Quality Rounds
Transplant Transparency
Public reporting of transplant center outcomes leads to better oversight and patient choices. Can we learn from this experience?
By Scott D. Smith
Transparency has become a buzzword in health care. The ascendant view among policymakers is that helping patients become informed consumers by arming them with cost and quality data will result in them making smart choices that will drive down prices and reward high-quality providers. One area of medicine that can shed light on the topic is solid organ transplantation, which has a long track record of airing its survival rates and other data. Local and national experts say transparency has improved quality, increased public oversight, and reduced the cost of transplantation. But it can be tough for patients to sift through all of the available data and make sense of the information without assistance.
Today, patients, payers, and physicians can go online to compare the survival rates, wait times, and number of procedures done at the nation’s 259 transplant centers, which offer 918 transplant programs. Patients turn primarily to two separate Web sites: www.ustransplant.org, which is run by the Scientific Registry of Transplant Recipients, a research group based at the University of Michigan, and www.unos.org, which is operated by the United Network for Organ Sharing (UNOS), the group that runs the organ transplant and procurement network in the United States. UNOS launched its Internet-based transplant database in 1999. Both sites present data from the individual transplant centers.
Knowing details about wait times, surgery volume, and outcomes enables patients to make a truly informed decision about where to have their surgery done. Because the average transplant costs $250,000, insurers are often willing to pay travel expenses for patients to go to a facility that does a high volume of transplant surgeries, has good outcomes and, thus, keeps costs down. This combination of available quality information and the freedom to travel—a relatively rare situation in health care—gives patients the opportunity to shop around on a national level. But do they?
Beyond the Facts
Area transplant surgeons say the occasional patient may delve into a transplant center’s statistics on their own; but for the most part, patients rely on their doctor’s referral and prefer hospitals close to home. Even a nationally known transplant program, such as the one at the University of Minnesota Medical Center, Fairview, receives about 60 percent of its patients from the Twin Cities and only a few from outside Minnesota, says John Lake, M.D., executive director for solid organ transplantation.
However, if the information is packaged and presented in a certain way, it can influence patients’ decisions.
Golden Valley–based United Resource Network (URN), a UnitedHealth Group company that manages transplant benefits for UnitedHealthCare, other health plans, and self-insured employers, has found that patients select high-quality providers nearly every time when they’re presented with and provided help interpreting the facts.
URN works with about 14,000 transplant patients a year, or about 10 percent of the entire U.S. transplant population. Prior to 2002, transplant patients were given a discount if they had their procedure done at a hospital on URN’s “centers of excellence” list. Despite that incentive, only 60 percent of patients chose those centers, even though their quality was superior, says Richard Migliori, M.D., URN’s chief executive officer.
“Most people didn’t realize the difference in capabilities from center to center in transplantation [under the old system], despite the fact it was published,” Migliori says. Because of that, URN decided to become more proactive and not just say a center was excellent but also provide patients with information about those centers.
In 2002, URN started allowing patients to pick from all centers on which UNOS gathered information and provided them with details about those centers’ survival rates, costs, waiting times, and patient satisfaction scores. URN then paired patients with a nurse, who helped them make sense of it all. Today, 98 percent of URN’s transplant patients choose one of the 120 transplant centers and 626 programs that meet the company’s “center of excellence” designation.
Migliori says the switch has helped patients by directing them to the higher-quality centers, where they have a better chance for a good outcome. It also reduces health care costs. “We think that 15 percent of the bill is reduced by directing care to high-quality centers,” he says, noting that transplants can cost as much as $1 million.
Interpreting the Numbers
That patients need help interpreting data on quality should hardly be surprising. Even information on volume, which is widely recognized as an indicator of quality, can be misleading. For example, Abbott Northwestern Hospital’s heart transplant program failed to meet Medicare standards for minimum number of procedures in 2005. Abbott performed eight transplants—four fewer than the Medicare threshold of 12. But the program’s survival rate was comparable to the national average.
In addition, bigger isn’t always better when it comes to transplant centers. For example, research shows that mid-sized programs transplanting between 40 and 120 livers a year seem to have better outcomes than larger programs. Bhargav Mistry, M.D., who performs kidney and pancreas transplants at MeritCare Hospital in Fargo, says programs such as his, which did 25 kidney transplants last year, can have outcomes as good as the large centers. Advances in transplant medicine and the ease of learning new techniques and communicating with colleagues have helped level the playing field between large and small centers, he says.
He even sees advantages to working at a smaller center. He says it is easy for him to schedule the operating room, he has quick access to labs and X-rays, and he’s part of a cohesive team. “Because we are in a smaller institution, it is usually a small team of people taking care of the patient. We know the patient, and it is so much easier to get things done.”
Protecting Resources
Public reporting clearly has provided an important check on the quality of transplant centers. It enabled the Los Angeles Times to expose failings of Kaiser Permanente’s start-up kidney transplant program last summer. In the fall of 2004, Kaiser stopped paying for kidney transplants outside its network and required 1,500 patients to switch to its start-up program at Kaiser Permanente San Francisco Medical Center. Times reporters analyzed the UNOS database and found that the change had significantly harmed patients. At Kaiser’s new center, twice as many people died while on the waiting list for kidneys in 2005 as received them. In California as a whole, twice as many patients received kidneys as died, the Times reported. Kaiser responded by shutting the program down.
Transplant surgeons say that it is essential to publish data about results so that problematic programs that might waste a resource as valuable as a donated organ or harm patients can be identified. “If you continuously fail to meet the expected outcomes, you will be forced to close down or have a change of personnel,” Mistry says.
Who Benefits Most?
Lake points out that patients being guided by companies such as URN, which are working for payers, need to understand that insurers factor price into their rankings of transplant centers. “To be a URN center of excellence, you need to have a basic requirement for good outcomes, staff, and facilities,” he says. “But make no mistake about it. They are going to negotiate on price, and if you are out of line, they are not going to select you.”
Roger Evans, Ph.D., a nationally recognized consultant on organ and tissue transplantation, based in Rochester, Minnesota, says the system of publicly reporting data has been more helpful to payers than to patients because patients often have little medical knowledge, loyalties to local institutions, and a strong desire to stay close to family and friends during the course of their care. “Practically, I think if a patient or family members have received care at a particular hospital, I don’t think the quality ratings mean that much [to them],” he says.
Payers, however, know the cost implications of sending a patient to a lower-quality center, which can result in complications, Evans says. Payers also saw that the UNOS data allowed them to establish preferred relationships with certain centers without sacrificing quality. Once the UNOS data became available, he says, payers were able to hold quality constant, negotiate hard for discounted prices, and exclude those high-quality centers that did not buckle on price. On the flip side, he says, centers were willing to strike a deal with companies such as URN to have the opportunity for more referrals. Evans questions whether third-party payers such as URN drive down prices and save money in the aggregate because they add another layer of administrative costs. He’s also concerned that payers such as URN have an interest in keeping networks small because small networks are less costly to manage. Taken to excess, he says, this could harm patients. For example, the mortality consequences of complicated long distance referrals of very sick patients have never been studied.
Perhaps the greatest benefit of public reporting has been exposure of the fact that the quality of care does vary among transplant centers, and that matters a great deal when it comes to a complex procedure such as a transplant. This alone should make patients realize that it’s in their best interest to be aware of a center’s quality statistics, Lake says. “It’s quite likely you can go most places for a laparoscopic cholecystectomy and get a good outcome. That may not be true for bone marrow transplantation for Fanconi’s anemia.” MM
Scott Smith is a staff writer for Minnesota Medicine.