HCFA Approval Pushed Intestinal Transplants Into Mainstream
Intestinal transplants are poised to become more "mainstream" since Medicare approved the surgery, the New York Times reports. On Oct. 4, Medicare dropped the "experimental" label from the $300,000 procedure and established a list of criteria under which the program would cover the costs. Only children or young and middle-aged adults with "irreversible intestinal failure" from disease, injury or abnormalities at birth are eligible. In addition, patients must suffer from life-threatening complications from total parenteral nutrition (TPN), or intravenous feeding, including liver failure, blood clots in major veins, episodes of severe dehydration or severe infections from the feedings. The rules stipulate that the procedure will only be covered at hospitals performing at least 10 operations a year and boasting a one-year survival rate of at least 65%. Only the University of Pittsburgh, the University of Miami, the University of Nebraska in Omaha and Mount Sinai Hospital in Manhattan qualify under the rules. About 300 Americans have had the transplant, but doctors estimate about 13,000 patients are eligible under the Medicare guidelines. Dr. Thomas Fishbein, chief of intestinal transplantation of Mount Sinai, said, "Patients are suddenly pouring in. We're getting e-mails everyday about somebody here or there across the county with some unusual problem." Intestinal transplants developed slowly, as the operation is "technically difficult" and carries a "high rate of severe rejection." The latter problem is due to the nature of the intestines, which are normally "barraged by foreign substances and microbes." As a result, the organ is "rich in immune system cells" that "antagonize the immune system" of a transplant recipient, causing a rejection. New antirejection drugs, however, have increased the success rate of the transplants, and doctors in Pittsburgh have also reduced rejections by "irradiating donor intestines" before the operation to kill off some of the more antagonistic cells. Despite HCFA's eligibility limitations, physicians predict use of the procedure will be expanded. They note that TPN -- which itself costs $150,000 a year -- may lead to liver failure, meaning that performing intestinal transplants before falling back on intravenous feeding could leave livers available for "other desperate recipients." "In the future ... [w]hen someone loses all their bowels, they won't be told, 'You can't eat anymore, but you can live on TPN.' They will get a transplant, and if it fails, they will live on TPN," Fishbein said. He noted that kidney failure is handled similarly: Transplants are tried for healthy patients before resorting to dialysis. Private insurers and state Medicaid programs, which "usually follow Medicare's lead," are expected to cover intestinal transplants as well (Grady, New York Times, 10/31).This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.