Financial and operational stresses at Jewish Hospital likely to be taking a toll on one of the headline partnerships between the Hospital and the University of Louisville. Increasing dependence on Medicaid patients and a blossoming load of uncompensated care may be blocking access for the medically indigent and recipients of color for at least some solid organ transplants such as heart and liver.
Since the middle 1980s when I came to Louisville, Jewish Hospital has branded itself as a high tech “Heart Hospital.” It promotes the early adoption of high-technology. Indeed, a few years ago it received a special designation as a heart hospital in Kentucky from U.S. News & World Report that it would not have received had it not had a cardiac transplant program. In the middle 1990s, the University of Louisville formally shifted the private practice activities of its cardiologists to Jewish Hospital. The transplant surgeons at Jewish, to my knowledge, all have formal University faculty appointments. Jewish Hospital and the University of Kentucky Hospital are the only two hospitals in the state with a Certificate of Need (CON) for adult human solid-organ transplantation. (The University of Louisville does not own this CON for transplant.) Accordingly, this high-profile program is both important for, and a marker of the institutional health of both Louisville institutions.
For this and for other reasons, I have been writing about Kentucky’s transplant programs for the last few years. Most medical schools with a major clinical medical center consider having a transplant program as an important part of their service profile. I became concerned that although in the 1990s through 2010, Jewish Hospital performed the most such organ transplants in Kentucky, that a steadily-growing UK program overtook our own as early as 2010. My academic pride was injured. My concern included that a weakening Jewish Hospital was losing the resources or the will to continue this important program. It is after all an expensive undertaking.
Frankly more troubling to me was additional proof confirming that without high-end medical insurance, transplants were effectively being denied to the poor or uninsured even as their organs were accepted for the use of others. In the early 2000’s, I confirmed that Jewish Hospital would not accept a Medicare patient for transplant. An analysis by me in 2015 confirmed that in Louisville and elsewhere, ones financial or socioeconomic status limited ability to receive a transplant. I termed this practice the “Reverse Robin Hood” approach to of human organ transplantation.” Organs were being harvested from the poor for use by the rich. Harsh words indeed, but compatible with the frankly racist heritage of our medical system here and elsewhere in which the poor or people of color have been segregated to a single hospital that few others seemed willing to use. (I have met older doctors who told me of racially segregated wards in the old Louisville General.)
The future of Louisville’s transplantation program is undoubtedly one of the major issues to be dealt with as KentuckyOne Health and Catholic Health Initiatives (CHI) sell off both of their acute care hospitals and their outpatient medical centers in Louisville. The CON is itself an asset that will be part of the sale of Jewish Hospital – should that hospital be sold or remain as an acute care hospital. I therefore went back into the truly massive collection of data related to transplantation maintained by the United Network for Organ Sharing (UNOS), and its associated Organ Procurement and Transplantation Network. In brief, what I learned is that since 2008, when both programs were doing the same number of transplants overall, that Jewish Hospital is at best treading water and UK is booming. I am concerned that the number of heart transplants done in Louisville is low enough that surgical teams may not be getting enough practice, that the procedures cannot be done cost effectively, or that accreditation may be in jeopardy. In 2016, the last year for which complete data is available, only ten heart transplants were done– none of them to black recipients. I will present and discuss the data below, but I have grave concern about the relationship between socioeconomic class and access to healthcare. I do not know what our Louisville healthcare landscape will look like when the departure of KentuckyOne Health is complete, but perpetuating a dual standard of care would be an anathema to me– and should be to all of us. In all of this, I venture no opinion about the quality of surgical outcomes, nor how traffic flows (or not) through the waiting lists, but data is available that can address those aspects.
For background, I refer the reader to my article of March 2012 in which I offer my concern about the effects of socioeconomic status on transplant availability. In November 2014, I describe in more depth the organ procurement and transplantation systems we use nationally, the cost of transplantation, and the inherently unfair exclusion of the uninsured or underinsured from benefiting. It is there I introduce the term “Reverse Robin Hood.” In December 2014, I dig more deeply into the national data. At this time, UK was making its great leap forward and Jewish Hospital was starting to dwindle. I speculated that the loss of patient volume at Jewish was at least in large part a direct result of KentuckyOne Health and the University declaring their ill-conceived war on Norton Healthcare. Norton and other physicians had the option of sending their patients to Lexington for surgery and following them further here in Louisville. (It is this 26 years of data I will extend to 2016 and present below.) In January 2015 I analyzed data made available for me by UNOS that focused on who pays for transplantation.
Two Kentucky Hospitals Compared.
Just below is a graph of the number of solid organ transplants done at Jewish and UK beginning in 1988 (the first year for which data is available to me) through 2016– the most recent full year for which data is available. Despite access of Kentucky patients to transplant centers in other states, the combined total number of transplants performed in these two hospitals continues to rise slowly. At UK, the number has been continuously trending upwards, while at Jewish, the trend since its heyday in 1995 is stagnant at best and appears to be declining. (The data underlying this graph is available in an Excel file or pdf.)
The total number of transplants can be subdivided by organ as tallied in the following table for transplantations in 2016. Kidney is by far the most common organ transplant. [This is not a surprise. Kidney transplantation was shown early to be a successful treatment for chronic kidney failure– of which there are plenty of cases to go around. Like dialysis, it is expensive and there is a special program administered within Medicare that covers chronic renal failure and kidney transplantation in all patients, not just the elderly. In other words, everybody for which a kidney transplant is medically indicated is covered if an organ is available.] In Kentucky, liver is the second most frequently transplanted organ– 79 in 2016. Heart comes in at third with 53 transplants, and lung the fourth with 36. Of these four major organs, all but liver are transplanted more often at UK.
