UNIVERSITY OF CALIFORNIA ALL AUDITORS CONFERENCE What you need to know on optimizing a transplant program s operations

1. UNIVERSITY OF CALIFORNIA ALL AUDITORS CONFERENCE What you need to know on optimizing a transplant program’s operations Napa, CA 2007 Alexander Aussi, BSN, RN, MBA Transplant Administrator

3. UCSD Medical Center: Overview UCSD Medical Center: San Diego’s only university health system Leads the way in bringing 21st century health care to the region Tradition of serving a diverse population A young campus - key dates 1962: SOM established at UCSD, first class enters in 1968 1966: UCSD assumes operation of County’s Hillcrest hospital 1981: UCSD purchases hospital 1993: Thornton Hospital opens 2002: Pharmacy school opens

4. UCSD Medical Center John M. & Sally B. Thornton Hospital, La Jolla Opened in 1993 5,200 Annual Discharges 86 Average Daily Census 119 Total Licensed Beds

5. UCSD Medical Center A Regional Resource UCSD Stroke Center awarded region’s first Disease-Specific Certification by Joint Commission on Accreditation of Healthcare Organizations UCSD Cancer Center of only 39 NCI-designated Comprehensive Cancer Centers in the nation Comprehensive Organ Transplant Center Regional Trauma-Burn Center More than 60 UCSD physicians named among San Diego’s Best Doctors in 2006

6. UCSD Healthcare is the only university based health system serving the region, so we have a unique mission (Review clinical vision)UCSD Healthcare is the only university based health system serving the region, so we have a unique mission (Review clinical vision)

9. Indicators of Excellence Our programs and staff are consistently recognized for excellence. These are just a few of the indicators.Our programs and staff are consistently recognized for excellence. These are just a few of the indicators.

10. Indicators of Excellence UCSD Medical Center has received 2nd DHHS Medal of Honor for organ conversion rates of 75% or higher; named among top 3% of hospitals in nation for organ conversion

11. UCSD- Center for Transplantation Milestones 1968 first kidney transplant* 1993 first kidney/pancreas transplant* 1993 first successful liver transplant 1997 first isolated pancreas transplant* 1999 first living-related pediatric liver transplant* 2001 first living-related adult liver transplant 2002 first liver/kidney/pancreas (multiorgan) transplant* *First in San Diego

12. Regulatory /Quality Assurance Environment Organ Procurement and Transplantation Network (OPTN) United Network for Organ Sharing (UNOS) Scientific Registry of Transplant Recipients (SRTR) Centers for Medicare/Medicaid Services (CMS) Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)

13. OPTN (www.optn.org) - Established by US. Congress - National Organ Transplant Act in 1984 - Unified Transplant Network, Operated by a Private Non-Profit Organization under Federal Contract - Membership consists of Transplant hospitals and Organ Procurement Organizations (OPOs) Regulatory /Quality Assurance Environment

14. UNOS (www.unos.org) - Private non-profit “Management” organization - Awarded the contract to Administer the OPTN - Develops policy and provides oversight of policy implementation in transplant centers (UNOS policies are normally prescriptive) - Manage Organ allocation in the US. Through the Organ Center in Richmond, VA. - Collect data on every transplant in the US. - Reviews Transplant programs Q 3years Regulatory /Quality Assurance Environment

15. SRTR (www.ustransplant.org) - Scientific Registry for Transplant Recipients - Located at the University of Michigan - Provides crucial Data analysis / Simulation Models using scientific methods - Acts as Decision Support to the OPTN Board of Directors (Policy makers through UNOS) - Publishes Center Specific Reports every 6 months - Focus on Observed stats, Expected stats and the Pi value Regulatory /Quality Assurance Environment

17. CMS (www.medicare.gov) - Special Conditions of Participations (COP) for Transplant Hospitals by Organ Type - Stem from the End Stage Renal Disease program Regs in 1973-1974 - Revising COPs since 2005 – Expected in April 2007 - Focus on volume and SRTR outcomes - Requires all Transplant programs to reapply (90, 180) Regulatory /Quality Assurance Environment

18. CMS - Reimburses Certified Transplant Centers at Cost for a substantial amount of Direct and indirect Operation in Organ Acquisition and patient work-ups Plus, Plus, Plus… - Reconciliates $ with Transplant Hospitals yearly - Is the Best payor for any Transplant hospital system - Subcontracts with the state to audit Kidney Transplant programs every 3 years and sooner for patient grievances - Depends on UNOS for notification of Program non-compliance - Hospital Medicare number currently tied to Transplant Program’s - Significant variances on Transplant cost reports in addition to whistleblowers normally drive OIG audits Regulatory /Quality Assurance Environment

19. JCAHO - Transplant Programs are Historically exempt - New Tracer Review Methodology follows patient to all departments where services were provided - Proposed rules for Voluntary Transplant program Certification - Expected after the new CMS Conditions of Participation for Transplant Hospitals are published Regulatory /Quality Assurance Environment

20. Regulatory /Quality Assurance Environment

21. Transplant is heavily Regulated? Patients transplanted are living longer? Waiting lists are growing fast and number of donated organs remains relatively unchanged? Questionable Clinical Practices? (In some programs) ?UNOS Oversight? Why Pick on Transplant Programs?!

