Understand outcomes and how they benefit candidates and health plans.

Advanced Achievement in Transplant Management Mastering the Centers of Excellence Concept This first section of the AATMC program builds the foundation of the transplant COE concept and provides summary discussions of the in-depth sections that will follow as part of this curriculum. It is important that nurses achieving an AATM certification be fluid and skilled in communicating with potential transplant candidates. The window of opportunity to share outcome information and influence a candidate s transplant center selection, is often short, so mastering the concept of outcome improvement is part of this program. Listed below are some of the major concepts and ideas associated with the Centers of Excellence concept that we feel are important for nurses to be able to communicate. A multiple choice proficiency test is required to pass this portion of the AATMC. Section Objectives: Become fluent in discussing the history and purpose of the Centers of Excellence (COE) Concept and networks. Understand outcomes and how they benefit candidates and health plans. Be able to identify the types of networks, discounts available and the pitfalls and advantages of each type. As the primary communicator, develop a basic understanding of the informational needs of each party. 1. Overview and Historical Development Over twenty years ago, an insurance company assembled a panel of experts to evaluate potential risks for the emerging solid organ and bone marrow transplant industry. Unless otherwise excluded, transplant care is a covered benefit of most health plans, and with

transplants becoming more common place at the time, concerns about their enormous costs had to be studied. At the time, transplants were occurring only at a handful of leading Universities and teaching medical centers, so the population available to study and compare was limited. Claims, medical records, and surgical outcome data was collected and evaluated. Another factor that initiated this study was the manner and methods in which transplant care was delivered. The stages of transplant care were evaluation, pre-transplant care, transplant episode and post transplant care. Most transplants happened in an academic setting often a great distance from where the candidate lived, so capturing claims and visit information was easy, and this is the case even today. After the information was collected and evaluated, the consensus was that although transplant care was expensive, those expenses could be managed by promoting access to centers where a great outcome was likely to occur. Several outcome measures were considered, such as average length of stay, re-transplant frequencies, and graft and patient survival data. By collecting and comparing outcome information from center to center, associations with variances costs and wellness began to emerge. Bottom line, an experienced and well functioning surgical team often produces good outcome transplants, which simply uses fewer units of service and costs less. On the flip side, an inexperienced transplant team often produces a wide range of surgical outcomes, resulting in long lengths of stay, surgical complications, less than full organ function and sometimes death of the member. A transplant with a bad outcome results in complications and costs the health plan more money in both the long and short terms. The recommendation was that transplant care was both a statistically predictable and financially manageable event. The concept of the Centers of Excellence was born, which is a term used today for transplant centers where a good outcome transplant is likely to occur supported by the collection of transplant outcome data. 2. Understanding Outcomes

The basic concept that not all transplant surgeons and programs produce identical results should not be complicated to communicate and is an important message for transplant candidates to grasp. Clearly a transplant surgeon performing his/her first transplant or an experienced transplantor performing his/her first transplant at a new center with a new team, would not be expected to produce the same outcome as an experienced transplantor working with an experienced team. Transplants are complicated procedures, and if not done properly, can lead to life-long complications or even premature death. Selecting a transplant center and team is perhaps one of the candidate s most important decisions of their life so help your candidate s find the best outcome center available to them! The term outcome is applied to many programs and aspects of life. An outcome is the result or end product of some action or occurrence. The term outcome has been used and applied to healthcare for a very long time. Much of the progress in medicine has been the result of trying new procedures and evaluating the outcome/results compared to other methods. Collecting and interpreting results/outcomes is not a perfect process; applying leaches to remove toxins from the blood likely did not produce the improved outcomes most thought it would including many leading professionals of the day. All transplant centers and transplant programs collect and report a large number of outcomes on the transplants they perform. All reputable transplant centers in the United States collect and report similar outcome data sets. Times are changing, not long ago access to those outcome data sets were limited to select Centers of Excellence networks and governmental agencies. Now, much of the same outcome information is available to anyone with web access and is displayed in easy to read and interpret formats. Some websites actually risk adjust patient mix and outcomes which provide a more comprehensive picture of how your candidate might do at a specific program. With access to this information, it is possible to compare and contrast the surgical team s performance at one facility verses another. As a case manager, it is important that you are able to find those websites, understand the contents, and discuss relevant outcome measures with your candidate. True COE networks often have prepared simplified resources for members like Facility Data Sheets and Candidate Education Booklets. Website tours and outcome discussions will be covered in-depth in following study sections

