| IX. IMPLEMENTATION CONSIDERATIONS
Transplant centers seeking to adopt the best practices
presented in this report must consider certain matters of
implementation. The sites visited for this study reported
having to overcome certain barriers within the transplant
system and to capitalize on particular opportunities in order
to achieve high performance in organ acceptance, transplantation,
and outcomes. These barriers and facilitators included the
following:
Barriers
OPTN Organ Allocation Policy
Several interviewees observed that the organ allocation
system can be a barrier to maximizing the number of organs
transplanted. While interviewees supported the allocation
system’s role in protecting the interests of all recipients,
several noted that the current system presents obstacles to
finding appropriate matches for organs in unstable donors
or for marginal organs. OPOs may know, based on experience,
which transplant centers will accept these types of organs.
However, allocation policies require the OPO placement coordinators
to call, in sequence, what can be a lengthy list of transplant
centers. Many OPOs have developed “hot lists” of aggressive
transplant centers that they contact when they have reached
the end of the placement process. They jump ahead to these
centers when the opportunity to recover an organ is in imminent
jeopardy because a donor is becoming unstable and the recovery
needs to take place soon. As required, OPOs will submit a
justification letter to the OPTN to explain why the National
placement protocols were not followed in these instances.
During the interviews, there was speculation about what impact
DonorNet will have on this practice. DonorNet, which was launched
shortly after the site visits were completed, is a system
for simultaneous, electronic organ offers and responses and
was developed in part to help achieve National goals of increasing
the number of organs recovered and transplanted. DonorNet
is an interconnected system that allows the transplant community
to seamlessly and securely exchange data and is intended to
make the allocation system more open and flexible. Some interviewees
speculated that while DonorNet may make the placement process
more efficient, it could make it more difficult for OPOs to
reach out to the aggressive transplant centers with offers
of marginal organs that other centers typically do not take.
It will take time for the OPOs, transplant centers, OPTN,
and other key stakeholders in the allocation process to determine
the impact of DonorNet on the placement of marginal organs.
Limited Availability of Skilled Transplant
Staff
Transplant programs require access to a diverse array of
surgeons, physicians, nurses, and other clinicians who are
skilled in transplant services. Many of the transplant center
staff interviewed for this study noted that one of the barriers
to growth is the shortage of certain types of qualified transplant
clinicians and other staff. Staff from some of the liver transplant
programs indicated that there is a particularly high demand
for transplant hepatologists. Smaller transplant programs
or transplant programs that do not have much flexibility in
terms of negotiating salaries or offering financial incentives
during the recruitment process may find it even more difficult
to recruit and retain staff for these positions for which
there are shortages of qualified individuals.
Reimbursement
One of the barriers for transplant centers seeking to increase
the number of transplant surgeries they perform can be inadequate
reimbursement from insurance companies, particularly for certain
types of complex cases. Several of the administrative and
financial staff interviewed noted that hospitals often are
not reimbursed for the full cost of transplant care. This
is particularly true when the cases are complex or when the
case involves a public payer. For example, financial staff
from one of the centers reported that on a recent Berlin Heart
bridge to transplant case, which involved a multi-month hospital
stay, the hospital was reimbursed for less than 20 percent
of its costs by the payer, which in this case was the State
Medicaid agency. Looking ahead, some of the centers are concerned
that insurance companies will impose lifetime maximum payments
on transplant services that are not adequate to cover the
surgeries, as well as the pre- and post-transplant services.
Market Saturation
While the staff of many of the high-performing transplant
centers speculated that operating in a competitive market
in close proximity to another strong transplant center likely
drives them to perform better, competition could be a barrier
to growing a transplant program if the market has reached
saturation. In other words, in a market in which, for a particular
type of organ, there are few organs exported to other DSAs
and there is a high number of imports (i.e., no excess supply
of organs), it may be difficult for any transplant center
in the region to significantly increase the volume of transplanted
organs. It would be even more difficult for a hospital to
launch a transplant program for that organ type because it
would likely struggle to achieve sufficient volume to ensure
quality outcomes.
Facilitators
Institutional Capacity
One of the keys to the success of a high-performing transplant
center is access to institutional resources, such as clinic
space, office space, operating rooms, administrative staff,
and financial resources. Some hospitals have these resources
in more abundant supply than others. For example, space is
at a premium in many of the hospitals in highly-populated
urban areas, making it more difficult for those institutions
to dedicate the needed space for transplant services. Hospitals
in better financial health may be more likely to invest in
their transplant centers’ staffing and operating needs (e.g.,
nurse coordinators, transportation, management information
systems) or may be better able to absorb the losses on medically
complex cases.
Healthy Competition
Several surgeons and other transplant center staff interviewed
noted that in the field of transplantation, competition can
actually be good for business. Many of the centers visited
operate in some of the most competitive markets with multiple
high-performing transplant centers. Surgeons and other staff
from these centers observed that operating in a market with
one or more other high-performing centers may actually result
in a net increase in the number of transplants they perform.
In an effort to provide the best available care, high-performing
transplant centers in close proximity push each other to continually
strive to improve their performance and to engage in innovative
practices.
Strong OPO and Donor Hospital Performance
The most significant limitation to increasing the number
of transplants performed in the United States is the limited
supply of organs available for donation. As reflected in previous
best practices studies conducted by HRSA, some regions of
the country have had more success than others in maximizing
the potential supply. Some donor hospitals and OPOs are more
effective than others at requesting and receiving consent
for donation. Likewise, some OPOs are more effective than
others at clinical management and placement of donor organs,
resulting in more organs recovered and transplanted per donor.
Transplant centers operating in DSAs where the donor hospitals
and OPOs are collaborating to maximize the supply of organs
for transplantation are at an advantage in terms of maintaining
and increasing their transplant volumes. As noted under Strategy/Driver
3: Aggressive Clinical Style, transplant centers do have an
opportunity to influence supply by lending their expertise
and support to OPOs and donor hospitals.
|
