HRSA Transplant Center Growth and Management Collaborative: Best Practices Evaluation Report - September 2007

Throughout the site visits to high-performing transplant centers, interviewees cited the importance of financial awareness and management in optimizing organizational performance across transplant-related services. Here, “financial intelligence” refers to the carefully calibrated mix of strategies, processes, systems, and skills necessary to achieve and maintain transplant program financial strength.

Key enablers contributing to transplant center financial intelligence include sound financial planning, focus on accurate cost accounting and cost management, maximizing third-party reimbursement through effective payer contracting, establishing mutually beneficial payer relationships, and providing transplant-specific financial counseling and coordination to patients and families early and often. These tasks are particularly complex within transplant centers where financial intelligence must take into account both internal and external drivers and trends.

The transplant centers visited continue to develop and use better approaches for optimizing, tracking, and rapidly adapting their financial intelligence to align with evolving internal and external drivers and trends. The programs we visited actively cultivate relationships and communicate regularly with other departments involved with financial aspects of transplant programs to ensure effective coordination, knowledge transfer, and rapid identification and resolution of any financial issues that may arise.

The transplant centers actively monitor external drivers and trends and factor these into financial intelligence. These include maintaining mutually beneficial payer relationships and understanding the impact of evolving clinical practice patterns and technology on transplant program costs and reimbursement by third-party payers.

Staff at the sites we visited demonstrated high levels of competency and subject matter expertise. This staff competency is essential to understanding the complex reimbursement, payer contracting, cost finding, and other issues involved in financially managing a transplant program. Such expertise takes time to develop, and high-performing transplant centers buy, lease, or develop it internally, depending upon their individual circumstances.

Exhibit 7 summarizes the four key change concepts and related action items that correspond with Strategy/Driver 5: Financial Intelligence.

Exhibit 7:
Strategy/Driver 5: Summary of Key Change Concepts and Action Items

Key Change Concept 5.1: Track and understand your program finances, reimbursement mechanisms, performance, and volume.

It is important that transplant programs have an accurate picture of the full range of services they provide and the support they receive from other hospital departments that influence their financial performance. Tracking and understanding their costs and revenues on a payer and service-specific basis allows programs to identify areas of profit and loss and to develop plans to better optimize future performance.

To accomplish this, at the transplant centers we visited, financial managers and administrators work closely with the clinical leadership to understand cost and revenue drivers. As described below, establishing the transplant center as a separate cost center helps create the structure and accountability needed to understand these drivers and to support the alignment of clinical and economic incentives. In addition to producing internal synergies, this clinical and economic integration allows for transparent pricing and better value for payers.

Close cooperation between clinical and financial staff also facilitates mutual understanding of the financial impact of potential future program initiatives. These may include considering and assessing the downstream effects of possible medical staff growth and technology infusions on center financial health. For example, the addition of a transplant specialist may require additional support staff and space should patient evaluations and other transplant-related activities generated by the new specialist significantly increase.

Financial managers at the transplant centers visited spoke of the importance of accurately preparing Medicare cost reports to track and understand drivers of transplant-related costs. Awareness of program costs and utilization allows transplant staff to exercise effective internal financial management and helps position the center to negotiate effectively with public and private payers. As payer coverage and payment policies change, it is also important that the financial team stay abreast of these developments and inform administration and clinical leadership of their possible financial implications.

Action Items

• 5.1a: If possible, establish the transplant program as a separate cost center. In our site visits, we found many financial benefits associated with organizing as a separate cost center or profit center. Doing so establishes a clearly delineated locus of accountability for transplant financial management. It also allows easier identification of direct and indirect costs associated with transplant services and facilitates tracking of program revenue. Direct costs include departmental salaries, supplies, and other costs directly incurred by the transplant center. Indirect costs include support provided to the transplant center by other hospital departments. These include such hotel services as housekeeping and plant operation and maintenance and ancillary departments, such as imaging and laboratory services. At the Cleveland Clinic, California Pacific Medical Center, Clarian Health, and University of Washington Medical Center, the transplant service is recognized as a separate cost center within the hospital. This enables better cost accounting (which supports more complete Medicare cost reports), financial analysis, and pricing because transplant costs and revenues can be easily tracked.
  