Some of the outcomes a COE network might collect while evaluating transplant programs include: Solid Organ: Procedure volumes: by program, by year for the last five consecutive years Graft survival: by one month, one year and three year intervals. Patient Survival: by one month, one year and three year intervals. Median wait times by blood type: reported and measured in days. Blood/Marrow: Volume by type (auto, allo, related/unrelated, cord blood etc.): by year for the last three consecutive years. Length of stay: by median days, by procedure type. Patient Survival: by type, by year for the last three consecutive years. Since a transplant is a procedure of last resort, obtaining good information and encouraging a sound decision may save the life of your client. 3. Quality Assurance Programs Benefits and Functions Transplant networks adhering to the Centers of Excellence concept always have a rigid Quality Assurance program. Not all transplant networks adhere to the COE concept and provide little more than access to a network of providers offering discount arrangements. There is a very limited number of networks today that employ the COE concept, so ask questions about their processes be fore recommending a transplant network to a client or recommending a transplant program to a member.

Quality Assurance Programs within a transplant network actively collect, analyze, compare and create participation standards for COE networks. INTERLINK for example, does not extend an invitation to participate in the COE network until outcomes have been collected, analyzed and credentials verified. Site visits are performed and surgical directors interviewed before the program is recommended to the Quality Assurance Committee for inclusion in the network. Collecting outcome and surgical information is an annual task for as long as the program wishes to participate in the COE network. Members of the Quality Assurance Committee collect and input information into approved forms and present them at monthly committee meetings for new programs and for programs continued participation. Programs not meeting Quality Assurance Committee standards are removed and others added at the Quality Assurance Committee meetings. Quality Assurance Committee meetings and processes are very formal in nature. Although "Centers of Excellence" networks do not guarantee a good outcome, a recommendation with a bad outcome may incur a greater risk of liability without substantial clinical and due diligence by the "Centers of Excellence" network. 4. Legal Considerations & Benefits from COE Quality Assurance In today s litigious world, it is not recommended that a nurse or medical professional provide facility selection choices to a member without some entity performing some level of a duediligence review. Almost every month, there are legal entities on the INTERLINK website for some undeclared reason. Although INTERLINK is unable to promise a good outcome, we can declare and share the depth and complexity of our facility/program monitoring process. It is important to clearly communicate that the centers included in a Centers of Excellence network undergo rigorous credentialing processes and outcome reviews, but individual outcomes are in no way assured. Transplants are complicated surgical procedures and, as with all medical procedures, a good outcome cannot be promised or assured. A more accurate point to communicate is that centers in the "Centers of Excellence" network have their credentials

verified and outcomes monitored; given their level of surgical and medical excellence, a good outcome is likely. The Quality Assurance Committee processes enable health plans and "Centers of Excellence" networks to offer a limited number of transplant centers to members. It is the regimented process of program selection and monitoring that provide the environment to assure patients they are in good hands. 5. Improved Outcomes - Benefits for Member A transplant, as with all medical procedures, brings a certain level of risk. Transplant risk can be compared and evaluated to ascertain sound information to make thoughtful decisions. As a transplant network, we often learn that a candidate has selected a center only because it is closest to where they live, even though the transplant program has completed only a few procedures. The risk to this candidate is greatly increased possibly resulting in a long hospital stay, rejection, only a partial recovery to health, or death. All members want a great outcome, but they often fail to take the necessary actions to ensure such an outcome for several reasons. Most often, candidates are unaware of their ability to choose a center other than the local center or are uncomfortable discussing or evaluating their options with their physician. Obviously this discussion is made easier for the case manager when benefit language and benefit limits encourage members to seek transplants on a national level. During the transplant facility selection process, the case manager may need to contact and speak with the referring physician regarding COE facilities. Physician referral patterns strongly influence where members seek transplant care. With or without benefit language, discussing the benefits of a Centers of Excellence network with the member as early as possible is important. Only one network has invested heavily in candidate educational tools. Candidate Education booklets are ordered by case managers for roughly 80% of all their referrals, even those that are already headed to a designated COE center and program. Booklets are ordered by the case manager at the time of referral and are customized for the patient and the programs of potential interest. Booklets are asse mbled and expressed to the case manager to help facilitate the case manager/candidate

