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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  • Mike

    Though I agree with much of the post, I can’t help but notice you rang an alarm to governmental intrusions in healthcare. This discussion is about Medicaid, a government (taxpayer) funded program. Whether one is for or against Medicaid and/or universal healthcare, it is hard to argue that there is government intrusion form the outset. However misguided the decision may seem, it is hard to argue that the state of Arizona is being intrusive in regulating how its disbursed funds are spent.

    This should be but a preview of the power of a single-payer system.

    • Smart Doc

      Mike nailed it.

      Arizona is acting no differently than every other Single Payer on earth. Wait until the millions of boomers find themselves trapped in Medicare, with no decent doctor willing to see them, and many treatments denied with no appeal.

      The only thing missing is the 5 star care surreptiously give to the corrupt Regime Elite on top. No wonder Congress and the White House exempted themselves from ObamaCare.

  • ShimC

    This is somewhat related to this topic:

    My wifes 83 year old great uncle smoked and drank his whole life. During the last 2 months of his life, he ran up $183,000 in medical bills. Some of his last words were asking “why did they spend so much money on me?”

    It seems that at some point, someone has to play God?

    indeed I am 50 years old and have paid a LOT into “the system” and don’t have high expectations about getting much back. But for God’s sake, someone has to pay for this?

    Who?

  • HJ

    RE: 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.

    I noticed that doctors don’t have to make any sacrifices so someone won’t die. Why should I take a pay cut?

    • Osler Disciple

      We make TOO many sacrifices to list every one of them. The most obvious and pertinent (to this thread)sacrifice is the loss of income we sustain on a daily basis because we have been run over by insurers and the governement and accept whatever payment is predetermined to us. Loss of the free market system to our detriment. And don’t get me started on EMPTALA. Not to mention loss of autonomy in making decisions and advocating for our patients. When I think about, not many components of the system have sacrificed as much as the doctors.

    • Smart Doc

      Any doctor who sees a welfare Medicaid patient and loses money in so doing, is making a sacrifice.

  • MH

    Seriously HJ? Doctors don’t make sacrifices? What about giving up our lives to learn to do this job? I guess that doesn’t count and isn’t a real sacrifice?

    How much would you pay a doctor to save your life?

  • Muddy Waters

    Any measures we take to “fix” our healthcare system are ultimately just kicking the can down the road. To truly balance our books, we MUST make people LESS dependent on government. However, no politician will make the necessary propositions because it will likely result in career suicide. Thus, our problems are only going to get worse until we break.

  • ShimC

    Seriously MH? Those paying for doctors don’t make sacrifices? Most all doctors I know live a pretty nice life. (Although Orthodontists really seem to have it made.)

    I guess the time I spent bcoming educated and paying my way doesn’t count as much as a ‘doctors?’ And what others do isn’t a real sacrifice?

    “How much would you pay a doctor to save your life?” Gimme a break man… How many save lifes? How many lose lives with mistakes? What about the homeless person who pushed some old lady out of the way of an oncoming bus?

  • Alison

    Maybe I’m just a heartless person, but I am OK with rationing on some level. At some point, we have to remember what Mr. Spock said, that sometimes the needs of the many outweigh the needs of the one. Would anyone argue that it’s a waste to spend, say, $1M per day to keep a demented 99-year-old man alive on a vent with a PEG? So obviously we are willing to say enough is enough, and we can get down to the ugly business of drawing the line somewhere. Unfortunately, our resources are not unlimited.

    We need to, as a society, start having these hard discussions NOW rather than leaving them up to faceless technicians at insurance companies and in government cubicles. Do we want to spend dollars at the beginning or the end of life? Is it more important to save one cancer patient or vaccinate ten thousand infants?

    Yeah, it will really suck to be the person denied a treatment. I’m currently unable to get an expensive treatment approved for myself, despite being part of the system, so to speak, and it’s frustrating. I don’t like my functioning being limited in order to beef up an insurance company’s shareholder dividends. On the other hand, I would be much more okay with the savings going to prenatal care or kid’s cancer treatments where the dollars would do more good to society than the marginal benefit I could get. That’s why we need to have a single payer system or at least make health insurance and coverage decisions non-profit.

    • Smart Doc

      Sorry, but Single Payer is not the way to prevent rationing.

      Medical care rationing is the “heart and soul” of socialist government control, unless you are in the ruling elite. So if you are a crooked Liberal politician in Canada, you get a special waiver for Five Star top medical care in the U.S.A., paid for by the very same Single Payer that would never in a million years let an ordinary Canadian get the same care.

      • Alison

        I think you missed my point there, Doc. We NEED some sort of rational rationing because the healthcare dollars are simply not unlimited. But we need to make these decisions as a society based on both our shared values/ethics and the hard realities of dollars and cents. To leave it up to the patchwork of bureaucrats and profit-maximizing executives is unethical and foolish. There will always be rationing, whether based on ability to pay, government guidelines, unwritten hospital culture, what have you. Let’s have a national conversation and make them explicit and decide where we want to put our money.

  • ShimC

    No one will ever make the hard decisions.

    Y’all can blame the right or the left or the middle. Fact is, no one – not a politician or doctor or managed care exec on the face of this earth will stick their neck out.

    And Wow, Alison…strong and right on. And do you think doctors will be as motivated to serve others and make do with less total renumeration under a single-payer, non-profit system? I don’t know…just asking.

    • Alison

      I don’t know, either, Shim. Is it necessary for average net compensation to go down in a single payer system? Sure, some who are becoming rich of high-value procedures might drop in income, but a revamping of malpractice procedures to a no-fault compensation fund (like the vaccines court) combined with professional sanctions with teeth imposed by health care professionals and not random jury members could help lower some of those costs. Add in subsidized medical education and the substantial savings of eliminating the huge office staffs needed to process insurance nonsense, and you’re talking a huge savings. As a former military member, I am aware that most on-base (single-payer) clinics have only one or two receptionists for several doctors rather than the small army of billers, coders, patient coordinators, and other nonsense a civilian practice requires. My dream system would have a basic, single-payer system that provides decent care for everyone with a pay-to-play system that would provide top-notch care to those who choose to invest in it.

  • HJ

    RE: How much would you pay a doctor to save your life?

    I don’t have enough money for a doctor to save my life.