with a consistent eye toward cost efficiency. Whether a new kidney allocation system, the Affordable Care Act or accountable care organizations (ACOs) will change this remains unknown. However, in today's world of cost containment, it is likely that there will be increased scrutiny regarding transplant center requirements for WL patients.
In 2001, the American Society of Transplantation (AST) released guidelines to facilitate the evaluation of candidates for renal transplantation. The recommendation focused primarily on frequent cardiac testing and immunological monitoring.
“Over the years, the reality has changed in that patients are waiting much, much longer than they did when the consensus conference recommendations were first made,” says Gabriel Danovitch, MD, medical director of the Kidney and Pancreas Transplant Program at the University of California, Los Angeles (UCLA). Based on the AST guidelines, patients would be given annual tests to keep them ready for a transplant that may not come for six or seven years. “Around the country, if the current AST guidelines are applied, there may well be excessive testing. I wouldn't want to tell any program what to do, but I believe every program should look critically at what is cost effective and clinically relevant,” says Dr. Danovitch.
In 2006, Michael Abecassis, MD, director of the Comprehensive Transplant Center at Northwestern Memorial Hospital in Chicago, suggested ways to reduce the burden of cost and inventory with proactive WL management. Rather than conducting routine tests under the umbrella of the Organ Acquisition Center (OAC), he said these procedures should be ordered by the primary care provider. Additionally, he recommended discounting services to a “reasonable level,” negotiating with the practice plan to decrease the percentage of charges billed by the physician to the OAC, adjusting staff size, decreasing the number and frequency of immunological tests (as well as the cost per test), and analyzing costs from outside labs, organ procurement organizations (OPOs) and transportation.
- Most transplant centers vary in the way they maintain patients on their wait lists, and transplant evaluation is not consistently conducted with an eye toward cost efficiency.
- A new kidney allocation system, the Affordable Care Act and/or accountable care organizations may necessitate a change in the way transplant centers approach wait list management.
- Currently, a patient's primary insurance pays for wait list testing, but this might change to a lump sum payment to cover lab testing and medications, and there are a lack of data pointing to the most cost effective best practices for this process.
A Sampling of WL Management
At UCLA, Dr. Danovitch and his colleagues manage a large WL of more than 2000 patients. “The current kidney allocation algorithm has many disadvantages, but one significant advantage is its remarkable predictability regarding WL patients,” he says. Based on these patient wait times, the UCLA team focuses WL management on the top 30 patients in each blood group, who are seen in the clinic and whose information is updated with cardiovascular and immunologic testing.
A similar approach to WL management is done at the Cleveland Clinic. Richard Fatica, MD, medical director of kidney transplantation at the institution, culls the top 10 or so in each blood group (out of 650 patients on the WL) and updates testing. The Clinic asks local nephrologists to notify them of any active issues. However, he says, “I don't think our program has looked at cost containment in WL management to the same degree as other areas. With the intense scrutiny on outcomes in the pay for performance area of transplantation, caution prevails. Pretransplant testing should be guided by the practice of evidence-based medicine as much as possible, and not the false sense of security provided by overtesting.”
Although he believes there will be changes with the Affordable Care Act and ACOs, Dr. Fatica says he doesn't know what they will be. “Transplant centers already function as ACOs in that we have dedicated professionals working for the common care of the patient in a coordinated fashion. Where we might see a change is in the incorporation of nontransplant professionals, such as the primary care provider, in a more structured way.” Mayo Clinic nephrologist Fernando Cosio, MD, says his healthcare organization focuses primarily on living donation, so their WL is smaller, with only 400 or so patients. “We don't put anybody on the deceased-donor WL until they are fully worked up and approved,” he says. Evaluations are completed in three days, rather than drawn out over weeks or months. Sometimes Mayo asks the home physician to do the work-up and send results. After going on the WL, patients are seen in the clinic yearly and are called by coordinators every six months. Once a week, Dr. Cosio meets with the coordinators to discuss all patients on the WL.