conversation about outcomes and programs of potential interest. These comprehensive booklets, used appropriately, will provide the member with the necessary information to find a good outcome program and center. Not all transplant centers and programs are equal even inside those Centers of Excellence networks with the most limiting criteria. Cancer Centers often have special areas of interest and are known for treatments of specific conditions. Helping your members find these centers is a great service, but with limited time and resources to do research, how can a case manager find these programs? COE networks understand the benefit of a great outcome, and often gather program specific information during site visits and through the credentialing process, and some networks make their medical profession als available to discuss specific centers and treatment programs. For example, INTERLINK s Vice President of Quality Programs and Chief Medical Officer perform on-site credentialing duties. Often they learn of centers with specific interests and can share them with you. As an AATMC recipient, they are available to you and can provide valuable information to share with the member. Since members often select their transplant center and program so rapidly, it is advised that you discuss facility/center options with the network and member as early as possible. An informed and knowledgeable case manager has immediate credibility and often success in re-directing members to centers with better outcomes. 6. Improved Outcomes - Benefits for Health Plan The benefit of a great transplant outcome verses a bad transplant outcome can be millions for a health plan. For the last four years, INTERLINK has reduced the gross billed charges and the contract allowable payments for its liver transplants. This is remarkable given that medical inflation and rising organ costs have been increasing the projected costs of transplants for years. Our winning formula: i mproved medical outcome + volume negotiated rate = lower transplant costs. Outcomes and clinical proficiency have continued to improve across the nation, but not at all centers equally. With the wide-spread adoption of the Centers of Excellence concept, COE networks now direct a bulk of the transplant candidates to a carefully selected number of transplant centers. Participating centers benefit from the increased volume; the surgical teams

benefit from increased surgical perfection; the health plan benefits as their member s regain their health faster; and the member realizes a greater return to health. On the flip side of this coin, as COE networks become more common in health plans across the nation, there are many centers that have declining referrals, leading to fewer transplants and their surgical teams have fewer transplant cases to perfect their surgical techniques. The result, unfortunately, is that their transplant recipients and health plans are exposed to a much larger range of potential outcomes and costs. It is not impossible for these centers to have a great outcome, but the risks to the member and the health plan are enormous and growing. Although experienced negotiators can negotiate excellent out of network contract terms, the financial risks to the plan are still growing. Most consultants and networks believe that transplants occurring at non-credentialed centers pose the largest transplant cost risk to a plan, both in the short and long term, and should be re-directed whenever possible. A bad outcome transplant can lead to re-transplant exposure, long lengths of stay, infections, poor organ/marrow adoption and many other complications. These complications all drive-up gross billed charges and many non-coe centers now require case rates with terms that limit their losses (stop loss provisions). Let s say for example, a patient has a liver transplant with complication which results in a long length of stay which ultimately ends with a re-transplant. The member survives, but the bill has reached $1,000,000. Although the case rate is $145,000, the additional costs trigger a contract provision that states that in no event with the case rate yield a discount greater than 45%. The good news is that the health plan saves $450,000 through the combined effort of their case management provider and negotiator, but the bad news is that the member is compromised and the plan now must pay $550,000 for an inferior transplant outcome. 7. Understanding Program Selection Processes Opportunities for Influence In some instances, candidates may have months or even years to select a transplant center, but for some there may be no time for a choice at all. Medical referral patterns, client type, location, medical severity and benefit language all affect facility selection. This section is intended to address the most common candidate decision methods reported to transplant networks and provide you with an understanding of the opportunities to provide critical information to influence facility selection. Unless benefit incentives require exclusive use of a COE network, referral from one physician to another likely remains the most common pathway to a transplant center and program. Within any medical community, there are established referral pathways for complicated care that

