Evans R W
Battelle Seattle Research Center, Washington.
Clin Transpl. 1990:343-55.
With few exceptions, most organ transplantation procedures are expensive, although there is considerable variability in costs across transplantation programs. Because of their high cost, many public and private insurers are in the process of carefully evaluating their transplantation coverage and reimbursement policies. Some public insurers have decided to discontinue paying for some procedures on grounds that the resources expended on transplantation could be used to benefit a larger number of people without catastrophic disease. Thus, transplantation is being pitted against health promotion and disease prevention initiatives. Some insurers have also been reluctant to pay for selected transplants, arguing that they are "experimental" or "investigational." Pancreas, lung, and heart-lung transplants are often classified as such. While these decisions have a reasonable basis, concerns related purely to cost, not benefit, have made insurers hesitant to extend coverage to procedures they view as inefficacious. Transplantation programs performing pancreas, heart-lung, and lung transplantation, therefore, do so at some risk. They may not be reimbursed for the procedures they perform, or, more likely, the level of payment received is likely to be substantially below actual hospital costs. To control costs, insurers have also begun to designate transplantation centers. In doing so they limit coverage and reimbursement to programs they regard as "centers of excellence." To become a designated center, a transplantation program must meet preestablished volume and outcome requirements, which insurers believe will assure quality and minimize costs. Thus, designated centers are expected to provide cost-effective transplantation services. If insurers choose to regionalize transplantation programs, controlling both their number and distribution, it is quite possible that patient access to transplantation, as well as their choice of provider, will be severely constrained. In conclusion, concerns related to transplantation costs undoubtedly will have enormous implications for the delivery of transplantation services throughout the foreseeable future. Most significantly, the number of "qualified" centers, using insurer criteria, may be restricted to a small subset of currently active programs. This could have a dramatic affect on the start-up of new programs and the continuation of others.
除了少数例外情况，大多数器官移植手术费用高昂，尽管不同移植项目的成本存在很大差异。由于成本高昂，许多公共和私人保险公司正在仔细评估其移植保险范围和报销政策。一些公共保险公司已决定停止为某些手术支付费用，理由是用于移植的资源可用于使更多无重大疾病的人受益。因此，移植与健康促进和疾病预防举措形成了竞争。一些保险公司也不愿为某些特定的移植手术支付费用，称其为“试验性”或“研究性”手术。胰腺、肺和心肺移植手术常常被归为此类。虽然这些决定有合理依据，但纯粹出于成本而非效益的担忧，使得保险公司在将保险范围扩大到他们认为无效的手术时犹豫不决。因此，进行胰腺、心肺和肺移植手术的项目存在一定风险。他们可能无法获得所实施手术的报销，或者更有可能的是，所获得的支付水平可能远低于实际医院成本。为控制成本，保险公司还开始指定移植中心。这样一来，他们将保险范围和报销限制在他们认为的“卓越中心”项目。要成为指定中心，移植项目必须满足预先设定的数量和结果要求，保险公司认为这将确保质量并使成本最小化。因此，指定中心有望提供具有成本效益的移植服务。如果保险公司选择对移植项目进行区域化管理，控制其数量和分布，那么患者获得移植的机会以及他们对医疗服务提供者的选择很可能会受到严重限制。总之，与移植成本相关的担忧在可预见的未来无疑将对移植服务的提供产生巨大影响。最重要的是，按照保险公司的标准，“合格”中心的数量可能会被限制在目前活跃项目的一小部分。这可能会对新项目的启动和其他项目的持续开展产生巨大影响。
