Below you see the big problem for the War on Poverty public health programs. Manor Care is a national corporation owned by the biggest hedge fund in the world----and it is sucking all of the senior and low-income care into its fold----all of those people unable to afford private health plans which will be 80% and more of people. Sending people to a hedge fund in the old age is very Charles Dickens. These are the people who bet on when people will die so as to determine how much life insurance will be paid. They also see people who cannot pay as their property to do as they want to get the money so what are we seeing for laws regarding aging patients forced into global funded model of health care?
PEOPLE DO NOT HAVE TO GIVE THEIR PERMISSION FOR ORGAN HARVESTING. IF YOU DIE OWING MONEY THEY GET YOUR BODY.
People outside of Maryland may find that startling, but citizens in Baltimore have been shouting this was happening for decades. Since Hopkins controls all public policy and there is no oversight and accountability----transplant medicine is a BIG GLOBAL HEALTH TOURISM INDUSTRY and Baltimore is filled with people unable to afford health insurance. It's no coincidence that Baltimore is saturated with hedge fund Manor Care.
THEY ARE COMING TO YOUR NECK OF THE WOODS SO GET RID OF THIS AFFORDABLE CARE ACT AND DEMAND EXPANDED AND IMPROVED MEDICARE FOR ALL!
News Release For Immediate Release
Steven M. Cavanaugh, Chief Financial Officer
Chris Ullman, Director of Global Communications
The Carlyle Group Completes Transaction with Manor Care
Temporary Restraining Order Dissolved in Michigan
TOLEDO, Ohio, December 21, 2007—Manor Care, Inc. (NYSE:HCR) today announced that global private equity firm The Carlyle Group has completed its $6.3 billion acquisition of Manor Care. Manor Care stockholders will receive $67.00 in cash for each share of common stock owned. The current Manor Care management team, led by Chairman, President and Chief Executive Officer Paul A. Ormond, will continue to operate the business. Manor Care also announced that the temporary restraining order filed yesterday in Michigan has been dissolved.
“We are pleased with this successful outcome,” said Mr. Ormond. “We look forward to working with Carlyle and continuing to provide quality care to our patients and residents.”
Karen Bechtel, Carlyle Managing Director and Global Head of Healthcare, said, “We are pleased to back a high-quality company and management team. We support Paul Ormond’s strategic vision and support his commitment to quality patient care.”
On October 17, 2007, Manor Care’s stockholders approved the merger agreement at a special meeting, with more than 99 percent of shares present voting for approval. The number of shares voting to approve the merger agreement represented more than 76 percent of the total number of shares outstanding and entitled to vote.
As a result of this transaction, Manor Care stock will cease trading on the New York Stock Exchange at market close today, December 21, 2007. Stockholders who hold shares through a bank or broker will not have to take any action to have their shares converted into cash, since these conversions will be handled by the bank or broker. Stockholders who hold certificates can exchange their certificates for $67.00 per share in cash, without interest, through Manor Care’s transfer and paying agent, National City Bank. National City will send out instructions to registered stockholders in the next several days regarding specific actions stockholders will need to take to exchange their shares for the merger consideration.
Manor Care, Inc., through its operating group HCR Manor Care, is a leading provider of short-term post-acute services and long-term care. The company’s nearly 60,000 employees provide high-quality care for patients and residents through a network of more than 500 skilled nursing and rehabilitation centers, assisted living facilities, outpatient rehabilitation clinics, and hospice and home care agencies. The company operates primarily under the respected Heartland, ManorCare Health Services and Arden Courts names.
The Carlyle Group is a global private equity firm with $74.9 billion under management committed to 57 funds. Carlyle invests in buyouts, venture & growth capital, real estate and leveraged finance in Africa, Asia, Australia, Europe, North America and South America, focusing on aerospace & defense, automotive & transportation, consumer & retail, energy & power, financial services, healthcare, industrial, infrastructure, technology & business services and telecommunications & media. Since 1987, the firm has invested $37.7 billion of equity in 737 transactions for a total purchase price of $213.1 billion. The Carlyle Group employs more than 990 people in 21 countries. In the aggregate, Carlyle portfolio companies have more than $87 billion in revenue and employ more than 286,000 people around the world www.carlyle.com.
