What's Your Perspective?

  • Accounting for Transplantation in an Accountable Care Organization (ACO)

    Dr. Sander Florman

    Sander S. Florman, MD
    The Charles Miller, MD Professor of Surgery
    Director, Recanati/Miller Transplantation Institute
    Mount Sinai Medical Center

    Accountable Care Organizations (ACOs) are programs designed by the Center for Medicare and Medicaid Innovation (CMMI) under the Affordable Care Act (ACA) to decrease health care costs while improving the quality of care.

    An ACO is composed of a group of providers (e.g., physicians and/or hospitals) that are contracted with Medicare to participate in the Medicare Shared Savings Program. If they can successfully reduce the costs of care for the group of patients they treat while maintaining pre-specified quality targets, they are then eligible to split the savings with Medicare. 

    Patients do not enroll in an ACO; rather, the ACO is held accountable for the patients attributed to them based on which patients they treat. There can be no marketing to patients or cherry picking—patients are assigned to an ACO by Medicare based upon their using one of the ACO physicians for the plurality of their primary health care needs (or using a specialist physician who is a member of the ACO for their health care needs if no primary care physician is identified). While patients cannot opt out of having their costs counted toward an ACO, they can decline to share their claims data with the ACO.

    Once assigned, Centers for Medicare and Medicaid Services (CMS) divides an ACO’s patient list into four cost categories, understanding that these characteristics partially predict utilization and cost: dual eligible (e.g., Medicare and Medicaid) patients, disabled patients, aged non-dual eligible (e.g., average worker who ages into Medicare eligibility after 65 years of age), and End-Stage Renal Disease (ESRD) patients. Each category has a calculated average cost of care based upon a 3-year average cost for similar patients. This is the basis for determining whether spending has been reduced and savings have occurred during the ACO performance year.

    Patients whose cost of care is very high (i.e., > 99th percentile in their assigned category) have their costs truncated at the 99th percentile for their specific patient group. This is intended to protect the ACO from failure due to outlier costs beyond their control. Not surprisingly, the costs for ESRD patients in an ACO will have a higher average annual spend rate as well as a higher truncation point than that for the other groups. 

    There are many benefits to ESRD patients inherent in the robust care coordination provided through an ACO.  In addition to this essential care coordination, the benefits of transplantation are well established, yet there are complex implications for an ACO when their ESRD patients undergo successful transplants.  

    The costs of a transplant raise the expenditures for the ACO. Three months after transplant, however, these patients are reassigned by CMS from the higher-cost ESRD category into one of the three other patient pools with less costly peers. Post-transplant, these ESRD patients are much less expensive to manage due to not needing dialysis. These lower costs are not compared to what the patient would have incurred if not transplanted, but rather to expected costs if they’d never had ESRD at all. This means that the ACO sees less of the long-term cost savings of transplantation.

    With accountability for costs and quality being driven into the health care system by programs such as ACOs, thoughtful consideration needs to be given to ESRD patient populations—especially in medical centers performing transplants—so that encouraging transplantation is central to care and payment models… from my perspective.


    Have a different perspective? The ASTS Communications Committee would love to hear it and share it with your fellow members in an upcoming issue of the Chimera. Comment below or send your thoughts to asts@asts.org!
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  • Balancing Basic/Translational Research and Clinical Practice

    Dr. Satish Nadig

    Satish N. Nadig MD, PhD
    Medical University of South Carolina
    Assistant Professor Surgery,
    Microbiology, & Immunology Transplant Surgery

    Balancing basic/translational research while trying to establish oneself clinically can be a daunting task. Currently, very few transplant surgeons leave their fellowship with thoughts of establishing a basic science lab to complement their clinical practice. In my opinion, one reason for this trend is diminishing returns.

    The work of starting a laboratory from the ground up is perceived as one that will detract from the enjoyable things about transplant (i.e., the surgery itself.)  Additionally, the barren job market means that new fellows inevitably face intense pressure to conform to the wants and needs of their particular division or department. Often this translates to a purely clinical job with no room for research endeavors; at least, that’s how it’s perceived at the moment.

    Actually, the opposite may be true. There are a lot of academic centers around the country that are interested in encouraging young surgeons to pursue basic science research and are willing to support them. But how prepared are the graduating fellows to take advantage of that support? I have some thoughts on this point that I’d like to share.

    As a junior faculty member, I have received my partner’s support in both my efforts to establish an immunology lab and my efforts to grow as a multiorgan transplant surgeon. The key word here is support. But before all that can happen, there are concrete steps that should be taken before signing on the dotted line.

    First, have a plan. This plan or idea must be feasible and something that you’re familiar with, whether it’s due to previous experience or because you’ve developed an intense interest in the topic. 

    Second, identify faculty at your target institution who share your passion; you can’t do this alone. Start talking with these potential mentors and collaborators while you’re still in your fellowship and make plans to start experiments immediately after your arrival or even earlier. 

    Third, hire a good lab tech. I can’t stress this point enough; a good lab tech will make a tremendous difference. Have some space assigned to you, whether it’s a bench in someone else’s lab or your own space.

    Fourth, block off time to write grants and start right away with foundation grants. Create a realistic timeline for submission of your first NIH grant and stick to it.

    Fifth, listen carefully to the advice of the successful people around you; many of them have made mistakes that they can help you avoid.

    Sixth, don’t listen to everyone—do what makes sense to you. 

    Finally, collaborate, collaborate, collaborate. Collaboration is the key to keeping your lab moving—you’re too busy clinically to stay on top of it.

    The need for real surgeon-scientists in transplant surgery is more pressing than ever before. Clinical transplantation was built on the foundation of research and innovation, two qualities that may be waning in the face of poor funding and regulation. Without the passion of the next generation, the pace of progress in transplantation will slow to a crawl… from my perspective.

    Have a different perspective? The ASTS Communications Committee would love to hear it and share it with your fellow members in an upcoming issue of the Chimera. Comment below or send your thoughts to asts@asts.org!

    Go comment!