Access to Transplantation with Andrea Tietjen

In this episode, our guest is Andrea Tietjen. She is the Assistant Vice President of Transplant Adminstrative Services. She has worked with this dynamic team since 1999. Hear about how she entered Transplant. 

https://www.rwjbh.org/cooperman-barnabas-medical-center/treatment-care/transplant-services/kidney-pancreas-transplant/our-team/administrative-leadership/ 

We discuss what changes have occurred in the Transplant space over the last 10- 15 years. 

We talk about how important ACCESS to Transplant Care is and what struck me about the leadership at their medical center, is how they are constantly trying to improve the care delivered to their patients. 

Please note this is not medical advice. It is meant for entertainment purposes only. 

Transcript

SPEAKER_00 0:02

All right. Welcome everyone to another episode of Totally Transplant. This is your host, my great Samura, and I'm really excited today to welcome Andrea Tejin. Andrea, you have to first tell me if I pronounced your last name correctly.

SPEAKER_01 0:16

Yes, it is. Tea and gin, two things that you drink, but not together.

SPEAKER_00 0:22

Okay, that's such a great way of remembering it. And if you could please introduce yourself to the audience. Thank you for having me.

SPEAKER_01 0:30

I'm Andrea Tejin, and I am a transplant administrator here in New Jersey. I've had the pleasure of really working with this team since 1999. And I will, you know, first say that even though I have a lot of years of experience, I feel like I learned something new each and every day. And every patient helps us to learn and continually improve our ability to increase opportunities for transplant and really overcome the barriers and challenges that some face.

SPEAKER_00 1:00

I love Ellen. And can you share with us? How did you enter a career in transplant medicine?

SPEAKER_01 1:08

Completely by accident. So prior to uh healthcare, I was actually in higher education. And I had a good friend who started to work here at the hospital, and she kept trying to woo me over. And I am an accountant by uh training. So I am a CPA. I still do a little bit of taxes on the side, but only pro bono taxes. And I remember thinking that in accounting and in finance, often people get stuck, rather, for a rat la, you know, uh lack of a better word, in certain industries. And I wanted to see if I could learn something new. I'd been in healthcare for 10 years. Could I learn something new and apply my skills in the healthcare setting? And when I met, there were three opportunities that I could have worked with. I could have worked in corporate, I could have worked for oncology, and I met with the transplant team. And the transplant team at that time had a real vision. And that was to have this triad leadership in that they wanted clinical, psychosocial, and financial leadership in transplantation, which finance and transplant was really, you know, unheard of at that point. But the intent is to really maximize opportunities in transplant research and budgeting and making the most of resources and trying to figure out where we could invest our resources wisely and so forth and contracting and all the things that go along with good financial management. So I had intended to stay for a few years and I just never anticipated having such a connection with such validating work. I mean, when you're an accountant, maybe you save people money on their taxes, but to be a small part behind the scenes of helping someone overcome a really tricky insurance contract or navigating an insurance denial, it really can help in their overall healing. So it's been an incredible, I think, experience for me being so non-clinical.

SPEAKER_00 3:14

It's amazing. Well, I have to then ask, what have you noticed over the last 10 to 15 years have been the biggest changes within the transplant world?

SPEAKER_01 3:27

I would say that patients are the insurance landscape continues to change for them. And, you know, first we it was very difficult for individuals, you know, prior to 10 years ago, it was very hard for individuals to get an insurance plan if they were not employed, if they were perhaps not eligible for Medicare and Medicaid. It has often struck me that I work in this industry and sometimes navigating even the public health systems is very complicated. And thinking of an individual who is newly diagnosed or chronically ill and has other psychosocial and clinical stressors, how can they navigate this? So even though there have been, I think, great strides, it's still very complicated. It's dynamic, it's ever-changing. We had Obamacare, and now that's changing. Each state has its own rules for Medicaid. We've most recently seen some Medicaid changes. We have individuals who were formerly under DACA protection who are now no longer eligible for some ACA affordability. So I think that there is a constant challenge to always ensure that we can help patients get the coverage that they need, not only for, and I'm talking specifically about transplant recipients, but their families and perhaps even their living donors when they show up and they're uninsured. We want to make their lives better, not only from this, this experience, but long-term. And helping to give them that knowledge and overcome some of the challenges and these systems that are complicated has, I think, really been a focus of my team and our efforts here.