I want people to think what the dismantling of Medicare and Medicaid and the defunding of the Federal agency that always subsidized cost paid to hospitals for the balance unpaid. Below you see a discussion that looks at how much Medicare and Medicaid funding went to transplants that will now disappear. People will now be forced to pay for health care received rather than think medical costs will be written off. I do not agree with all of what this doctor writes regarding which institutions are doing what-----I know under the current health law deregulation and paying what you owe opens venues for how people pay for ordinary health costs. Does someone in a family donate a kidney so their loved one can have cancer treatments? OF COURSE THAT IS WHERE THIS IS GOING. All of those seniors heading for Manor Care will have the burden of paying SOME WAY. Hedge funds and global health tourism in transplants meaning ORGAN HARVESTING.
Hospitals are now sending around Living Wills each time you enter that gives you the right to ask that certain medical procedures not be used in keeping you alive ...every hospital in Maryland has these Living Wills for every patient entering. With the emphasis on saving cost in delivering care and with the urgency always surrounding harvesting organs......we already see conflicts of moral and ethical medical standards. Healthcare for profit will end all Hippocratic Oath and working for the patient's interest away. People with lower health insurance coverage will be victim to what they can do to pay these hospital bills....YOU BETCHA.
SEE WHY HEDGE FUNDS AND A DEFENSE CONTRACTOR WANT IN ON MARYLAND'S HEALTH CARE BUSINESS?
No time to linger in a predatory profit-driven health system. If your pols supported Affordable Care Act this is to what they are moving!
Hospitals Harvesting Organs From Patients That Doctors Were Pressured to Declare Brain Dead: Lawsuit
Sep 26, 2012 12:31 PM By Christine Hsu
New York hospitals are routinely "harvesting" body parts from patients before they're even dead, a lawsuit is claiming. The suit claims that transplant non-profit, The New York Organ Donor Network, of bullying hospital staffers to declare patients brain dead when they are still alive so to take their organs.
New York hospitals are routinely "harvesting" body parts from patients before they're even dead, a lawsuit is claiming.
The suit accuses the transplant non-profit, The New York Organ Donor Network, of bullying hospital staffers to declare patients brain dead when they are still alive in order to take their organs.
Plaintiff Patrick McMahon, 50, an Air Force combat veteran, is a former transplant coordinator who claims he was fired just four months into the job for protesting about the practice and estimates that one in five patients is still showing signs of brain activity when surgeons declare them dead and start ripping out their body parts.
"They're playing God," McMahon told New York Post. The lawsuits, filed in Manhattan Supreme Court Tuesday, cited four examples of improper organ harvesting.
One of the examples cited details of a 19-year-old man injured in a car crash who was still struggling to breath and showed signs of brain activity when doctors at Nassau University Medical Center declared him brain dead under pressure from the donor-network officials, including Director Michael Goldstein, who allegedly said during a conference call: "This kid is dead, you got that?" the suit claims.
McMahon said that the teenager could have easily recovered.
"I have been in Desert Storm, Iraq and Afghanistan in combat," he told New York Post. "I worked on massive brain injuries, trauma, gunshot wounds, IEDs. I have seen worse cases than this and the victims recover."
The three other examples of patients who were still clinging to life when doctors declared them brain dead included a female patient admitted to St. Barnabas Hospital, a man admitted to Kings County Hospital in Brooklyn and a woman admitted to Staten Island University Hospital after a drug overdose who was given "a paralyzing anesthetic" because her body was still jerking, according to the Post.
McMahon said when he flagged up the injection, another network employee told hospital personnel McMahon was "an untrained troublemaker with a history of raising frivolous issues and questions," the suit charged. "I had a reputation for raising a red flag," he said.