  
  
• 5.1b Communicate with people who are responsible for finances as well as other hospital departments to understand the “multiplier” or “spillover” impact of transplant services. The “value contribution “of a transplant center must account for the revenues and costs associated with all transplant-related services. The ability to identify these across the continuum of patient care is complicated by the fact that costs are incurred and revenue is generated across a range of transplant-related services. These span multiple settings across a continuum of care, from patient selection through pre-transplant work-ups, the transplant procedure itself, and post-transplant follow-up. Accurately identifying each service and its financial impact on the transplant center is a complex process requiring expertise and effective communication and coordination. We found that financial and administrative staff who work closely with transplant clinicians, coordinators, and other staff involved with medical evaluation and testing and post-transplant follow-up are able to more accurately determine the true financial contribution made by transplant centers to their parent health systems.
  
  
  
  • At the Cleveland Clinic, costs and revenues of transplantation are measured across the continuum of care, which has allowed transplant administrators to make a business case for expanding the program. Services provided pre- and post-transplant (e.g., evaluation tests, post-transplant visits) are considered in the institution’s financial assessments of the transplant program. In addition, the transplant administrator monitors how transplantation generates downstream revenues from radiology, laboratory testing, and other procedures required by many chronically ill patients years after surgery. While transplantation alone is a costly service for the hospital to provide, assessing its upstream and downstream revenues, along with the reimbursement for the procedure itself, provides a clear picture of how transplantation financially benefits the Clinic.
    
    
    
  • Understanding that transplant services have a financial “multiplier” or “spillover” impact on other hospital departments (e.g., pharmacy, radiology, laboratory, nutrition), Clarian Health’s transplant reimbursement team regularly communicates with other hospital departments in order to accurately identify all associated transplant costs and revenues. This is essential not only for budgeting and planning purposes, but for contract negotiations by enabling contract managers to present payers with the true or total costs of transplant services and to maximize reimbursement rates.
    
    
    
• 5.1c Encourage open communication and collaboration among financial staff, administrative staff, and clinicians to understand transplant cost and revenue drivers, the clinical aspects of transplantation that affect cost, and emerging clinical practices and technologies that are affecting the field. Transplant center staff work closely with clinicians and others to understand the impact of new clinical practices and technology on program costs. This information provides centers with the evidence and transparency necessary to work effectively with payers to incorporate these factors into contracting and payment negotiations. A better understanding of new clinical practices and technology also allows transplant centers to convey availability of state-of-the-art services and the basis for improved clinical outcomes to payers, which can be persuasive in contracting and reimbursement decisions.
  
  
  
  • At the University of California, San Francisco, the financial and administrative staff work collaboratively with the transplant clinicians to understand the costs and revenues associated with transplant procedures, the clinical aspects of transplantation that affect cost, and new clinical practices and technologies that are emerging in the field. This clinical and economic integration allows for the preparation of more accurate proposals to payers, transparent pricing, and better value for payers.
    
    
    
  • Clarian Health’s financial and administration staff engage in collaborative decision making with clinicians on all financial aspects of transplantation through quarterly executive committee meetings and other regular multi-disciplinary meetings. This process allows finance and administration to understand the clinical aspects of transplantation and appropriately factor-in the costs associated with the changing technology and medical practices in transplantation for contracting and other financial purposes.
    
    
    
  • The Assistant Director of Transplant and Specialty Services Contracting at Stanford meets with physicians of each transplant program on a quarterly basis to remain apprised of the clinical aspects of transplantation. She finds out what is new in the field and how forthcoming scientific advances may influence the cost structure. These meetings help to inform how contracts should account for transplant costs.
    
    
    
  • At the Hospital of the University of Pennsylvania, the surgical and medical directors of the transplant programs, as well as the financial and administrative leaders of the hospital, collaboratively review financial and clinical outcome measures of the transplant programs during quarterly “transplant economics” meetings. The discussions typically include an examination of clinical outcomes such as patient length of stay and inpatient admissions, an evaluation of the costs and revenues associated with new and emerging clinical practices and technologies in transplantation, a review of managed care contracts, as well as an evaluation of the Medicare cost report to ensure that all transplant costs have been captured appropriately. In addition to monitoring and ensuring the best quality of care and outcomes for patients, these meetings allow the financial and administrative leaders of the hospital to better understand the clinical aspects of transplantation that affect costs, enabling them to negotiate cost-effective and financially viable contracts with payers.
    
    
    
• 5.1d Accurately prepare and understand Medicare cost reports and involve clinical and other staff in ensuring that all Medicare costs are recognized. Each of the transplant centers visited stressed the importance of accurately identifying transplant-related costs and revenues, understanding what they represent, and ensuring that they are appropriately reflected on the annual Medicare cost report. This cost report is the end result of transplant-related activities throughout the year and provides information regarding the current effectiveness and weaknesses of the program and the possible financial impact of future program changes. A substantial amount of reimbursement for pre-transplant services comes from Medicare. While this applies to most solid organ transplantation, it is particularly common in kidney transplantation, where many patients suffer from end-stage renal disease, a condition that qualifies for Medicare coverage. As a result, it is important that the Medicare cost report accurately portrays the pre-transplant costs incurred while providing services to this patient population. The cost report also provides financial information necessary to effectively contract with private payers and to help assess the implications of participating in public managed care plans, such as Medicare Advantage and State Medicaid managed care plans. At Stanford, an experienced business manager monitors the Medicare cost report to ensure accurate reporting of all allowable transplant-related costs, such as organ acquisition costs and costs of ancillary services. She also maintains close contact with colleagues in the Transplant Financial Coordinators Association to help stay informed about Medicare regulatory changes, which can affect reimbursement. Stanford employs a transplant operations analyst, whose primary responsibility is to track costs for the Medicare cost report. Stanford estimates that this level of careful, detailed management of its Medicare cost report accounts for approximately 5-10 percent of its Medicare revenues.
  
  
  
• 5.1e Convene monthly or quarterly transplant revenue management meetings with all staff involved in any part of transplant finances, including the front-end and back-end staff (e.g., billing personnel, patient financial services, financial coordinators, managed care managers, transplant administrators). Regularly convening staff involved with transplant financial management and contracting is an efficient way to facilitate coordinating all of the interrelated aspects of revenue management and contracting. Revenue management involves a complex mix of transactions carried out across a number of separate hospital departments. Bringing staff together regularly helps minimize errors and quickly identify and resolve those that do arise. These regular interactions also help patient billing and financial counseling staff to coordinate their work with contracting staff to resolve third-party coverage and payment issues.
  
  
  
  • Administrative and financial staff at the University of Washington Medical Center hold monthly or quarterly revenue management meetings where all staff involved in any part of transplant finances, such as billing, financial counseling, and social work, evaluate contracting strategies and resolve any contracting problems. Since they began this practice, they have experienced far fewer commercial claim denials.
    
    
    
  • At the Cleveland Clinic, quarterly meetings are held with personnel from managed care contracting, payer contract services, patient financial services, transplant financial analysts, contract economics analysts, finance, financial counselors, and the transplant center administrator. The purpose of these meetings is to discuss contract negotiation updates, payer issues (billing, administrative, registration, etc.), and operational issues and/or updates. The benefit of these meetings is that everyone involved in any part of transplant finances gets updates at the same time and can ask any questions that may apply to more than one area of finance. Also, these meetings, which typically last for 90 minutes, allow for feedback related to contracting negotiations.

  
  Key Change Concept 5.2: Negotiate payer contracts with awareness of program strategy, finances, and strengths.

Given the inherent complexity of the transplant continuum of care, centers and payers often negotiate payment arrangements for covering transplant-related services, while managing financial risk for both parties. A relatively common contracting approach is to negotiate global payment rates that feature a single payment for all transplant-related services provided. To minimize transplant center financial risk, a keen understanding of patient resource use and program cost is essential in developing and updating global payment rates.

Awareness of local market dynamics also plays a role in contract negotiating strategies. For example, transplant centers that dominate their local markets by such attributes as size, market share, or patient outcomes may have negotiating leverage with payers seeking to include transplant services with their provider networks.

Action Items

• 5.2a Model contracts and rates based on program costs and actual patient resource use. Transplant program costs are dynamic and mediated by many factors. Among the high-performing centers visited, actual costs are monitored and compared to departmental budgets to identify variances. Costs are also compared with public and private payer reimbursement at the individual payer level to better understand trends in the relationships between payments and costs. This information is used to inform negotiations with payers concerning payment rates and alternative reimbursement methodologies.
  
