National Trends in Organ Acquisition Costs Brigitte Sullivan

National Trends in Organ Acquisition Costs Brigitte Sullivan Administrative Director The Johns Hopkins Comprehensive Transplant Center

Today • Brief History of Organ Acquisition • Audit Experience • Available Benchmarking Data

Unique Reimbursement for Transplantation • Medicare reimburses hospitals for organ transplants by paying a DRG for the hospitalization • Medicare also pays hospitals for transplant services based on the Organ Acquisition Costs reported on the hospital’s Medicare Cost Report • Transplant is one of the few areas within a Hospital that is reimbursed on costs through the MCR • Medicare is a major revenue stream for transplant hospitals and programs ($4. 7 M annual)

Medicare Organ Acquisition • Organ acquisition costs include: – OPO fees – Support costs: transplant coordinators, transplant database, financial counselors – Pre-transplant evaluation services – Deceased donor and living donor hospital expenses – Share of hospital overhead • Cost reimbursed: – Medicare usable organs/total usable organs x total organ acquisition costs

OAC Timeline • 1974 – Medicare Reimbursement for OAC based on reasonable cost basis. CTC establishes 1 SAC for DD and 1 for LD, after the close of the FY, the charges are aligned with actual costs, and any necessary adjustments are made • 1983 – HCFA establishes Medicare PPS, plans to include OAC in DRG; however decides to leave cost reimbursement because of the “unique characteristics of organ procurement activities and the desirability of maintaining an adequate supply of kidneys. ” • 1987 OIG Report “Organ Acquisition Costs: An Overview” – Estimated $52. 3 M spent on kidney SAC in 1985 ($20 -30 K per transplant) – Recommended Demonstration Project & that OAC incorporated into DRG for kidney transplant – FI’s conduct priority audits of OAC

OAC Timeline • 1991 OIG Report “Addressing Increased Organ Acquisition Costs” - HCFA felt not enough $ to invest HCFA resources in recommendations • 2002 – CA whistleblower case - $6. 2 M Medicare refund and 2004 OIG push to audit OAC • 2006 – OIG Publishes Results of Audits done in 2005 – Recommended that “CMS consider the results of our 11 audits in prioritizing areas to be evaluated in annual audits by the fiscal intermediaries. ”

OIG Audit Results Years Medicare Claimed Costs Audited Reimbursement Total 21 Average Per Hospital 1. 9 Estimated Medicare Overpayment $203, 281, 448 $105, 094, 038 $28, 430, 118 $18, 480, 132 $9, 554, 003 $2, 584, 556 $124 M not audited: Medicare eligibility of beneficiaries, Inpatient days claimed, Indirect cost pools on B Worksheets Cost Category Salaries Medical director fees Laboratory costs Floor space Other costs Total Unallowable $ 1, 177, 528 $ 1, 512, 210 $ 1, 589, 176 $ 2, 050, 939 $ 4, 878, 419 $ 11, 208, 272 Medicare Share of Unsupported Unallowable & Unsupported $ 24, 506, 226 $ 14, 818, 705 $ 1, 803, 027 $ 2, 084, 638 $ - $ 1, 273, 992 $ 5, 618, 406 $ 5, 027, 405 $ 3, 669, 597 $ 5, 225, 378 $ 35, 597, 256 $ 28, 430, 118

Unallowable/Unsupported Costs • Lacked effort reporting for salaries & med director fees pre/post • Did not use reasonable compensation equivalent limits on medical directors’ compensation • Lacked a method to accumulate allocation statistics on floor space

Common Error: Did Not Include All Direct Costs Total Costs in Medicare Transplanted OAC Transplants Organs Does not Include Non-Medicare Patient Costs $ 1, 000 50 25 Does Include non-Medicare Patient Costs $ 2, 500, 000 50 25 Medicare Ratio Medicare Payment 50% $ 500, 000 50% $ 1, 250, 000

OIG Audits • Officials at the Hospitals either asserted that they lacked awareness and understanding of Medicare requirements for claiming OAC, or that they had inadvertently claimed costs that were not allowable • OIG audits are instructive for both risk areas and potential cost recoveries

What Do Organ Acquisition Costs Look Like?

