Running head: Medicare Funded Organ Transplants

Medicare Funded Organ Transplants Chandra Beasley Keller Graduate School of Management Health Rights and Responsibilities HSM 542 March 4, 2013 Professor Gomillion

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Medicare Funded Organ Transplants: Ethical Issues Introduction

Ethical issues are the branch of philosophy that defines what is good for the individual and for society and establishes the nature of obligations, or duties, that people owe themselves and one another. In modern society, ethics define how individuals, professionals, and corporations choose to interact with one another. (Ethics, Legal legal definition of Ethics, Legal. Ethics, Legal synonyms by the Free Online Law Dictionary.) The ethical issue with Medicare funded organ transplants is who it should be eligible and the problem that the needed immunosuppressant drug is only available for a limited amount of time through Medicare funding. The value of a persons life has been fragmented down to if they have worked long enough, have enough wealth and/or resources to deserve an organ transplant; and the required drugs. This is troublesome in the regard to should everyone have an equal shot to a prolonged life and quality of care. Only those who have the ability to pay will be put on the waiting list for an organ.

Define Problem How can Medicare better handle the ethical issues faced with funding organ transplants and the medication needed? Since 1973, end-stage renal disease has been the only condition specifically covered by Medicare regardless of age. In 1988, coverage was extended for 12 months to antirejection drugs, which had recently been developed. Congress gradually lengthened the cutoff to 36 months, and then in 2000 made the benefit unlimited for those who are at least 65 or disabled. The rationale for leaving out younger transplant recipients was simply that the money was not there. (Medicare Covers Transplants, But Limits Payments for Anti-Rejection Drugs - NYTimes.com) There are cases where the government has actually paid more money because the organ was rejected after the patient was unable to pay for the immunosuppressant; and a second transplant was needed which is extremely more costly than the drugs itself. Iimmunosuppressant drugs, which are also called anti-rejection drugs, are used to prevent the body from rejecting a transplanted organ. (Immunosuppressant Drugs - blood, pain, time, infection, medication, pregnancy, heart, cells, risk, cancer, nausea, Definition, Purpose, Description, Recommended dosage, Precautions) This drug must be taken throughout the duration of the patients life. It poses a major problem if the patient cannot afford the drug required to stay healthy. The story of Ms. Whitakers two organ donations the first from her mother and the second from her boyfriend sheds light on a Medicare policy that is widely regarded as pound-foolish. Although the government regularly pays $100,000 or more for kidney transplants, it stops paying for anti-rejection drugs after only 36 months. (Medicare Covers Transplants, But Limits Payments for Anti-Rejection Drugs - NYTimes.com) An added problem is who Medicare covers for organ transplants. Someone without the correct economic standings will

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not even be spoken to about the option of a transplant because hospitals cannot take on the burden of paying that bill themselves. For those who have End-Stage Renal Disease (ESRD), you are eligible for Medicare if your condition requires a kidney transplant or dialysis treatment. In order to qualify for Medicare eligibility, you would also have to either be the spouse or dependent of someone who is eligible for Social Security or RRB benefits or have to have worked long enough to receive these benefits. (Medicare Eligibility - Medicare Consumer Guide) That means a person; their spouse or sponsor will have to have earned 40 credits which is the equivalent of working 10 years; if they are not receiving RRB benefits. This can be problematic since the cost of a transplant is extremely high and some private policies do not even cover it in their plan. Search the Literature Medicare is funded through Social Security contributions (Federal Insurance Contributions Act payroll taxes), premiums, and general revenue. The program is administered through private contractors, referred to as intermediaries under Part A and carriers under Part B. The financing of the Medicare program has received much attention by Congress because of its rapidly rising costs and drain on the nations economy. (Pozgar, 2007) Given that the budget for Medicare is already exhausted it stands to reason why it has not been able to accommodate everyone with funding for organ transplants. Medicare is already in jeopardy of not being available for future generations. Once the Baby boomers reach the age of 65 much of the funds will be used on them while there will be less people in the workforce to replenish the system. The majority of patients waiting for a kidney transplant is disabled and has Medicare as a primary insurance. They have to go to their dialysis treatment three times a week for 4 hours a piece. It is very hard to hold a job with insurance in this situation. Some of them are wiped out for the rest of the day after dialysis. They rely on their social security income to make ends meet. They will still get a kidney transplant when the time comes. The average wait time for kidney transplant these days is anywhere between 3 to 5 years. This is why a lot of people are working hard to improve the rate of organ donation because life on dialysis can be miserable. There are not many people that could pay for their organ transplant surgery with cash. The average kidney transplant cost around $500,000 without any major complications. A heart-lung transplant is on the most expensive with the price tag being just under $1,000,000. (Do I need to be rich to qualify for organ transplant? | Organ Transplants) The government has a great responsibility when it comes to managing Medicare. Even after the organ transplant there is still the responsibility of the immunosuppressant drug needed to keep the patients body from rejecting the organ. The Medicare program is not sure how many of the countrys 100,000 transplant recipients are without insurance for their immunosuppressant drugs. Officials with the National Kidney Foundation said some dialysis patients never put themselves on transplant lists because they fear that they will not be able to afford the drugs. (Medicare Covers Transplants, But Limits Payments for Anti-Rejection Drugs - NYTimes.com) It is hard to imagine what a person must feel when their health is deteriorating and it is not much they can do. Different management strategies of Medicare may

