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REORGANIZING THE SYSTEM
March 27, 1998The NewsHour with Jim Lehrer Transcript |
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Health and Human Services Secretary Donna Shalala has proposed changes to the way donated organs are allocated. Under the plan, location would no longer be a factor; the nation's sickest patients would receive donated organs first. Is the proposed way a better way? Two experts join Margaret Warner for a discussion.
MARGARET WARNER: Yesterday, Health and Human Services Secretary Donna Shalala ordered big changes to the way donated organs are allocated. She said organs should go to the nation's sickest patients--wherever they live. About 19,000 organ transplants are performed each year in the United States, but there are about 55,000 patients
A RealAudio version of this segment is available.
NEWSHOUR LINKS:
Online Forum:
1/2/98: A debate over the ethics of organ donation.
December 12, 1996
Federal health officials are considering a new policy that would change how liver transplant recipients are selected.
Browse the NewsHour's coverage of health.
OUTSIDE LINKS
United Network of Organ Sharing
HRSA Division of Transplantation.
The Transplant Recipients International Organization, Inc. homepage, featuring the National Organ Waiting List.
waiting for donated organs to become available. Annually, some 4,000 patients--or 10 per day--die still waiting for a transplant.
The current allocation system is operated by a private, non-profit group called UNOS--the United Network for Organ Sharing--under a contract with HHS. The UNOS system is based on 11 geographic regions, with 63 local areas within those regions. When an organ becomes available, it is given to the sickest patient in that local area--or in that region, if not needed locally--even if there are needier patients elsewhere.
Secretary Shalala's proposed plan.
The new HHS regulations would require UNOS to make three changes: eliminate geography as a factor in determining who gets an organ; develop uniform national criteria for placing patients on transplant lists; and develop uniform national criteria for ranking those patients by need. In addition, Secretary Shalala ordered the nation's transplant centers, which are usually based in hospitals, to release more information about their transplant success and survival rates. The HHS plan is controversial. UNOS, for one, opposes it. Secretary Shalala has delayed the rule to permit an additional 60 days of public comment. Sen. Bill First
of Tennessee has said he will hold hearings on the issue. Once a plan is approved, the changes would be made in a matter of months.
MARGARET WARNER: For more, we're joined now by Dr. John Rabkin, a transplant surgeon at Oregon Health Sciences University. He is representing UNOS. And Dr. Alan Langnas, chief of liver transplantation at the University of Nebraska Medical Center.
Dr. Langnas, first of all, what's wrong with the current system? Why does it need changing?
DR. ALAN LANGNAS: Well, I think one of the important issues with the current system is that we have these artificial geographic barriers that prevent proper sharing of organs to help people who are most in need. These 63 separate local units that you've mentioned can be as large as an entire state, but sometimes they're representing every single hospital. So those local organs are first used within that local
bit of geography, so that that center's or that state's list of patients has run and the sickest patient there is transplanted first, and down the list. But these lines can be drawn between one state and another, which can be simply the Missouri River in our case here in Nebraska between ourselves and Iowa. Or sometimes these organ procurement agencies are a single hospital, and the patient can be literally across the street dying and in need of an organ transplant, and these rules prevent that from occurring.
Are some patients disadvantaged, depending on where they live?
MARGARET WARNER: So are you saying then that there's tremendous inequity in the amount of time people have to wait, depending on where they live?
DR. ALAN LANGNAS: I think that's what the system lends itself to. There's a lot of reasons that go into that. Some of it is a philosophy of different transplant centers as to when patients are placed on a transplant waiting list. But other times it's done based on organ availability. Patients are moved to various transplant centers based on what insurance companies tell them, the expertise at various transplant programs, or the lack of it--of a local transplant program that could take care of these patients.
MARGARET WARNER: UNOS opposes, though, changing the system to a national system. Why?
DR. JOHN RABKIN: Well, I think UNOS really objects primarily to the fact that now the government is really going to be replacing the medical care team at the bedside. I think what the HHS--
MARGARET WARNER: I'm sorry. Explain that about the new rules. How will the government be?
"The government is really going to be replacing the medical care team at the bedside."
DR. JOHN RABKIN: The current allocation policy was derived and has been continually evolving over the past decade based on the collective participation of people involved in the transplant community and that includes patients and patient families, donor families, as well as the medical care professionals. So far, the decision making has all been up to UNOS to decide how patients should be transplanted or meaning how the organs should be allocated. Now, with the secretary's new policy directive the secretary will usurp that authority, and that really means putting the government at the bedside. The government's going to be making a decision on who gets transplanted.
MARGARET WARNER: Is that how you see it, Dr. Langnas, is this going to put the government in a position of making these decisions?
DR. ALAN LANGNAS: Well, I think the government is already at our bedside. I think any physician practicing medicine in the United States today recognizes that to a certain extent. I think the secretary has been very even-handed and fair-minded in her approach to this and thoughtful. The system--excuse me--could you repeat what you were asking me?