Milliman & Robertson Organ Type Heart Kidney Liver Lung - Single Lung - Double Pancreas 2011 Estimated U. S. Billed Charges Per % Increase 2002 Transplant for Procurement (in 1, 000's) 2011 2002 2005 2008 2011 $ 57 $ 74 $ 94 $ 80 $ 23 41% $ 46 $ 51 $ 68 $ 67 $ 22 47% $ 54 $ 57 $ 74 $ 71 $ 17 31% $ 42 $ 54 $ 73 $ 15 26% $ 58 $ 83 $ 97 $ 90 $ 24 40% $ 44 $ 67 $ 68 $ 65 $ 21 48% *“Procurement…includes donated organ recovery services, which may include retrieval, preservation, transportation, and other acquisition costs…we based procurement charge estimates on our judgment and…data from Washington hospitals, trended to [the current year] and normalized to a national average basis using Milliman area relativity research. ” – M&R 2005 report

Payor Practices • Global/case rates • $25 K to $50 K OA Caps • Payment of Invoice from OPO • No coverage

Organ Procurement Organization Kidney Standard Acquisition Charges Source: Medicare Fiscal Intermediaries for OPOs - Trailblazer <2009, Cahaba >2009

HCRIS Data • Hospital Cost Report Information System • All Medicare Cost Reports in the U. S. • Publicly Available

Definitions • CTC = Certified Transplant Center • Hospital = The institution that performs transplants. One Hospital can have multiple CTCs • Each Cost Report is for one Hospital. There are multiple CTCs defined on a given Report, through completion of the D -6 Worksheets (one D-6=one CTC)

Hospitals with CTC(s) in Dataset • 250 • Status of Cost Reports as of September 2012 • 200 • 150 • 100 • 50 • 2001 • 2002 • 2003 • 2004 • 2005 • 2006 • 2007 • 2008 • 2009 • 2010 • Amended • As Submitted • Reopened • Settled With Audit

CTCs in Dataset

2009 Detailed Analysis ORGAN Heart Intestine Kidney Liver Lung Pancreas Total CTCs Total Usable Organs 107 2, 655 9 166 22, 101 113 7, 512 53 2, 457 120 1, 654 628 36, 545 % Total % Living Medicare Transplanted Donor Usable Organs Transplants Organs 41% 20% 68% 37% 42% 63% 57% 2, 127 150 17, 245 6, 055 2, 067 1, 164 28, 808 36% 4% 22% UNOS HCRIS Data % in Data Unique Hospitals performing at least 1 Transplant in 2009 253 234 92% Total Organs Transplanted in 2009 28, 459 28, 808 101%

Reporting Variability Total Costs Per Usable Organ 2009 Total Cost Per Usable Organ CTCs Heart 107 $ 79, 328 $ 38, 382 $ 23, 249 $ 321, 118 Intestine 9 Average Standard Deviation Minimum Maximum $ 96, 434 $ 67, 894 $ 45, 528 $ 267, 297 Kidney 226 $ 50, 694 $ 27, 584 $ 10, 882 $ 249, 371 Liver 113 $ 63, 273 $ 33, 563 $ 20, 873 $ 285, 002 Lung 53 Pancreas Total $ 65, 328 $ 32, 962 $ 21, 165 $ 177, 878 120 $ 44, 282 $ 41, 667 $ 992 $ 423, 594 628 $ 58, 539 $ 40, 564 $ 992 $ 423, 594

FY 2009 Cost Report D-6, Part III Worksheet for All Organ Types

FY 2009 Cost Report D-6, Part IV Worksheet for All Organ Types

Line 51 “Direct Organ Acquisition” = Direct Costs from Worksheet A + Indirect Costs from Worksheet B

Direct Costs Direct costs that are directly related to organ acquisition and are accumulated in the organ acquisition cost centers on Worksheet A

Guidance from Medicare: Reporting Salary • The costs associated with preservation technicians, transplant coordinators, and administrators, etc. must be allocated among the types of organs procured • The provider must establish a unit cost per organ by dividing the indirect cost by the total number of organs retrieved • This unit cost is multiplied by each organ obtained

FY 09 Salary Reported on Worksheet A % Hospitals Reporting $0 All Organs Cost Per Usable Organ 20% $ 9, 164 % Total Cost Per Usable Organ Heart Cost Per Organ Kidney Cost Per Organ Liver Cost Per Organ Lung Cost Per Organ 15. 4% $ 20, 634 $ 8, 536 $ 8, 123 $ 5, 593