McMahon accuses the federally-funded network of having a "quota" system and hiring "coaches" to teach staff how to be more persuasive in getting family members to give consent to organ donation. McMahon claims that on November 4, he told the network's CEO and president, Helen Irving, that "one in five patients declared brain dead show signs of brain activity at the time the Note is issued."
However, according to the suit, Irving replied: "This is how things are done."
Maryland is rewriting these 1996 health laws that work against the privatization and profit-driven health system of today. We already see these hospital systems telling their doctors on staff to drop patients that become 'expensive' and as we send more and more people to home health care only-----these impersonal and highly unregulated corporations will be making really, really important life and death decisions. It is incredible to think that what was the duty of highly regulated hospitals and doctor's offices bound by law to keep us safe will now have profit-motive to end all health care arrangements that become too costly. As Medicare and Medicaid patients are sent to home health care and not good public nursing facilities----their lives will be determined by these staff.
As with the article above that addresses the judgement calls on keeping people alive and how they will pay hospital bills-----this system gets dirtier and more murky with the home health corporations.
Remember, under the Maryland global funding model----all Federal, state, and local health funding goes into this pool and a bolus given to all hospitals who now under ACA do not have to take people-----they can select and patient abandonment will become a business strategy.....
SEE WHY GLOBAL CORPORATIONS AND THEIR POLS THINK THE AFFORDABLE CARE ACT IS GREAT!
Think how Americans being moved from the care of professional regulated health offices to what is a wild-west of home health corporations all with a model to maximize profits. Think how someone with a chronic illness having few options are forced into a system that can easily find reasons to dismiss you. If you do not choose to follow their treatment protocol----you can be dismissed. The 'skilled nursing' coming with these exploding home health corporations make health care more dangerous than ever in Maryland. If you have private insurance, you do not face this-----but how long will you be able to afford---our have corporate private plans? Do not allow the right to quality health care be dismantled in the US. The decline has the US second world in health care-----these reforms will take the US to third world as Trans Pacific Trade Pact seeks to void all Constitutional rights of American citizens.
Home Health Care
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
An Aspen Publication
Aspen Publishers, Inc.
1996 Patient Abandonment Introduction
The relationship that exists between a physician and patient, or between other types of health care providers and the client, continues until it is terminated with the consent of both parties. A patient having health needs, especially a patient who is disabled or feeble, may be dependant on the home health professional. The patient has the right to expect that he or she will have access to the services he or she needs until receiving proper notice to the contrary and, preferably, until a substitute is provided.
Such a relationship can be terminated by the patient at any time. The patient has the freedom to choose his or her health care providers. However, the physician, nurse, or home health provider may also withdraw from the case as long as it is done properly and the patient is not harmed by this action.
The premature termination of medical treatment is often the subject of a legal cause of action known as "abandonment." Abandonment is defined as the unilateral termination of a physician-patient or health professional-patient relationship by the health care provider without proper notice to the patient when there is still the necessity of continuing medical attention. 
Elements of the Cause of Action for Abandonment
Each of the following five elements must be present for a patient to have a proper civil cause of action for the tort of abandonment:
1. Health care treatment was unreasonably discontinued.
2. The termination of health care was contrary to the patient's will or without the patient's knowledge.
3. The health care provider failed to arrange for care by another appropriate skilled health care provider.
4. The health care provider should have reasonably foreseen that harm to the patient would arise from the termination of the care (proximate cause).
5. The patient actually suffered harm or loss as a result of the discontinuance of care.
Physicians, nurses, and other health care professionals have an ethical, as well as a legal, duty to avoid abandonment of patients. The health care professional has a duty to give his or her patient all necessary attention as long as the case required it and should not leave the patient in a critical stage without giving reasonable notice or making suitable arrangements for the attendance of another. 
