Monday, January 12, 2009

Michigan transplant limits face review

State may study letting more hospitals do some operations

By Jay Greene Crain's Detroit Business

The Michigan Certificate of Need Commission will decide Feb. 5 whether to appoint a work group to study changing 23-year-old state regulations governing the number of hospitals allowed to offer certain organ transplant services.

Under current regulations, just three hospitals in the state are permitted to perform bone marrow transplants, and just three are allowed to conduct heart-lung and liver transplants.

Regulations for pancreas and kidney transplants do not restrict the total number of hospitals, but hospitals must perform a minimum number of the procedures each year to maintain their certificates.

Royal Oak-based William Beaumont Hospitals and St. John Health in Warren have asked the state to revise organ transplant regulations. They want the state to open up the CON process to allow other hospitals to apply based on institution-specific criteria or other reasons, including relaxed minimum volume restrictions.

On the other hand, the three hospitals allowed to do bone marrow transplants, Henry Ford Health System in Detroit, the University of Michigan Health System in Ann Arbor and Barbara Ann Karmanos Cancer Institute in Detroit, want the rules unchanged.

The University of Michigan's C.S. Mott Children's Hospital and University Hospital and Henry Ford also hold CONs to perform heart-lung and liver transplants.

In a statement to Crain's Detroit Business, Robert Riney, Henry Ford's COO, said the three approved transplant centers are enough to handle the number of patients seeking bone marrow and heart-lung and liver transplants.

“Adding another center would reduce volume at these centers, resulting in higher cost per transplant and therefore impacting changes to employers and patient out-of-pocket expenses,” Riney said.

“There are even fewer solid organ transplants (heart-lung and liver) performed compared to bone marrow transplants,” he said. “Adding more centers would dilute the volume at current centers even more.”

Several years ago because of low volume, Dearborn-based Oakwood Healthcare voluntarily surrendered its CON for bone marrow transplants, according to the state Department of Community Health.

Because of low volume, St. John and DMC's Harper University Hospital in Detroit also dropped their CONs for pancreas transplants.

However, officials for St. John are supporting changes in the pancreas transplant regulations to eliminate the required 12 minimum number, which would allow hospitals to reinstitute the services, according to testimony at an October CON Commission hearing.

Norma Hagenow, vice chair of the CON Commission, said it is likely the commission will appoint either a work group, a standard advisory committee or ask DCH to look at updating the organ transplant standards. New rules could be ready for review and possible approval by September.

“I have an idea we will open it up to consider whether the regulations need to be reviewed,” Hagenow said. “There hasn't been a need to change the regulations in 23 years. There have been changes in technology, and there is a little more interest in it now.”

Dr. Adil Akhtar, director of oncology services at Beaumont Hospital in Troy, said Beaumont wants the CON regulations revised to make it more convenient for patients and to hold down health care costs.

“We already have the pieces in place here, and the additional financial impact would be minimal,” Akhtar said. Beaumont has three bone marrow transplant specialists, lab and imaging technology and a dedicated nursing staff, he said.

“We already diagnose the patient and start the treatment, but then we need to send patients to totally different teams of doctors, who do the entire testing again,” Akhtar said. “There is a duplication of services and costs.”

Akhtar said the cost of bone marrow transplant services has dropped considerably since the regulations went into effect 23 years ago.

“Technology has evolved and more people are candidates,” Akhtar said. “Used to be just 55 years or younger were recommended. Now there is no age limit.”

For patients using their own bone marrow, the cost for a transplant could be $75,000, he said. If a donor is required, the cost could be $150,000 to $250,000, he said.

Akhtar said Beaumont could conduct at least 40 to 50 bone marrow transplants a year. In 2007, the three bone marrow transplant hospitals performed 536 transplants, a number that has been rising the past three years.

“We could do more than 50. Karmanos' transplant patients come from up north. They could easily go to Beaumont,” Akhtar said.

But in the October CON Commission hearing, Barbara Jackson, an analyst with Blue Cross Blue Shield of Michigan, said the state's largest insurer only could support studying the regulations if “compelling evidence” of community need is demonstrated.

“Opening up the standards for review could result in more programs, which could seriously deplete existing programs, patient volumes and staffing, reduce quality of care and increase health care costs,” she said.

On heart-lung and liver transplant services, Jackson said there is no need to review the standards because volumes have been stable.

Kenneth Matzick, Beaumont's CEO, said the CON Commission should appoint a committee to develop institution-specific criteria for bone marrow transplant services with minimum volume thresholds.

“Given the fact that bone marrow transplants can now be performed on an outpatient basis and often cost significantly less than chemotherapy or other cancer treatments, there are now reasons for changing this standard,” he said in a letter to the CON Commission.

Beaumont has CON approval to conduct kidney and liver transplants and may seek approval to conduct pancreas transplants. If the regulations are changed, Beaumont might seek approval for heart-lung and liver transplants, Akhtar said.

Dennis McCafferty, director of health policy with the Novi-based Economic Alliance of Michigan, said additional transplant capacity in Michigan is not needed.

However, McCafferty said the alliance could support expanding the number of hospitals offering bone marrow transplants to the western side of the state.

“There should be a minimum volume to ensure staff is well-equipped and experienced,” McCafferty said. “When too many places are doing it, patients take a higher risk.”

But Matzick said there are no studies that link higher volume with better outcomes for bone marrow transplants.

“The most compelling argument we believe, however, is that patients are being negatively impacted if they are forced to leave their existing physician and hospital,” he said. “The CON Commission has not studied increased health care costs or impacts on the patients of these transfers.”

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