How do we keep costs low in liver transplantation?

There are 3 major hospitals where liver transplant is performed in Chennai. The average cost of the procedure is 26 L and are up to 32 L at admission in one of the centers. When we were a growing GI medical and surgical team 4 years ago, we sent our patients for transplant to these centers and we found that none of our patients were getting transplanted, the main reason being inability to meet the costs.

This was the basic tenet for us to start a new transplant center in the city of Chennai. We are the fourth team in the city to serve this ailing population and we feel that our technical expertise in solving patient problems is the least of our challenges.

The original pioneers of transplants, Thomas Starzl and Sir Roy Calne never intended this treatment to be unaffordable to the many suffering patients. The same concept was noted in the many gastroenterologists and surgeons who worked from 1997 onwards to bring liver transplant is a reality also wanted to keep the costs low. In fact, Prof. Chandy who worked with the original team, told me once that he wanted costs to be as low as 10 L per liver transplant (costs worked in 2005), but felt that costs will go up with inflation.

Following are the reasons that we are able to do liver transplants at affordable costs:

# Cost plus pricing strategy Vs Value based pricing strategy: One of the first things that we did in Chennai was to evaluate the actual cost of the transplant process and we found the actual cost of the procedure is roughly 16 L (inclusive of all medications, ICU stay, without including complications). Even if we add a complication cost, it would add another 4 L to the cost. So we found that most of the transplant centers are following a value-based pricing for the transplant. This increased the cost beyond the affordability of the patients. Once this information was available, we decided to follow the cost plus pricing strategy for liver transplants, which brought the costs to affordable levels.

# Key cost control: The key cost of  liver transplantation is the use of blood products. These costs are variable and substantial. A liver transplant normally consumes close to 20 - 30 units of blood and blood products. However, the senior surgeon in the transplant team trained in USA where the average MELD score was close to 40 at the time of transplants. The blood transfusion for patients in the MELD score of 15 - 20 was none to minimal. This is the patient group that benefits from transplant. And he was known for his bloodless hepatectomies in USA that led to successful liver transplants.

If that is an advantage, would that be not the same for other teams as well? True, and we know that it will be the same everywhere. The main reason that some of the hospitals, that employ internationally acclaimed surgeons, are unable to contain costs is the substantial salary that is paid to these consultants. These surgeons are used to large teams that work with them and use disposables that cause enormous wastage in a developing country like ours. Even in the USA, it is now getting to a point where every small element has to be taken into consideration to keep costs low. Our team was trained in both medical systems and we have been through the fellowship in both India and USA and are aware of the costing issues in India. We also have good expertise in very successful locally developed surgical methods that have very good results in our hands.

# Fast tracking: When we came back to India, our colleagues were surprised by our method about rapidly allowing the patient to feed after surgery. In fact, our first patient was a surgeon herself and was surprised that I allowed her to drink and eat on the first post operative day. Her rapid recovery was no surprise to us as it was to them. Now we feed every patient at the earliest possible timeline and move them our of bed on day 1. This allows us to prevent many complications that delays recovery. We also start respiratory care and musculoskeletal exercises far earlier than other teams and prevent most of the complications that are associated with it.

# Philanthropic support: We also have a lot of well meaning individuals that are supporting patients and children who undergo this procedure. We also make sure that the hard earned money of our support team is not wasted and goes to benefit the patient as a whole.

# Our team spirit: None of our team members feel that the money is of any importance in transplant. All of us have had very successful professional lives till now, before we took up transplantation as the challenge. We have taken this to reinstate our beliefs that any treatment must be affordable for the patient to be beneficial to the society at large. It is more so, in a treatment that is life changing as a liver transplant.

We believe that it must be made a routine in our country to go for liver transplantation at affordable costs and this should always be accompanied by efforts to prevent the illness that led to a transplant situation.

We are in this together for all our patients. Try us ....... We feel we can make the difference.