SPEAKER_00 5:08

And the plant recipient is listening to this. What would you recommend that they do to get their insurances in order and ready for a transplant?

SPEAKER_01 5:19

So every transplant program is required by CMS regulations to have a transplant social worker, a transplant financial coordinator as part of their multidisciplinary team. And oftentimes, I think patients, for example, who are on dialysis, when they're working with maybe their transplant dialysis social worker, there's a different intention. We want to make sure that you have dialysis coverage. We're going to set you up for this. But we want to set this patient up for success. So seek the resources that are available to you. And also don't be afraid to ask questions and to reach out when there are changes or to verify changes. So for example, in the state of New Jersey, and this is really in every state, but for example, managed Medicare plans are available to patients based on their zip code. So wherever they live. And many of us between October 15th and December, if you watch any television or you listen to the radio, we hear a lot of advertisements about this plan or that plan, or we have Joe Namath or some other celebrity talking about a plan. Well, they will give you dental coverage and transportation and a gift card. But that might work for the average individual, but that plan may not be great for someone with end-stage renal disease. So seeking the advice of a transplant professional is going to give you the best education and will help you make the best decision for you. And also remember that that decision making may have to change. So your circumstances may change. You may be working and now you're on dialysis and you're not feeling well and you are looking to go on disability or stop working. And, you know, any number of circumstances can present themselves. But this team is there for you, unlike some other specialties, throughout your continuum of care, from the point of evaluation and referral all the way through the time where you lose your graft, which could be hopefully many, many, many years after transplant. So the transplant programs always have these experts available to you. And they may not have the answer, but they have the connections and the networking to help you find the answer so that you can make the best informed decision for yourself.

SPEAKER_00 7:41

That is wonderful. Thank you. And that leads us, kind of segues us into what we'll be talking about today, which is transplant access. And let's start off by talking about what that means to you.

SPEAKER_01 7:53

So when I hear access, you know, it's the exact opposite. When I think of transplant access, I think of mitigating any barriers. So that, you know, we want to make sure that everyone can avail themselves to the care that they need. And individuals at different points in time will have different challenges and barriers. And they can be numerous. They can be health literacy, they can be psychosocial, they can be financial, and they can be comorbid. You know, some of the things that I think from a transplant perspective that over my career I've been really mindful of, and again, not having a clinical background, my eyes have been open to ensuring that we don't intentionally put barriers in front of the patient. So an example would be is that the regulations for transplant programs are that each transplant program must have selection criteria in which they've identified, based on their clinical care, what types of individuals would best benefit for a transplant or, you know, to have a transplant. And we really are careful not to say you're a candidate, you're not a candidate. It's more of a point of is transplant a is the benefit of transplant better than the risk of not having a transplant for you? And sometimes when we think of checklists and selection criteria, there's a presentation to the patient is like, do all these tests. And once you do, we will determine whether you can move forward. And sometimes giving individuals a list of things to do is a barrier, unintentionally. And we want to really understand and craft, I think, a personalized plan of care for individuals. So an individual is the primary breadwinner of the family and works, has limited vacation, may also be on dialysis. It's going to be a challenge for that individual to make appointments for chest x-ray, EKG, colonoscopy, needs time off, may need child care, may have dependent care that they have to worry about, has limited days off, has also been sickly. And can they take time off? Yes, but in reality, difficult for them to walk away. So they span, again, all I think socioeconomic categories of patients. There's not one size fits all. And we just want to always make sure that we're meeting the patient where they are and doing a good assessment and asking the questions in the right way. And the way we do that is putting the why behind things. And a lot of times when I'm educating patients, I'll say, I'm going to ask you some sensitive questions. And the reason why I'm asking them is that in the event that you ever need resources, these answers will help me to identify what resources you may be eligible for. And they usually open up. But if I start right off the bat saying, what is your income? Do you work? Then people are now thinking, what is the answer she wants me to say so that I can move forward in the process? And if I don't explain it up front, I'm putting an access barrier to that patient unintentionally. So I think communication and education and connecting and establishing that trust with the patient is so valuable to this, the continuum of care and really making sure that the patient can get the services that they need at any point in time.

