Académique Documents
Professionnel Documents
Culture Documents
Robert S. Brown, Jr., MD, MPH Associate Professor of Medicine & Surgery Chief, Division of Liver Disease & Transplantation Columbia University College of Physicians & Surgeons New York-Presbyterian Hospital
I have no financial relationships to disclose with in the past 12 months relevant to my presentation My presentation does not include discussion of off-label or investigational use
Tennessee Williams
hard work and cognitive-fellows want more procedures Cognitive collections<cost Need to depend on other income sources
GI Division revenue Doing GI--cannibalize procedures from referring MDs Research Transplantation
is the best answer as it provides a full range of tools to hepatologist but need to make the numbers work Adequate staffing -- prevent burnout Adequate finances If you build it (right) they will come
want this service -comprehensive transplant center Liver transplant programs make hospitals money and improve quality of care Catalyze translational and basic research
Liver Transplantation
How to afford it?
Hepatologists
collections<cost Drain on GI can leads to significant rifts Hepatologists generate significant income for
Hospital Surgery, anesthesia Radiology Endoscopists, cardiology
Liver Transplantation
How to afford it?
Have
only surgeons Get Hospital support for hepatologists Improve contracting Create an integrated business unit with surgeons and hospital Need to move beyond piece-work mentality
Group Practice Long term partnership with hospital Global contracting Service line concept
In MELD era need to care for very sick patients for transplant program to survive HCC--need to screen and manage
List management and outreach are critical Theres enough money--share with partners not poorer divisions in surgery
Surgical model 7 Surgeons 1 hepatologist 100 OLT Surgeons <15 cases/yr Only can evaluate 10 cases/week
Medical Model 3 Surgeons 4 hepatologists 100 OLT Surgeons >30 cases/year Can evaluate >40 cases/week Savings = 1 FTE + salary differential
Medical and Surgical patients, not limited by diagnosis (e.g. HCC) Need dedicated team for continuity of care and education Dedicated unit improves quality of care and education of patients and families Housestaff - ideally medical and surgical residents PA/NP ARE needed Ensure compliance with protocols and clinical pathways, educate housestaff Daily rounds with two attendings
Joint practice-hepatology and surgeon Each patient assigned to primary hepatologist and NP/PA Transplant Coordinators--preferably NP/PAs
Routine management of pre-OLT candidates and Postoperative immunosuppression Hepatology practice and research patients Patient education, both pre and post
Clerical support and electronic data essential Surgeons participate in evals, hepatobiliary surgery and immediate post-op period
driven primarily by length of stay--ICU and total Hospital costs are largest component Medication costs relatively constant except for IV infusions
Liver Transplantation
Components of cost
Evaluation Candidacy (per month) Procurement Hospital (to discharge) Physician fees Follow-up Immunosuppressants Total Average Charge ($) 11,000 10,600 24,700 188,900 42,600 26,400 10,300 314,500
From Milliman and Rob ertson, Inc., R. Hauboldt, 1996 . accessed at: http://www .gao.gov/spec ial.pubs/ organ/ chapt er7.pdf# search ='gao%20a nd%20c o sts%20and%20or gan%20tr ansplant'
Liver Transplantation
Components of cost
Hospital
Hepatology
M e dications Physicia n Labs Organ procur e me nt
Age
3 Phases
Phase I--pre-OLT. Can separate initial evaluation Phase II--OLT admission +/- 30-90 days post-OLT Phase III--post-OLT care
Hepatologists involved in all 3 phases Phase I and III usually reimbursed as % charges Phase II usually contracted amount with outlier provision Hepatologist is poorly reimbursed, particularly in Phase II (or any inpatient care)
Evaluation
Medical Surgical Tests (radiology, laboratory, cardiac)
Pre-transplant management
Mostly medical care Hospitalizations for complications lucrative for hospital, not physicians Variable based on waiting time Other than discounted charges, difficult to contract for Eliminating/reducing this phase major advantage of living donation
Admission
Surgery, anesthesia, radiology well reimbursed Often money loser for medicine Hospital profit most marked
Post-op
Often included in global Only a problem if readmission or iv infusions given in clinic Surgical post-op visits traditionally not billed
%
54% 2.7 19 11 15
Reimbursement
$13,500 675 4700 2700 3300
Joint practice with surgery Management fee--~20% (~$5K) removed from risk pool
Economics of Transplantation
How to make a profit
Transplant Hepatology
The future
Reclaim procedural revenue Comprehensive care like cardiology
Ultrasound--probably all GIs should do Transjugular biopsies and pressures Percutaneous tumor therapy Laparoscopy Probably no colonoscopy, just EGD +/- ERC, ESO
Better care and more appropriate decisions Reason for additional year for CAQ--will attract more fellows ASHE
Transplant Hepatology
Summary
Hepatology requires an integrated business unit that recognizes downstream revenue Surgery and hospital are necessary business partners--deliver value to partners Know your costs, make the money work and embrace collaboration The future will bring more procedural revenue into hepatology Motto for tomorrow -- the futures so bright I gotta wear shades--Timbuk3