Jewish Hospital’s pioneering transplant program is in trouble, and its demise could produce far-reaching repercussions on the community.
Surgical teams have performed only one heart transplant in the first six months of the year, according to the most recently available data, running afoul of federal minimum requirements and likely triggering notification of local patients awaiting a new heart of the inactivity and spelling out their options.
A local doctor told Insider that in the interest of patient safety, a transplant program that performs just one or two heart transplantation surgeries a year should not be performing any.
And if the struggling Jewish Hospital closes, the local transplant program, which performed the state’s first heart transplant in 1984, would end altogether.
The stalled program could hurt the University of Louisville as well: the university’s finances, the status of its hospital and its medical school. The university told Insider that the health of its patients and the education of students and medical residents remain its top priority and that it would continue to support the program, “either at Jewish or in another location.”
However, a national health care consult said that if Jewish Hospital closed, the university could not simply transfer the program to another hospital. Instead, the university would have to start from scratch to establish a new transplant program and obtain certification from the Centers for Medicare & Medicaid Services, which would take more than a year and cost the university millions of dollars.
Even more worrisome, the national consultant told Insider that an interruption of the transplant program could prompt an exodus of transplant surgeons, which could lead to departures of medical staff in transplant-related subspecialties.
Ultimately, those developments could jeopardize UofL Hospital’s status as a Level 1 Trauma Center and cause it to lose medical residency spots.
The potentially devastating ripple effects help explain the increasing desperation with which university officials in the last few months have tried, so far in vain, to save the struggling Jewish Hospital, which, together with related facilities, has been losing more than $1 million per week.
The hospital’s owner, KentuckyOne Health, has been trying to sell the facility, together with eight others in Louisville, since May 2017. When yearlong exclusive negotiations with a potential buyer did not conclude in a deal, the university in December decided to intervene and early this year tried to find a partner to acquire the properties, primarily to save Jewish Hospital.
Even so, that effort, too, failed. University President Neeli Bendapudi said last month that the institution’s search did not identify a partner willing to put up enough cash and assets for the purchase of the health care facilities.
Though university and KentuckyOne officials have said that the hospital won’t close any time soon, local industry insiders and observers have told Insider that they fear the facility’s demise is but a matter of time.
The Jewish Hospital Trager Transplant Center occupies about 18,000 square feet in the Frazier Rehab Institute on the Jewish Hospital campus in downtown Louisville.
The center performed 10 heart transplants last year, and only one so far this year. In the last decade, surgeons at Jewish annually have performed at least seven such procedures, and as many as 18. The transplants are performed by physicians affiliated with the University of Louisville.
UofL declined to answer Insider’s questions about why heart transplants are declining and would not make anyone available for an interview. Dr. Mark Slaughter, chairman of UofL’s Department of Cardiovascular and Thoracic Surgery, did not return a phone message.
KentuckyOne Health told Insider via email that a national change in how hearts are allocated has caused local heart transplant numbers to decline.
The Membership and Professional Standards Committee changed the heart allocation policy in October for reasons including to better identify the most medically urgent transplant candidates, a spokeswoman for the United Network for Organ Sharing told Insider via email.
The committee ensures that transplant centers comply with membership requirements of UNOS and the Organ Procurement and Transplantation Network, which is part of the U.S. Department of Health and Human Services.
While heart transplants at many other centers in the region have declined as well this year, none has declined as much as the program at Jewish, which is down 80% from 2018.
The University of Kentucky Medical Center is on pace to perform 24 heart transplants this year, which would be a drop of 17%. The Cleveland Clinic is on pace to complete 46 such surgeries, which would be down 11.5%. Heart transplants at Ohio State University Medical Center are on pace to be up slightly. Nationally, transplants are on pace to be down 12.6%.
But it’s not just heart transplants that have seen a precipitous decline at Jewish Hospital. Kidney transplants are down 56%, liver transplants are down 29%. Both have fallen just 11% nationally. Only lung transplants at Jewish are in line with national declines. KentuckyOne said that increase, too was a result of a national allocation policy change from November 2017.