Guidance From Medicare: Reporting Other Direct Costs • Fees for physician services (preadmission for transplant donor and recipient tissue-typing and all tissue-typing services performed on cadaveric donors); • Cost for [organs] acquired from other providers or [organ] procurement organizations; • Transportation costs of [organs]; • [Organ] recipient registration fees; • Surgeons' fees for excising cadaveric donor [organs]; and • Tissue-typing services furnished by independent laboratories

Other Direct Organ Acquisition Costs from Worksheet A % Hospitals Reporting $0 Overall Cost Per Usable Organ % Total Cost Per Usable Organ Heart Cost Per Organ Kidney Cost Per Organ Liver Cost Per Organ Lung Cost Per Organ 8% $ 33, 129 55. 7% $ 44, 996 $ 30, 713 $ 36, 336 $ 32, 229 2009 OPO Kidney SAC = $27, 543

Indirect Costs • Transplant center overhead costs that are accumulated in general service cost centers and allocated through the cost report “step-down” process on Worksheet B • Include staff fringe benefits based on salaries, space costs (depreciation, plant operations, utilities, etc) based on SQF, equipment depreciation, social services, general administration based on accumulated cost, data processing, and other costs as appropriate and consistent with the overall allocation process.

Worksheet B

Allocation of Worksheet B Costs Cost Category Administrative & General Cafeteria Central Services & Supply Dietary Employee Benefits Interns & Residents Program Costs Interns & Residents Salary & Fringes Laundry & Linen Service Maintenance & Repairs Maintenance of Personnel Medical Records & Library Nursing Administration Nursing School % Total % Hospitals Reported Cost Per Reporting Per Usable $0 Organ 0% $ 7, 140 12. 0% 15% $ 129 0. 2% 58% $ 68 0. 1% 93% $ 96 0. 2% 12% $ 1, 219 2. 0% 90% $ 105 0. 2% 92% 86% 55% 99% 41% 49% 99% $ 92 $ 9 $ 260 $ 213 $ 270 $ 0 0. 2% 0. 0% 0. 4% 0. 5% 0. 0%

Allocation of Worksheet B Costs Cost Category % % Total Reported Cost Hospitals Cost Per Usable Reporting Usable Organ $0 Organ 36% $ 480 0. 8% 83% $ 517 0. 9% 89% $ 12 0. 0% 77% $ 28 0. 0% 73% $ 385 0. 6% Operation of Plant Other General Service Paramedical Education Pharmacy Social Service Old Capital Related Costs - Bldgs & Fixtures Old Capital Related Costs - Movable Equipment New Capital Related Costs - Bldgs & Fixtures New Capital Related Costs - Movable Equipment 91% $ 27 0. 0% 96% $ 3 0. 0% 27% $ 361 0. 6% 42% $ 197 0. 3%

Organ Acquisition Day An organ acquisition day is an inpatient day of care rendered to: • an organ donor patient who is hospitalized for the surgical removal of an organ for transplant • a cadaver in the inpatient routine service area for the purpose of surgical removal of organ(s) for transplant

FY 09 Inpatient and Routine Ancillary Costs Per Day and Per Organ Hospitals Inpatient OA Days Reported Deceased Donor Organs Excised at Hospital Living Donor Organs Excised at Hospital % Living Donors Days Per Donor Reported Per Diem Cost Reported Routine & Ancillary Costs Per Organ Excised Reported Revenue Per Organ Excised Routine & Ancillary Days Reported >0 0 Total 218 23, 431 16 - 234 23, 431 7, 964 54 8, 018 6, 069 43% 1. 67 $12, 761 139 72% N/A 6, 208 44% 1. 65 $12, 831 $21, 307 $8, 583 $21, 134 $2, 964 $1, 268 $2, 941

Medicare Usable Organs (from Medicare Provider Reimbursement Manual) • Equals total usable organs minus organs sent to military hospitals, to veterans’ hospitals, outside the United States, and organs transplanted into non-Medicare beneficiaries. • Include organs that had partial payments by a primary insurance payer in addition to Medicare. • Do not include organs that were totally paid by primary insurance other than Medicare, as they are non-Medicare. • Do not include organs procured from a non-certified OPO.

