Living Donation Business Case Toolkit: FAQs

First and foremost, living donor kidney transplantation (LDKT) offers the best quality of life for people with kidney failure who are interested in receiving one and healthy enough to undergo the surgery. With limited kidneys available for transplant, a waiting list of 90,000 or more patients, and hundreds of thousands more on dialysis and in the late stages of kidney disease, living donation also provides the fastest path to transplant – including preemptive transplant before dialysis is needed. The PowerPoint template in this toolkit includes a thorough background on the need for LDKT.

In addition to the substantial benefits to patients, there are several financial benefits to growing the volume of kidney transplants performed at your center, especially LDKT:

• Investing strategically in resources for living donation increases volume.
• More volume leads to increased revenue for your facility and your providers, including a higher case mix index (CMI).
• Higher CMI increases reimbursement for providing care as the program treats a larger, sicker patient population.
• Higher volume also increases the entire hospital’s bottom line when patients and living donors seek ancillary (additional) services or care (e.g., evaluation testing, post-donation care, etc.)
• High alignment with Medicare’s stated purpose to reimburse programs for their investments to increase access to kidney transplantation.
   

This toolkit is designed to build a strong, personalized, and convincing business case to present to your hospital leadership. NKF worked with well-known transplant administrators and finance experts to develop the following components:

• A calculator preloaded with YOUR data — the ROI calculator has been preloaded with your own center’s Medicare Cost Report data. Adding your specific institution’s non-Cost Report data in the other available fields makes the financial estimates more precise and personalized.
• A PowerPoint template — This template was designed for kidney program leaders of all experience levels to individualize a successful financial “pitch” to organizational leaders. This includes guidance on how to incorporate a competitive analysis that highlights your program’s opportunity relative to other transplant centers in your area or nationwide.
• Robust Guidance — utilize these frequently asked questions as well as demo videos by transplant finance expert Robert Howey that provide step-by-step guidance on the use of the calculator and how to explain the output to your audience.

Understanding transplant finance will help you demonstrate the ROI of resources into the program. This toolkit will walk you through the steps to make a successful request for growing your living donation program, improving financial performance AND patient care and quality of life — our most important mission.
 

1. Select your transplant center from the drop-down menu at the top of the tool.
2. Click on 1-3 of the slider buttons to open the part of the calculator you wish to use.
3. Enter your program-specific data in the required fields. Many fields are pre-filled with reasonable estimates based on experience of other kidney transplant centers. The more program-specific data you can include, the more accurate your estimate will be.
4. Click Submit.
5. Review the Summary tab for your overall financial impact. Detail tab(s) show a view of the calculations, including the inputs you provided or the reasonable estimates you chose not to change.
    

This calculator includes pre-loaded data in the backend that generates the ROI estimate. Hospital-specific information is obtained from your most recently available Medicare Cost Report, which includes the amount of Medicare and Total usable organs for kidney acquisition (Worksheet D-4, Pt III, Lines 62-64 of CMS Form 2552-10). To see exactly which data points are used, see the “Cost Report Information” tab found in the Summary after you click Submit. 

Many of the fields in the calculator contain pre-filled numbers. These are not institution specific. Instead, these are reasonable estimates from leading experts that you can use as a starting point in your analysis. We highly recommend replacing pre-filled numbers with your specific information to optimize the ROI calculation.
 

Pre-loaded data are included in the backend of the calculator. The Medicare Cost Report information is obtained through CMS’s Healthcare Cost Report Information System (HCRIS), which is updated quarterly to reflect new submissions of Medicare Cost Reports. These reports are due by the end of the 5th month following the hospital’s fiscal year end. After acceptance by the Medicare Administrative Contractor (MAC), the Medicare Cost Report is then transmitted to CMS and stored in HCRIS. More information can be found in the linked CMS pdf. The toolkit is updated with these reports at least annually.

This section will estimate the cost savings from performing non-Medicare kidney transplants with living donors compared to deceased donors. Typically, the acquisition costs are less with a living donor than with a deceased donor. Medicare (and Medicare Advantage) are excluded because Medicare reimburses in line with the reported costs of living donor acquisition. In contrast, reimbursement from commercial payers is typically not based on cost and uses a fixed fee for performing kidney transplants.

This section will estimate the financial benefit within the Medicare Cost Report from additional living donor transplant volume through participation in an external paired exchange. External kidney paired exchange is often facilitated through a third party, such as the National Kidney Registry or Alliance for Paired Kidney Donation, but programs can also be in arranged exchanges with one or more local or regional centers.  

Transplant centers understand that external exchange systems create a larger pool of living donors and recipients, which optimizes the matching process and generates additional benefits for waiting candidates.
 

This section of the calculator provides an estimate of the portion of new staff expenses that Medicare will reimburse. Medicare continues to reimburse its share of kidney acquisition costs on a “reasonable cost basis”, so even as your staffing costs dedicated to living donation rise, Medicare will pay a portion of these costs. Thus, if your program’s volume growth benefit is higher than the true cost of hiring new staff, your estimate will show positive ROI for the program.

The reimbursement amount is based on your input of the estimated salaries, full-time equivalents (FTEs), and percentage of time involved with organ acquisition activities. The calculator then applies the information in the Kidney Staffing section to your most recently available Medicare Cost Report. The final estimate of your program’s total financial benefit or return on investment of increasing staff and other resources will be based on both these costs and your projected volume in one or both of the Growth Strategy sections.
 

The PowerPoint template includes a robust list of best practices that can be tailored to your transplant program’s existing and planned resources. Look for these ideas in the Growth Opportunity section of the PowerPoint.

None of the institution-specific information you put into the calculator will be retained. NKF will only collect the institution names that are selected to track the dissemination of the calculator.

NKF developed this toolkit with the expert advice and partnership of Jennifer Milton, Andrea Tietjen, and Robert Howey. This project is the result of their in-depth expertise, dedicated support, and commitment to supporting living donation across the country.