SPEAKER_00 11:54

That is so true. I had actually never thought about it like that. I mean, there's no doubt clear communication, education, expectations is very true. And our patients already may have their own barriers. And it's it does fall upon us to ensure that we're not adding unnecessary barriers to them where they already may have that clinical tie-in of Monday, Wednesday, Friday dialysis and ensuring that limited days is not something that we're imposing on them. I was thinking, as you mentioned, the selection criteria. So there's 250 kidney transplant programs around the country. There's 250 different selection criteria. And I've tried searching this for a few programs to see if their selection criteria are available. Do you think that this should be like publicly placed somewhere for patients to see?

SPEAKER_01 12:50

I think that would be really beneficial to the patient because if you think we're of the society we live in, patients have choices. And right now, the information that patients do have to their, you know, that are publicly available are really dated. So you think of the scientific registry for transplant recipients. So there's a public website which is supposed to educate a patient as to in their area, how quickly I can get a transplant, what are the patient outcomes. But first of all, those results are somewhat dated. So if I'm today in March of 2026 looking at a program, the report card that I'm looking at goes two and a half years back. So two and a half years ago, they could have been great and now they're not, and vice versa, they could have been really bad and now they're great. I think the other challenge that patients have, and I'm just going to relate this back a little bit to access again, is that, you know, one of the biggest silent drivers of access is the patient's insurance. So we forget. Now, we would all love to say that we have an open pocketbook and we could go anywhere. You know, I live in New Jersey, and there are a lot of individuals in New Jersey which will that, and they just, you know, anecdotally say, I would only go to New York for the best care ever, because there's the perception that New York City has the best and you know, most, I think, advanced options. But the reality is very few of us can go out of network. And especially for transplant, by definition, is uniquely considered a elective surgery, which is pretty remarkable. And we found that out really during COVID. Now, we always kind of knew that that was in the contract language, but when COVID sanctions came upon us and there was a directive to stop elective surgeries, we had to really think hard about this because it was considered an elective surgery. Now, if I'm going to have elective surgery, I can tell you that's not what I'm electing, especially as an aging woman. But in theory, that's what happens. And so you can imagine when you look at your insurance card and it says uh PCP visit, $10 copay, specialist visit, $25 copay. Transplant care is usually not indicated on that card. So people presume because they have an insurance card that transplant's going to be covered and it can be covered anywhere. And that's unfortunately just not the case. I mean, insurance, private insurance companies, and to some extent, the commercial insurance companies that are managing the managed Medicare and Manage Medicaid plans, they are gatekeepers of this. And they are directing patients to these facilities. And I think that having this information, you know, if I live in an area where I have choice and I have access and transportation, I can be an informed consumer. I can look and I would want to know not only are the outcomes, I want to know who's in my plan, if I have Aetna or Verizon or Cigna, what are my options? You know, what do we do? We Google, we research, and then understanding if I'm elderly or if I have some other underlying comorbid condition, I want to know I can go to transplant A because they indicate that this is something they would consider. But transplant B is saying that this is not a type of patient that they're come, you know that. And quite frankly, when you're newly diagnosed or you've been referred, a lot of people have that anxiety around, I want to get there. I want to start this process, I want to get to my transplant fast. And it is a prolonged period of time. Even if you show up with a living donor and motivated, it's going to take several months for you to have this. So having all those pieces kind of fall into place are, I think, the responsibility of the transplant program and the patient working together and really understanding what that means and how can we get the best access. And some of that is transplant access and having consumer choice is is a, I think, not only a nice to have, it's really a right to every patient. Yes.