23. For more liver waitlist and transplant statistics, see Annual Report Tables 9.1 through 9.5 and CSR Liver Tables 1 through 6. For more liver waitlist and transplant statistics, see Annual Report Tables 9.1 through 9.5 and CSR Liver Tables 1 through 6.

24. Medicare is fetching for additional $s Transplant Hospitals have inadequate systems in place to track data for Their Transplant Cost Reports as Federally Mandated IN SOME WEIRD TIME TO COME, WE ARE ALL GOING TO FIND OUT THAT WE ARE BEING SUBJECTED TO : Why Pick on Transplant Programs?!

25. THE MEDICARE SMELL TEST!

26. OIG Audit Report (Nov. 06) Regulatory /Quality Assurance Environment

27. Transplant is the Last frontier in Hospital Medicine that is reimbursed based on “true” costs through the Organ Acquisition Cost Centers Medicare is a major revenue stream for transplant hospitals and programs Optimal reimbursements require optimal reporting of costs Transplant cost report is only 3 pages long (W/S D6) Why is the Medicare Transplant Cost Report Important?

28. Medicare Regulation for Organ Acquisition Reimbursement - 42 CFR, Section 412.100 Special Treatment: CTC - CMS Adjusts the Transplant DRG rates to remove organ acquisition costs - Hospital payments are adjusted to compensate for the reasonable expenses of “Organ Acquisition” Why is the Medicare Transplant Cost Report Important?

29. Medicare Regulation for Organ Acquisition Reimbursement “Organ Acquisition Expenses include both Live Donor and Cadaveric Organ Acquisitions irrespective of whether the organ was obtained by the hospital or through an OPO.” Why is the Medicare Transplant Cost Report Important?

30. Organ Acquisition Costs Include 1- All Tissue typing and Crossmatch services including services furnished by independent labs (provided they are UNOS approved to provide the service) 2- Living Donor and Recipient Evaluations 3- Operating room and other inpatient ancillary services applicable to the donor 4- Other costs associated with excising organs, such as donor routine and special care services Why is the Medicare Transplant Cost Report Important?

31. Organ Acquisition Costs Include 5- Charges to register the patient with the UNOS registry 6- Preservation and Perfusion costs 7- Surgeon fees to excise the CADAVER organ 8- Transportation of ORGAN from and to the transplant hospital 9- Costs for organs acquired from other OPOs 10- Cost of services applicable to excisions rendered by residents and interns NOT in approved teaching programs 11- All DIAGNOSTIC Pre-transplant admission physician professional services, including lab, pathology and X-Ray interpretations Why is the Medicare Transplant Cost Report Important?

32. Organ Acquisition Costs Include 12- Direct Costs of Transplant Personnel (clinical and administrative) assigned for Pre-Transplant and Outreach activities 13- Other Direct Costs related to “12”: Travel and meeting expenses, professional education, subscriptions, telecommunications, professional dues, equipment maintenance and rental, auto mileage, office rent, office supplies, parking, printing and publications. Why is the Medicare Transplant Cost Report Important?

33. Organ Acquisition Costs Include 14- Indirect Costs to include: Building Depreciation & Interest - Housekeeping Hospital Admin and Finance - Laundry Data Processing - Plant Operations Accts Receivables/Collections - Purchasing Admissions - Telephones Med Records - Dietary Nursing Admin - Cafeteria Personnel Benefits - Central Supply Equipment Depreciation and Interest - Social Services Why is the Medicare Transplant Cost Report Important?

34. Would have the Ability to Track patients by visit type and reason for the visit all through the 4 phases of the Transplant process Phase I – Referral and Evaluation Phase II - Maintenance Period Phase III - Actual Transplant (DRG) Phase IV - Post Transplant follow-up (APC) The Successful Transplant Program will Have the following attributes

35. Would have established a separate acquisition cost center for each organ Would have managed to account for all revenue streams generated from professional fees and purchased services Would have divided the clinical flow into Pre-versus Post Would have allocated the program’s higher number of personnel to facilitate the patient’s access to transplantation Would have allocated the program’s higher percentage of resources including office space to support Pre-transplant patient evaluations and maintenance activities while on the list Would have agreed with the physicians to provide ample administrative time paid at market rate/hour and would have documented time spent on a monthly basis Would have implemented a robust Transplant Dbase that interfaces with all clinical software to manage new regulatory bylaw changes Would have implemented a system for performance review on a regular basis and ensure that the changes in practice are made to avoid citations Would have successfully implemented a system to review Commercial payor contracting practices The Successful Transplant Program will Have the following attributes

36. WHAT WERE OUR RESTRUCTURING & RESOURCE ALLOCATIONS EFFORTS ? DO THEY TIE THE TRANSPLANT PROGRAM TO OVERALL UCSD-MEDICAL CENTER STRATEGIC PLAN?Have we Optimized Our Operations?CASE STUDY – KIDNEY TRANSPLANT

37. ON PEOPLE:

38. ON SERVICE:

40. ON QUALITY:

44. ON INNOVATION: