Transplant providers dispute changes to allocating donated livers

The nation's liver transplant community is sharply divided over a proposed plan to revamp the way donated livers are allocated to patients with end-stage liver disease, even though most experts agree that reforms are needed to address significant geographic disparities in patient waiting times.

At stake for hospitals are the revenue and prestige associated with adult liver transplants, which total more than 6,200 a year in the U.S. Medicare, the largest single payer for liver transplants, pays $188,000 for each transplant. The total estimated cost of care for each year's cohort of liver transplant recipients, including pre-transplant needs, transportation and post-surgery follow-up, is about $5.6 billion, according to the United Network for Organ Sharing.

“We give lip service all the time to being one country and being unified around important goals, but when it comes down to the practicalities of who gets what, people get to be very parochial,” said Bruce Vladeck, a former Medicare chief and senior adviser to the Greater New York Hospital Association who has written about the issue.

UNOS, a not-for-profit that contracts with the federal government to oversee the organ transplant system, issued a preliminary proposal in June to address geographic disparities. It recommended reducing the number of allocation districts from 11 to possibly as few as four and creating a national pool for donated livers.

There are nearly 15,700 people on the waitlist for a liver, according to the Organ Procurement and Transplantation Network and the U.S. Scientific Registry of Transplant Recipients. And 3,002 people died in 2012 waiting for a transplant or were removed from the list because they had become too sick for the procedure.

“We're talking about change, and change is scary,” said Dr. David Mulligan, chair of UNOS' Liver and Intestinal Organ Transplantation Committee. “But it's my job to try to develop systems that are fair to everyone.”

The UNOS proposal immediately sparked criticism from liver transplant providers in states with shorter waits, who warned the change could increase how long organs must travel and would hurt regions with higher donation rates. Dr. Tim Schmitt, director of transplantation at the University of Kansas Hospital in Kansas City, said attention should focus on increasing the number of liver donors.

Mulligan said, however, that UNOS' effort to increase donations through programs such as Donate Life America have had little success.

Donated livers fall within 11 UNOS regional districts that were designed for administrative, not distribution, purposes. As a result, over the past decade geographic disparities have become more glaring, Mulligan said.

In states with longer waiting lists, transplant surgeons often tell more affluent patients to temporarily relocate to another state to boost their chances of getting a liver. In 2013, 1,400 patients had their transplant done in a state that was not their primary residence, according to findings presented during the UNOS forum in Chicago last week. Including patients from states that do not have a liver transplant center, 21.8% of patients travelled out of state in 2013.

Transplant surgeons use a so-called MELD score for end-stage liver disease, which helps prioritize the sickest patients on a scale ranging from 6 for least urgent to 40 for the most critical. Patients in Arkansas, Louisiana, Nebraska and South Carolina are more likely to receive a liver transplant when their MELD score is between 22 and 25, according to UNOS research. But in California, Maine, Utah and parts of New York, patients' median MELD score before receiving a liver must be between 30.5 and 40, meaning they may no longer be good candidates for a transplant.

Dr. Sander Florman, transplant director at Mount Sinai Medical Center in New York, said he understands both sides of the debate, having worked both in Louisiana, where about 173 patients are on the liver waitlist, and in New York, where about 1,330 are waiting.

“But no matter what side of the fence you sit on, the system is broken,” he said, adding that he's critical of centers that accept transplant patients from other states but won't send livers to that patient's home state.

A bipartisan group of more than 50 members of Congress have criticized the UNOS proposal. In a Sept. 12 letter to HRSA Administrator Mary Wakefield, they wrote that if the UNOS proposal is implemented, “more organs for transplant would travel significantly longer distances, areas with high organ-donation rates would be disproportionately affected, organs would experience longer cold ischemic times, and the proposal may not have the desired effect of lowering overall waitlist mortality.”

A UNOS representative said there is no set time frame for a final policy proposal.

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