Financing of Organ Donation. and Transplantation. Guenter Kirste, MD. 3. Dezember 2008, Frankfurt

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2 Financing of Organ Donation 3. Dezember 2008, Frankfurt and Transplantation Guenter Kirste, MD L'Auberge Del Mar, Del Mar, California, USA; May 22th. 2012

3 Models of Health Care Funding Private (insurance system Bismarck Modell Beveridge Modell National health system Semashko Modell Funding private Risk adjusted public Mix of public/private public taxes government taxes Health care provider private public some private public government

4 Classification of social security in the EU Bismark System Beveridge System Semashko System contribute balanced by salary and wages principle of payment in kind and cost-refunds option for additional insurance state budget / tax factoring payment of kind provided by national health offerer option for additional insurance state budget payment of kind provided by national health offerer no further insurance possible

5 Classification of social security in the EU

6 Amenable mortality

7 Total expenditure on health

8 Public expenditure on health

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10 EU vs. member state responsibility EU Agenda* for heathcare R&D, reforming information transfer Control of epidemics HIV prevention Pandemia planning Compositeresponsibility Pharmaceutical approval and research R&D rare disease e.g.german responsibility Gesundheitsfonds Praxisgebühr DRGs EBM PKV Improving health conditions Art. 152 (5) EGV / 168 AEUV: responsibility remains of the single member state.!? Mitgliedstaaten für die * : EU financing the topic with 353 Mio. Euro

11 Is there a European Approach?: Article 168 TFEU (ex Article 152 TEC) 4. By way of derogation from Article 2(5) and Article 6(a) and in accordance with Article 4(2)(k) the European Parliament and the Council, acting in accordance with the ordinary legislative procedure and after consulting the Economic and Social Committee and the Committee of the Regions, shall contribute to the achievement of the objectives referred to in this Article through adopting in order to meet common safety concerns: (a) measures setting high standards of quality and safety of organs and substances of human origin, blood and blood derivatives; these measures shall not prevent any Member State from maintaining or introducing more stringent protective measures; 7. Union action shall respect the responsibilities of the Member States for the definition of their health policy and for the organisation and delivery of health services and medical care. The responsibilities of the Member States shall include the management of health services and medical care and the allocation of the resources assigned to them. The measures referred to in paragraph 4(a) shall not affect national provisions on the donation or medical use of organs and blood.

12 Regulations on Transplantation EU-Directive

13 Transplantationsgesetz (TPG) TPG 1997 German Bundestag, aims: Predictability of legal decisions Assignment of transplantmedicine in patient care Increase organ donation transparency prevention of organ trade

14 Task control according to TPG Transplant centers waiting lists organ harvesting organ transplantation Allocation Stiftung Eurotransplant Leiden / The Netherlands Coordination of organ donation Deutsche Stiftung Organtransplantation since June 2000 DSO

15 Organ Donation in Germany Bundesministerium für Gesundheit Verband der Angestellten- Krankenkassen (VdAK) Deutsche Krankenhausgesellschaft Bundesärztekammer 7 Spitzenverbände der Krankenkassen Prüfkommission nach 12 TPG 16 Landeskrankenhausgesellschaften Ständige Kommission der BÄK Gemeinschaftsaufgabe Organspende 18 Landesärzte - Kammern Überwachungskommission nach 11 TPG Eurotransplant Deutsche Stiftung Organstransplantation Transplantationszentren Spenderkrankenhäuser Regierungspräsidien Sozialministerien d. L. Wissenschaftsministerien

16 Finances in Organ Donation and Transplantation Lump sum per Tx organ removal (DSO) 11 TPG refund donor-hospital Health insurance company of the organrecipient registration -lump sum organ allocation (ET) 12 TPG DRGs organ transplantation (TPZ) 10 TPG

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18 12 (TPG): Vermittlungsstelle Eurotransplant ET Budget is negotiated yearly Consists of a basis budget for financing cross border tasks plus country budget for member state specific tasks For every patient put on the waiting list a registration fee has to be paid which is related to the forecasted number of registrations In 2011 registration flat rate 626 per case, calculated on a basis of registrations (total of 6.6 mio Euro, indexed for inflation & wage development) )

