The Financing Debate

Transplant centers are continually faced with the difficult assignment of deciding who is eligible to receive available organs from limited resources. This decision cannot always be based strictly on medical criteria. Unfortunately, the patient's ability to pay is often the deciding factor. And now what becomes the real issue in question is whether it is ethical to make medical decisions based on financial criteria.

Under current fee schedules, Medicaid reimburses a maximum of sixty percent of the actual cost of a transplant. Amounts payable by Medicaid and Medicare are pre-set by HCFA. Any authorized Medicaid or Medicare provider must accept the amount set, regardless of the real costs incurred by the hospital. If they fail to comply, the hospital risks losing all of their Medicaid and Medicare billings. It is not uncommon for transplant programs to run on a deficit, and as a result, simply keeping the hospital in business becomes a real concern.

One of the principal problems identified by transplant patients and their families focuses on the cost of the anti-rejection drugs and follow-up treatments that will be part of their daily routine for the rest of their lives. These drugs and follow-up treatments can cost upwards of $45,000 every year, although the average yearly cost is about $20,000-25,000 (1997 dollars).

Current Medicaid and Medicare regulations do not provide for life-long care, nor do a number of insurance companies. For example, Medicaid covers all transplant related expenses for children, but they no longer quality for Medicaid as soon as they turn 19. The most logical next step would be for that child to obtain individual health insurance, but with pre-existing condition clauses and escalating premiums it is doubtful whether this is a workable option. This same problem rears it’s head if private insurance has paid for a child’s transplant. As soon as the child is no longer eligible under the parent’s insurance, few options remain.

If the patient receives Social Security Disability payments, then Medicare is part of the care plan. Medicare will pay for the transplant, follow-up care and anti-rejection drugs -- but three years after the transplant surgery, recipients are considered cured, and their benefits with regard to anti-rejection drugs are cut off whether or not they still qualify for Disability. These people are then faced with the same dilemma described above -- it is almost impossible for them to get affordable health insurance.

It is simply irresponsible of our legislative bodies and the medical community to let things continue in this vein. The mixed messages are monumental: we’ll cure you, we’ll make you dependent on us for this expensive care which we tell you right up front you’re going to need for the rest of your life -- and then we’ll yank the rug out from under you!