Existing Transplant Nephrology Compensation Models and Opportunities for Equitable Pay

Introduction

The American Society of Nephrology (ASN) formed the ASN Task Force on Academic Nephrologist Compensation and Productivity in 2020 to understand how the subspecialty is evolving and where there are needs for alignment in compensation in US transplant centers. The task force's review of the roles and responsibilities of transplant nephrologists is in the companion perspective (1). Transplant nephrologists are required for successful kidney transplantation, the ideal treatment from a survival and quality-of-life perspective for patients with kidney failure (2,3). Unfortunately, work relative value unit (wRVU) requirements for compensation models vary tremendously across institutions and limit the ability to adequately staff programs. This article addresses transplant nephrology models of care, how different models affect funds flow and compensation, and opportunities to more equitably compensate transplant nephrologists.

Overview of Different Models and Their Pros and Cons

Oversight of the transplant system is conducted by the US Department of Health and Human Services (HHS) through the Organ Procurement and Transplantation Network (OPTN) (4,5). The revenue for transplant services, covering much of the care provided to transplant recipients and potential donors, is included in the global payment for transplant services provided to health care systems by the Centers for Medicare & Medicaid Services or private payers, with additional revenue from organ acquisition costs through Medicare. Transplantation is a prestigious clinical operation for health systems, and the organization of transplant within a health system greatly affects how that health system distributes this revenue, which, in turn, affects physician compensation. The task force discussed three models common in the United States and discussed the pros and cons of each.

The Division/Department Model

Historically in academic centers, the transplant nephrologist is aligned with the nephrology division. A principal advantage of the department/division model is that the academic home of transplant nephrologists remains well defined, allowing close coordination around fellow education, interactions with other nephrologists to encourage transplant referrals, and collaboration in treating patients with CKD.

The principal disadvantage of this model is the absence of well-defined (The Association of American Medical Colleges, Vizient, etc.) transplant-specific wRVU targets, forcing transplant nephrologists into traditional department/division compensation models on the basis of the higher-earning wRVU procedure of dialysis. Salaries are inadequate because they are tied to unrealistic wRVU generation; some require nontransplant work, such as dialysis, to achieve desired targets. The downstream effect is that hiring a transplant nephrologist potentially exerts a negative effect on the financial bottom line of the division or department. Because the dollar value per wRVU for nephrology is relatively low, some programs have negotiated a non-nephrology rate, such as the immunology rate, which is consistent with transplant nephrology work and pays more per wRVU.

The Transplant Institute Model

In a transplant institute, similar to a transplant service line, the program sits outside the traditional academic department/division model. Transplant nephrologists may therefore have dual reporting to both an academic home/division and a clinical home in the institute. The transplant institute leadership may reside in another department (surgery) or within the health system itself. If there is a deficit at the end of the year related to a transplant nephrologist’s clinical revenue, this deficit is absorbed by the transplant institute, not the nephrology division.

Pros of this arrangement include using clinic and transplant volumes and outcomes to assess clinical productivity, resulting in transparency regarding the clinical earnings. If the transplant nephrologist is paid from a different funding structure than a division, more resources are available to support transplant nephrology, including understanding the unique features of transplant billing and the non–wRVU-generating work done by the transplant nephrologist (1). The transplant institute revenue is on the basis of transplant volume, allowing the value of transplant nephrology services to the overall program to be recognized and potentially accounted for in compensation models.

Potential downsides of the institute model are the dual reporting; unless the leadership of the transplant institute and the academic home communicates and coordinates, the transplant nephrologist may receive conflicting priorities for clinical work versus academic endeavors of teaching and scholarly activity. This may negatively affect promotions and academic success. Most transplant institutes are led by surgical directors and rarely by medical leadership alone, although sometimes, they are comanaged. Further, transplant institute leadership may reside outside the kidney program (e.g., liver or heart) and have a limited understanding of kidney transplantation. Finally, transplant institutes may be structured around business models that promote pretransplant evaluations and outreach activities over less profitable activities, such as long-term patient follow-up. The consensus of the task force in this current era of change is that most patients want ongoing access to their transplant nephrologist over the long term to promote a successful outcome.

The Community Model

Although most transplant nephrologists work in academic centers, some work in community health care settings, where models also vary substantially. Transplant nephrologists may be employed by the hospital, and the hospital, therefore, assumes risk and controls funds flow. Financial compensation may be in the form of salary, benefits, and a bonus structure that is aligned with the transplant center's defined measures of productivity. With the stability of the negotiated salary on the basis of market compensation, compared with the academic models, one pro is fewer negotiating layers between the transplant nephrologist and the health system.

An alternative community model is one in which the transplant nephrologist may be contractually associated with a transplant program but is employed by a separate nephrology practice. In this model, the nephrologist (or nephrology group) may receive compensation in the form of medical directorship as well as patient care–related billing, but also may have additional sources of income (care of patients on dialysis and patients with CKD, directorships, and even joint ventures or real estate), which are shared or pooled with the group. The transplant nephrologists focus their efforts on transplant work, and thus, any financial deficit–related transplant work is shared by the entire group. However, one con is that unless a practice is willing to subsidize the transplant nephrologist, transplant nephrology is a nonviable model.

Summary of Models

Regardless of the model, the transplant nephrologist's wRVU clinical activity does not generate adequate reimbursement to cover the salary of a transplant nephrologist performing comparable hours of work as a general nephrologist, and thus undervalues the additional year of required training. Each model typically relies upon supplemental support (from the institute, division, health care system, or practice), support that is not uniform across centers even within a single model. Within the academic setting, the transplant nephrologists on the task force felt strongly that the division model offered long-term security and is more aligned with an academic career; after all, they are nephrologists. However, similar to subspecialization in cardiology, transplant nephrology should be recognized for the additional training and special services provided and compensated adequately.