MARGARET WARNER: I just asked you if you feel that--is there something to what Dr. Rabkin says, that this is going to go from a system that's essentially privately run to a system that the government is going to have a lot more to say about who gets an organ?
DR. ALAN LANGNAS: Right. Well, I think what the government is looking at is that we have a situation here where there's a tremendous shortage of donor organs. And they're taking the perspective of if you are a patient dying of liver disease or chronic renal failure or heart disease, what kind of system would you like in place, so that if you are really quite ill, you would have a reasonable chance, or a fair chance to get an organ transplant, regardless of where it is that you live, or regardless of the efficacy or equality of the organ transplant program or organ procurement agency in your region.
MARGARET WARNER: Dr. Rabkin, I read somewhere, for instance, let's go back now to the inequity and whether there is one in how long people wait but say in Kansas for some reason they've got a lot of people donating livers; people wait 12 days. In Massachusetts, they wait 18 months. Is there that kind of inequity?
DR. JOHN RABKIN: Well, the question is how you define waiting. And the problem is that most people define waiting for an organ transplant from the day they're added to the National Transplant Waiting List. But people get on the waiting list at different points in the disease progress, in the progression of their disease, and most of the time the local practitioners have changed their practice so that they get patients on waiting lists based on how long it's expected they're going to have to wait. So the waiting time really doesn't represent a very important feature in how fair the system is.
MARGARET WARNER: So you're saying really there is no inequity in the waiting time?
DR. JOHN RABKIN: If you look at the group of patients who are the sickest, and look and see how they differ around the country in terms of a period of time they wait, there's almost no difference when you move from one region of the country to the next.
MARGARET WARNER: Let me just get--Dr. Langnas, let me--I don't want to beat this horse to death, but is there an inequity or isn't there?
DR. ALAN LANGNAS: There's a tremendous inequity in this country. We live in Nebraska. We know what goes on in Kansas. The reason for that is the majority of patients in Kansas come to Nebraska for their liver transplant. We do not have access to organs in Kansas. There is fiefdom there so that the people in Kansas control those organs. They can put them as the few patients they have, and then when they decide they don't want to use the organs, they can offer them up to other programs. And that is really unfair to patients. And I think that's what the secretary is getting at. We're trying to get a patient directed organ distribution system, not a transplant program directed process, which is what we've had for many years now.
MARGARET WARNER: All right. Dr. Rabkin, setting aside now or going beyond the issue of whether the government's involved or not, from a patient's perspective, who will be the winners and who will be the losers if we switch to a national system? Because with a three to one ratio between people who want organs and the amount--the number down every year, it would seem somebody's going to win and somebody's going to lose.
"The problem is one of a lack of available organs for transplantation. And somebody has to lose in that system."
DR. JOHN RABKIN: Well, you're absolutely right. The problem is one of a lack of available organs for transplantation. And somebody has to lose in that system.
MARGARET WARNER: And who is it now and who would it be if it was changed?
MARGARET WARNER: Excuse me. You're talking about people who might have to have multiple transplants because they're so sick they reject the first one.
DR. JOHN RABKIN: Or they would lose their initial transplant for various other reasons. That's correct. We have currently a re-transplant rate that's about 10 percent, and through computer modeling we've seen that that rate may increase to as much as 20 percent.
MARGARET WARNER: All right. Let me get Dr. Langnas. Is that a danger, that if you go to the sickest patients nationwide, you could have the same people essentially getting multiple transplants?
DR. ALAN LANGNAS: Well, I think that's just a reactionary approach by John and his colleagues to this whole process. I think the secretary has given us a policy in allowing us to make medical decisions about what we think is the sickest but not so sick that it'll be a futile type of transplant or require re-transplantation. One has to think about if you or a family--family member needed a transplant, got sick, but was so desperately ill that you were not going to survive, wouldn't you like to have a system in place that would give you an opportunity to get transplanted, not to have somebody across the river or across town be called in from home, get transplanted at another program, while you or your family member died? I think that's what we're trying to get at here.
MARGARET WARNER: Organ transplants, speaking of winners and losers, is also a very profitable business. What are the business implications if this changes, change goes into effect?
DR. JOHN RABKIN: I think of course there are business implications because medicine is a business, and organ transplantation is a big business in medicine. But that's not what's driving this process.
MARGARET WARNER: But are there certain hospitals that would win again and certain that would lose business?
DR. JOHN RABKIN: Any hospital that would gain more organs to do more transplants would gain business, but you have to remember that everyone in this discussion really has the patients at heart, and everybody wants to do the best they can for their patients. If there's a way that they can help their patients more by getting more organs to transplant them, that's what they'll do. And that's what's really driving this discussion. I think the problem is that we have a different perspective on which patient should be transplanted and at what point in their time course. And with our current policy, we're able to maximally utilize this resource and make the most benefit for the most number of patients.
MARGARET WARNER: All right. Dr. Langnas, briefly, on the sort of business or financial implications of a change?
MARGARET WARNER: Okay. I'm sorry. That's all the time we have, but thank you both, doctors, very much.
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