Organ transplantation costs, insurance coverage, and reimbursement

With few exceptions, most organ transplantation procedures are expensive, although there is considerable variability in costs across transplantation programs. Because of their high cost, many public and private insurers are in the process of carefully evaluating their transplantation coverage and reimbursement policies. Some public insurers have decided to discontinue paying for some procedures on grounds that the resources expended on transplantation could be used to benefit a larger number of people without catastrophic disease. Thus, transplantation is being pitted against health promotion and disease prevention initiatives. Some insurers have also been reluctant to pay for selected transplants, arguing that they are "experimental" or "investigational." Pancreas, lung, and heart-lung transplants are often classified as such. While these decisions have a reasonable basis, concerns related purely to cost, not benefit, have made insurers hesitant to extend coverage to procedures they view as inefficacious. Transplantation programs performing pancreas, heart-lung, and lung transplantation, therefore, do so at some risk. They may not be reimbursed for the procedures they perform, or, more likely, the level of payment received is likely to be substantially below actual hospital costs. To control costs, insurers have also begun to designate transplantation centers. In doing so they limit coverage and reimbursement to programs they regard as "centers of excellence." To become a designated center, a transplantation program must meet preestablished volume and outcome requirements, which insurers believe will assure quality and minimize costs. Thus, designated centers are expected to provide cost-effective transplantation services. If insurers choose to regionalize transplantation programs, controlling both their number and distribution, it is quite possible that patient access to transplantation, as well as their choice of provider, will be severely constrained. In conclusion, concerns related to transplantation costs undoubtedly will have enormous implications for the delivery of transplantation services throughout the foreseeable future. Most significantly, the number of "qualified" centers, using insurer criteria, may be restricted to a small subset of currently active programs. This could have a dramatic affect on the start-up of new programs and the continuation of others.