may have existed for decades. These pathways may be the easiest course for the professionals due to familiarity and comfort, but they may lead patients to centers performing few transplants, new programs and centers with poor outcomes. Often when cases are identified, members are following the medical referral pathway and entering a transplant program without gathering information or even realizing they have a choice in the location of care! Comparing outcome data from the proposed transplant program with one or more COE program may encourage your candidate to seek care elsewhere. Location or proximity from where the candidate lives unfortunately is also a very common transplant center selection process. If a member operates under the belief that all transplant centers and programs produce identical outcomes, then why not pick the most convenient service location? The fact of the matter is that transplant volumes and outcomes vary greatly from one center to another. A discussion with the member to compare and contrast outcomes at the proposed center with those of COE centers may change this fundamentally flawed belief. A transplant is a life changing event and depending upon the outcome of the surgery, their life may improve or be filled with life-long complications and limitations. Medical severity of the member s condition may dictate the transplant center location, even with the strictest benefit language penalties. Transplants, at least in today s world, are often procedures of last resort. In most cases, transplant recipients would have expired shortly without the life saving procedure. The problem you may encounter is that your member s condition is so dire that to transfer or redirect may present additional risks. In this instance, check the member s benefit plan language and communicate any limitations or benefit reductions to a qualified negotiator. By far, the most sincere redirection comes from benefit language incentives and penalties; in fact, the greater the incentives or more severe the penalty, the more receptive the member will be to new and beneficial information. There are many types of benefit language, some are helpful and some may limit the choices available to your member. The best benefit language provides near full coverage for hospital, organ and professional fees at COE network facilities, and severely limited benefits for non-coe centers. Even the largest percent discount penalties for out-of-network transplants are nullified by out-of-pocket maximum provisions which revert to 100% insurance payment when the often low threshold is exceeded. Maximum transplant benefits, like $250,000 total for treatment, often have a negative effect and COE centers will not transplant your candidate with such low benefits. Benefit language that limits organ costs are typically so low that only the most marginal centers will accept your member. Benefit language can work for you or against you when determining a transplant program.

The last major factor that controls facility selection is client type. Imagine a continuum of client types, with closed panel HMOs on one end and pure unmanaged indemnity on the other. In a closed panel HMO, members are directed to centers and programs that are part of the program only HMOs enjoy pure direction and steerage. Pure unmanaged indemnity members have total access to the health care system and can seek and obtain care at almost any location. However, most of the clients AATMC case managers work with will be somewhere in the middle. Understanding your client type and the regulations of their reinsurer will help you determine how much steerage and influence you may have. In conclusion, there are several ways that members find their way to transplant centers. Many of the ways would lead the member to believe that he/she has no choice or the opportunity to make a choice has expired, when in fact that is not true. As an AATMC recipient, it would be expected that you become proficient in discussing outcomes and experienced in working with members to make sound decisions. Transplant center selection is perhaps one of the most important decisions of their lives - one they should not make without serious evaluation and consideration. 8. Centers of Excellence Networks Case Rates / PPO Discounts / Other Negotiated Agreements Given the current managed care market, it is not uncommon to have the choice of two or more discounts at any one institution. Members often have access to a local PPO for everyday care; access to a national PPO for emergent and out-of-area care; and finally, access to specialty networks for care like transplants. The question this section attempts to resolve is: How do these networks compare and how do they work together? The purpose of this subsection is to identify the types of agreements you might encounter, provide you with an assessment of their appropriateness for transplant care and guidelines to consider when developing a financial plan with the transplant center. Before your solid organ transplant candidate is placed on the transplant waiting list, a committee at the transplant center meets and ensures the candidate has: 1) fulfilled all medical need criteria for transplantation; and 2) passes a financial viability study regarding their ability to pay for the transplant. Be prepared to help the transplant financial coordinator understand the health plan transplant benefits of your candidate, and also be prepared to declare the transplant network or discount that will be applied for the care delivered. Once the transplant begins, it is nearly impossible to upgrade networ ks or discounts so do your homework first!

