One Fifth of Federally Funded U.S. Heart, Liver and Lung Transplant Centers Substandard
According to a recent investigation undertaken by the Los Angeles Times, Medicare and Medicaid have allowed 48 (out of a total 236) heart, liver and lung transplant centers to continue operating despite often glaring and repeated lapses. The heart, liver and lung programs considered in the Times investigation had 71 more patients die than expected within a year of transplant. Of the 236 total programs considered, 36 heart transplant programs failed to meet survival or volume standards and accounted for 43 more deaths than expected. Nine lung programs failed to meet the standard number for surgeries and/or survival, accounting for 21 more unexpected deaths.
According to Dr. Mark Barr, a cardiothoracic transplant surgeon interviewed by the Times:
The bottom line message is that there are too many programs in the United States that need to be shut down.
According to Medicare rules, if a program falls short of the requirements for minimum number of transplants or to achieve a specific survival rate, both prequisites to be certified for funding, no sanctions are imposed. The program is required to turn itself in. Although Medicare has the authority to pull its certification and the attendant funding that goes with the certification, this is a rare occurrence. In fact, since 2000, Medicare has only cut off 11 centers and, in most of those cases the programs had already voluntarily ceased operations.
The Los Angeles Times investigation uncovered the following:
Wake Forest University Baptist Medical Center in North Carolina fell 10 transplants short of the mandated 12 transplants required per year by only performing 2 transplants in the last year. Moreover, of the transplants that did occur, 4 out of 7 patients died within a year of the transplant (between January 2002 and June 2004). This is 87.5 percent below the national survival rate and well below the 73% threshold required by Medicare.
Hartford Hospital in Connecticut has been deficient since 1999, failing to perform 12 heart transplants in any calendar year. Of those performed 6 out of 17, a survival rate of approximately 65%, died within a year.
Similarily, St. Vincent Hospital and Health Care Center in Indianapolis experienced a survival rate of 65% and also failed to perform the yearly heart transplants since 2001.
UCI Medical Center in Orange, California was found by the Times to have had 32 patients die while awaiting transplants while the hospital turned down organs that might have saved some of them. Worse yet, patients at UCI were apparently unaware that UCI had no full time liver transplant surgeon for more than a year, which limited its ability to perform operations. The Times investigation prompted the agency to pull the funding from this institution.
Dr. Barry Straube, chief medical officer at the Medicare agency told the Times:
I personally can't get hung up on the volume issue. A center might do four transplants a year with 100% survival. We should shut those down?
However, according to the Times article, researchers working at the United Network For Organ Sharing reported in 1994 that "mortality increased sharply and exponentially" at centers performing fewer than nine heart transplants each year. The federal standard is 12. Dr. Michael Acker, a heart transplant surgeon and chief of cardiac surgery at the Hospital of the University of Pennsylvania, stated
that to be versed enough to maintain quality, programs should be required to perform at least 20 transplants annually. It's not just doing the transplant. It's doing everything else. It's the follow-up care. It's how to deal with immunosuppression. It's how to deal with (patients) when they get infected. There are so many reasons for why you need a vigorous team.
The Times article reported that private insurers say they vigilantly monitor a centers' performance because they believe patients have a better chance of surviving and lower risk of complications at centers with more experience. According to Ross Lagerblade, director of Humana's national transplant network, "we do still believe that volume has a role to play in the quality and the outcome of transplants."
Incredibly, Medicare has continued to fund programs that private insurers have dropped or steered clear from as a result of relatively high death rates and low volumes.