Clinton would alter care, focusing on basic services

January 11, 1993|By Los Angeles Times

President-elect Bill Clinton has promised health care reforms that, his policy advisers say, will effectively shift money from high-tech care to basic medical services. This is anything but an academic issue. The cost of one liver transplant, $150,000, for example, is equal to vaccinations for 10,000 youngsters, many of whom are now going unvaccinated and dying as a result.

While high-tech medicine covers a wide range, from sophisticated surgery to such diagnostic techniques as magnetic resonance imaging, or MRI, transplants are probably the most avant garde and glamorous. Transplant medicine is a relatively new science, dating back to the first successful kidney transplant between identical twins in 1954.

Over the years, hearts, lungs, and livers have joined the list of transplantable solid organs, as well as combinations such as heart-lung and pancreas-kidney. New drugs to counteract the body's natural rejection of foreign tissue permitted thousands of patients to benefit from this remarkable surgery.

From the beginning, though, organ transplants have been extraordinarily expensive. In addition to the operation itself, transplant patients require intensive care, blood transfusions, extensive laboratory tests and costly anti-rejection drugs.

Liver transplants today go for upwards of $150,000, lungs can be $135,000 or more, hearts hover around $100,000, and kidneys are $40,000 to $50,000. Complications with any of them can easily drive the bill over $200,000.

The prices leave most people aghast, says Ellen Severoni, whose research group, California Health Decisions, monitors public opinion on health care issues. The vast majority of those she has surveyed believe this sort of "high tech" medicine is a major cause of the United States' runaway health costs.

In the meantime, uninsured Americans are prey to illness and death from things most Americans never have to worry about. For example, 40 children died among the thousand stricken in a recent Los Angeles measles epidemic. Each death could have been prevented by a $15 dose of vaccine.

"Los Angeles is a living, breathing, hyper example of what is wrong with the American health care system," says Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota. "You've got too many children who can't get a leg up on life, because their prenatal care stinks, they can't get a measles vaccine, or their diabetes goes unchecked for too long."

Yet in its major hospitals, he adds, the city offers some of the finest medical care in the world -- "if you have money. Then you can have pig liver transplants, gene therapy, anything you want."

Why do some hospitals go into the transplant business? For money, health economists say.

Although a program's startup costs can be considerable, transplant centers historically have been well paid by insurers. Hospitals also see potential profits in the prestige such programs confer.

Hospital consultant Marian Jennings says many of her clients want transplant programs because they consider them a lure for medical talent as well as for patients who might be impressed by this badge of cutting edge sophistication.

The burgeoning popularity of these programs is seen in statistics kept by the United Network for Organ Sharing, or UNOS, the federally mandated watchdog agency for transplant medicine. In the last five years, UNOS has measured a 39 percent increase in heart transplant centers in the United States, while liver programs have leaped by 70 percent.

The one thing that hasn't increased is the supply of donor organs, which is a problem with grave implications for the quality of transplant medicine, should the proliferation of centers continue.

The more organ transplants a hospital does, the better chance the patient has of surviving, studies show. But with more transplant centers competing for a limited supply of organs, expertise can only be diluted, says UNOS's incoming president, Dr. Douglas J. Norman.

E. Richard Brown, a professor of public health at University of California, Los Angeles, says patients subsidize these costly and duplicative programs either directly through higher payments for routine medical services, or indirectly through taxpayer supported health insurance programs such as Medicare and Medicaid. And since having insurance coverage is often a prerequisite for transplant surgery, some of those whose tax dollars subsidize these services will never be able to benefit from them.

"It is a wonderful sort of microcosm for what ails the American health care system," says Dr. Robert Tranquada, former dean of the medical school at University of Southern California. "There is money to do this kind of thing. And there isn't money to address the basic health care needs of the uninsured."

Transplant surgeons respond that their work may offer long-term savings. A successful kidney transplant, for example, pays for itself within five years through savings on weekly dialysis treatment and complications of the condition. That makes it the most cost-effective treatment for end-stage kidney disease, says UCLA kidney expert J. Thomas Rosenthal.

Health insurers, nevertheless, are putting pressure on organ transplant programs to cut costs and prove their worth.

"There is no doubt that the payor community is exerting its muscle," said Dr. Steven Udvarhelyi of the Prudential Insurance Co., one of the nation's largest private purchasers of medical services. "We have to ask ourselves as a country whether there are too many of these (transplant) centers, and whether there ought to be some consolidation."

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