SPEAKER_00 17:10

Could not agree more. And along those lines, and framing this within the context of transplant access, we know that there's disease donor kidney transplantation for which you're on a wait list and you wait for the catiferic kidney to become available versus having a living donor, a family or a friend available. How does transplant access show up within that framework?

SPEAKER_01 17:34

I think it all really boils down to education. Now, individuals show up. And again, you know, one of the things that you and I just talked about is it's the transplant team's responsibility to really expertly assess and educate the patient. So all of our team members at every point of contact and every touch point should really be sharing the importance of this information. So here's a like an interesting parallel. A few years ago, I had breast cancer and I went to the oncologist. Of course, I was very lucky. I worked for healthcare. My doctor called downstairs and I got right into oncology, had my treatment. And when we were deciding what my long-term course of treatment was, the oncologist said to me, We have two options. We have this and we have this. Now, I'm not clinical. I was overwhelmed. And I said, What would you choose? Because I want to know you're asking me, but I feel completely unprepared and uneducated to make a good decision. So he very kindly shared, if it were my daughter, I would recommend this and here's why. And the transplant program, similarly, that really shaped me because we have the knowledge to help our patients. We just don't want to ask them, do you have a donor? Then they're looking around, there's no donor here, and then they're like, I don't have a donor, I'm moving on. But it's really understanding, you know, if you compare it to the oncology example, my oncologist described the two different options and what the rationale was. If you think about transplant, you know, deceased donor is great and it's the option, the only option for some patients, but there may be some benefits to living donor. And there's different ways and different resources to help individuals find a living donor. And somebody said something to me once which was really impactful. It was an individual who was a deceased donor coordinator. So it was an individual who worked for an OPO. And her first job was to approach families to ask if their loved one that was unfortunately declared brain dead was interested in pursuing deceased donation. And she said she was so nervous. She remembers her first couple approaches. And a family member on her second family that she approached said, I would have been disappointed if no one asked me and educated me and given me the chance to contemplate this. And it's the same thing with living donation. So maybe you, as the recipient, think, I don't have donors, but your family and friends would do anything to help you. And had they not been asked to give you that chance, that's a real miss and that's an opportunity. And I think we all know of someone that we would do anything for. And I think every one of us has someone in our family or our friend group or extended group that feels that same way. So it's really about education, information, and dispelling the myths and getting that to the right individuals.

SPEAKER_00 20:48

Yes, I could not agree more. As a fellow breast cancer survivor, I will say I am clinical. And it was still extremely overwhelming because it was beyond my field of expertise. And that did also shape me as a physician and how I move forward now and how I show up for my patients. And that is such an important point that it should not just be a question on a checklist. Do you have a living donor? Yes or no? If no, you move on. No. It should be exactly as you outlined. It's assessment and education. So if they say no, we ask them, what do you know about living donation? Could there be anyone? What are the various resources to help you? And this is why we recommend this is so important. Could not agree with you more. On this topic, what do you think the future of transplant access looks like? And then I'll ask the next question after.