You may wonder why any one member might have access to a national PPO discount, a local PPO discount and Centers of Excellence case rate contract. Health plans with members spread across the nation often arrange layers of contracts that can be applied to specific types of care. It is not likely that hospitals would allow a health plan to access two local PPOs and choose the lowest price by procedure. Hospitals and providers understand that not all care happens at their institution and medical service region, so contracts can be layered for care delivered outside their market and for care not delivered at their institution. Most health plans will have access to a national PPO. You can tell by looking at the member s benefit card; on the backside there may be a small logo in the bottom corner for a company such as MultiPlan. National PPOs seldom yield a large discount and the discount provided is rarely the discount approved or recommended by reinsurers or consultants for transplant care. Most National PPO discounts are a percentage discount from billed hospital charges, and sometimes, billed professional charges. The big advantage for National PPOs is that they have discount access to most medical centers, and although the discount may not be large, there is always a discount available. Where ever there are large concentrations of members, health plans are likely to arrange access to a local PPO. Local PPOs typically have larger discounts than their National PPO counterparts because local PPOs contract more selectively. To get larger discounts, they often pick one of two competing hospital systems in their service area and channel all their members to the selected hospital system. By omitting the competitor, hospitals offer larger discounts. The local PPO will have a dominant log o on the member s benefit card. With a larger discount, AATMC nurses would be expected to apply that discount for all care rendered in the area. Most discounts are a percentage discount, but those discounts apply to hospital inpatient, outpatient and professional care. There may be some per diem and low level discounts available. Specialty contracts, like COE transplant case rates, are negotiated for specific types of care at specific institutions. Specialty networks are the most selective contracting networks and may not even offer access to centers in any one state. By being highly selective and maintaining a smaller network the opportunity to negotiate a deep discount case rate is created. Case rates are complicated to negotiate and must be renegotiated as technology and treatment methods change, but typically address all aspects of care at a facility yielding their deepest discounts. Using a transplant agreement that uses a case rate methodology at a transplant center is the recommended contract by most health plans, consultants and reinsurers.

9. Case Rates, Case Rate Pitfalls & PPO Discounts Choosing the right contract is not always easy, and sometimes, you have to manage more than one! Say, for example, that you have a patient living in Sarasota, Florida but will be having a heart transplant at Tampa General Hospital in Tampa, Florida. The patient has been receiving hospital and professional care in Sarasota under the PPO of Florida, but is evaluated at Tampa General for the heart transplant, also a PPO of Florida center. The consultant has arranged INTERLINK network access and the reinsurer offers access to the XYZ COE Network. In today s market you are expected to know and understand three or more agreements and you now must recommend the best contract to the health plan. Lucky you! The member already has access to the PPO of Florida; keeping that access open for all care delivered in Sarasota is a must. Transplant agreements only cover care delivered at the transplant center, so the PPO agreement will likely yield the largest discount for care in his local community. The PPO contacts you, and insists that the PPO discount be used for the transplant. They claim to have a case rate, but upon inspection you see that the standard PPO percent discount is 25%. Even though the offered case rate amount is low, there is a provision that limits the discount to 25%. This is a common contract problem that comes when using most PPO discounts for transplant care. On occasion, the PPO will insist that the plan use their agreement, which is not in the interest of your client and their reinsurer. You collect Contract Rate Summaries for INTERLINK and XYZ COE Network and begin comparing them. It is difficult because the contract terms and structures differ in many ways. Since you are experienced with care delivered at this transplant center, you know that the Ventricular Assist Device (VAD) will be expensive and that organ charges will also be high. You delve into those provisions and find that one contract has these provisions buried inside the case rate while the other contract has them carved out. By digging deeper, and contacting the networks, you learn that one network contract has a maximum achievable discount provision of 40% on the case rate which includes the organ and the VAD, but the other network contract has the organ and VAD reimbursed outside the case rate at invoice cost. Identifying this key contract difference will save your client a significant amount should the transplant proceed forward. Another consideration is that since Sarasota is a distance from the transplant center, your candidate is more likely to get his follow-up care close to home. The PPO discount is good and is secured for all care delivered in Sarasota. The INTERLINK contract is for the transplant episode and all follow-up care at a percentage and the XYZ COE Network case rate is for the transplant plus 90 days of follow-up care. It is unlikely in this instance that the member will get much, if