19 Basic Budget Countryspecific 12 (TPG): Vermittlungsstelle Eurotransplant Basic budget for basic mandate: Allocation services Development of allocation External networking Reporting and accounting Supportive services - Clearinghouse function in case of cross border organ exchange etc. Country specific budget: E.g. country specific allocation rules (LAS) HU audits Number of registrations for the different countries

20 DRGs in Transplantation 2011 DRG Bezeichnung Mittlere Verweildauer Bewertung Preis bei BBFW A01A Lebertransplantation mit Beatmung > 179 Stunden 58 31, ,41 A01B A01C Lebertransplantation mit Beatmung > 59 und < 180 Stunden oder mit Transplantatabstoßung oder mit kombinierter Nierentransplantation 34,7 15, ,58 Lebertransplantation ohne Beatmung > 59 Stunden, ohne Transplantatabstoßung, ohne kombinierte Nierentransplantation 26,9 11, ,53 A02Z Transplantation von Niere und Pankreas 26,8 10, ,07 A03A Lungentransplantation mit Beatmung > 179 Stunden 72,5 45, ,54 A03B Lungentransplantation ohne Beatmung > 179 Stunden 27 14, ,19 A05A Herztransplantation mit Beatmung > 179 Stunden oder Alter < 16 Jahre 76,3 47, ,52 A05B Herztransplantation ohne Beatmung > 179 Stunden, Alter > 15 Jahre 61,2 22, ,34 A17A Nierentransplantation mit postoperativem Versagen des Nierentransplantates oder Alter < 16 Jahre oder AB0-inkompatible Transplantation 25,1 8, ,65 A17B Nierentransplantation ohne postoperatives Versagen des Nierentransplantates, Alter > 15 Jahre oder ohne AB0-inkompatible Transplantation 18,4 6, ,83 A18Z Beatmung > 999 Stunden und Transplantation von Leber, Lunge, Herz und Knochenmark oder Stammzelltransfusion 110,4 72, ,54

21 DSO: Budgeting systematics Organisational flat rate DSO does not recieve an entire budget sum but recieves a lumpcompensation for every transplanted organ, negotiated yearly. In the year 2012, the organisational flat rate is per transplanted organ transplantations are assumed. DSO covers all costs that occur during the donation process as well as structural costs with this flat. DSO has contracts with organ retrieval surgeons, neurologists, labs beside the own staff. Exeptions: refund of costs to the donor hospitals and flight costs for nonrenal organs. Compensation mechanisms if the fixed number of cases is not reached or exeeded.

22 DSO budget organisational flat rate air transportation donor hospital reimbursement payment for OCS

23 DSO budget organisational flat rate air transportation donor hospital reimbursement payment for OCS

24 DSO budget organisational flat rate includes staff (coordinators & administration personal) education public raltives safety / traceability HLA-typing donation process organ retreval IT (DSO.isys) documentation housing

25 DSO budget Compensation mechanisms If exceeding the number of cases (organ donors), 25% of the additional revenue (up 1.2 million) is refunded by DSO to the central associations of the health insurance funds. If falling below the number of cases (organ donors), 25% of lower revenues (up 1.2 million) is refunded by the central associations of the health insurance funds to the DSO.

26 Tausend Euro Break/Even organisational flat rate 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5, ,000-10,000-15,000-20, ,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000 Anzahl Transplantationen Gesamtkosten Erlös prozessabhängige Kosten prozessunabhängige Kosten Ergebnis vor FZ-Ausgleich Ergebnis nach FZ-Ausgleich

27 11 (TPG): Koordinierungsstelle DSO Regional central office Regional supply office Rostock Headquarter NORD Hamburg Hannover NORDOST Regional abd. team NORDRHEIN- WESTFALEN Essen Marburg Berlin Leipzig OST DSO 7 regions 14 teams, 50 TPZ MITTE Mainz Homburg BADEN- WÜRTTEMBERG Freiburg Stuttgart Erlangen München BAYERN donor Hospitals (ICU)

