Anyone Need a New Heart?

In a city famous for its cheesesteak sandwiches, a generous portion of heart transplant programs seems no surprise. Philadelphia has five adult heart transplant programs operating in and around the city—that’s as many programs as Los Angeles and one more than Chicago, both of which have significantly larger population bases.

Even in a place known for its love of artery-clogging lunchtime fare, however, some healthcare leaders are questioning whether there are enough patients to go around.

“Certainly, the advantage of having a lot of programs is that it pushes you to be better,” says Michael Acker, M.D., chief of the division of cardiovascular surgery at the 695-licensed-bed Hospital of the University of Pennsylvania, which runs the largest heart transplant program in the city. “But when there are multiple programs doing less than 20 transplants or less than 15 transplants a year, then that is not ideal. There isn’t enough activity to maintain optimal results.”

Acker’s program performed 49 heart transplants in 2005, compared to just 13 at the second largest program at Temple University Hospital. The three other local programs—Thomas Jefferson University Hospital, Lankenau Hospital and Hahnemann University Hospital—did a combined total of 18 transplants in 2005, according to data from the Chicago-based United Network for Organ Sharing.

Overall, the number of transplants performed each year—in the Philadelphia market and across the country—has been on a decline. Heart transplants peaked nationwide at 2,348 in 1998, but were down to just 2,015 in 2004, UNOS reports. Procedures were up slightly in 2005 to 2,125 and were on pace to top 2,200 through the first six months of 2006.

Many programs may be a victim of their own success, says Acker. “We’re doing a better job of managing end-stage heart failure for longer periods of time—both medically and with devices,” he says. “I think that’s why the number of transplants is declining.”

The high cost of building and maintaining multiple heart transplant programs that perform a limited number of procedures can place considerable strain on a city’s healthcare infrastructure. But some believe that applying strict accounting principles to transplant programs is both unfair and unrealistic, because such programs are often part of a broader service line and provide ancillary benefits that reach beyond the actual dollars generated by the transplant surgery itself.

“In a direct way, the amount of money made on an individual transplant procedure has become fairly small, relatively speaking, because many of the insurers have essentially established centers of excellence networks that negotiate a lower price with the transplant centers,” says Roger Evans, an independent consultant in Rochester, Minn. “But what does happen is that there are often patients who are referred for transplant that benefit from other types of care and may not even require transplanting. So that means a center enjoys additional referrals simply because they have a transplant program.”

Conversely, institutions that have made significant investments in cardiac care programs are often loath to then refer a patient out of their facility for transplant.

“You want to give a patient the full range of services at a center where they’re comfortable with the physicians,” says Paul J. Mather, M.D., director of the Advanced Heart Failure and Cardiac Transplant Center at the Jefferson Heart Institute at Philadelphia’s 550-staffed bed Thomas Jefferson University Hospital. “At the patient’s most vulnerable point, transfer to another institution can be very scary.”

Mather, whose team recently completed its 15th transplant since moving from Temple University in 2004, maintains that Jefferson is focused more on its broader heart failure program and that the transplant center is only a part of the whole offering.

“With the baby boomers booming, our population is aging, so the pool of people who will get heart failure is growing exponentially,” he says, noting that about 500,000 people a year are being newly diagnosed with the disease and about 5 million currently have it. “So there’s a significant need for advanced heart failure centers to deal with this population, and one of the things these centers do is transplants.”

Despite concerns about the dilution of the heart transplant community, Evans—who formerly headed what is now the Division of Healthcare Policy and Research at the Rochester, Minn.-based Mayo Clinic—maintains that the abundance of transplant centers has been largely created by the more established programs themselves.

“Many of these major programs are offering transplant fellowships. They’re training people to go out and do exactly what they are arguing against, and that is to have a proliferation of centers,” says Evans. “If we’re really committed to ratcheting back on the number of programs, then we have to start at the level of training, because you can’t train people and send them out into a field where there is no future for them.”

Brad Cain is editor of California Healthfax and associate editor with HealthLeaders magazine. He may be reached at bcain@healthleadersmedia.com.