How to Build a Heart Transplant Program in an Unlikely Place

An entrepreneurially minded cardiologist who started a heart transplant program against the odds in the early 1990s, shares lessons he's learned along the way.

By 1989, Newark Beth Israel Medical Center had already been dabbling in establishing a heart transplant program for about three years.

But the program at the flagship hospital of RWJ Barnabas Health in northern New Jersey didn't really take off until the arrival of cardiologist Mark J. Zucker, MD, in 1989.

Even though it was located only a few miles from Manhattan and its major academic medical centers with competing transplant programs, Zucker saw the service line as a "natural extension" for the inner city hospital.

The program he envisioned would be integral in making sure Beth Israel thrived in an area with a poor reimbursement mix and other serious challenges.

This summer, on the cusp of performing its 1,000^th heart transplant, Zucker spoke with HealthLeaders about the journey and what he's learned. The following is a lightly edited transcript of that conversation.

HealthLeaders: Why was developing a heart transplant program so important to Beth Israel?

Zucker: The hospital had already performed the first heart transplant in New Jersey in 1986, before I got here [in 1989]. We saw transplantation as one of those natural extensions to provide a full scope of services at a major academic medical center.

But the early barriers were that there were very few people with skills and knowledge about heart transplantation. The number of transplant cardiologists probably didn't break into three digits.

HealthLeaders: What were the biggest challenges to the development of this service line?

Zucker: Recruitment of surgeons and cardiologists was the first hurdle, but there were also the unique hurdles of Newark Beth Israel. We're no more than 20 miles from New York and no more than 80 miles from Philly. So there were geographic considerations with major academic medical centers on both sides.

The unspoken reality was that Newark had its own issues as a city.

HealthLeaders: Was there an entrepreneurial angle to developing the program?

Zucker: If we talk about it as a business, the reality was that the competition in the New Jersey market was increasing. We started the program in 1990 and the number of surgical centers doing angioplasty and other heart procedures was growing.

What's common for most academic medical centers is that you train physicians and then they leave the inner cities and go to the suburbs, [which] surround the places where they learned, and compete.

So you find yourself in an awkward spot. The more people you train, the more they compete and take away patients. By doing transplantation, it helps the institution have a patient base that the surrounding facilities can't provide.

That's a compelling business argument. The other aspect about this is that transplant programs spin off a variety of other programs like TV shows spin off sequels.

Through the transplant program, we could develop end-stage heart failure programs, pulmonary heart programs, and stem cell and amyloid programs. These are spokes of the central hub of a heart transplant program.

HealthLeaders: Does healthcare need more of transplant programs?

Zucker: Transplant programs get complicated, because they are limited by the number of donors. Transplant is a zero-sum game.

If there are 150 transplants done by four centers and you double that to eight centers, it won't double the number of transplants.

I would argue that we don't need more centers, but I recognize I am part of the haves.

Frankly, I don't want competition for a different reason: If we did only 20 a year instead of 50 to 60, I don't think we could do it with the same quality. And costs will go up because we still need the same number of workers and talent doing 20 as we do 50.

HealthLeaders: High-end programs have been suggested as ways for hospitals to diversify income streams in areas that aren't commoditized. What lessons does your experience provide on that front?

Zucker: Transplant actually doesn't turn out to be all that profitable. The reality is that the majority of transplantations are covered under Medicare, so there's a fixed amount of money.

Some of them cost the hospital money.

If one wants to get into this to improve revenue and the bottom line, there's some truth to that, but you could hurt yourself badly with a couple of complicated procedures.

Also, many patients going for transplants are waiting in the hospital for long periods of time for the transplant. The hospital may make money if they go home in 15 days. But sometimes they wait for a month and half for that transplant.

And if that bed has been occupied for 40 days for one patient and it's the same DRG for that patient as one who comes in with acute MI, you might have lost eight other admissions while you've maintained this one.

HealthLeaders: What have you learned that's transferrable for hospitals and health systems that are trying to build new service lines?

Zucker: I was walking down street at the University of Pennsylvania, and on the ground was a message that success doesn't happen from luck. For me, that was a message from God.

Success happens from commitment and longevity.

Here, there hasn't been a lot of turnover at the senior level. We've had the same names since 1990.

And nothing beats communication with the people who send you work. While patients are referred to us for transplant, they were someone else's patient initially, and they sent them to us somewhat reluctantly for the next level of medical care.

So you have to maintain that dialog with the referring doctor. Sometimes it's as simple as telling them that the patient is doing well after transplant.

Last thing is that you have to keep an open mind. There are many ways to practice medicine, and people can teach you in different ways.

You make the work environment fun and enjoyable. You identify people who live and breathe transplant. We're committed to these patients for rest of their lives, so the people you work with have to have the right personalities.