28 Organisation and reimbursement of organ retrieval Allowance for abdominal retrieval teams: 1 organ (individual kidney, liver or pancreas) 820,00 2 organs 1.640,00 3 organs 2.460,00 4 organs 3.280,00 5 organs 4.100,00 If no organ has eventually been transplanted 290,00 Special cases: Kidneys en bloc: 820,00 Split liver, if both splits are transplanted: 1.640,00

29 Organisation and reimbursement of organ retrieval Allowance for thoracic retrieval teams : Heart 1.100,00 Lung (en-bloc) 1.100,00 Single lung 1.100,00 2 Single lungs (2 recipients) 2.200,00 Heart and lung (en-bloc) 2.200,00 Heart and Single lung 2.200,00 Heart and 2 Single lungs 3.300,00 If no organ has eventually been transplanted 290,00

30 Reimbursement of brain death diagnosis internal consultant (Monday-Friday) 300,-- external consultant (Monday-Friday) 480,-- internal consultant (Weekend/bank holidays) 460,-- external consultant (Weekend/bank holidays) 640,--

31 DSO budget flat rate / organisational air transportation donor hospital reimbursement payment for OCS

32 DSO: Air transport - extrarenal organs Establishing an air transport network responsible for the organisation of all national and international transports of organ retrieval teams and organs. Main goals and principles: quality, safety and economic efficiency medical necessities, CIT consideration of transport distance avoiding empty flights rare use of cost-intensive jets trustworthy und competent partners

33 DSO: Air transport - extrarenal organs Air transport of extrarenal organs In 2011, the lump sum for an air transport of an extrarenal organ is per transplanted organ for which a separate flight is carried out. Unsuccessful operations are included in the lump sum and will noch be refunded separately. The lump sum is based on the assumption that 970 air transports will be carried out in If the number of 970 flights is exeeded 50 % of the additional proceeds will be refunded to payers. If the number of flights is lower than 970 flights 50 % of the lacking revenues will be refunded by the payers.

34 DSO budget flat rate / organisational air transportation donor hospital reimbursement payment for OCS

35 InEK Institute for the Hospital Remuneration System May 2001: The Head Association of the health insurers (Bund), Association of Private health insurers and the German Hospital Federation found the Institute for the Hospital Rumuneration System as a private limited company (PLC). Since 2007 the institute operates under the name InEK GmbH. The Institute supports the contractual partners of self-administration and their boards in implementing and continuously developing the German-Diagnosis Related Groups-System ( 17b KHG)

36 Post Mortem Organ Donation Reimbursement Therapy of underlying desease Post mortem efforts Consultation on Organ Donation Brain Death Diagnosis Next of Kin/ Consent (1) Organ Protective Therapy / Diagnostics (2) Organ Removal (3) Fee / day, Flat fee (Health Insurance) Time Flat fee (DSO): Process completed: Process interrupted: (1): 200, (2): 759, (3): 2.907

37 DSO: Reimbursement of costs to donor hospitals Initial calculation by InEK Case definition of post mortal organ donation

38 DSO: Reimbursement of costs to donor hospitals Module Presumed number of cases Amount Discontinued while on intensive care unit due to refusal Discontinued while on intensive care unit prior to organ removal Discontinued during organ removal Single-organ recovery Multiple-organ recovery Total budget

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40 DSO: Reimbursement of costs to donor hospitals Module Calculated Costs Difference compared to 2011 Discontinued while on intensive care unit due to refusal % Discontinued while on intensive care unit prior to organ removal % Discontinued during organ removal % Single-organ recovery % Multiple-organ recovery plus 200 for additional instrumental diagnostic procedures + 3 % Total increase + 10 %

41 DSO: Reimbursement of costs to donor hospitals Every year, the contract partners agree on lump sums for the reimbursement of costs to donor hospitals. Modular lump sums for each possible result of a donation process : discontinued before or during organ removal, actually performed donation) are paid out by DSO in order to cover the costs that incur in the donor hospital. The reimbursement does not depend on the fact whether a transplantation is carried out or not! Actual trends in ownership of german hospitals

42 DSO budget flat rate / organisational air transportation donor hospital reimbursement payment for OCS

43 OCS Organ Care System Challenge: Financing the OCS Disposible costs The recipient s health insurance pays a flat rate of ,00 Euro per transplanted heart to DSO in addition to organisational and air transport flat rates. Benefit for the patient has to be proven...

