Transplant specialists are snipping some of their ties to academic medical centers and forming multispecialty organizations.
Their goal is to streamline and enhance clinical practices, further research, attain economies of scale and compete for managed-care contracts. In the process, transplant specialists are gaining varying degrees of administrative, financial and clinical independence and creating work environments rich with opportunities they would not find in an academic setting.
Such was the case for Jorge Estrin, M.D., who left his position as chairman of anesthesiology at the University of New Mexico two years ago to join LifeLink Transplant Institute as associate director for transplant anesthesiology and critical-care medicine.
"This is a community-directed service that is designed to enhance the care of transplant patients with the best possible financial arrangements," he says, "while at the same time creating for the members of the group a very cross-cultural environment of several specialties, some of which have never been together."
While most of the new multispecialty organizations remain closely affiliated with a major teaching university, Tampa, Fla.-based LifeLink is unique. A subsidiary of the LifeLink Foundation, a not-for-profit organ procurement organization also based in Tampa, the transplant institute is governed by a separate board of directors and handles its own contracting.
The foundation formed the institute in 1994 to provide comprehensive medical, surgical and transplant care for patients suffering from end-stage organ disease. The foundation provided a $200,000 loan to cover the startup costs of the group after Tampa General Hospital sought help in re-establishing its liver transplantation program. The group repaid the load within six months, and the institute has been growing steadily ever since.
Today, the not-for-profit institute comprises 21 full-time salaried transplant specialists, including hepatologists, nephrologists, anesthesiologists, cardiologists, transplant physicians and surgeons. The foundation and institute reported combined operating revenues of $36 million and expenses of $34.5 million for fiscal 1998-99. The institute performed 160 kidney and 37 liver transplants between January and November 1998.
"We have achieved critical economies of scale as well as a consistency of approach and philosophy," says Dennis Heinrichs, the institute's president and chief executive officer. "LifeLink has been able to minimize administrative overhead costs that often negatively impact other private practices."
Patients benefit too. According to Heinrichs, the care is closely coordinated because the various specialty practitioners are working under one roof and interacting daily. Physicians also can access a computerized medical record system from home computers, which allows them to handle emergencies more expediently.
According to Estrin, LifeLink's physicians enjoy a close, continuous relationship they don't find in the university hospital setting. That cross-cultural effect benefits patients through improved care and outcomes.
"The only way to improve patient care is by the doctors being in very close contact," he says. "That allows a lot of depth and a much better understanding of the problems. There is no question about that."
Patients also benefit through the streamlined clinical practices LifeLink has been able to develop. Plus, LifeLink physicians have privileges at most hospitals in the Tampa Bay region, which cuts down on unnecessary transfers between facilities.
"We can't do transplants anywhere but Tampa General Hospital, but we don't have to transfer a patient to Tampa General for evaluation, then back again if they're not eligible," says Hector Ramos, M.D., director of LifeLink's liver transplant program. "The managed-care company is happy with us, the hospitals are relatively happy, and we didn't inconvenience the patient, which is the most important thing."
Ramos says the LifeLink structure also benefits physicians because it lets them set their own policies without having to deal with the bureaucracy of a university that may have differing goals.
"If I were a university-based physician, I would have to answer to the whims of the regents, a dean and the chairman of a department whose raison d'etre may not necessarily be transplantation," he says. "At any one time, the priorities of transplantation may not be the priorities of my bosses or others who are controlling my professional life." The same goes for hospital-based physicians, he says.
But at LifeLink, Ramos says, "99% of the reason for existence is transplantation, therefore it is always a priority. There is no person who has administrative or even legal or business power in this institute who is not dedicated to transplantation."
Not all transplant specialists are seeking complete autonomy, however. Several groups have found a happy medium between independence and the security offered by remaining affiliated with a major university.
One such group is the University of Pittsburgh's Thomas E. Starzl Transplantation Institute. Originally formed in 1981 as the Pittsburgh Transplantation Institute, Starzl maintains close ties to the university but still enjoys the freedom to set its own strategic course, says John Fung, M.D., director of transplantation.
"We identified a few people within each discipline who were involved in transplantation and brought them together as a cohesive group to determine candidacy, developmental issues, anything that has to do with patient care," he says. "We work within that group to provide patient care and clinical research."
