Marlene Piturro

Simplistic, for sure. But a movie pitting a man with modest income against the big bad managed care plan has drawn attention to the enormous cost of transplants and the difficulty of matching organs and recipients.

Marlene Piturro

Managed care is known to have a poor image in the popular media, although it isn't particularly clear whether the media reflect or lead public opinion. Certainly, health plans have been timid and ineffective in confronting their opponents, and to some degree, that has led to the recent vicious circle of cost increases and benefit reductions, as consumers irrationally demanded unlimited choice at highly limited cost.

That willingness to be branded the bad guy may be lessening, though. John Q, starring Oscar winner Denzel Washington, has provoked some managed care folks to fight back. The story line: John Q is a blue-collar worker whose son collapses during a Little League game. ER doctors say the boy needs a heart transplant — pronto. Dad discovers that he is "underinsured" (only $20,000 for a catastrophic illness) and that the hospital won't put his son on the heart-transplant list without a large up-front payment. Desperate, John Q holds the ER hostage until his son gets on the transplant list. Lest anyone miss the message, John says: "The enemy is us — we shot down national health care."

Demonization

Recognizing its latest demonization by Hollywood, the American Association of Health Plans struck preemptively before John Q's release. Ads in the Wall Street Journal and the Washington Post quoted AAHP President Karen Ignagni: "It's a crisis for 40 million people who can't afford health care. We're not being defensive here; we're trying to really shine a spotlight on the problem."

Mohit Ghose, AAHP spokesman, says that John Q of course did not address the most critical issue, a UNOS (United Network for Organ Sharing) list of 80,000 vetted candidates waiting for transplant. He also says that, as far as he knows, there is no HMO in the country that places a $20,000 limit on catastrophic coverage.

"If there are limits, they're usually $250,000 to $1 million — sometimes $2 million," says Ghose. "That's the general range in the industry."

Is John Q really about affordable health care coverage, the UNOS list, or something else? Is it about Americans' shared vision of health care entitlement — that all of us should have high-tech, expensive, Big Medical Center treatment immediately regardless of ability to pay?

Jill Fraggos, director of government affairs at Children's Memorial Hospital of Chicago, struggles to find answers. "Federal law mandates that we cover ER indigent care and prohibits government reimbursement for organ-transplant-related services for undocumented aliens." (This is the same government that financed a heart transplant in January for a California prison inmate serving 14 years for armed robbery.)

Despite the hospital's provision of $24 million in unreimbursed care annually and the federal prohibition on paying for organ transplants for illegal aliens, it got publicly clobbered when it asked for money up front before putting 11-year-old Ana Esparza, an undocumented Mexican, on its liver- transplant list. Family and friends raised $191,141 when Miami's Jackson Memorial Hospital, having fortuitously gotten a compatible liver, volunteered and did the transplant for $250,000.

Organ transplants are complex procedures done on very ill people weakened by disease, and money doesn't guarantee Hollywood-perfect outcomes. Two stem-cell transplants on illegal aliens at the Chicago Hospital cost $500,000 each and failed. A feature story about Melannie Veliz, an undocumented Chilean youngster awaiting a double-lung transplant, pointed out that she is one of 52 Illinois residents waiting for a lung transplant, and that 350 on national lists died last year waiting. Who would John Q take hostage to solve this problem?

While some hospital and managed care professionals don't mind working against negative public sentiment, others find the oversimplification of John Q maddening. Andrew Krueger, MD, Louisville-based Humana's director of emerging technologies and transplants, is angry: "The critics are dead wrong. They just don't live in my world." Humana, which approved 401, 319, and 363 organ transplants in '99, '00, and '01, respectively, says: "We approve many, with exceedingly minimal denials."

He explains that hospitals, rather than MCOs, create transplant lists, deciding who has the best chance of survival. The MCOs, in turn, evaluate hospitals' volume of procedures, outcomes, and willingness to negotiate rates. Rates are often the sticking point: "We'd love to have all institutions that are proficient in transplant in our network, but some won't even take our calls because they won't negotiate rates. It takes more than one to tango," adds Krueger. Managed care's record on transplants is excellent, Krueger notes, because volume, outcomes, and cost data are widely available, making it possible to discern good from poor programs.

Flash points

Despite MCOs' consensus on managing transplant cost and quality, thorny issues crop up with providers and consumers. Francis Delmonico, MD, professor of surgery at Harvard Medical School and director of renal transplantation at Massachusetts General Hospital, understands John Q's vantage point: "Minorities believe they don't have the same access to transplant lists as whites, and that when they're on the list, they don't get organs as fast." While medical issues such as human leukocyte antigen compatibility are involved, the transplant community recognizes this as a genuine concern and is addressing it. "Socioeconomic status should not be a disadvantage for transplant," he adds.

Aside from list access, Delmonico takes issue with managed care, arguing that transplants at so-called "centers of excellence" hundreds or thousands of miles away from a patient's home are driven by cost rather than clinical proficiency, but should not be. "The relationship between doctor and patient is broken when he or she is forced to have a transplant elsewhere because there's a contract. Any Medicare-, state-, or UNOS-certified program should be acceptable to insurers." Krueger of Humana counters: "We have to be concerned with cost. If volume and outcomes are equal, we'd choose a lower contractual rate; lower costs and premiums are better for everyone."

Despite its view through the Hollywood lens of good versus evil, John Q offers an opportunity for managed care to change the public's perception of its attempts to provide quality care that is affordable — and some are bravely starting to speak out.

Better late than never.

Marlene Piturro, PhD, MBA, is a free-lance writer in Hastings-on-Hudson, N.Y. She writes frequently about managed care issues.

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