Abandonment by the Physician
When a physician undertakes treatment of a patient, treatment must continue until the patient's circumstances no longer warrant the treatment, the physician and the patient mutually consent to end the treatment by that physician, or the patient discharges the physician. Moreover, the physician may unilaterally terminate the relationship and withdraw from treating that patient only if he or she provides the patient proper notice of his or her intent to withdraw and an opportunity to obtain proper substitute care.
In the home health setting, the physician-patient relationship does not terminate merely because a patient's care shifts in its location from the hospital to the home. If the patient continues to need medical services, supervised health care, therapy, or other home health services, the attending physician should ensure that he or she was properly discharged his or her-duties to the patient. Virtually every situation 'in which home care is approved by Medicare, Medicaid, or an insurer will be one in which the patient's 'needs for care have continued. The physician-patient relationship that existed in the hospital will continue unless it has been formally terminated by notice to the patient and a reasonable attempt to refer the patient to another appropriate physician. Otherwise, the physician will retain his or her duty toward the patient when the patient is discharged from the hospital to the home. Failure to follow through on the part of the physician will constitute the tort of abandonment if the patient is injured as a result. This abandonment may expose the physician, the hospital, and the home health agency to liability for the tort of abandonment.
The attending physician in the hospital should ensure that a proper referral is made to a physician who will be responsible for the home health patient's care while it is being delivered by the home health provider, unless the physician intends to continue to supervise that home care personally. Even more important, if the hospital-based physician arranges to have the patient's care assumed by another physician, the patient must fully understand this change, and it should be carefully documented.
As supported by case law, the types of actions that will lead to liability for abandonment of a patient will include:
• premature discharge of the patient by the physician
• failure of the physician to provide proper instructions before discharging the patient
• the statement by the physician to the patient that the physician will no longer treat the patient
• refusal of the physician to respond to calls or to further attend the patient
• the physician's leaving the patient after surgery or failing to follow up on postsurgical care. 
Generally, abandonment does not occur if the physician responsible for the patient arranges for a substitute physician to take his or her place. This change may occur because of vacations, relocation of the physician, illness, distance from the patient's home, or retirement of the physician. As long as care by an appropriately trained physician, sufficiently knowledgeable of the patient's special conditions, if any, has been arranged, the courts will usually not find that abandonment has occurred.  Even where a patient refuses to pay for the care or is unable to pay for the care, the physician is not at liberty to terminate the relationship unilaterally. The physician must still take steps to have the patient's care assumed by another  or to give a sufficiently reasonable period of time to locate another prior to ceasing to provide care.
Although most of the cases discussed concern the physician-patient relationship, as pointed out previously, the same principles apply to all health care providers. Furthermore, because the care rendered by the home health agency is provided pursuant to a physician's plan of care, even if the patient sued the physician for abandonment because of the actions (or inactions of the home health agency's staff), the physician may seek indemnification from the home health provider. 
ABANDONMENT BY THE NURSE OR HOME HEALTH AGENCY
Similar principles to those that apply to physicians apply to the home health professional and the home health provider. A home health agency, as the direct provider of care to the homebound patient, may be held to the same legal obligation and duty to deliver care that addresses the patient's needs as is the physician. Furthermore, there may be both a legal and an ethical obligation to continue delivering care, if the patient has no alternatives. An ethical obligation may still exist to the patient even though the home health provider has fulfilled all legal obligations. 
When a home health provider furnishes treatment to a patient, the duty to continue providing care to the patient is a duty owed by the agency itself and not by the individual professional who may be the employee or the contractor of the agency. The home health provider does not have a duty to continue providing the same nurse, therapist, or aide to the patient throughout the course of treatment, so long as the provider continues to use appropriate, competent personnel to administer the course of treatment consistently with the plan of care. From the perspective of patient satisfaction and continuity of care, it may be in the best interests of the home health provider to attempt to provide the same individual practitioner to the patient. The development of a personal relationship with the provider's personnel may improve communications and a greater degree of trust and compliance on the part of the patient. It should help to alleviate many of the problems that arise in the health care' setting.
