Transplantation - Medicare's ESRD Program, part 2 - End State Renal Disease - column

Physician Executive, May-June, 1989 by Hugh W. Long, Richard M. Lauve

Thus, medical as well as financial considerations tend to favor transplantation over chronic dialysis as a long- term treatment plan for ESRD patients. These facts, coupled with the existing apparent price to the patient for renal transplantation (20 percent of cost) have resulted in demand far in excess of supply, with the gap expected to increase. In March 1988, one year after congressionally mandated participation in national organ "clearing houses," there were 12,500 people on waiting lists for kidney transplantations, 150 percent of the number of patients transplanted in the previous year. By January 1989, the waiting list had grown to 13,943.1-1 No one is quite sure how many dialysis patients could undergo a transplant, but some experts estimate that as many as 50 percent might benefit from the procedure.9 With more than 110,000 patients currently receiving chronic dialysis therapy, the January 1989 waiting list may be only one-fourth of the ultimate demand for renal transplantation at current subsidized price levels.

Economic pressures for a large hospital system to develop a transplantation program are heightened by the prestige factor involved with this service. The public views organ transplantation as the newest medical miracle, and a health care system may not be viewed as truly first-rate if it doesn't offer the service.

The ability of a medical center to provide transplantation services depends on much more than direct economics. High-quality transplantation surgeons are in limited supply. Many transplant recipients are also eligible for Medicaid benefits in their states. Thus, Medicaid funds can be used to augment a medical center's transplant program, but this also results in state political processes affecting the nature of that program. Oregon's decision in the summer of 1987 to discontinue funding of transplants under Medicaid is an extreme example of how a state's health care policy can effect the success of a transplantation program.

Regulatory involvement in a transplantation program can also result in a negative public image for the entire health care institution, especially when ethical issues surrounding transplantation become a media topic. The Oregon decision to fund prenatal care rather than transplants is only one aspect of this thorny ethical issue. Hospitals providing transplant services are finding it more difficult to turn away patients who have limited financial resources. In some states, disapproval of funding on an individual case can leave a hospital in the precarious position of having recommended a transplant that it cannot afford to perform.

Although the causes are not clearly delineated, renal transplants are not uniformly provided to all races. White males represent one-third of all patients on dialysis, but constitute one-half of those patients having working kidney transplants. Blacks suffer chronic kidney failure at three times the rate of whites, but are only half as likely to receive a kidney transplant.8 Such statistics have led to accusations of racial discrimination in transplant programs. Similar sexual differentials also exist, although they are not as numerically extreme as the racial differences.