The organ transplant debate
The green screen’: Why the poor don’t get organs
Organ transplantation is a perk of the more well-to-do, with economically deprived patients trapped behind what ethics professionals call "the green screen."
In plain English, that means unless your patients have money or great insurance, they won’t get access to the few organs, particularly livers, that are available despite the fact that the percentage of those without money and in need of the transplants far outweighs the numbers of those with more economic resources.
For ethicists, this creates the ultimate bioethical paradox: the needs of the many vs. the needs of the few, filtered through a health care delivery system that virtually ignores the most vulnerable. For the federal government, it is creating an even bigger headache, as the U.S. Department of Health and Human Services struggles to reform the decade-old National Organ Transplant Act. And plopped in the middle of this like a giant behemoth are insurance companies eager to call all the shots, even to the point of deciding where patients can get transplants by authorizing payment only at certain hospitals.
Data gathered by Roger W. Evans, PhD, head of the section of health services evaluation in the department of health sciences research at the Mayo Clinic in Rochester, MN, documents both the extent of the problem and the involvement of private insurance companies and the federal government in implicitly fostering the inequities.
Drawing from a study over a decade of data, Evans found:
• Billed charges for a liver transplant, including hospital services and professional fees, can exceed $286,000, and charges vary widely among transplant centers. For example, the University of Pittsburgh Medical Center (UPMC) is the most expensive center with an average charge per case of $347,970. When adjusted for patient case mix, hospital charges at UPMC are 141% higher than expected, compared with charges per case 6% to 37% below expected at centers such as the University of Michigan in Ann Arbor, Mount Sinai Medical Center in New York City, and the Mayo Clinic in Rochester, MN.
• In 1994, the median hospital charge for liver transplants, excluding professional fees, was $145,263.
• Under a fee-for-service health insurance system plan, total payments have averaged $172,000 for liver transplantation.
• Global prices paid on behalf of managed care organizations now average $119,500 per procedure. Many insurers have developed their own, or contracted with, "center of excellence" networks. They no longer pay billed charges.
• Overall charges for patients who are in the hospital and on life support awaiting a transplant are 84% higher than for patients who are at home.
• Medicaid payment and eligibility criteria for liver transplantation differ by state. However, no state Medicaid program pays more than $100,000 for the procedure and most pay an average of $50,000. "Medicaid patients are hardly attractive for the transplant centers when the reimbursed payment will not even cover the hospital’s accounting costs," says Evans.
• Medicare covers the cost of liver transplantation only in a small percentage of patients who have been disabled for more than two years and have applied and qualified for permanent Social Security disability income. Evans says Medicare is far more likely to cover patients with end-stage renal disease who are waiting for a kidney transplant.
"There is a green screen that means that if one does not have the fiscal resources they will never get on the transplant waiting list in the first place," argues Clive O. Callender, MD, a liver transplant surgeon and director of the transplant center at Howard University Hospital in Washington, DC. A physician will not refer the patient to a transplant hospital, transplant hospitals cannot afford to offer the treatment for free, and the patient dies without ever being afforded the option of transplantation, he charges.
"Most people who understand this implicit rationing get frustrated talking about it. But the more we are silent, the more patients and their families are victimized," he says. "This accounts for the perception that celebrities get favored treatment and why minority communities do not believe the [transplant] system is fair," says the surgeon, and is one reason for the shortage of organ donation nationwide. (See cover story on how one hospital is increasing education and donation.)
Callender uses the example of the dearth of transplants in the African-American community to show how this "green screen" works: Although African-Americans comprise 12% of the U.S. population and are two to three times more likely than whites to have end-stage liver disease, this racial group rarely accounts for even 10% of the total number of patients on liver transplant waiting lists. He contends the real determining factor of whether a patient gets a transplant is not severity of disease or even race but the presence of medical insurance to cover the expensive treatment.
"Today’s rhetoric focuses on managed care. As a result, physicians are being forced to find clinical excuses for economic decisions, all within the context of a global budget," says Evans.
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