If the patient requests replacement of a particular nurse, therapist, technician, or home health aide, the home health provider still has a duty to provide care to the patient, unless the patient also specifically states he or she no longer desires the provider's service. Home health agency supervisors should always follow up on such patient requests to determine the reasons regarding the dismissal, to detect "problem" employees, and to ensure no incident has taken place that might give rise to liability. The home health agency should continue providing care to the patient until definitively told not to do so by the patient.
COPING WITH THE ABUSIVE PATIENT
Home health provider personnel may occasionally encounter an abusive patient. This abuse mayor may not be a result of the medical condition for which the care is being provided. Personal safety of the individual health care provider should be paramount. Should the patient pose a physical danger to the individual, he or she should leave the premises immediately. The provider should document in the medical record the facts surrounding the inability to complete the treatment for that visit as objectively as possible. Management personnel should inform supervisory personnel at the home health provider and should complete an internal incident report. If it appears that a criminal act has taken place, such as a physical assault, attempted rape, or other such act, this act should be reported immediately to local law enforcement agencies. The home care provider should also immediately notify both the patient and the physician that the provider will terminate its relationship with the patient and that an alternative provider for these services should be obtained.
Other less serious circumstances may, nevertheless, lead the home health provider to determine that it should terminate its relationship with a particular patient. Examples may include particularly abusive patients, patients who solicit -the home health provider professional to break the law (for example, by providing illegal drugs or providing non-covered services and equipment and billing them as something else), or consistently noncompliant patients. Once treatment is undertaken, however, the home health provider is usually obliged to continue providing services until the patient has had a reasonable opportunity to obtain a substitute provider. The same principles apply to failure of a patient to pay for the services or equipment provided.
As health care professionals, HHA personnel should have training on how to handle the difficult patient responsibly. Arguments or emotional comments should be avoided. If it becomes clear that a certain provider and patient are not likely to be compatible, a substitute provider should be tried. Should it appear that the problem lies with the patient and that it is necessary for the HHA to terminate its relationship with the patient, the following seven steps should be taken:
1. The circumstances should be documented in the patient's record.
2. The home health provider should give or send a letter to the patient explaining the circumstances surrounding the termination of care.
3. The letter should be sent by certified mail, return receipt requested, or other measures to document patient receipt of the letter. A copy of the letter should be placed in the patient's record.
4. If possible, the patient should be given a certain period of time to obtain replacement care. Usually 30 days is sufficient.
5. If the patient has a life-threatening condition or a medical condition that might deteriorate in the absence of continuing care, this condition should be clearly stated in the letter. The necessity of the patient's obtaining replacement home health care should be emphasized.
6. The patient should be informed of the location of the nearest hospital emergency department. The patient should be told to either go to the nearest hospital emergency department in case of a medical emergency or to call the local emergency number for ambulance transportation.
7. A copy of the letter should be sent to the patient's attending physician via certified mail, return receipt requested.
These steps should not be undertaken lightly. Before such steps are taken, the patient's case should be thoroughly discussed with the home health provider's risk manager, legal counsel, medical director, and the patient's attending physician.
The inappropriate discharge of a patient from health care coverage by the home health provider, whether because of termination of entitlement, inability to pay, or other reasons, may also lead to liability for the tort of abandonment. 
Nurses who passively stand by and observe negligence by a physician or anyone else will personally become accountable to the patient who is injured as a result of that negligence .... [H]ealthcare facilities and their nursing staff owe an independent duty to patients beyond the duty owed by physicians. When a physician's order to discharge is inappropriate, the nurses will be help liable for following an order that they knew or should know is below the standard of care. 
Similar principles may apply to make the home health provider vicariously liable, as well.