Transplant nephrologists provide complex care to at-risk patients. However, failure to recognize and appreciate the nonbillable, essential services they provide often leads to inappropriately low compensation. Attempting to “retrofit” their compensation into a wRVU-based system does not work, leading to variability in compensation components and inadequate salaries. Transplant nephrologists are essential to the success of a kidney transplant program, unique from both surgeons and other nephrologists, and they should be recognized for their essential contributions to the success of kidney transplant programs. It is time to change the view of many health care systems that transplant programs are surgical. The task force’s deliberations (also see the companion Perspective [1]) led to the following opinion-based recommendations for consideration.

• (1)Transplant nephrologists’ pay should not solely depend on wRVU generation.
• (2)There should be an effort to establish national benchmarks for transplant nephrology productivity and compensation.
• (3)The number of transplant nephrologists needed to care for patients also requires nationally based standards that can take into account program growth needs, outreach efforts, referral patterns, the size of the waiting list, the volume of transplants followed, preemptive transplants, and the numbers of patients undergoing long-term follow-up. Until this can be determined, it is recommended by the task force that, at minimum, there be two transplant nephrologists at low-volume programs (<50 kidney transplants annually), with one serving as the transplant medical director. For stable programs (those that are not growing), a minimum of two transplant nephrologists is required for transplant annual volumes up to 40–50, with another transplant nephrologist included for every 40–50 additional kidney transplants performed annually.
• (4)Compensation for nonbillable work, including pretransplant evaluations, meeting time, and outreach, should be paid by the health system receiving the global payments and organ acquisition fees. Such compensation should be on the basis of the number of transplants per year and the number of donors/recipients evaluated; documentation should not detract from other responsibilities.
• (5)Quality bonuses should reflect the work of the transplant nephrologist, not surgical-related outcomes. Transplant nephrologist activity would be better assessed by metrics that are important in improving quality outcomes, are meaningful to patients and families, address equity, and are aligned with ASN initiatives to promote improvements in kidney transplantation.
• (6)Medical directorship percentage effort should be standardized by HHS/OPTN, not left to the individual discretion of health systems. Pending such standardization, the task force recommends a minimum of 25% per program, with additional effort for growing (>20% growth per year), large programs (>200 transplant per year), combined organ transplants (greater than ten annually), and large outreach volume (three or more distant locations) for up to 50% per director, which can be split among multiple directors.

Disclosures

D.C. Brennan reports consultancy agreements with CareDx, Medeor, Sanofi, and Veloxis; research funding from Allovir, Amplyx, CareDx, and Natera; honoraria from CareDx, Sanofi, and Veloxis; and serving on the editorial board of Transplantation and in an advisory or leadership role for UpToDate. R.S. Gaston reports employment with CTI Clinical Trial and Consulting, Inc. and ownership interest in AbbVie Pharmaceuticals, Eli Lilly and Co., Merck and Co., Organon and Co., and Pfizer, Inc. S.B. Gurley reports spouse’s employment with United Therapeutics. M.A. Josephson reports consultancy agreements with Exosome Diagnostics, IMMUCOR, Labcorp, Otsuka, UBC Pharmaceutical Support services for the mycophenolate pregnancy registry, and Vera Therapeutics; ownership interest in Seagen; research funding from the Gift of Hope and the Bucksbaum Institute; honoraria from ASN for Highlights and ASN Board Review Course; and serving in an advisory or leadership role for ASN. S.M. Moe reports consultancy agreements with Amgen, Ardelyx, and Sanifit; stock in Eli Lilly; research grants from Chugai, Keryx, and the National Institutes of Health (NIH); honoraria from Amgen, Ardelyx, and Sanifit; and serving on the editorial boards of American Journal of Nephrology and American Journal of Nutrition. M.A. Mujtaba reports honoraria from CareDx and Mallinckrodt; serving on the editorial board of Clinical Transplant; serving in an advisory or leadership role for Mallinckrodt; and speakers bureau for CareDx. R.J. Schmidt reports research funding from Arbor Research, NIH/National Institute of Diabetes and Digestive and Kidney Diseases, and Retrophin and serving as a member of the American Association of Kidney Patients Medical Advisory Board, a member of the Kidney Transplant Collaborative Board of Directors, a member of the Quality Insights Board of Directors, and past president and a member of the board of directors of the Renal Physicians Association. M.S. Segal reports employment with the Malcom Randall Veterans Affairs Medical Center and research funding for a clinical trial with Alexion and for a clinical trial with RegenMed. J.K. Tucker reports serving as a peer reviewer for UpToDate. A.C. Wiseman reports employment with Centura Transplant; consultancy agreements with CareDx, Hansa, Immucor, Meteor, Natera, Nephrosant, and Veloxis; and speakers bureau for CareDx, Sanofi Genzyme, and Veloxis. The remaining author has nothing to disclose.

Funding

None.

Author Contributions

D.C. Brennan, M.D. Doshi, R.S. Gaston, S.B. Gurley, M.A. Josephson, S.M. Moe, M.A. Mujtaba, R.J. Schmidt, M.S. Segal, J.K. Tucker, and A.C. Wiseman wrote the original draft, and D.C. Brennan, M.D. Doshi, R.S. Gaston, S.B. Gurley, M.A. Josephson, S.M. Moe, M.A. Mujtaba, R.J. Schmidt, M.S. Segal, J.K. Tucker, and A.C. Wiseman reviewed and edited the manuscript.