FY 2009 Cost Report D-6, Part IV Worksheet for All Organ Types

Revenue for Organs Sold (from Medicare Provider Reimbursement Manual) • Total revenue applicable to organs furnished to other providers, to OPOs and others, and for organs transplanted into non. Medicare patients. • If organs are transplanted into non-Medicare patients who are not liable for payment on a charge basis, and as such there is no revenue applicable to the related organ acquisitions, the amount entered on line 58 must also include an amount representing the acquisition cost of the organs transplanted into such patients. • Determine this amount by multiplying the average cost of organ acquisition by the number of organs transplanted into non. Medicare patients who are not liable for payment on a charge basis.

FY 09 Reported Organ Revenue Hospitals Reporting >=1 Excised Organ Hospitals That Reported 221 % Hospitals in Dataset 94% Excised Organs Reported 14, 226 Hospitals Reporting Revenue for Organs Transplanted Hospitals That Reported 53 % Total Organs % Hospitals in Transplanted Organs Transplanted Dataset Reported by All Hospitals 23% 7, 089 25% Total Revenue Reported $467 M Rev Per Organ Transplanted $65, 884 Hospitals Reporting Revenue for Organs Sold Hospitals That Reported 114 % Hospitals in Dataset 49% Sold Organs Reported % Total Organs Sold Reported by All Hospitals 4, 665 58% Total Revenue Reported $42 M Rev Per Organ Sold $8, 967

Average FY 09 Medicare Settlement by Hospital Transplant Volume Total Usable Organ Volume 1 -20 21 -50 51 -100 101 -200 201 -300 301 -400 401+ All % Hospitals Medicare 26 40 54 52 26 16 19 234 61% 64% 70% 62% 54% 57% Avg Medicare Cost Per Settlement Organ Amount $ 546, 985 $ 81, 733 $ 1, 501, 100 $ 63, 606 $ 2, 920, 823 $ 55, 871 $ 4, 602, 623 $ 51, 782 $ 7, 320, 823 $ 54, 790 $ 9, 926, 582 $ 55, 436 $14, 313, 291 $ 45, 303 $ 4, 718, 163 $ 52, 564

Common Errors: Decrease Medicare Ratio/Payment • “Unusable/Discarded Organs” not subtracted from total organs to calculate “Total Usable Organs” • No Days or Less Days than Excised Organs Reported for "Inpatient Routine" but did report Excised Organs • Did not report Excised Organs, but had Excised per SRTR Data

Common Errors: Audit Risks for Medicare Overpayment • No Revenue reported for Organs Sold or Transplanted • “Usable Organs” and “Medicare Usable Organs” on Lines 54/55 differs from adding organ statistics schedule

Cost Report Costs, Transplant and Donor Volumes by Year • 30, 000 • 2, 000. 0 • 25, 000 • 1, 500. 0 • 20, 000 • 1, 000. 0 • 15, 000 • 10, 000 • 500. 0 • Medicare Payments • Total Costs • Transplants • 2010 • 2009 • 2008 • 2007 • 2006 • 2005 • 2004 • 2003 • 2002 • 2001 • 2000 • 1999 • 1998 • 1997 • - • 5, 000 • 1996 • Total Costs (in millions) • 35, 000 • - • Donors • Transplants and Donors $1. 1 billion • 2, 500. 0

Average Cost Per Organ by FY • $ 70, 000 • $ 60, 000 • $ 50, 000 • $ 40, 000 • $ 30, 000 • $ 20, 000 • $ 10, 000 99 • 2 9 00 • 2 0 00 • 2 1 00 • 2 2 00 • 2 3 00 • 2 4 00 • 2 5 00 • 2 6 00 • 2 7 00 • 2 8 00 • 2 9 01 0 • 1 99 8 • 1 99 7 • 1 99 6 • $ - • Medicare Payment Per Organ • Total Cost Per Organ

Average Cost Per Organ by FY Fiscal Year 1996 2010 Increase 1996 to 2010 Medicare Payment Per Organ Dialysis Organ Cost If Medicare Total used 3% Payments Per Transplants annual (UNOS) Patient Year inflation (USRDS) $ 28, 635 30, 917 $ 56, 101 46, 765 96% 51% 52, 879 19, 765 86, 608 28, 661 64% 45%