  
  
  • In an effort to ensure adequate reimbursement for transplant services, the financial staff at The Children’s Hospital of Philadelphia (CHOP) examined its transplant resource use profile. After careful examination, staff determined that the payer reimbursement models did not correlate with the pediatric patients’ resource use and experience. CHOP proposed a new contracting model to National payers based on a charge threshold, rather than a per diem threshold, so that contracts and rates would mirror actual patient resource use. This resulted in more accurate reimbursement for CHOP’s transplant services.
    
    
    
  • At Stanford, the contracting staff continuously monitors transplant program costs, enabling them to derive contract terms based on actual costs. Stanford uses a quantitative transplant model that assesses and validates data retrospectively, as well as prospectively, to accurately predict future costs. The model takes into account the pre-transplant phase, the transplant case period (which includes transplant admission through 90 days post-discharge), and post-transplant care for up to 12 months.
    
    
    
• 5.2b Recruit dedicated, expert transplant contract managers and dedicated and expert financial coordinators. Dedicated contract managers and financial coordinators are aware of and understand the regulations and payer requirements affecting transplant services coverage and reimbursement. Staff at the centers we visited cultivate relationships with their payer counterparts based upon mutual transparency and professionalism. Financial coordinators are active partners with patients and their families, helping them to navigate complex benefits issues with payers. In order to support growth and maintenance of transplant volume, programs at the centers we visited generally adopt an aggressive approach to recruiting and retaining staff for these important positions.
  
  
  
  • The University of California, San Francisco (UCSF) and Stanford have dedicated transplant contract managers. This is essential given the complex and evolving nature of transplant contracting. By being dedicated, these staff members are able to develop expertise and credibility in the field and to build strong relationships with payers and case managers. They also are able to leverage their understanding of transplant medicine to negotiate contracts with payers and to ensure favorable reimbursement. UCSF and Stanford also have financial coordinators that are dedicated to transplant services. These coordinators provide transplant-specific financial counseling to patients and ensure that they are properly insured for the procedure, as well as for pre- and post-transplant care. Given its volume and recognition of the importance of this function, UCSF has a financial coordinator dedicated to living kidney donors.
    
    
    
  • Duke University Medical Center recently created a centralized billing and collections department for both hospital and physician services. This new department has 20 staff members dedicated to transplant services. With this team, patients and payers receive faster, streamlined service, resulting in increased patient and payer satisfaction. Among the benefits of this arrangement is that nurse coordinators receive fewer calls from patients inquiring about billing issues, which allows them to focus on providing clinical care.
    
    
    
• 5.2c Monitor shifts and changes in payer mix. Financial staff at the centers visited stressed the importance of monitoring trends in payer mix. Payment rates and coverage for transplant services vary across payers, and it is important to ensure that a transplant center’s payer mix remains sufficiently robust to support a high quality program. Citing the utility of its TSI/Eclipsys cost accounting system, the finance team at Clarian Health is able to identify all transplant services by DRG, patient, and payers, which allows staff to monitor shifts in payer and service mix and to estimate costs for individual patient services. This information can be sorted, classified, and summarized, and then added to the information base for effective contract negotiations.
  
  
  
• 5.2d Monitor payer policies and annual coverage changes. Changes in payer policies and coverage can adversely affect transplant center reimbursement. At University of California, San Francisco (UCSF), financial managers communicate with their counterparts at other hospitals to stay abreast of payer policies and annual coverage changes. As noted above, financial managers and coordinators at UCSF and Stanford use the Transplant Financial Coordinators Association as a mechanism to remain apprised of changes in payer policies and regulations. This awareness helps UCSF and Stanford to optimize reimbursement for transplant services.
  
  
  
• 5.2e Seek diverse payer mix to ensure that financial viability of transplantation is not dependent on one payer. In 2003, 45 percent of the University of California, San Francisco’s (UCSF’s) kidney transplant volume came from Kaiser Foundation Health Plan. When Kaiser initiated its own kidney transplant program in September 2004, and required all of its 1,500 patients to receive their surgeries at its San Francisco hospital, UCSF was able to avoid a 45 percent drop in its kidney transplant volume due in part to having a portfolio of multiple payer contracts. UCSF increased referrals from payers (other than Kaiser) by opening clinics in outlying community areas to increase access to pre- and post-transplant care for patients.
  