any, follow-up care at Tampa General, so the XYZ COE Network contract may in fact result in double payment for care. You select the INTERLINK network and have the documents executed by the plan. Copies of the documents are sent to INTERLINK, who in turn sends them to Tampa General Hospital and the financial rate decision is behind you. There are many potential pitfalls when arranging contracts for transplants. First, the PPO may play hard ball and insist you access their contract even though you both agree this is not the best agreement and likely not in the best interest of your plan client. As an AATMC trained nurse, we expect you to contact the networks and learn the specifics about this facility and how their contract terms might affect your case. Understanding and applying contract provisions can be confusing, but it is one of the primary differences between a competent transplant case management nurse and one that is not. 10. Gathering Medial Information, Dispensing Insurance Information & Communicating Care Plans Your Role As The Central Communicator Experienced transplant nurses play a critical role in the transplant process. The number one complaint we hear from hospitals, health plans, TPAs, MGUs and reinsurers is that they receive minimal and/or inconsistent communication throughout the process. As a network, we often agree with this statement. Understanding your role, which persons require information, and providing them with the appropriate information in a timely manner, will make you a more valuable asset. To help organize your communication plan, the course directors created a Master Case List as part of this program. This form was created for you to record all your contacts for a case in one place; so that you can easily direct information seeking persons to one another. We caution against quoting or interpreting benefits. For example, the financial coordinator at the hospital wishes to understand the outpatient benefits for the upcoming visit direct them to the appropriate benefits contact at the health plan. Having contact information at your finger tips is very helpful.

Some of the standard case contacts would include: Health Plan The health plan requires a lot of information to coordinate benefits and reimbursement for their candidates. They may require monthly or weekly updates from you. Reinsurer/MGU Most self-funded health plans have notice provisions for all cases that are expected to exceed 50% of the individual plan reinsurance deductible or a specific diagnosis as defined by the reinsurer/mgu. Providing early notice and keeping them informed as needed, often expedites reimbursement for your client. Hospital Pretransplant Coordinator: Often the coordinator and the case manager are interfaces between the medical based world and the insurance world where much information is exchanged enabling the transplant to occur. Hospital Financial Coordinator: Few transplants occur without first verifying that pay ment and coverage are ample to cover the costs associated with the transplant. Financial coordinators will be gathering benefit information from the plan and network and discounting information from you. COE Network - Contracting: Nearly all transplants are performed under a transplant network agreement of some sort. Understanding the agreement, executing the appropriate documents, and ensuring claims flow properly requires communication at various times.

COE Network Medical Support: Although most COE networks have nurses experienced in case management, they seldom, if ever, speak directly to members. These nurses and physicians are there to discuss outcome information, complicated cases and emerging technologies and new treatment options. Local PPO/Care Networks: Transplant agreements and discounts typically only apply to services rendered at the transplant center. Care delivered in the member s home community requires discounts arranged through other sources. Forms and in-depth discussions about communication will occur in the webinar section Getting Prepared Part 1. We cannot stress enough the importance of coordinating timely, accurate, and useful information to the parties above.