Cost Drivers • Increased overhead resulting from regulatory requirements • Increased costs of OPOs, HLA (also paid on Cost Reports) • Education about allowable costs on Cost Report • The system is not designed to incentivize cost reduction

• FY 09 Total Cost Per Usable Organ by Hospital’s Total Volume of Organs • $ 80, 000 • $ 70, 000 • $ 60, 000 • $ 50, 000 • $ 40, 000 • $ 30, 000 • $ 20, 000 • $ 10, 000 • $ • 1 -20 • 21 -50 • 51 -100 • 101 -200 • 201 -300 • 301 -400 • 401+ • Range of Usable Organs for Hospital in FY 2009

• $ 90, 000 • FY 09 Total Organ Acquisition Costs Per Usable Organ by Type of Cost • $ 80, 000 • $ 70, 000 • $ 60, 000 • $ 50, 000 • $ 40, 000 • $ 30, 000 • $ 20, 000 • $ 10, 000 • $ • Heart • Indirect Costs • Kidney • Liver • Salaries & Other Direct Costs • Lung • Routine & Ancillary

• FY 09 Organ Acquisition Costs Per Total Usable Organs and Per Transplanted Organs • $ 100, 000 • $ 90, 000 • $ 80, 000 • $ 70, 000 • $ 60, 000 • $ 50, 000 • $ 40, 000 • $ 30, 000 • $ 20, 000 • $ 10, 000 • $ • HR • IN • Direct OAC Per Usable Organ • KI • LU • PA • Direct OAC per Transplanted Organ

• Heart: Avg Total Cost Per Organ by UNOS Region • $ 120, 000 • $ 100, 000 • $ 80, 000 • $ 60, 000 • $ 40, 000 • $ 20, 000 • $ • 1 • 2 • 3 • 4 • 5 • 6 • 7 • 8 • 9 • 10 • 11 • $ 100, 000 • Lung: Avg Total Cost Per Organ by UNOS Region • $ 80, 000 • $ 60, 000 • $ 40, 000 • $ 20, 000 • $ • 1 • 2 • 3 • 4 • 5 • 6 • 7 • 8 • 9 • 10 • 11

• $ 80, 000 • Kidney: Avg Total Cost Per Organ by UNOS Region • $ 70, 000 • $ 60, 000 • $ 50, 000 • $ 40, 000 • $ 30, 000 • $ 20, 000 • $ 10, 000 • $ • 1 • 2 • 3 • 4 • 5 • 6 • 7 • 8 • 9 • 10 • $ 70, 000 • $ 60, 000 • 11 • Pancreas: Avg Total Cost Per Organ by UNOS Region • $ 50, 000 • $ 40, 000 • $ 30, 000 • $ 20, 000 • $ 10, 000 • $ • 1 • 2 • 3 • 4 • 5 • 6 • 7 • 8 • 9 • 10 • 11

• $ 90, 000 • Liver: Avg Total Cost Per Organ by UNOS Region • $ 80, 000 • $ 70, 000 • $ 60, 000 • $ 50, 000 • $ 40, 000 • $ 30, 000 • $ 20, 000 • $ 10, 000 • $ • 1 • 2 • 3 • 4 • 5 • 6 • 7 • 8 • 9 • 10 • 11 • Intestine: Avg Total Cost Per Organ by UNOS Region • $ 300, 000 • $ 250, 000 • $ 200, 000 • $ 150, 000 • $ 100, 000 • $ 50, 000 • $ • 2 • 3 • 5 • 6 • 8 • 9 • 10

Conclusions • OIG audits are instructive for both risk areas and potential cost recoveries • Organ Acquisition cost reporting varies greatly across transplant programs • Accurate reporting is critical for obtaining maximum reimbursement from both Medicare and non-Medicare payers • Organ Acquisition costs have increased more than other similar healthcare costs

Resources • CMS – National Cost Report Dataset http: //www. cms. hhs. gov/Cost. Reports/ • Milliman & Robertson U. S. Organ and Tissue Transplant Cost Estimates http: //www. milliman. com/pubs/HRR 20. pdf • HHS Office of the Inspector General - Audit Reports http: //oig. hhs. gov/oas/cms. html • United States Renal Data System Annual Reports http: //www. usrds. org