January 11, 2008

Edwards Needs A Little More Than One Data Point

John Edwards has used the story of Nataline Sarkisyan on the campaign trail to underscore the heartlessness of the American health-care industry, and specifically its insurers. The teenager died from complications of liver failure and cancer, after applying for and initially being rejected for a liver transplant. Edwards wants to remake the health-care system in order to prevent anyone from being denied a transplant, but as the Wall Street Journal points out, the Sarkisyan case was a good deal more complicated than Edwards lets on -- and the US leads government-run health care systems around the world in transplants:

Research provides little support to Mr. Edward's underlying premise that single-payer health-care systems would do better. On balance, data suggests that in the U.S. transplant patients do quite well compared to their European counterparts, with significantly more opportunities to undergo transplant procedures, survive the surgery, and benefit from new organs.

Some of the best data pits the U.S. against the U.K. and its National Health Service. A study published in 2004 in the journal Liver Transplantation compared the relative severity of liver disease in transplant recipients in the U.S. and U.K. The results were striking. No patient in the U.K. was in intensive care before transplantation, one marker for how sick patients are, compared with 19.3% of recipients in the U.S. Additionally, the median for a score used to assess how advanced someone's liver disease is, the "MELD" score, was 10.9 in the U.K. compared with 16.1 in the U.S. -- a marked gap, with higher scores for more severe conditions. Both facts suggest even the sickest patients are getting access to new organs in the U.S.

On the whole, the U.S. also performs more transplants per capita, giving patients better odds of getting new organs. Doctors here do far more partial liver transplants from living, related donors, but also more cadaveric transplants (where the organ comes from a deceased donor). In 2002 -- a year comparative data is available -- U.S. doctors performed 18.5 liver transplants per one million Americans. This is significantly more than in the U.K. or in single-payer France, which performed 4.6 per million citizens, or in Canada, which performed 10 per million.

What about the differences in outcomes between ours and single-payer systems, an issue Mr. Edwards hasn't directly addressed? One recent study found that patients' five-year mortality after transplants for acute liver failure, the type from which Ms. Sarkisyan presumably suffered, was about 5% higher in the U.K. and Irleand than the U.S. The same study also found that in the period right after surgery, death rates were as much as 27% higher in the U.K. and Ireland than in the U.S., although differences in longer-term outcomes equilibrated once patients survived the first year of their transplant.

Some people do get so sick that they cannot receive transplants, and sometimes the transplant simply won't solve the problem. We've been through four transplants ourselves, and the transplant teams explain that in the beginning of the process. They will not use up a viable organ that could go to someone else on a patient unlikely to survive the surgery or its immediate aftermath. That appears to have been what CIGNA concluded in this instance, although their concern was still obviously the cost and not the organ.

In working with two different transplant centers, though, the message we always got was that insurance hassles would not stand in the way of saving lives. If the doctors felt the transplant was necessary, they would do it and worry about the billing situation afterwards if an organ became available. I can't speak specifically to what the Sarkisyans were told, obviously, but we never heard at any time that insurance would stop the transplant or the medications that followed it.

The numbers bear this out. More Americans receive transplants in this system than others do in any other single-payer health system. Part of this springs from the fact that we have more facilities to do transplants, as the people who comprise the medical teams get compensated for the additional education and training -- years of it -- that transplant surgeries require. In the UK three years ago, hospitals were discussing the necessity of discarding viable organs because the NHS didn't have enough surgeons qualified to do the transplants.

Not every transplant case has a happy ending, and the case of Nataline Sarkisyan is tragic. But when people propose transforming a health-care system based on a single anecdotal data point while ignoring the real success we have with American health care, it's not just demagoguery. It will cost lives, and they may belong to people we know and love -- like the First Mate.

UPDATE: Bruce Kesler points out more criticsm of Edwards here and here.


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