These are trying times for health care optimists. Despite all the hype surrounding breakthroughs in clinical practice and technology, American medicine is stuck in in neutral. Though the engine is revving loudly, little progress is being made.
This unfortunate truth came into clearer light last week when I was preparing lesson plans for the health care strategy course I teach at the Stanford Graduate School of Business. During the first class of the semester, I offer a summary of health care-system successes over the previous year. This year, the pickings were slim: New developments in artificial intelligence and progress with Haven, the much-discussed Amazon-Berkshire-Chase venture, offered some glimmers.
The bulk of industry movement, however, was heading in the wrong direction. Dozens of scandals, from generic-drug price fixing to gross conflicts of interest, plagued some of health care’s biggest players. Even more discouraging, there was no concrete evidence that U.S. medical care has become more affordable, more accessible, more convenient or better (as measured in quality outcomes) since this time last year. Life expectancy in the United States fell for an unprecedented third year in a row. Americans still spend 50% more on health care than any other nation (as a percentage of GPD). And, to rub salt in the wound, the United States slipped again in the latest global health rankings.
Wanting to introduce a ray of optimism, and to stoke the possibility of positive change, I thought about the following question.
What could our nation realistically do to improve patient health and reduce medical costs in the next year?
With the operative word being “realistically,” this query proved difficult to answer.
Congress could cap drug prices or legalize the importation of effective biosimilars like insulin. But how likely is either action, given that the pharmaceutical industry spends hundreds of millions each year to influence legislation?
What about health care’s outdated information technology platforms? Six in 10 physicians think electronic health records (EHR) need a complete overhaul. That could achieved if the leading manufacturers were forced to open their application processing interfaces (APIs) to third-party developers. But, once again, how likely is that? EHR vendors are just as protective of their profits as drug industry reps.
One solution: Pay people for their kidneys
The idea of paying people for their organs is not new, but it is currently illegal. Back in 1984, the National Organ Transplant Act (NOTA) outlawed the buying and selling of human organs.
Prior to the U.S. government’s involvement in the transfer and transplantation of organs, one doctor in Virginia had attempted to establish a company for the express purpose of buying and selling kidneys commercially. And because there were no laws in place to stop him, NOTA made sense. Today, it doesn’t.
We should let the government purchase kidneys and continue to use an independent agency to decide exactly which individuals should receive these organs.
To understand why this solution makes sense now, it’s helpful to look at how far we’ve come in the past 35 years. In the 1980s, transplantation was an inexact science and often dangerous. At the time NOTA was signed into law, only 80% of kidney transplant recipients survived the operation and the associated immunosuppression. Today, transplant success rates exceed 95% among experienced surgeons and transplant teams.
Back in the ’80s, the lack of diagnostic tests for infectious diseases like AIDS and hepatitis stoked fears that people might lie about their health status to sell an organ, thus increasing the risk of disease transmission for organ recipients.
Finally, proponents of NOTA felt an ethical obligation to uphold the goodwill of organ donation. They didn’t want to see it tainted by those seeking personal, financial gain. In 1983, Dr. David A. Ogden, president of the National Kidney Foundation, told The New York Times, “It is immoral and unethical to place a living person at risk of surgical complication and even death for a cash payment to that person.”
With advances in both science and society, NOTA needs to be modernized for the 21st century. We can realistically save tens of thousands of lives and billions of dollars if Medicare were allowed to purchase kidneys for appropriate recipients and if it paid for transplantation, rather than dialysis.
To highlight the benefits of this approach, two sets of numbers are worth considering. The first set pertains to the discrepancy between kidney need and availability, courtesy of “The Kidney Project” at the University of California in San Francisco (UCSF):
- More than 100,000 patients in the United States are currently waiting on the kidney transplant list.
- Just over 21,000 donor organs were available for transplant last year.
- The need for donor kidneys in the United States is rising at 8% per year.
The other important set of numbers, also from UCSF, are financial:
- Americans living with end-stage renal disease (ESRD) comprise 1% of the U.S. Medicare population but account for 7% of the Medicare budget.
- Dialysis comes with an average treatment cost of $89,000 per patient annually.
- The average cost of a kidney transplant is $32,000 for the surgery and $25,000 per year in post-surgery care.
Armed with these numbers, let’s calculate how much money would be saved by providing 100,000 people on the kidney transplant list with new kidneys, versus keeping approximately 100,000 people on dialysis.
Knowing the annual dialysis expense for this population is $89,000 per patient, the total expense for all 100,000 people over the next five years would be $44.5 billion.
The expense for this same population to receive new kidneys would be $32,000 for the procedure itself, plus $25,000 for post-op care annually, which over the same five-year period would equal $15.7 billion.
That’s a savings of nearly $25 billion.
Of course, these latter calculations assume we can find 100,000 new kidneys donors. Finding living donors would be best for a couple of reasons. First, kidney transplantations that involve “living” donors are more successful than when organs are harvested from the deceased. And second, there are millions of Americans who could contribute.
To find 100,000 donors, the United States government could offer to pay $50,000 for a kidney (plus all surgical costs and follow-up care expenses) for about $5 billion. Doing so would not only improve the health and life-expectancy of the recipients, it would still result in a total health care savings of $20 billion over the next five years.
The savings could then be used to fund programs that improve medical prevention, help manage the nation’s high blood pressure problem and lower the rates of adult-onset diabetes—all of which would go a long way toward preventing kidney disease and lowering future health care costs.
So, if the proposal has the potential to improve American health, lower medical costs and fund future programs to help more Americans avoid kidney failure, what are the potential pitfalls?
Legalizing the sale of organs, some say, would lead to the wealthy taking advantage of the poor. This concern, however, isn’t based in fact. According to UCSF data, kidney disease disproportionately affects the nation’s minority and low-income patients. Therefore, a government-run kidney purchasing program would disproportionately benefit the poor, not the rich.
Others fear that amending NOTA would create a black market. In fact, implementing this proposal would eliminate the need for a black market, since organs would be readily available and controlled by a federal agency.
There’s also the concern that low-income individuals would be coerced by economic factors to donate kidneys at the expense of their personal health. Here too, the argument is specious. Science has proven that a donor’s remaining organ compensates for the loss. Following removal, the twin kidney enlarges and becomes just effective as when there were two.
Furthermore, science has mastered screening for communicable diseases, rendering historical concerns that poor people might lie about their existing diseases for the donor money both outdated and culturally insensitive.
Finally, what about the risk of the donor losing the remaining kidney from trauma or cancer? Currently, people who anonymously donate kidneys are automatically placed at the top of the transplant list should they need one in the future. By making this same promise to the paid donors, the small risk associated with having a single kidney would be offset by the certainty of receiving immediate access to transplantation should it prove necessary.
There is no silver bullet for solving our nation’s health care crisis, and every solution has its risks and downsides.
Using money to incentivize kidney donations carries certain dangers, but also tremendous upside. Those willing to donate would earn $50,000, which would go a long way toward a college education, a home or other family expenses. And those receiving the organs would have a better and more productive life. This solution is realistic. And, done well, the program’s biggest problem might be having to turn away potential donors due to popular demand.
Robert Pearl is a physician and CEO, Permanente Medical Groups. He is the author of Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong and can be reached on Twitter @RobertPearlMD. This article originally appeared in Forbes.
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