Liability to the patient for the tort of abandonment may also result from the home health care professional's failure to observe, examine, assess, or monitor a patient's condition.  Liability for abandonment may arise from failing to take timely action, as well as failing to summon a physician when a physician is needed.  Failing to provide adequate staff to meet the patient's needs may also constitute abandonment on the part of the HHA.  Ignoring a patient's complaints and failing to follow a physician's orders may likewise constitute a tort of abandonment for a nurse or other professional staff member.
Hopkins has already been charged in connection with illegal organ trafficing in a case. Allowing foreign patients to come to the US with organs they procure overseas FEEDS ORGAN HARVESTING. That is what is happening in health tourism. South and Central America is becoming a huge market for this as drug cartels get into the business of garnering and selling organs. If Medicare and Medicaid does not exist then the poor will have to come up with payment or have no access to ordinary health care in the US.
This doctor is calling for an end of selective transplants to one that gives transplants to all -----he says Medicare for All. What is does not write is how the current health reforms take away even that Medicare and Medicaid ability to access transplants and the organ donation is now a very profitable global business that Wall Street predatory health systems like Johns Hopkins will exploit.
'In this government-regulated and essentially government-financed enterprise, and with the full weight of law and omnipresent marketing behind it, it is this discrepancy between those called upon to donate and those eligible to receive that has led me to characterize this aspect of the American transplant industry as the “Reverse Robin Hood” approach to healthcare— taking from the poor and giving to the rich. I welcome anyone to make the contrary argument. I would like to be wrong'.
Posted on January 16, 2015 by P Hasselbacher
In response to a recent article in these pages about human organ transplantation in Kentucky, it was alleged that the University of Kentucky Hospital accepted Medicaid as payment for solid organ transplantation but that the Jewish Hospital program did not. I interviewed a number of individuals with first-hand knowledge but was unable to dispute the assertion that the source (or lack thereof) of a patient’s health insurance makes a difference in who receives an organ— not only here in Kentucky but nationwide. I recently obtained comprehensive payer-specific information from the United Network for Organ Sharing (UNOS)– the government-sponsored organization that regulates and oversees virtually all organ transplants performed in the U.S. The short answer is that there is a considerable difference in the payer-mix for solid-organ transplantation between Jewish Hospital and the University of Kentucky (UK). In 2013– the last year for which a full 12 months of reporting is available– Medicaid beneficiaries made up 6.4% of all transplant recipients at Jewish and 15.9% at UK. These figures can be compared to the national proportion of 8.7% Medicaid beneficiaries. It cannot be said that the Jewish Hospital program does not accept Medicaid beneficiaries altogether. Additional details and commentary concerning local and national transplant programs are presented below. Frankly, I had not encountered such data before and I think it will be of general interest to many.
Source of the data.
UNOS hosts an extensive interactive database, much of which is available to the public on its website. Center-specific information is available on a wide range of elements from 1988 to the present for both donors and recipients. Non-patient-identifiable data is presented in custom reports by organ, sex, age, ethnicity, graft survival, status of donor, numbers and time in waiting lists, and much more. I was impressed! However, in this age of spiraling medical costs, the absence of information about cost or insurance coverage was noticeably absent. As it happens, some such data has been collected beginning in 1994 but had not been made available on the website. At my request, the good folks at UNOS gave me a massive series of spreadsheets identifying the primary payer broken down by every organ, every state, every transplant center, and for every one of the last 20 years. A smaller amount of information is available about the insurance status of living organ donors as well. There is enough information to choke a horse, and extracting data form the heavily formatted tables is tedious, but I have bitten-off a manageable amount to begin some discussion.
Specific categories of payer identified.
Some 96% of all transplants since 1994 had as their primary payer either private insurance (46.5%), Medicare (40.5%), or Medicaid (9.0%). Smaller proportions of less than 1% each were covered from other (mostly) government programs. Any secondary sources of health coverage such as Medicare supplements are not included. For presentation below, I combined three different Medicare categories in the collected data to consolidate traditional fee-for-service Medicare and Medicare Managed Care since 1994. Only a single Medicaid designation was provided by UNOS and while I wait for confirmation, I am provisionally assuming that it includes Medicaid Managed care.