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better the situation. The patient count is rising not decreasing so there is even more of a need for change. More people are receiving transplants. Once regarded as medical miracles, transplants now are performed at more facilities by more specialists. More people of advanced age who formerly were not transplant candidates now qualify. At the end of 2005 there were 163,631 people in the U.S. living with a functioning transplanted organ. This number reflects an increase of 2.1 percent over the prior year and a 60 percent increase since 1997. (Solutions for Medicare Advantage Transplant Challenges) Different approaches have been discussed to increase funds available for Medicare such as increasing Medicare payroll taxes, beneficiary premiums, or taxes on social security; or lowering spending by reducing benefits or payment providers. There is also an organization that is skilled in lowering the cost of organ transplants. As the largest private-sector transplant management organization, OptumHealth Transplant Solutions insures and/or manages approximately 10 percent of all U.S. transplants. It is the only carrier combining commercial insurance experience and Centers of Excellence network resources with a separate Medicare Advantage program tailored specifically for the unique needs of the Medicare population. (Solutions for Medicare Advantage Transplant Challenges) The expertise of such a company can be beneficial to reducing Medicaid spending and effectiveness. Without companies like this price capping might need to be mandated. The clinical excellence and sophisticated case management coordinated by Transplant Solutions reduces cost for health plans and improves health outcomes for patients. Both of those advantages are reflected in an important statistic: Transplant Solutions COE facilities have an average 17 percent decrease in hospital length of stay, compared to non-COE facilities. In addition to reduced hospital costs, Transplant Solutions also reduces the costs that payers incur by negotiating preferred rates with its network providers. Through contracts with its COE network, Transplant Solutions leverages its purchasing power to give clients an average savings of 48 percent per transplant episode compared to billed charges, representing a substantial discount compared to prevailing market rates. (Solutions for Medicare Advantage Transplant Challenges) Analyze Problem The problem remains that the issues of healthcare expenditures are not easily agreed upon. The issues are clear; options are understood but no one method can seem to be agreed upon. Everyone seemly wants the same thing but has a different perspective on how to acquire it. The government is considering cutting back on Medicare when more is going to be needed not less. Issues The issues are obtaining and reserving enough funds, in this case when it comes to organ transplants, through Medicare funding. Also, ensuring that after transplant the care patients medications can be afforded; while at the same time increasing the population access to care. This

