Organ transplantation criteria represent insurer dilemma

In its simplest form, technology assessment, as used for coverage decision making, involves an analysis of published data regarding the safety and effectiveness of a technology, either on its own merits or in comparison with a competing technology. However, while the medical literature, and thus technology assessments, typically focus on a well-defined population, a positive coverage policy almost immediately creates pressure for broadening patient selection criteria. A variant on this phenomenon is the patient selection criteria for organ transplantation. These criteria are based not only on the scientific merits of the procedure but also on frequently ill-defined notions of the most appropriate allocation of a scarce resource, which in turn is determined by supply and demand at individual transplant centers. In these cases, the payer may defer to the patient selection criteria of the individual transplant center. However, the situation arises when a patient, rejected at one transplant center, "shops" and finds another center that has more favorable selection criteria. How, then, can the payer resolve these discrepancies and establish consistent policy guidelines? Should allocation of scarce donor organs be part of a technology assessment and coverage decision? The case of liver transplantation will be used here to illustrate the insurer's dilemma.