Table 1 (PDF attached) identifies the primary payer source for all solid organs nationally (except combined kidney-pancreas) and for the three solid-organ transplant programs in Kentucky for the years 2011 through 2013. Data collection for 2014 is not yet complete and is omitted. For the most recent comparison year of 2013, I was surprised to learn that overall, the federal government was the largest payer for organ transplantation,covering just over 57% all recipients. Private insurance covered 41.8%. Of the big three, Medicaid covered 8.7%.
Results vary by organ!
The payer mix varies for the specific organ transplanted. (See Table 2.) Because virtually all patients with chronic kidney failure on dialysis become eligible for Medicare, that federal program is the major payer for kidney transplantation. In 2013 the big three for kidney were Medicare (58%), Private (35.3%), and Medicaid (4.8%). For all the other organs, private insurance was the predominant payer. Medicaid was the third most frequent payer except for intestine for which Medicaid was second at 32.1%. This latter apparent anomaly may be due to the relatively large proportion of covered children undergoing this procedure. Perhaps an expert reader can clarify any of the observations above (or below for that matter).
Results in Kentucky.
The UNOS numbers confirm that economic factors are determinative of whether a prospective transplant patient is accepted to a waiting list and makes it to actual transplantation. Even in our major urban area with more than our share of medically indigent people, the proportion of Medicaid patients receiving an organ at the Jewish Hospital program is less than the national average (6.4% vs. 8.7% in 2013). In contrast, the proportion of Medicaid patients at UK was 15.9%, almost double the national proportion and 2 1/2 times that of Jewish. The University of Kentucky program also had a slightly higher proportion of private payers and considerably fewer Medicare patients than Jewish. No doubt there are many other factors that effect the patient profiles presenting to these two centers— it is a complicated business. However, given that UK makes the point that it accepts Medicaid beneficiaries as a matter of public policy, the considerable difference between these two centers begs to be explained as a matter of social justice.
The solid-organ transplantation program at Kosair Children’s hospitals is smaller than that at its sister Kentucky programs with only 99 transplant procedures recorded in the UNOS database since 1994. Over the years, the three major payers were more or less evenly represented, although in recent years Medicaid and disabled Medicare recipients appear to be in the majority. Because of the small numbers, little more can be said here.
Kentucky by organ.
As is the case nationally, payer mix by organ varies in Kentucky. Table 2 above also extracts the Kentucky numbers for 2013. As expected, Medicare plays a larger role in kidney transplants. There are no doubt several dynamics that influence payer mix. For example, the percent private insurance for heart transplants at both adult transplant centers is much lower than the U..S average. The total number of heart procedures at both is relatively small– 11 and 14 for the year. It might be necessary to adopt a more liberal payment policy for heart in order to maintain a minimum number of procedures for Medicare accreditation. Private patients may be being referred out-of-state by their physicians to higher volume centers. Perhaps there is not enough demand in KY for heart transplants such that all candidates are being served. Someone with more practical experience than I will need to address these matters.
Because the annual volumes of all transplants in Kentucky is relatively small, a few patients may distort the percentages statistically one way or the other by chance. I will extract the total experience since 1994, and if it adds to the discussion, will append it here.
No information is available to me about the insurance coverage or financial status of deceased donors, but that is an unknown close to my heart and which is driving this series of articles. The cost of harvesting and preparing organs from dead donors is generally assumed by the payer of the recipient. I am uncertain how matters are handled for live donors of a kidney, or portions of livers, lungs, pancreas or intestine. According to UNOS, of 5988 live donors in 2013, 79.7% were insured, 14.2 were uninsured, and the status of 6.1% was unknown.
What are we to make of all this?