SPEAKER_01 21:49

I feel like it's been slow growing, but I'm more excited for the future to see how technology is going to help us. So there are a lot. Of really amazing innovations coming. And it feels slow growing, but it's still there. I mean, I thought when I first started that I was going to see xenotransplantation in five to 10 years. And now I'm 20 plus years in and it's, you know, it's still coming. But I think that as we embrace that, and it's been so interesting to me as as I've learned about the desire and the dedication to these advanced and novel technologies, is that in almost every case, there's a passionate patient or donor behind this. They've recognized the need and they're committed to this. So it's not only a scientific commitment, it's really, I think, like a heartfelt commitment. And we're going to see hopefully access improve in so many ways. So the ultimate test would be if there's a zero waiting list and how do we get there? And it's not going to be one single factor that's going to do it. It's going to be all of these small interventions that in summation and in sum are going to all chip away at continuing to increase opportunities, whether it is xenotransplantation, whether it is increased preservation, whether it is better education. And there's talk about making sure that the living donors are followed up differently so that we can better educate living donors on, you know, what their long-term outcomes are going to be. So there's so many pieces to this that are really going to make a difference. But I would say that more now than ever, we're seeing novel agents being developed, which have less toxicity on the body. You know, we were talking a little bit before where we're celebrating patients here that have had their kidneys at least 25 years. And that is remarkable considering the techniques that were used more than 25 years ago, the medications that they were on more than 25 years ago. Now these medications have less side effects, they're more tolerable. And it's it's being open to embracing these changes, learning about them, incorporating them in your practice so that patients can benefit from, you know, whether you're committed to actual clinical research or you're a Me Too, someone starting something and you learn about it. I think when we talk about, you know, novel inventions, it's not just even kind of the scientific discoveries that we're doing, but use of AI, better use of communication tools. How can we use those technological agents to better educate ourselves, better educate our patients, create more access to this education, you know, and improve the delivery of this education? Those are all things that are going to make collectively, I think, a big impact on how we we deliver care.

SPEAKER_00 25:01

So well said. And um along those lines, if you could blank slate, create an ideal method of transplant access and transplant care delivery, what would that look like?

SPEAKER_01 25:16

I think that one of the things that I would say to that is that there's no ideal state. I almost feel like this is ever evolving. And one of the things that has engaged me and even my team is that, you know, we're a dynamic program, constantly looking for a better way to do it. Not in a schizophrenic way where we're always upending things, but you know, when I mentioned before, when we're talking about patients and we're saying the why behind things, when we come up with something, we're asking why. And we often always find a more efficient and more effective way to do things. So I think an ideal state is somewhat static. And as we get more resources, different resources, different ways to use resources, our own medical record, for example, every month there's a new feature. We happen to be doing an upgrade this coming weekend. And there are 10 new features that we're salvating at to kind of help. And so we recognize, oh, we can now link this or we can send this, and we're gonna be able to do this. And it helps patients, it helps providers, it helps us to better communicate with our payers. So that's again, when we talk about transplant access, we want to streamline everything. And so we were on a webinar, we heard another program had found a way to utilize the same electronic medical record that we had to create a document builder. And essentially, when patient testing comes in, we flag it. And then when all the checklists are completed, it creates a document that we can automatically send off to the insurance company. So we used to have a very manual process and it was extremely organized and it was ideal when you've thought about it. But what could be better is making it faster, right? And so now, you know, our financial coordinators are they're alerted to now someone's got a completed chart. They can pull it up. We have well-established relationships with all of our case managers. We know the dates. We know that we want to get almost everything we can on a Friday. Most of them meet on a Tuesday. We will hear on a Wednesday on decision, and then we can get the off and get them listed. So I really feel that when you think you know it all, you're done in this business.

SPEAKER_00 27:42

That is so true. I mean, transplant is ever evolving and you are continuously learning and improving. And like they say, if you're not growing, you're dying, and it's really important to maintain that growth. And um as always, Andrea, I mean, your your answers just always are stimulating more questions for me. But I would like to, you know, as we conclude today, we talked about what the future of transplant access looks like. I want to broaden that question a little bit. And this is what I like to ask everyone is where do you see the future of transplantation going?

