Withholding liver transplants for Medicaid recipients in Arizona

Governor Brewer’s decision to withhold liver transplants for Medicaid recipients in Arizona should serve as a loud warning to the electorate regarding governmental intrusions into health care financing and health care operations.

The decision was ill advised on the basis of multiple factors.  The survival rates differ from one facility to another.

What is the liver transplant survival rate and what information needs to be considered when looking at such numbers?

For example, the country and facility in which a liver transplant is performed can have rates that are vastly different from the overall number. Also worth considering is the type of transplant (full organ or partial, i.e. liver graft) and the status of the donor (living or deceased).

At the Mayo Clinic in Florida, the survival rate for liver transplant in adults (both living and deceased donors) at the Florida location is higher than the national average.

The one-month survival rate there is over 98 percent for recipients; nationally it’s almost 97 percent. The one-year rate is almost 94 percent, beating out the national average of over 88 percent. Finally, the three-year rate comes in at over 82 percent, as opposed to the over 78 percent rate nationally.

In an article published in the journal Transplantation Proceedings, the MELD/PELD system is credited with an “excellent” transplant survival rate in multiple categories. The study followed 4163 adults and pediatric recipients of whole organ and liver graft transplant from deceased donors from February 2002 through December 2003. The conclusion reads, “We conclude that patient and graft survival have remained excellent since implementation of the MELD/PELD system. Although recipients with MELD scores in the highest quartile have reduced survival compared with other quartiles, their 1-year survival rate is acceptable when their extreme risk of dying without a transplant is taken into consideration.”

There are many considerations besides the availability of funding when a decision is made for or against a patient undergoing liver transplantation. The overall chances for success or failure of a liver transplant are always considered when appraising a waiting list by those responsible for allotting available donor livers. In the case of individuals these cannot be disclosed publicly due to privacy and/or confidentiality issues regulated by HIPAA.

Some of these considerations include the etiology of liver failure, a malignant  process may not be confined to the liver,  another comorbidity, such as alcohol or other substance dependency, hepatitis C, heart disease,  socioeconomic living conditions (homelessness) which can impact postoperative care and follow-up, age of the recipient, co-dependency of other family members, children’s ages, and other factors.  Tissue committees usually review all of these factors prior to assigning liver disposition.  Like it or not these are realistic and time proven methods of recipient selection.

Unfortunately Governor Brewer did not publicly disclose, or the media misrepresented the decision making process done prior to the announcement that Medicaid would not fund a liver transplant in this case. Has the process been politicized?  The media would like this to be the case for whatever motivates their reporting.

There was also a lack of transparency of the process.  Where was DHS, Medicare and other public agencies? Is this a last minute crisis decision or another failure of incompetent legislative planning?

There are many alternative solutions, including cutting back public services to a four day week, furloughing some public employees, delaying of funding pension plans, re-allocating funds from other programs.  Delay health IT expenditures, and other non-essential services of Medicaid.   Why have health IT and EMR if patients must die to fund it?

According to the Kaiser Family Foundation,  Arizona ranks poorly in regard to Medicaid cost containment.  Arizona as not implemented pharmacy cuts, decreased eligibility, implemented co-pays or share of costs.

Hopefully the AMA, and the Arizona State Medical Society have lodged their protest and guidance to alter this policy immediately.

Gary Levin is a physician who blogs at Health Train Express.

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