Sunday, December 5, 2010

Banning Transplants

Aaron Carroll points to an article by Marc Lacey in the NYT to illustrate problems in our health care system. Arizona is now refusing to pay for some kinds of transplants for Medicaid patients.
Effective at the beginning of October, Arizona stopped financing certain transplant operations under the state’s version of Medicaid. Many doctors say the decision amounts to a death sentence for some low-income patients, who have little chance of survival without transplants and lack the hundreds of thousands of dollars needed to pay for them.
“The most difficult discussions are those that involve patients who had been on the donor list for a year or more and now we have to tell them they’re not on the list anymore,” said Dr. Rainer Gruessner, a transplant specialist at the University of Arizona College of Medicine. “The frustration is tremendous. It’s more than frustration.”….
State Medicaid officials said they recommended discontinuing some transplants only after assessing the success rates for previous patients. Among the discontinued procedures are lung transplants, liver transplants for hepatitis C patients and some bone marrow and pancreas transplants, which altogether would save the state about $4.5 million a year.
“As an agency, we understand there have been difficult cuts and there will have to be more difficult cuts looking forward,” said Jennifer Carusetta, chief legislative liaison at the state Medicaid agency…
Across the country, states have restricted benefits to their Medicaid programs, according to a 50-state survey published in September by the Kaiser Commission on Medicaid and the Uninsured. But none have gone as far as Arizona in eliminating some transplants, which are considered optional services under federal law.
Before the Legislature acted, Arizona’s Medicaid agency had provided an analysis to lawmakers of the transplants that were cut, which many health experts now say was seriously flawed. For instance, the state said that 13 of 14 patients under the state’s health system who received bone marrow transplants from nonrelatives over a two-year period died within six months.
But outside specialists said the success rates were considerably higher, particularly for leukemia patients in their first remission.
Accompanying the article we have pictures of a plumber who needs a heart transplant.

This article encapsulates several of the problems we face with health care issues. First, when we deny care to people, some will die. People who oppose reform like to think that emergency room care, funded by the government, will keep everyone from dying. They like to think that no one will actually die because they cannot obtain care. That is not true. Some people will die. Many more will have difficulty working or caring for themselves and family. Not all life saving care is emergency care, as we see with transplants.

Another problem we see illustrated is the difficulty in deciding what care we should pay for. Arizona is not stopping payment for all transplants. It is stopping transplants on some that it thinks have poor results. The ones it chose to stop funding are transplants for which there is at least some controversy. They are, at least in some studies, lower yielding transplants with higher failure rates. However, they do have some success. Not performing the transplant is certain death for some of those not receiving them. How do we then decide what we will pay for? People do not want government deciding (death panels), but they do not want to pay for procedures that do not work. With these procedures that do work in these patients, but with lower success rates, there is no bright line available for decision making.

I wrote not long ago about Avastin use in breast cancer. it has been clearly shown to not increase life expectancy or increase quality of life. Still, people do not want Avastin taken off the list of drugs for which Medicare will pay. They want to retain the choice of using that drug, and having it paid for. This becomes worse with these transplants which actually do work sometimes. Which leads to our next problem. .

Any attempts to cut health care spending leads to pictures in the newspaper. These pictures will almost always sympathetically portray those losing their benefits. In this NYT article we have family pictures. With Medicare cuts we will see the elderly eating cat food or with loving family gathered around them. If we do not get pictures, we get demagoguery. Think death panels or claims that the budget is being balanced on the backs of the elderly. Which leads to another issue.

On this one I am going to extrapolate and make some assumptions. This jumped out at me. Bear with me.

For instance, the state said that 13 of 14 patients under the state’s health system who received bone marrow transplants from nonrelatives over a two-year period died within six months.
I am guessing that not many in the Arizona legislature have a medical background. I am also assuming that many of them have a rudimentary grasp of statistics. Using such a small number of patients to determine policy is not a sound practice. If the expected survival rate is 30%-50%, a larger sample size is needed to make sure that you are deciding correctly. The would have been best served by looking at national rates where you have large enough numbers to be meaningful. Which leads to the last topic.
It is much more likely that spending cuts for transplants will take place in the Medicaid population. The poor do not reliably vote or make contributions to elections. They do not have the money to effectively advocate for themselves. Imagine the public outcry if Medicare announced that it would not pay for these services. Cutting services to the poor will gain politicians votes from some people, cutting care to the elderly risks losing office.
As is so often the case when it comes to public spending, we see that people want to cut spending, i.e. pay less in taxes, but they do not want to cut the actual services that spending provides. At best, they want to cut spending in areas that will not hurt their own constituents, or cost them votes. Already, the Arizona politicians who cut transplant spending are having second thoughts. I will leave you with the words of the state representative who is also chairman of the Appropriations Committee. (Aaron Carroll’s thoughts are here.)
But a top Republican, State Representative John Kavanagh, has already pledged to reconsider at least some of the state’s cuts for transplants when the Legislature reconvenes in January. Mr. Kavanagh, chairman of the Appropriations Committee, said he does not believe lawmakers had the full picture of the effect of the cuts on patients when they voted.
“It’s difficult to be linked to a situation where people’s lives are jeopardized and turned upside down,” he said in an interview. “Thankfully no one has died as a result of this, and I believe we have time to rectify this.”

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