At Emory University in Atlanta, the WL typically has between 1700 and 1800 patients, about half of whom are “active,” according to Stephen Pastan, MD, medical director of the university's Kidney and Pancreas Transplant Program. During a yearly phone interview, patients are asked about any recent illness. If the patient is older than 35 and has been diabetic at any age, “we want an echocardiogram and nuclear stress test every two years,” he says.
While the patient's primary insurance, including Medicare, pays for WL testing, this could change to a global payment system whereby centers are given a lump sum to cover lab testing and medications. Dr. Pastan wonders if pretransplant evaluation would be part of a global fee for dialysis. “How are we going to manage that?” he asks. “How are we going to balance the benefits of keeping a patient's cardiac testing up to date with the actual cost, and who is going to pay for it? We need to know the cost effectiveness of this.” However, the data are lacking. “So, the way we come up with this is we sit in a room with a cardiologist, a nephrologist and a transplant surgeon,” says Dr. Pastan. “It ends up being based on our experience, and that's reasonable. But we are going to have to get the data.”
He adds that, right now, Medicare is focusing on hospital readmissions, as are all healthcare specialties. “We're probably going to have to do this with WL management, to better understand those costs,” he says.
One answer may be for the AST or the American Society of Transplant Surgeons (ASTS) to hold a consensus conference and/or advocate for studies to better determine cost-effective strategies. “It would make sense for AST and ASTS to get together to make critical recommendations as to how we can most effectively manage the WL when faced with the new reality of cost containment,” says Dr. Danovitch.
- 1The evaluation of renal transplant candidates: clinical practice guidelines. Am J Transplant 2001; 1(Suppl 2): 3–95., , , , , , et al.
- 2Organ acquisition cost centers part II: reducing the burden of cost and inventory. Am J Transplant 2006; 6: 2836–2840..
Wait List Management in Canada
In Canada, WL management varies among provinces and programs. According to John G ill, MD, with the University of British Columbia, “we do not have regulatory requirements or fees to activate someone on the wait list. Most of us are operating within blood groups where waiting times are very predictable.”
Canadians utilize a guideline for patient referrals and evaluations, the “Canadian Society of Transplantation consensus guidelines on eligibility for kidney transplantation.”
- 1Canadian Society of Transplantation: consensus guidelines on eligibility for kidney transplantation. Can Med Assoc J 2005; 173: S1-S25., , , , , , et al.
KEY CONCEPTS AND FEATURES OF THE KIDNEY ALLOCATION PROPOSAL
After months of public comment on a proposed new kidney allocation policy, the United Network for Organ Sharing (UNOS) reports that it received 230 responses. Of these, 122 (53%) supported the proposal, 98 (43%) opposed it and 10 (4%) had no opinion.
The following are key concepts and features of the proposal:
- A Kidney Donor Profile Index (KDPI) replacing “standard” and “expanded” criteria donors will estimate length of function of a potential kidney.
- The estimated posttransplant survival (EPTS) formula will estimate the likely benefit a specific patient would get.
- The 20% of kidney offers with the longest estimated function determined by the KDPI would first be considered for the 20% of candidates estimated by the EPTS to have the longest time to benefit; of the remaining 80% of candidates, the organ offer process would be similar to the existing system.
- The 15% of organs with the shortest estimated function would be offered on a wider geographic basis.
- A national policy will be established to offer kidneys from donors with certain subtypes of blood type A (A2 and A2B) for transplant candidates with blood type B.
- Candidates with an immune sensitivity beginning at 20% would fall under a sliding scale of additional priority.
- Waiting time will begin when a candidate has either a glomerular filtration rate of 20 mL/min or less, or begins dialysis or other renal replacement therapy.
- The practice of “payback” will be ended.
- The proposal recommends the dissolution of a number of alternative kidney allocation systems operated in different local areas.