The business of organ transplantation carries with it all the baggage of our health system in general but is punctuated by the high cost of the procedure, subsequent medical and pharmaceutical requirements, and the scarcity of available organs. In such a situation, the already impaired access to our main-stream healthcare system faced by disadvantaged persons is magnified. It is a reality that persons of limited financial means, those without employer-sponsored health insurance, or those belonging to ethnic groups that have been systematically disadvantaged by structural racism do not fully enjoy the financial and quality benefits of our healthcare system.
What if you are poor?
The proportion of Medicaid patients in a hospital has long been used as a marker for its share of uninsured and medically indigent patients. Do even the 9% Medicaid transplant recipients nationally fairly reflect the insurance status of people, let alone the medical necessity of those making application for a transplant, or are the poor winnowed out even before making a waiting list? I do not have information about the insurance, or financial, or ethnic status of potential transplant recipients to render a fact-based opinion about the degree of exclusion, but I have little doubt such individuals are blocked at the starting line just as they are for most other medical services. Of the 28,192 people who received a transplanted organ in 2013, only 39 (0.1%) were provided services considered to be donated or free. Even if we include some of the 79 “Self-Pay” recipients, is this enough to justify the non-profit status of transplant centers? I am sure there are no questions asked about the financial status of families who are asked to donate the organs of their loved ones. In ironic counterpoint, it is considered inappropriate to offer compensation to donors or their families! In this government-regulated and essentially government-financed enterprise, and with the full weight of law and omnipresent marketing behind it, it is this discrepancy between those called upon to donate and those eligible to receive that has led me to characterize this aspect of the American transplant industry as the “Reverse Robin Hood” approach to healthcare-- taking from the poor and giving to the rich. I welcome anyone to make the contrary argument. I would like to be wrong.
Why is it so different in Louisville and Lexington?
Can anyone make the argument that the indigent of Louisville are being as well served as those in Lexington? Where do the medically needy from Western Kentucky go when transplant is needed? Do they bypass Louisville for Lexington? I am impressed and grateful that the University of Kentucky views it as their duty to accept Medicaid as payment-in-full for transplant services, but even UK has not listed any “donated” or “free” transplants in the last twenty years. Perhaps some of their 12 “self-pay” patients fell into these categories. Perhaps they were successful in securing public funding for their patients.
Who should hold the monopoly on transplantation?
In Kentucky, a center needs a state Certificate of Need to offer transplant services. Given the degree of federal and state support for organ transplantation in law, finance, and in promotion; and given concepts of equity and justice concerning who should have access to those services; and especially given an obvious difference in commitment to the public exhibited by the state institution in Lexington— when and under what conditions is it defensible to give a transplant monopoly to a private institution? The surgical staff at Jewish Hospital are members of the faculty of the University of Louisville, but the transplant program itself is in private hands, a pair that has promised to provide healthcare to the needy of Kentucky regardless of ability to pay. What should therefore reasonably be the expectations of the Commonwealth and its citizens for our transplant centers, or those of citizens in other states for theirs?
How should the trains be run.
I have been writing about these issues for the past 3 years and it is no secret that I am unhappy with the degree of access and equity inherent in our current American health system. Sadly, I do not see a transformation to a “Medicare for all” solution in my lifetime, but what about for organ transplantation? We are already as a society paying for kidney transplants for all who need them medically and for half of the other organs. Why not just extend the coverage to all those for whom transplantation of other organs is medically necessary. How can we justify our current organ-based discrimination? No one should have to have to shake a can or offer a bake sale to raise money for a transplant. And while we are at it, lets assume a legal presumption of consent that suitable organs are available for donation to those who can give them an extended life? Why stop there? How about basic healthcare for all such that untreated hypertension and diabetes does not lead to the need for so many kidney transplants in the first place.
Enough for now. Tell me how wrong I am— please! If I have made errors in fact or interpretation, or if there are other rational explanations for the differences I have observed, please let us know. If there is another view of the data you would like to see, or if you would like to see the profile of another center, let me know that too.
Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
January 16, 2015