  
  
• 5.2f Leverage program strengths (e.g., quality outcomes, ability to take on tough cases, transparent pricing, being one of few transplant centers in the region) to negotiate payer contracts. From the standpoint of contracting, transplant services are characterized by their high cost, extended relationship between patients and provider institutions, and the reported relationships between program volume and patient outcomes. As such, transplantation is a service in which program magnitude, particular indicators of patient outcomes, and reputation are considered carefully with price in contracting decisions. Many payers are shifting toward a center of excellence (COE) approach in which they will contract only with centers that demonstrate high levels of performance in such areas as patient outcomes, presence of quality assurance and utilization management systems, high physician productivity, and rich nurse staffing ratios.
  
  
  
  • Given its high 1-, 3- and 5-year survival rates, the transplant program at Hospital of the University of Pennsylvania (HUP) is an example of one viewed by payers as a center of excellence. HUP leverages its high quality outcomes to attract payers, aggressively negotiate contracts with payers, and optimize reimbursement for transplant services. Payers view quality as saving them money in the long-run.
    
    
    
  • The transplant center at University of Washington Medical Center (UWMC) is one of the few centers in the Pacific Northwest. The contracting staff leverages this attribute to negotiate favorable payer contracts. For example, unlike transplant centers in more competitive markets, UWMC is able to request from payers information about their transplant network before contract negotiations begin. A request for information is given to every payer to complete so that UWMC has sufficient basis upon which to decide whether or not to contract with them. The request for information inquires about the payer’s corporate overview, network overview, whether it has a proprietary network or a lease network, the administrative processes for claims, and the benefits structure.
    
    
    
  • Clarian Health is the only comprehensive transplant center in the State of Indiana. Several of the center’s transplant programs have some of the highest volumes and best outcomes in the country. Because payers prefer comprehensive programs with high volume and quality outcomes, Clarian Health is able to effectively negotiate payer contracts.
    
    
    
• 5.2g Educate payers about program strengths and outcomes to increase payer referrals. Payers increasingly stress the importance of quality and clinical excellence, as reflected in favorable patient outcomes, in their decisions about contracting with transplant centers. In our visits to high-performing transplant centers, we found a focus on sharing patient outcomes and other information with payers on an ongoing basis to build and maintain referrals.
  
  
  
  • To help increase payer referrals, the Cleveland Clinic markets several strengths of its transplant center, including its high quality outcomes, its short waitlist time, the experience and multi-disciplinary nature of its transplant teams, and its staff model in which its physicians are employed as salaried staff, rather than contracted. This diminishes the potential for financial incentives to influence patient care decisions.
    
    
    
  • The Children’s Hospital of Philadelphia (CHOP) educates payers and community physicians about the high volume and high quality outcomes of its transplant center, as well as the strong technical skills of its surgeons. These marketing efforts help to increase payer referrals.
    
    
    
  • At the Hospital of the University of Pennsylvania, the finance and managed care contracting staff meet with representatives from different private payer groups and managed care organizations at least once every 2 years and conduct presentations on HUP’s transplant programs, highlighting the hospital’s ability to deliver cost-effective and high quality transplant care and services to patients and their families. These presentations result in better relationships and improved communication between the hospital and payers and increase referrals by raising HUP’s reputation among payers.
    
    
    

  Key Change Concept 5.3 Develop and maintain constructive, mutually beneficial payer relationships.

Building and maintaining solid professional relationships with payers is a high priority among transplant center staff whom we interviewed. This involves proactive communication and transparency of financial and clinical data.

Effective communication is critical in view of the complexity of transplant center-payer interactions. We found that transplant center staff work closely with their payer counterparts in sharing the specialized clinical and other knowledge needed to make informed decisions regarding coverage and billing for clinical and supportive transplant services. Center staff also establish open lines of communication with payers about topics of mutual interest, such as new or expanded hospital programs and new technologies or other practices in the transplant program.

Transparency supports the ability of centers to provide more predictable pricing to payers, because transplant data critical to establishing equitable and predictable service pricing are shared with payers. Examples of data used to develop payment rates include costs, utilization, patient acuity, and outcomes. Action item 5.3b provides several site-specific examples of the benefits of transparency to payers and centers.

