The Numbers Behind a Transplant Funding Cut

By Carl Bialik | The Wall Street Journal

My print column this week examines the numbers behind Arizona’s decision to cut Medicaid funding for several kinds of transplants. The move has sparked controversy among transplant groups and widespread coverage in the local and national press. As I detail in the column, transplant experts question the numbers behind the decision. Arizona’s Health Care Cost Containment System, the Medicaid agency, has responded by pointing to the state’s tight budget.

This same conversation, more or less, played out on a conference call a few weeks ago that included Michael Abecassis, director of Northwestern University’s comprehensive transplant center and president of the American Society of Transplant Surgeons, and representatives of the Arizona agency. He recalls saying something like, “All I can tell you is, the rationale for this is stupid.” At that point, the call ended. “I didn’t mean to use it in a bad sense,” Abecassis said in an interview this week. “Maybe in retrospect, I wouldn’t use that word.”

Abecassis said he doesn’t unilaterally oppose transplant cuts, saying some of Arizona’s are justifiable. “My beef is that the medical justification for these legislative decisions has no basis in medicine,” he said. “If the state of Arizona said, we have such budget constraints that we are not providing any medical help to Medicaid patients, we wouldn’t be having this conversation.” It was the targeting of transplants, with — in his view — flawed reasoning that troubled him.

Monica Coury, assistant director of intergovernmental relations for the state’s Health Care Cost Containment System, said the state consulted with outside experts. Yet by Abecassis’s readings, none of these outside experts’ advice squared with the eventual recommendations. For instance, Jacqueline A. O’Donnell of Indiana University’s Krannert Institute of Cardiology said heart transplants are indicated for patients who “who meet criteria, and for whom all other medical and surgical modalities have been exhausted” — which describes pretty much every patient on the transplant list, transplant experts said. O’Donnell and consultants on the liver and lung decisions didn’t respond to requests for comment.

If the reasoning behind the transplant cuts is flawed, “then the flaw is with Congress,” said Coury, pointing out that Congress limits which areas state Medicaid agencies can cut.

“The concern we’ve had is that the decisions they made were based on flawed, outdated data,” said Maryl R. Johnson, medical director for heart failure and transplantation at the University of Wisconsin Hospital and Clinics in Madison, and president of the American Society of Transplantation, a professional organization.

Researchers whose data was cited by Arizona were troubled by the decision. The state cut lung transplants in part because of a dated study at the University of Washington that found the procedure didn’t extend life expectancy. “Clearly, the standard of care and outcomes have changed and evolved over the last 15 years and it is not appropriate to extrapolate the results of our study published in 1996 to current standard of care and outcomes,” Ganesh Raghu, professor of medicine at Washington’s medical school and medical director of its lung transplant program, wrote in an email. He said a multi-center study would be more useful. Given current data, Raghu backs lung transplants in select cases. “Lung transplantation is not an ‘experimental treatment’ and it is routinely done for select patients and patient populations in several centers in the world,” Raghu said. At least two recent studies point to extended life expectancy from lung transplants.

Further reading: See Arizona’s justification for the cuts in heart, liver and lung transplants. Outcomes for heart, liver and lung recipients have improved nationally. More transplant data is available from the U.S. Organ Procurement and Transplantation Network.