Q & A: Why The Oregon Health Plan Won't Pay

By Joe Rojas-Burke

of The Oregonian staff

Coverage for the state's program for the poor and people with disabilities is based on a prioritized list of treatments. The list provides for lung transplants and liver transplants, but until April, the state commission that sets priorities for the plan had never considered the rare circumstances that would require a simultaneous lung and liver transplant.

Q: Would the operation be covered by another state's Medicaid program or a commercial insurance plan?

A: Few plans have ever had to decide because the operation has been performed only 10 times in this country, according to the United Network for Organ Sharing. But at least two commercial insurers have authorized the operation: Blue Cross of California three years ago approved the operation for Dennis Weber, a 30-year-old from Southern California who is still waiting for donor organs. Aetna U.S. Healthcare in Tennessee paid for 18-year-old Darrell Hedgecoth to have a combined heart-lung-liver transplant in January.

Q: How effective is the operation?

A: Hedgecoth said he's suffered pneumonia, an immune rejection and a seizure since his transplant six months ago. Still it's improved his quality of life immeasurably, he said, freeing him from 24-hour oxygen therapy, crippling shortness of breath, feelings of suffocation and episodes of internal bleeding.

"It's like you get another chance at life," said the Tennessee man. A 23-year-old Wisconsin man who underwent lung-liver transplant in 1995 continues to lead a full life, according to his surgeon at Children's Hospital in Milwaukee.

Long-term studies are sparse, but in the largest published report, a team of French surgeons in 1995 calculated an average survival rate of 70 percent at three years in a group of 10 patients who ranged from age 10 to 24.

"That's roughly equivalent to survival after lung transplantation alone," said Dr. Jeffrey Edelman, a pulmonologist at Oregon Health Sciences University. "We don't know what the long-term survival is."

Q: Doesn't the combined transplant take organs that could help up to three people and give them all to one individual?

A: Bioethicist Arthur Caplan, who has raised this theoretical objection, said it has little bearing on the immediate case of Brandy Stroeder. "It may not make the best sense in terms of saving the most lives to allow any multiple organ transplants," he said. But, he added: "The policy of this country is to give organs to those who are the sickest." The Oregon Health Plan itself allows for heart-lung transplants, liver-kidney transplants, and pancreas-kidney transplants.

Q: Won't cystic fibrosis immediately begin to destroy the donor organs after the transplant?

A: No. The malfunctioning gene that causes cystic fibrosis acts within glandular cells in the lining of the lungs and other affected organs. Transplanted organs come with normal copies of the gene. The defect, however, persists in other tissues of the body, said Dr. William Chapman, one of the surgeons at Vanderbilt University Medical Center in Nashville who performed the heart-lung-liver transplant on Hedgecoth. In the lining of the upper airway, for instance, abnormal mucus flow can foster harmful bacteria and increase the risk of infection.

Q: Why have surgeons attempted so few lung-liver transplants?

A: Cystic fibrosis affects about 30,000 children and adults in the United States, but only about 15 percent develop serious liver complications in addition to life-threatening lung damage. An even smaller fraction suffer failure of both organs to the degree that it requires simultaneous transplantation.

The French experience reveals a more tragic reason: Half of the patients accepted for combined transplantation died while awaiting donor organs which are in short supply all over the world.

Copyright © 2000 Oregon Live.

This article posted June 24, 2000.