44 Organ Donation in Germany (Age of Organ Donors)

45 Organ Donation in Germany Proportion of each age group Germany 50% 40% 30% 20% 10% 0% ND NO OS BY BW MI NW ND NO OS BY BW MI NW ND NO OS BY BW MI NW ND NO OS BY BW MI NW 15 years years years 65 years Stand

46 Removed and transplanted organs per donor per Region 2010 und Germany 3, Nord Nord-Ost Ost Bayern Baden- Württemb. Mitte NRW Spender (2011) Stand

47 Extended Criteria Donor (ECD) Virus hepatitis (alternatively HBS Ag+, anti-hbc+ or anti HCV+) Sepsis with positive blood culture Meningitis Tumour malignancy in anamnesis drug abuse

48 Figure 1. Times to Equal Risk of Mortality and Equal Cumulative Mortality for Expanded Criteria Donor (ECD) Kidney Recipients vs Patients Receiving Standard Therapy A, Time to equal risk of mortality for ECD kidney recipients vs patients receiving standard therapy (combined group of non-ecd recipients and wait-listed patients still receiving dialysis) as reference group. Merion, R. M. et al. JAMA 2005;294: Copyright restrictions may apply.

49 Figure 2. Algorithm for Expanded Criteria Donor (ECD) Kidney Transplant Acceptance Percentages shown represent the proportion of the total US kidney transplant waiting list as of November 1, 2004 (N = ) that corresponds to each decision point. Merion, R. M. et al. JAMA 2005;294: Copyright restrictions may apply.

50 C. Moers et. al.

51 The Cost-Effectiveness of Organ Preservation H. Groen et.al.: Cost Effectiveness of Hypothermic Machine Preservation versus Static Cold Storage Renal

52 DRGs in Transplantation 2011 DRG Bezeichnung Mittlere Verweildauer Bewertung Preis bei BBFW A01A Lebertransplantation mit Beatmung > 179 Stunden 58 31, ,41 A01B A01C Lebertransplantation mit Beatmung > 59 und < 180 Stunden oder mit Transplantatabstoßung oder mit kombinierter Nierentransplantation 34,7 15, ,58 Lebertransplantation ohne Beatmung > 59 Stunden, ohne Transplantatabstoßung, ohne kombinierte Nierentransplantation 26,9 11, ,53 A02Z Transplantation von Niere und Pankreas 26,8 10, ,07 A03A Lungentransplantation mit Beatmung > 179 Stunden 72,5 45, ,54 A03B Lungentransplantation ohne Beatmung > 179 Stunden 27 14, ,19 A05A Herztransplantation mit Beatmung > 179 Stunden oder Alter < 16 Jahre 76,3 47, ,52 A05B Herztransplantation ohne Beatmung > 179 Stunden, Alter > 15 Jahre 61,2 22, ,34 A17A Nierentransplantation mit postoperativem Versagen des Nierentransplantates oder Alter < 16 Jahre oder AB0-inkompatible Transplantation 25,1 8, ,65 A17B Nierentransplantation ohne postoperatives Versagen des Nierentransplantates, Alter > 15 Jahre oder ohne AB0-inkompatible Transplantation 18,4 6, ,83 A18Z Beatmung > 999 Stunden und Transplantation von Leber, Lunge, Herz und Knochenmark oder Stammzelltransfusion 110,4 72, ,54

53 Summary: organ donation/transplantation Each EU member state has own regulations role of the EU Impact of the German Transplant law Payments of Insurance company of the recipient, organ transplantation as G-DRGs. Efforts for allocation, registration flat for ET Efforts of the donor hospitals due to organ donation, payback through DSO (flat) Transport and retrieval, organisational flatrate for DSO Challenge: eg new preservation methods (OCS)

54 Summary: organ donation/transplantation PRINCEPLE: Transparency and no financial incentives!

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