News: Analysis & Commentary: MEDICINE
CAUGHT IN THE ORGAN GRIND
Liver-transplant pioneer Dr. Thomas E. Starzl tells of flying to Nova Scotia for a liver--with the pilot nearly crash-landing the plane--and then racing back to Pittsburgh to sew the organ into a dying patient, saving a life. Those were the glory days of the 1980s, when the University of Pittsburgh was the liver-transplant capital ef the world.
Things have changed since then: Pitt surgeons watched from afar as Mickey Mantle underwent his transplant at Baylor University Medical Center in Dallas in June. When it turned out the Hall of Famer's cancer had spread to his lungs (making him an unlikely candidate for a precious liver), Pitt sniped that the cancer's spread could have been caught with a $10 test--one developed at Pitt.
RESEARCH ROLLBACK? Such backbiting is growing common in the $4 billion transplant business. "The transplant programs don't trust each other," admits John J. Fung, chief of the Pittsburgh Transplantation Institute. Indeed, as the miracle of transplants becomes routine, market forces are roiling the industry. Hospitals are battling over a tight supply of hearts, kidneys, and livers. At the same time, insurers are negotiating cut rates for transplants, forcing hospitals to slash surgical costs and research.
This could mean a big squeeze on the industry. Already, nearly one-fifth of heart- and liver-transplant prospects die while waiting for organs. Despite an advertising push urging Americans to donate, the supply is barely growing. That means that as transplant demand rises, deaths on the waiting list will follow apace--unless substitute animal or mechanical organs can be developed. But such advances are less likely with insurers driving down costs. "The managed-care organizations are not terribly interested in funding research and development," says Roger W. Evans, head of health-services evaluation at the Mayo Clinic.
Imitating health maintenance organizations (HMOs), insurance companies are selling discounted transplant packages to companies. To get the business, hospitals are slashing prices: Some now offer liver transplants, for instance, at $120,000--vs. an average of $153,000. Insurers also are pushing most transplants to large, well-established hospitals. The upshot: a retrenched transplant business. The Mayo Clinic's Evans foresees a shakeout of providers, from 278 hospitals now to perhaps fewer than 100. "Contracts with insurance companies will be the lifeblood," says Pitt's Fung.
Meanwhile, transplant centers continue to fight over organs. The national allotment system divides the country into 11 regions, with each one keeping its organs to itself. This fosters a sense that donors are saving their neighbors' lives, says Laurence Swasey, community-education liaison for New York's Regional Transplant Program. But surgeons at Pitt argue that the sickest patients are dying simply because they're on the wrong side of a state line.
PIG PUSH. Desperate surgeons are now loosening the standards for donors: They're pulling organs from people in their 80s, up from 55. And some of the donors have histories of hepatitis and hypertension. At the same time, researchers are continuing to experiment with large primates. And at a recent transplant convention in Bethesda, Md., several pig farmers circulated, looking to move upmarket from wieners and kielbasa.
If scientists perfect mechanical organs or cross-species transplants, the number of operations could skyrocket, perhaps to 100,000 a year. But then insurers would ask even more hard questions. Dr. Starzl didn't think about such things on his flight to Nova Scotia. Back then, "managed care" was a new idea, and the only health-care crisis was disease.By Stephen Baker in Pittsburgh