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may seem like an overwhelming task to handle but it can be done. Other countries possess a universal program where everyone pays into the healthcare system and care is administered as needed. Countries like Brazil handle organ transplants more effectively as well because they consider everyone a donor unless otherwise stated. The biggest struggle is the ability to agree. Healthcare reforms are constantly up for debate with no clear direction. Cause Maybe improper screening for candidates is the cause for Medicare depletion. When it comes to organ transplants perhaps Medicare should consider not covering criminals. Students who apply for federal loans get denied for felony charges. Maybe the same principle should be applied to inmates who are in need of organs. Though there is a law that protects prisoners when it comes to medical care but must it apply to receiving someone elses organs? The Eighth Amendment of the Constitution protects prisoners from cruel and unusual punishment. The U.S. Supreme Court has decided that failing to provide medical care to prisoners violates this amendment. In 1976, the Court explained in Estelle v. Gamble that deliberate indifferencepurposely ignoring the serious medical needs of prisonersamounts to cruel and unusual punishment forbidden by the Eighth Amendment. (Your Right to Adequate) Another cause could be that taxes are too low. Higher taxes for the wealthier population might seem unfair but necessary. The funds must come from somewhere to provide for so many. We all are stakeholders when it comes to the health of our country. Procedures may also be price to high. Some Americans go out of country for procedures because they are done at a cheaper cost. The government may need to take a closer look at what the pricing system is based upon. Possible Solutions One solution is to use an organization like OptumHealth Transplant Solutions to minimize cost and increase effectiveness of the Medicare program. The positive affect of this approach is that it will bring cost down for transplant procedures. The negative aspect could be that it may not be available everywhere since it only provides for 10% of the Medicare population. Another solution could be increase taxes for the wealthy and large business. The positive of this would be the needed extra money for Medicare expenses; while the negative would be unwanted tax increases. Lastly, reduce the pool of Medicare eligibility for transplants by eliminating prisoners. All other medical procedures remain applicable but transplants excluded. Since the living conditions of inmates makes those more prone to need transplants this could cut into cost substantially. The pro to this is less Medicare costs and the con is the controversy of prisoners rights being taken away.

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Solution and Implementation

The solution is to implement the OptumHealth Transplant Solution to minimize cost and increase effectiveness of the Medicare program. The hospital (CEO) should arrange a consultation with OptumHealth Transplant Solution. From there everything should be just a matter as agreeing to the terms of the premium and signing the paper work. OptumHealth Transplant Solution makes everything simple and clear cut. OptumHealth allows you to outsource all the risk for transplants. You simply pay a standard monthly premium, and we will then pay virtually all claims that result from transplant cases: Eliminates volatility through first-dollar transplant coverage so that transplant costs can be a stable budget item Allows you to focus attention on other high return-on-investment areas of your business Frees up dollar reserves, allowing you to reinvest in your business Eliminates needless costs by using OptumHealths Centers of Excellence network and clinical management team to avoid inappropriate transplants, identify eligible patients for Medicare and reduce the re-transplant rate Reduces costs of health reinsurance premium Covers virtually all transplant-related costs including immunosuppressant (anti-rejection) drugs Covers all transplants: solid organ, blood and marrow (cord blood, stem cells, and bone marrow transplants) Covers transplant-related expenses from one day prior to the transplant through a maximum of 365 days following the transplant Includes coverage of evaluation, search & registry, organ procurement, home health, outpatient treatment, and travel and lodging benefits Risk sharing options available from full risk to specific or aggregate deductibles (Transplant Solutions) This seems like the best solution since the other options will take time to come to pass. Whatever immediate actions that can be done will best serve everyone involved until a better solution can be administered. As a contingency plan we can continue to follow legislation and vote for plans that are in favor of preserving Medicare.

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References
Do I need to be rich to qualify for organ transplant? | Organ Transplants. (n.d.). Retrieved October 7, 2012, from http://www.organ-transplants.com/rich-qualify-organ-transplant/

Ethics, Legal legal definition of Ethics, Legal. Ethics, Legal synonyms by the Free Online Law Dictionary. (n.d.). Retrieved October 7, 2012, from http://legaldictionary.thefreedictionary.com/Ethics,+Legal

Immunosuppressant Drugs - blood, pain, time, infection, medication, pregnancy, heart, cells, risk, cancer, nausea, Definition, Purpose, Description, Recommended dosage, Precautions. (n.d.). Retrieved October 7, 2012, from http://www.surgeryencyclopedia.com/FiLa/Immunosuppressant-Drugs.html

Medicare Covers Transplants, But Limits Payments for Anti-Rejection Drugs - NYTimes.com. (n.d.). Retrieved October 7, 2012, from http://www.nytimes.com/2009/09/14/health/policy/14kidney.html

Medicare Eligibility - Medicare Consumer Guide. (n.d.). Retrieved October 7, 2012, from http://www.medicareconsumerguide.com/medicare-eligibility.html

Pozgar, G. D. (2007). Legal Aspects of Health Care Administration. Sudbury: Jones and Bartlett Publishers.

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