As the Starzl institute grew, Fung says they had to find a way to work around the traditional academic profile wherein the different physicians within a particular division, such as infectious diseases, would rotate into and out of transplantation services according to their academic schedule.
"That wasn't good for patient care because not everyone has the same experience taking care of these patients as one person (who would see) them all the time," Fung says. "So we negotiated with the different divisions in medicine, surgery and pathology to identify a specific person we could work with."
Once identified, those individuals moved from their original department within the university to the Starzl institute on a full-time basis. In return, Starzl provided physicians with such privileges as priority for their own research in transplantation and assistance in development.
Physicians affiliated with the Starzl institute also benefit from the financial and research support provided by its close affiliation with the university, while still enjoying the freedom of having a say in the strategic direction of the institute.
"We all have alliances to both the university and the medical center," Fung says. "The university supports us (financially) and the medical center supports (the university), so it really has become a big, happy family."
According to Fung, the institute serves both the academic and clinical interests of its 45 physicians. Because the university supports the medical center and vice versa, the structure makes it possible to have a broader research base and better access to research grants than would be possible in a private group.
Private groups "don't have the multidisciplinary approach to answering (research) questions that an academic institution has," he says. "And frankly, they don't have the pooled resources to draw from to do these kinds of clinical research programs that may not always be funded by the industry."
While the Starzl institute is closely tied to the University of Pittsburgh, Dallas-based Baylor Institute of Transplant Sciences could be considered the other end of the academic spectrum. The institute is affiliated with Baylor University but operates as a separate entity.
"At Baylor the physician's role, not just in providing healthcare but in providing strategic directions for the institution, is very marked. Physicians have significant numbers of board seats at the trustee level. The institution and physicians realize we are linked, and we cannot do any planning or strategy in lieu of the other party," says Goran Klintmalm, M.D., chief of transplantation at the institute.
But he emphasizes the institute's doctors have the final say in decisionmaking.
"We do not have an 'us and them' relationship between the institution and physicians. It's all us. This is not just a line, it's actually true; and it's different from any other institution I've heard of."
Klintmalm says the Baylor Institute actually grew out of the onset of managed care. The group had been contracting for transplantation services on behalf of the university since 1987 as the Transplant Associates of Baylor. The university continued to handle administrative tasks.
In 1995, the group and university decided to create a legal entity that would handle contracting and administrative tasks for the physicians as a way to achieve cost savings and control the strategic direction of the group. Today, Baylor Institute includes marrow, cardiothoracic and abdominal organ transplant programs as well as transplant immunology and research.
"There are numerous advantages to the way we have it here. No. 1, physician representation and participation in all the decisionmaking, including strategic development, is ensured," Klintmalm says. "No. 2, by pooling together, we are a very strong voice at Baylor because so much of the revenue of the institution is coming from us. We have a better voice in demanding resources than we otherwise would have if we were just a section under surgery or under medicine.
Then we may just get the crumbs from the table. Here we have a voice that is strong, and we can make demands that represent all of us."
Baylor Institute does not hire physicians as salaried employees. Its physicians are in private practice and are affiliated with the institute, which then negotiates and manages contracts.
"We tried to build up an organization that was smooth, responsive and not overburdened. It's that simple," Klintmalm says.
Regardless of the reasons behind the formation of each of these transplantation groups, they all have the same goals for their work: to improve transplantation and make it more widely available to those in need.
"The only reason I'm in this is for the academic," says Fung of the Starzl institute. "The surgery itself is a means to get to the end. The end is the development of concepts, proving a hypothesis. While patient care is very important-if you don't have patient care, you can't prove your hypothesis--in the end really what we're trying to do is understand the science of organ transplantation."
Adds LifeLink's Estrin: "We are only beginning in terms of creating the clinical-care conditions that are required from an enterprise of this nature. We have begun developing the educational aspects that are part of the process, and certainly we will be emphasizing what brought all this activity to the forefront, which is research. In the absence of research, it is very difficult to exert leadership in this field."
Elizabeth S. Roop is a freelance writer who previously edited Medical Business Gulf Coast Edition in Tampa, Fla.