Action Items

• 5.3a Make fairness an explicit aim in relations with payers (e.g., communicate mistakes in payment to payers even when they would have been financially advantageous to the hospital). Stanford makes an effort to have collaborative relationships with payers. Its managed care and financial counseling staff members are proactive about communicating with payers regarding new clinical practices that could affect costs or potential unexpected outcomes. They also will investigate outlier costs and correct mistakes in billing. For example, if there is a transplant case that becomes very expensive, Stanford will examine the case. If staff perceive that a certain item presents an undue burden to the payer, they may suggest carving the item out of the case rate, so it is paid at cost and will not contribute to stop loss dollars. Another example involves Stanford negotiating rates with payers for implanting Berlin Hearts. Only a few facilities in the United States use Berlin Hearts. The Lucile Packard Children’s Hospital (LPCH), which is affiliated with Stanford, has done about 8-9 Berlin Heart procedures in the past few years. Berlin Hearts are very expensive devices, and patients who receive them can be hospitalized for 6-7 months. LPCH has approached payers and negotiated a different rate for these cases. The negotiated rate usually covers the cost of the Berlin Heart, plus a small administration fee. This approach strengthens Stanford's relations and reputation with payers and may result in more payer referrals.
  
  
  
• 5.3b Provide predictable pricing to payers. The Cleveland Clinic strives to provide affordable, dependable, and transparent pricing to payers. It is able to do this because it accounts for its transplant program as a separate cost center, which enables tracking and calculation of allocated transplant costs and revenues. Several of the Clinic’s services and products are transparently priced. For example, it charges a set fee for the third (of four) phase of the transplant process, which is the transplant episode. The four phases include evaluation, pre-, peri-, and post-transplant. By providing predictable pricing, the Cleveland Clinic is able to interact more effectively with payers. Similarly, having the transplant program organized as a service line at California Pacific Medical Center supports better cost-based pricing. As a result, the institution is better equipped to negotiate with payers.
  
  
  
• 5.3c Establish open, ongoing communication with payers and contact them for multiple reasons, not just when there is a problem (e.g., to let them know about new programs at the hospital and new advances and practices in the transplant program).
  
  
  
  • At University of Washington Medical Center, transplant contract specialists have established open and ongoing communication with payers. They contact case managers for multiple reasons, not just when there is a contract or payment problem. Contract specialists will inform case managers of new programs at the hospital and changes in technology and other processes in the transplant program that may affect quality or costs. On occasion, the contract specialist will schedule in-person meetings with the case manager.
    
    
    
  • Toward ongoing attention to customer relations, the contract managers at the Cleveland Clinic recently began reaching out to payers to gain feedback on their working relationships. They also gather feedback from payers on what the Clinic can do to improve and what could be added to its current operations and functions to be better.
    
    
    
• 5.3d Involve transplant program clinical staff in maintaining relationships with payers. Some transplant centers engage clinical staff to work closely with payers to share clinical and other knowledge that will help them to make more informed decisions regarding coverage for clinical and supportive transplant services. This helps to build and maintain constructive, mutually beneficial relationships with payers.
  
  
  
  • Since 1999, financial coordinators with a nursing background have been hired at Clarian Health to educate payer case managers about the transplant process, including the need for flexibility and responsiveness in arranging transplant procedures; greater resource needs for multi-organ transplant procedures; and the breadth of services required to support transplantation, such as social work, home care, pharmacy, and rehabilitation services. This willingness to educate the case managers has enabled Clarian to negotiate improved contracts for comprehensive pre- and post-transplant care and has increased referrals by enhancing Clarian’s reputation among payers.
    
    
    
  • At the Cleveland Clinic, the transplant physicians are very committed to education. As such, they make themselves available to conduct presentations to payer case managers and medical directors at National payer conferences, local payer meetings, regional payer meetings, conference calls, and Webinars. In some instances in which physicians make presentations, payers can offer continuing education units (CEUs) to their case managers. (Presentations with objectives that are not specific to Cleveland Clinic, e.g., an overall process, technique, or study, may be eligible for CEUs. Otherwise, physicians can focus more on the Clinic programs, outcomes, etc.) During these presentations, the senior contract manager, along with a nurse manager, also conducts a short presentation about the services that the Clinic has available to transplant patients and families. The impact of these presentations by physicians includes: relationship development between payer personnel and Clinic physicians/nurse managers; earning CEUs for case managers; and improved communication involving payers and the clinical and administrative personnel at the Clinic.
    
