Organ transplantation in an era of economic constraint: Liver transplantation as a case study

Abstract

A L T H O U G H EFFORTS to reform the health care system have fallen on hard times, the issues that spurred contemporary debate remain unresolved. 1-3 Although th~ annual rate of increase has decreased, health care expenditures reached approximately $1 trillion in 1994. While hope springs eternal, there is still cause for concern. As a society, we have responded to the symptoms of an impending catastrophe, but we have not addressed the root cause that made health care reform a social issue. Over time, people soon recognized that the reform of our health care system had a significant expense, a price few people, including employers, were willing to bear. What people realized in the end, is what they should have known all along: it was impossible to insure the uninsured, expand health care benefits, and aggressively pursue technological innovation, without substantially increasing total health care expenditures. 4-6 Even preventive health care initiatives, despite their intuitive appeai, are costly; rarely do they decrease health care expenditures. It is against this backdrop that we now consider liver transplantation. Significant changes have begun to take place in the health care delivery system: Whereas the Clinton Administration endorsed managed competition as the preferred strategy, employers and third-party payers were more impressed with a less-radical a l ternat ive--managed care. 7-m If change was necessary, those persons and organizations most affected were inclined to endorse an alternative that was less extensive and more familiar than managed competition. Managed care had the necessary assets and the fewest disincentives. By networking providers, and selectively contracting based on quality and price, traditional third-party payers and managed-care plans have settled on an approach to control the costs and assure the quality of expensive medical and surgical procedures. Often mistakenly referred to as of excellence, designated centers for transplantation at tempt to balance economic goals with quality concerns. 1~-17 A1though the approach does not usually diminish the significance of quality relative to price, critics often refer to transplant centers of excellence as of discount. This accentuates a fear that, in the end, quality is truly relative to price. Unfortunately, health policy anecdotes, much like clinical anecdotes, are neither valid nor generalizable. Many transplant networks are composed of excellent transplant programs and, most importantly, their excellence is not necessarily compromised by the price of their services. While there are reasons clinicians should be fearful of managed care, there are many experiences that underscore the value of the approach. As defined by the Physician Payment Review Commission (PPRC), managed care is: