March 2nd, 2011
For the past two years, debate as to whether health reform would result in rationing has underscored the contradiction between the health care Americans would like to have and what we’re actually willing to pay for it. One may note that the terms budgeting and rationing are synonymous – especially today in an era of undeniably difficult choices.
That is one reason it was disappointing that as Congress considered health reform, charges of health care rationing blocked a more thoughtful discussion on achieving better value. In this climate a new proposal has been announced to address how to better match scarce kidney donations with transplant patients. In applying a thoughtful, evidence-based process to confront a difficult ethical issue, the United Network for Organ Sharing (UNOS) has formulated a proposal which doesn’t deny care, but instead aims at making existing resources as effective as possible.
The proposed policy is aimed at addressing the situation as it is – not as it should be. This year approximately 87,000 renal patients are awaiting transplants, while only about one in four will receive one. Today kidney transplants are received largely on a “first-come, first served” basis. Though other factors also play a role in allocating organs, the system sometimes fails to provide the best matches, and a significant number of donor kidneys are inappropriately discarded. So for almost six years, UNOS has examined how to improve the system.
One of a number of changes proposed is the “age matching” of donor kidneys with recipients, which responds to the fact that the limited supply of donor kidneys isn’t being used to its greatest potential. Some young recipients receive much older transplant organs and thus need additional surgeries as they outlive their donated organs. Conversely, when young organs are transplanted into older recipients, much of the potential of the organs to function a very long time can be lost. Thus UNOS has proposed a new system in which the age of the donor kidney and recipient are key factors in the matching process”
In practice the policy proposed is not as simplistic as some critics will contend, and it considers many different factors. Under the new proposal, kidneys which offer the lowest risk of transplant failure would be offered first to those local transplant candidates projected to have the longest post-transplant survival. Other donor kidneys would be made available first to transplant candidates who are within 15 years (older or younger) of the age of the donor organ.
The system is much more complex than a simple consideration of age: An older patient with a good projected outcome could receive an organ over a younger person with poorer survival prospects. Overall though, the system would direct donor organs with the greatest useful life to younger patients, and slightly shift donations toward those in lower age groups. While the new system is projected to maintain the longevity benefit of renal transplants in those who receive them, younger transplant recipients are projected to experience large improvements in lifespan while older patients would see much smaller reductions. UNOS estimates the new system would result in an increase of 5,000‑15,000 additional life years from each year’s kidney transplants…a substantial benefit to patients.
The new system would also reduce the number of wasted kidneys: Currently, kidneys from older donors are sometimes declined by patients at the top of the waiting list who assume a “better” organ might be offered later – and this contributes to a significant number of discarded organs.
A Good Move In A New Direction – Or Back To The Same Old Arguments?
The system proposed certainly isn’t perfect, and the toxic debate continuing around health reform could raise opposition to what appears a well-founded plan. The proposal’s acknowledgment of patient survival projections and the realities of aging could reawaken the “death panels” debate. Charges of age discrimination have already been issued, yet those making these claims ignore the trends of the past 20 years. While not adjusting for census changes, UNOS notes that in that period, those over 50 grew to comprise the majority of organ recipients, while the percentage of transplants of those in the 18 to 49 age group actually declined significantly, from 67 to 40 percent.
This policy announcement illustrates the sort of indisputably difficult health choices we must confront. Today our nation could choose to increase our health expenditures further, yet even if we wanted to do so, this would likely ruin our global competitiveness – and we already spend more on health care than other, more efficient industrialized nations. So thoughtful policy which makes the most of the resources Americans are willing to spend is essential.
Yet instead of addressing the need to achieve better value, we’re having a partisan ethical debate which frequently denies reality. Recently, some in the Pro-Life movement have expanded lobbying beyond the divisive issue of abortion to confront non-existent death panels and the rationing of health care. Concurrently, some in Congress argue that no procedure with potential benefit should be denied. They insist that we “let doctors and patients decide”. Yet private plans don’t issue such blank checks, because that simply invites insolvency.
I suspect some of those in Congress realize this blank check approach will wound Medicare finance so severely, that it could be collapsed into a privatized defined benefit system. I’ve even heard the argument that we should just “give people their money that’s in the Medicare Trust Fund” – a most disturbing level of ignorance. Many more representatives have found it simply too difficult to impose fiscal discipline – and others find that the health care industry’s influence in funding campaigns makes prudent action difficult A sea change in health policy based on evidence is essential – we need policy just as studied and thoughtful as the UNOS approach.
Achieving Value-Based Health Care
Value is the central issue before us, but we still don’t have the mechanisms in place to adequately achieve it. Under Section 1182 of the Affordable Care Act, comparative effectiveness research (CER) will be conducted, but cost analysis is largely set aside, and the use of quality-adjusted life years (QALYs) or a comparable measure is specifically prohibited. Additionally, the Act prohibits discrimination in coverage and reimbursement on the basis of age, disability or terminal illness. However, the HHS Secretary is wisely not prohibited from determining coverage or reimbursement based on comparison of effectiveness – including when that varies due to age, disability or terminal illness.
So it appears possible to create a system to achieve higher value, and it seems certain that private payers will utilize CER results and incorporate economic analysis to do just that. Yet taxpayers funding the research enterprise aren’t likely to see the same outcome for Medicare and Medicaid.
The route to do so would be through the HHS Secretary, and each determination on coverage or reimbursement is likely to be exceedingly painful, prolonged and political. Tragically, the new Independent Payment Advisory Board (IPAB) – a candidate to harness findings to achieve better value and lower costs in Medicare – is so limited by what it cannot propose that it may largely rely on provider cuts. Without these constraints, IPAB could implement value-based purchasing which engages both beneficiaries and health care providers. For example, tiered co-payments, step therapy requirements and other creative approaches could produce higher value for expenditures, and even cost reductions. Ironically, those are the sort of strategies that private Medicare Part D plans are permitted to employ – but they appear off the table for the Board. Relying on the current framework of Secretarial action and a hamstrung IPAB to ensure the fiscal health of Medicare or Medicaid may simply be wishful thinking.
These aren’t easy decisions. Today while health industry lobbyists promote big-ticket Medicare spending – such as $93,000 for Provenge therapy to provide marginal treatment for prostate cancer, and expensive joint replacement surgery promoted by the QALY concept – the Medicare recipient of such treatment may return home unable to afford the costs of out-of-pocket medical expenses or heating his or her home. The fact is, everyone is entitled to debate what our budget priorities should be, but not the reality of what is actually spent. The path to assuring the fiscal health of Medicare and Medicaid – and the sustainability of health reform – is paved with difficult choices. The UNOS proposal raises more hope we can make those choices based on evidence, rather than rhetoric or campaign dollars.
As a post-script, please join me in carrying an organ donor card. Perhaps some recipients will be math teachers. We’re certainly going to need them.Email This Post Print This Post