Increases in recent years.
In the table above, I calculate the increase in number of transplants of individual organs from 2008 through 2016. [I chose 2008 because in that year Jewish and UK were transplanting the same total number of solid organs.] For the state as a whole, only kidneys and hearts have been transplanted in significantly larger numbers. In fact, liver transplants went down a little. [In the middle of a statewide epidemic of hepatitis-C, I am surprised not to be seeing an increase in liver transplants. Perhaps this will be visited upon us as the opioid-abuse epidemic rolls on because i.v. drug abuse is the major cause of hepatitis-C. On the other hand, the fabulously expensive drugs to treat hepatitis may diminish the liver complications.]
The state-wide trend upwards of some organs was not shared equally by the two university medical centers. At UK, the number of kidney and heart transplants increased notably over the last 10 years while the number of liver transplants fell. At Jewish Hospital, only the member of liver transplants improved meaningfully. The other organs pretty much stayed the same except for kidney, falling by 12.
[Of interest, when I looked at the volumes of transplants done across the river at the University of Cincinnati, there were zero heart transplants listed in the data! I wonder if they are all being sent to the Cleveland Clinic. Is this an opportunity for a tuned-up Kentucky system to help our neighbors?]
Organs and Race.
The UNOS data allows one to break down the recipients of individual organs by race. I did so for the year 2016. Frankly, it is this table that gave me the impetus to publish this article. That in Louisville only three of 43 livers transplanted, or one of 13 lungs, and indeed none of 10 hearts transplanted were received by a black person frankly slapped me in the face. Only for kidney were black people more than infrequent recipients– indeed more often than their numbers in the community might predict. This is hardly a redeeming statistic. A reason African-Americans have more chronic renal (kidney) failure is that they as a group have more untreated hypertension. This latter is due in major part to lack of effective participation in our healthcare system. In any event, Jewish Hospital now accepts Medicare patients for transplantation– at least for Kidney. I do not know if Medicare without a secondary supplemental insurer makes the cut. It may be in these financially stressed times that even oft-criticized Medicare reimbursement is not to turn one’s nose up to.
Are there palatable justifications for apparent discrepancies?
Some, but not all, of the other apparent disparities displayed in this table may also in part be predictable by medical reasons. For example, a common reason for lung transplantation is cystic fibrosis which is more common in white people. Lexington and Eastern Kentucky do not have the same population density of black people as Louisville such that eight of 43 heart transplants may be representative or better. It is also possible that black heart-transplant patients are being sent to Lexington from Louisville for their surgery! [I had been told once by Lexington authorities that they considered it their duty to take on all Medicare and Medicaid patients. I do not know what they do with the completely medically indigent.]
On the other hand, I am rather surprised that not a single one of the 36 liver transplants done in Lexington in 2016 was recorded in the data as having been given to a black person.
There is no doubt that one’s socioeconomic status is the calling card many if not most transplant centers look at first when an person presents for help. Our African-American communities continue to wrestle a long, vicious, and persisting history of discrimination. As a result of this handicap, this group has inherited or accumulated fewer than their fair share of economic resources. While Jewish and UK and their affiliated universities may well offer a medical explanation or some justifiable unique circumstance, I believe that both medical centers need to take a long hard look at how they are serving their communities, because in my opinion, this picture does not look good.
I was going to use this article as a vehicle to update what I know about, and to express my concerns about the future of my medical school, the downtown Medical Center– indeed, the future medical fabric of Louisville. I have been trying to remain in a relatively uncritical background to give the new leadership of the University– for which I have respect and hopeful confidence– an opportunity to fix what in my oft-spoken opinion was a predictable disaster.
I concede that Catholic Health Initiatives, KentuckyOne Health, and the University of Louisville are in tough spots. The assets that KentuckyOne Health wants to sell need to appear viable to attract a buyer. This is particularly so here in Louisville. CHI needs to look like it can manage its huge debt and its widely distributed facilities so as to be a credible partner in an “alignment” with Dignity Health. [Some national media reporting on the CHI-Dignity discussions are backing away from using the word “merger.”] The University of Louisville is at risk of losing clinical teaching facilities and access to the broad spectrum of all kinds of patients that a medical school of its size must have. In my personal experience and opinion, University of Louisville Hospital by itself is insufficient. UofL may wish to retain high-end programs like transplantation. Can the state justify or afford having two centers 70 miles apart? Might they be merged to a single site, or the various organs divvied up if necessary surgical expertise is that specific? Will UofL even have an option in the matter? All of this is happening to a University that probably has little idea of who it’s next neighbor/potential partner will be. All of this is happening in an environment where the Governor’s office actively seeks to impose its Tea Party and religious agendas on our Universities jeopardizing the accreditation of the University itself. The SACHS accreditors need to hold firm until University governance can be demonstrated to be independent of inappropriate political control. New University President Greg Postel is urging the University community to emphasize a fresh forward look. I hope that means looking through greater transparency and less of the secret or closed-door planning that contributed to the disaster from which we are emerging. Louisville’s healthcare future does not belong to the University alone. I for one, look forward to a healthcare community where access to quality healthcare is not so obviously constrained by socioeconomic status and race, and where people enter the system though the same doors.
As usual, if I have made an error of fact, or if a better conclusion should be drawn, please help me fix it.
Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
4 August 2017