    
    

  Key Change Concept 5.4 Provide transplant-specific counseling and coordination to patients and families.

Aside from the considerable clinical challenges facing transplant patients and their families, financial challenges loom large. This is particularly burdensome for the many patients who, along with their families, have been compromised financially, as well as physically and emotionally by the time they are eligible for transplantation. The centers that we visited demonstrate “patient-centered” approaches and other means to provide financial counseling, coordination, and assistance during all aspects of the transplant experience.

Financial assistance is a major focus of transplant patient support. As the first point of contact, financial counselors educate patients about their insurance status and the implications of any gaps in coverage. For example, patients lacking proper coverage may not be able to afford their immunosuppressant regimens, which would seriously compromise graft survivability. Because many patients and families are not initially aware of the financial implications of transplantation, providing accurate and timely information, options, and guidance allows them to make necessary and timely financial arrangements.

Financial coordinators maintain “constant contact with patients on the waitlist” to monitor and often help them manage their finances, even those aspects not pertaining directly to transplantation, but that will improve or stabilize their financial status through and following transplantation. As described below in one action item example, financial coordinators serve as intermediaries between transplant patients and the hospital billing department to resolve issues and reduce patient stress. With their extensive experience with Medicare and State Medicaid programs, financial coordinators also are able to help low-income patients become eligible for publicly-funded coverage.

Action items 5.4a-5.4c feature examples of practices from centers that we visited that are designed to offer transplant patients the attention that may be required to address financial challenges.

Action Items

• 5.4a Help patients with handling all transplant financial matters and offer assistance with financing their transplant services.
  
  
  
  • At the Duke University Medical Center, patients are educated early and repeatedly regarding the cost of transplantation and coverage provisions. Financial coordinators assigned to each transplant program communicate with potential transplant patients early in their evaluation process about the financial responsibilities associated with transplantation and continue interacting with patients to answer questions, provide resources, and minimize confusion throughout the entire transplant process. The coordinators have a checklist of information to cover with patients, including explaining their insurance coverage, reviewing the transplant approval process, outlining the various expenses involved with successful transplant procedures (e.g., travel and lodging while at Duke for evaluations and surgery), and offering ways to secure additional financial resources (e.g., applying for disability, fundraising, pharmacy benefits) if needed.
    
    
    
  • The financial counselors at the University of California, San Francisco make patient education one of their top priorities. They help patients maintain, manage, use, and understand their health insurance. Six months before patients are ready for transplantation, financial counselors seek to ensure that they have adequate insurance coverage. They also conduct a complete analysis of various “what if” financial scenarios and review solutions and options with patients. Financial coordinators that are successful in this role can help to ensure timely transplantation, avoid unnecessary further deterioration of a patient’s condition, and contribute to better patient outcomes.
    
    
    
• 5.4b Help patients identify ways to fill gaps in their insurance coverage, including switching health plans where appropriate and feasible.
  
  
  
  • At Stanford, financial coordinators have regular contact with patients on the waiting list regarding their insurance and any gaps in their coverage. They help patients identify and secure alternate sources of coverage or other assistance, such as reduced-cost medications through local county hospitals. For example, the financial coordinators may try to work with patients to change their coverage, such as making a change during open enrollment. They also consider the health care coverage status of any dependent family members and may seek to intervene as appropriate because insufficient coverage can drain family resources and can indirectly affect patients’ transplant experience, treatment regimens, and ultimate health outcomes.
    
    
    
  • The priority among the financial managers and coordinators at Clarian Health is to make sure that “patients suffer the least financially.” They accomplish this by verifying insurance benefits, determining coverage for transplantation, and obtaining any necessary approvals prior to the patient’s initial evaluation. If gaps in coverage are identified, the financial coordinators work with the patient to try to secure alternate coverage. This allows any gaps in coverage to be addressed before the evaluation phase begins.
    
    
    
• 5.4c Assist patients with billing matters by being their liaison to the hospital billing department. At Stanford, patients are asked to contact their financial coordinators if they receive a bill from the hospital billing office. As a result, financial coordinators can assist in managing the billing and payment process and help diminish unnecessary exposure of patients to what may be a confusing and stressful experience.