Regulatory scrutiny, patient safety
The low number of heart transplants at Jewish also means that the program is violating the bylaws of the Organ Procurement and Transplantation Network. Heart transplant programs that fail to perform at least one transplant every three months are deemed to be functionally inactive.
“When a program is notified of functional inactivity, they have 30 days to notify their candidates on their waiting list and patients being evaluated of the timeframe the program was inactive, why they didn’t do any transplants during that time period and let them know that they have the option of listing at multiple centers and/or moving to another center and transferring their waiting time,” said Anne Paschke, a spokeswoman for UNOS.
“These are just patient options,” she said. “Patients do not have to change centers.”
She said UNOS cannot provide any information about actions with any of its members. OPTN and UNOS manage the U.S. organ transplant network by contract with the federal government. The agency’s website lists no action against Jewish Hospital. UofL said it has not been notified by anyone to say the program is inactive or out of compliance.
Meanwhile, a local doctor and health care industry observer who has written extensively about the transplant program at Jewish had tough words for any heart transplant program that performs fewer than five such procedures per year.
“You shouldn’t be doing any,” said Dr. Peter Hasselbacher, emeritus professor of medicine at the University of Louisville.
He said he worries that surgical teams aren’t getting enough practice for the complicated procedures.
Would you want to have your heart transplanted at a hospital that’s doing just two such surgeries a year and is embroiled in controversy and possibly shutting down, Hasselbacher asked.
Hasselbacher writes about health care on the Kentucky Health Policy Institute blog.
Dr. Ryan Davies, chair of the Organ Procurement and Transplantation Network’s Thoracic Committee, agreed that a low number of transplants can inhibit surgical expertise, which is critical especially for high-risk patients.
Davies, a cardiothoracic surgeon at UT Southwestern Medical Center in Dallas, said that if transplant surgeons perform just one or two procedures a year, “it becomes harder to be good at it.”
A study published in the journal for the American Heart and American Stroke associations indicates that “centers performing under 10 to 12 heart transplants per year may have higher mortality than centers performing” more than 12.
Laura J. Aguiar, a national organ transplant program consultant, said that before transplant programs are deemed functionally inactive, leaders of that program are given the opportunity to explain why they have not performed transplants.
She said a low number of transplants could simply reflect that available organs were not good matches for the patients on the local waiting list. Changes to the way organs are allocated, too, can affect transplant numbers, she said.
Aguiar also said that while a low number of transplants could result in worse outcomes for patients, they do not necessarily have to. Some boutique transplant programs have very good outcomes, while some high-volume programs have poor outcomes, she said.
Aguiar is principal and managing partner at Glendale, Ariz.-based Transplant Solutions LLC. She works with transplant programs on organ procurement, helps health systems develop new transplant programs and train staff, and also helps existing programs maintain regulatory compliance.
CMS guidelines call for transplant programs to perform 10 heart transplants over any 12-month period to retain certification. The agency could not be reached to explain what happens to programs that fail to meet that threshold.
Aguiar said CMS certification of transplant programs is critical for hospital revenue.
Without CMS certification, neither the federal government nor many private insurers will reimburse hospitals for the cost of transplant surgeries. A heart transplant can easily cost $300,000. CMS also helps pay for facilities’ transplant infrastructure through cost reports, a quasi-tax return for hospitals. Without certification, that revenue stream, too, comes to a halt.
A potential downward spiral
While UofL scrapped plans to find a partner to buy Jewish Hospital, the university and KentuckyOne are continuing to work together. Meanwhile, KentuckyOne is still looking for a buyer, and UofL is trying to find other health systems that can host School of Medicine-related functions currently housed at Jewish.
“We obviously recognize the critical importance of the solid organ transplant program to our community,” university spokesman John R. Karman III told Insider via email. “Our commitment to that program has not wavered. It will continue, either at Jewish or in another location,” he said.
However, Aguiar said, transplant programs and CMS certification cannot be transferred to another location — even if the new location were to house the exact same equipment and staff.
“If you lose your Medicare certification, you have to start all over again,” she said.