SPEAKER_01 28:25

I I really would love to see the day where there is no wait list or there's a very short wait list. And I mean that is like nationally. So there are a lot of geographic differences. I also would love to see that there are a lot of what I would say successes in many programs. For example, we want patients to have good choices, to not have to travel, to have early access to a lot of this information. You know, so when you think about the society that we're living in, we're at a point in which we have almost a glut of information. We can Google anything at any time. Yet we're seeing increased comorbidity. So we're seeing we still see hypertension, we still see diabetes, we still see obesity. And those are unfortunately some of the main contributing factors to the individuals that have end-stage kidney disease. And they unfortunately wind up having a transplant. I think that if we could really somehow join forces and, you know, almost prevent some of these cases from moving forward and really have when you talked about an ideal state, in my mind, ideal state when I talk about transplantation is really minimizing the number of individuals that progressed to needing a transplant. And that is even end stage disease, you know, kind of management. And that, you know, it's preemptive, proactive, and bringing kind of that that whole complement of I think care together. And a lot of times, you know, think about individuals don't recognize. We Google things once we were having a symptom that's advanced or we've been diagnosed. But is there an opportunity to really better manage that? So maybe I have occasional hypertension that's elevated. And I think, okay, I'll go on medication and that will fix it. But you know, it may be too late even at that point sometimes. And I don't think people recognize that it affects everyone differently. And had we have known, now, not every case is like that. Sometimes there's congenital factors that really have done that, and and that is outside of the control. But are there things that we can control? And we tend to be siloed. So we have neprology care, then we have when it really gets bad, then it goes to transplant care. But ideally, could we really look at that spectrum and work together for the lessons that we learned in both places? And, you know, hopefully prevent some cases from moving forward to transplant. And then those that unfortunately need a transplant, having the opportunity where, again, equal access wherever you live, regardless of your socioeconomic status, having people not have to travel. I think for a kidney, it's a little bit different, but just through my experience with my colleagues nationally, there are other organs, for example, where, you know, there are limited options for them. And I was really touched by a story. There's a patient that she tells an amazing story where she went to work and felt like she had the flu and it was kind of lingering. And she went to work and someone said, You don't look good. And they said, You need to go to the ER. And she's like, No, I'm fine. So they said, You, I'm taking you to the ER. So she said, fine. So she called her husband and said, My colleague is telling me, taking me to the ER, says I'm looking a little ashen. She wound up going to the ER and was in end stage heart failure, complete shock. Not only that, they stabilized her and told her that based on her insurance, she had to go to a transplant center 90 miles away. So can you imagine getting a devastating diagnosis and then being an hour and a half away from your family and they couldn't even get to her? So we don't see that too much in kidney, but it's it's impactful from a transplant perspective, in that as providers, we have not really walked in their shoes. And so thinking about all their experiences and working to improve the system so that some of these circumstances, whether it is payer-related, whether it is provider-related, whether it is systemic, how can we advocate and mitigate the unintended barriers that are placed in this delivery of care? And I think that's the real success. And I hope that this community continues to really advocate and push forward to address all these issues. You know, there's a big effort to really look at is there a way to increase the financial neutrality of living donors? And will that in fact have it, you know, an impact on living donation? That could really be one of the main contributing factors to decreasing the wait list and increasing, you know, living, living donation and transplant rates. So there's just so many exciting opportunities. And as individuals that work in this field, it's incumbent on us to participate, to vocalize, to talk with our patients and really be their voice and advocate so that we can really ensure that everything that is within our power is really done to help patients.

SPEAKER_00 34:00

We could not agree more. Now, if patients would like more information about your transplant program, can you please share that and what the best way for them is to get in touch for an evaluation?

SPEAKER_01 34:12

Absolutely. So uh I'm at Cooperman Barnabas Medical Center. We are located in northern New Jersey. New Jersey, relatives of some states, you know, we like to say we're kind of like a postage stamp, and you can drive probably within 30 to 45 minutes and hit many transplant centers. We encourage individuals to actually access education at all transplant centers. Get informed, make the best decision. We're on the website, Cooperman Barnes Medical Center. We have a transplant webpage. We have a direct phone number that individuals can call if they're needed. Um, we will guide you, even if it's something that we can't help with, we can direct you to the right resource. And that's really our commitment to all of the patients that reach out to us.

SPEAKER_00 34:58

Wonderful. Well, thank you so much, Andrea. Thank you for this. I mean, excellent conversation. And I will look forward to our next conversation. Thank you for having me. Thank you.