MEDICARE SAYS IT
DOESN'T BAR LIVING DONOR SURGERIES,
BUT DOCTORS SAY IT HAS PAID FOR NONE
EXPENSE OF CARING FOR THE DONOR PUSH UP COST OF THESE OPERATIONS
By John G.
Of the Post-Dispatch
Aug. 22, 1999
Edited by Virginia Baldwin Gilbert
A few years ago, liver disease would have killed Richard Malfon. Today, his insurance may do it.
Malfon has an inherited disorder that is destroying his liver. Without a transplant, doctors at Barnes-Jewish Hospital say, he will soon die.
A new surgical procedure, called a living donor transplant, could save his life by giving him a new liver before his fails. Medicare, which insures Malfon, has refused to pay for it.
If the new liver came from a brain-dead donor, Medicare would cover the cost. But doctors say it will be a year or more before he reaches the top of the waiting list. They don't think he will live that long.
Malfon, 68, a father of five from Peoria, is failing quickly.
"I'm doing terrible," he said last week, his voice weak with fatigue.
A Medicare spokesman said no policy specifically bars living donor transplants. But doctors and hospital officials said the agency has turned down all attempts to arrange coverage.
Malfon has been sick for the past six years. In recent months, he has significantly deteriorated.
Because of an inherited condition, Malfon's liver fails to produce enough of a protein called alpha-antitrypsin. Without it, his liver has been severely damaged.
"He's been hospitalized six times in the last two years," his wife, Donna Malfon, said. "He's much worse today than he was even in June or July."
Malfon, a retired auto parts manager, isn't the only patient caught between medicine's cutting edge and insurance companies' slow response.
"We've had this problem with a number of other patients," said Dr. Todd K. Howard, director of liver and kidney transplantation at Barnes-Jewish. "It hasn't become a national issue yet because so few hospitals do this surgery."
In a typical transplant, the recipient's insurance company pays a fee to cover the cost of retrieving organs from a brain-dead donor. That fee varies in different regions of the country. It's about $25,000 in St. Louis.
In living donor transplants, charges are substantially higher -- about $10,000 to evaluate potential donors and an additional $40,000 to $60,000 for organ removal and treatment of the donor.
But that cost is offset by several factors, Howard said. Because they don't delay as long before being transplanted, people who get organs from living donors can avoid the frequent, expensive hospital stays that other patients often experience.
And transplants involving healthier recipients are more likely to be successful.
When hospital officials originally approached Medicare about Malfon, they were told it would not cover a living donor transplant. Howard said he became involved last month, contacting Medicare; the Health Care Finance Administration, which runs it; and Missouri's two U.S. senators.
Late last week, after speaking with a reporter, he received a letter from Medicare promising to study the issue.
Julie Brookhart, a Medicare spokesman, said the agency's policy doesn't address living donor liver transplants. She was unfamiliar with Malfon's case.
The most recent revisions to the agency's transplantation guidelines were made in July 1996. At that time, just six living donor liver transplants had been performed in the United States.
Some other insurance plans have been quicker to accept the new transplant techniques, Howard said.
"Sometimes, we've had to explain it to their medical directors, and then they understand," he said. "But with Medicare, we haven't even been able to talk to anyone. They just tell us it's against their policy and that's that."
Some patients can't afford the time for an appeal.
Earlier this year, after two months of delays, one insurance company decided to cover the procedure, Howard said. He declined to name the company.
"By the time they approved it, the patient had died," he said.
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