If UofL moved the transplant program to another local hospital, for example, the university would have to perform 10 heart transplants within 12 months before it could even send a letter to CMS to ask for certification.
That means, Aguiar said, that the new hospital or the university (or both) would have to cover the cost of the program without dollars from the federal government or private insurers. At $300,000 per transplant, that’s at least $3 million — excluding costs to set up and maintain the program, including space and equipment.
Transplant programs can improve hospital profitability if the institution manages its resources well and negotiates for good contracts with private insurance companies, Aguiar said, but not all of them are.
She has dealt with health systems in which executives were leaning toward closing a transplant program until they were reminded that CMS, through cost reports, pays a sizable portion of running the program. Closing a transplant program can actually be a hit to a hospital’s bottom line, she said.
Hasselbacher said that, generally, higher volume programs tend to be more profitable because they can spread the cost of equipment, facilities, salaries and other overhead over more procedures.
There, too, Jewish Hospital’s low volume is problematic. It’s much like a hotel with 100 rooms that constantly has 90 rooms vacant. Mortgage payments don’t drop by 90 percent because the rooms are vacant.
Davies, the pediatric heart surgeon, said transplant programs can be profitable even with low volume, primarily because heart transplant surgeons perform procedures other than transplants. That’s unlike liver and kidney transplants surgeons who mostly perform transplants.
Davies said his team of five heart surgeons performed 550 surgeries last year, and only 26 of them were transplants — though the transplants are the most complex procedures and take a disproportionate amount of time.
However, he said, the loss of a transplant program could undermine a health system’s revenue streams in other significant ways.
Hospitals with transplant programs see a lot of patients with serious problems —heart, lung, kidney, liver — that may not require transplants but likely will need other services, from scans to serious surgeries, all of which may generate profit for the hospital. Without a transplant program, a lot of those serious cases may get referred to different facilities, Davies said.
In many ways, heart transplant programs can be viewed as a “loss leader” that brings other patients to the hospital, much like a retailer may sell one item at a loss to get customers in the store.
Losing a transplant program and having to refer patients with complex medical conditions to other medical facilities also looks bad, Davies said.
“It’s hard on your reputation,” he said.
Lack of a transplant program also reduces scores that hospitals get in the influential hospital rankings of U.S. News & World Report.
For the University of Louisville and its medical school, the loss of the transplant program harbors even more worrisome outcomes.
Aguiar said transplant surgeries require broad expertise not just among surgeons but among supporting infrastructure, including cardiology, pulmonology, nephrology, hepatology, infectious diseases, tissue typing and other specialties that a general community hospital may not have.
If a hospital’s transplant program expires, transplant surgeons may leave and prompt departures of a whole host of other medical professionals from related subspecialties that may not be needed — or needed as much — without a transplant program.
And those departures, Aguiar said, could undermine a hospital’s trauma certification and reduce medical residency spots and fellowships.
The University of Louisville Hospital is one of only two Kentucky facilities with a Level 1 Trauma Center designation.
‘Can mean all the difference …’
For local patients and potential patients, the loss of a transplant program in their community can have dire consequences, health experts told Insider.
“It’s always beneficial to have a transplant program relatively close to where you live,” said Davies.
Organs can become available at any time, and as soon as they do, a countdown begins because they are viable only for a few hours. That means patients who are waiting for a transplant may get called at any time and have to make their way to the facility quickly. The farther patients live away from the transplant location, the less likely it is that they will be there in time.
In addition, Davies said, transplant patients may be required to remain in the hospital for an extended period. If their families live far away, that can present an additional hardship in an already difficult situation.
And, Davies said, after patients are released from the hospital, they have to come back weekly or even more frequently, especially in the first year after the procedure. A greater distance to a transplant facility makes those follow-up appointments more difficult.
Aguiar said most programs require most organ recipients and their support to stay in the area of the transplant center for three to six months, depending on the patient’s health and transplant type. That means the patient and family members may have to take many days off work and figure out how to take care of their children, pets and plants.
“Having those services available locally … can mean all the difference” between being able to get a transplant — or not, Aguiar said.