Meltzer combines public policy, economics and health care expertise in classroom and in organ transplantation regulationBy Peter Schuler
David Meltzer, Assistant Professor in Medicine and a faculty associate in the Harris Graduate School of Public Policy Studies and Economics, teaches a course in the Harris School on the economics of health and medical care with particular emphasis on the role of government and how constructive public policy can improve health care.
Meltzers students have examined such complex health care issues as the impact of Medicare payment policies on the cost and quality of care; appropriate teaching methods to determine the value of new medical techniques; and the determinants and consequences of access to health care.
The course is designed to act as a bridge between the tools, models and policy analysis provided to students by foundation economics courses and the difficult public policy problems that students may face after they graduate.
One public policy issue that Meltzer has played a key role in is the regulation of organ transplantation. Since the first transplants were performed 20 years ago, legislators, government healthcare officials, the medical community, patients and others have all hotly debated the issue.
Every day, nearly 60 Americans receive a transplanted kidney, liver, heart or lung, while 11 others die waiting for an organ transplant.
In 1998, in response to growing recognition of the wide variation in waiting times in different regions of the country, the U.S. Department of Health and Human Services published a regulation that promoted greater sharing of organs in the United States, with allocation based more on medical criteria and less on geography.
Because of the controversy it generated, shortly afterward the U.S. Congress asked the Institute of Medicine to form a committee to study the potential impact of the regulation. Meltzer was asked to join this committee, and he and his colleagues launched a comprehensive review of organ transplantation in the United States. This resulted in a detailed study titled Organ Procurement and Transplantation, which has become the principal reference in this field.
There is an incredible shortage of organs in the United States for transplantation, Meltzer said. At the same time, there has been a growth in capabilities, and transplants are now more attractive than ever before. He noted that transplants are increasingly successful with patients who are older or are more severely ill at the time of transplantation.
Initially, organ transplants in the United States were handled locally. A doctor with a patient needing a transplant would wait for an organ donation from another patient in the same hospital or community. As the procedures became more frequent, physicians began to have excess organs available for transplantation and began sharing them more broadly. In the 1980s, organ procurement organizations developed to manage supply and demand. They served a really wonderful purpose, Meltzer said, by helping to efficiently allocate organs and encourage increased donations through an organized system.
In 1984, Congress passed the National Organ Transplant Act, which created the Organ Procurement and Transplantation Network to maintain a computerized listing of potential donors and all patients waiting for organs. The United Network for Organ Sharing is the contractor that manages the program, using a complex computerized algorithm to determine which patient is the most appropriate recipient of an available organ.
Nevertheless, that system still favors a relatively local exchange between donors and patients needing transplants. This has resulted in large variations in waiting times across the country. Organs are often allocated to people who are not severely ill even when a severely ill person may be nearby. The 1998 legislation focused on equalizing waiting times among different areas of the country. The legislation called for standardized medical criteria to determine the status of a persons illness and when that person could be placed on a waiting list.
Even though our capabilities were increasing, diseases continued to increase the demand, Meltzer said. In urban areas, for example, the increase in patients with Hepatitis C created a need for more livers. Large urban centers found they could not get all the organs they wanted and started pushing for mandatory sharing.
Many of the smaller organ transplantation centers resisted because they feared that they would lose their advantage in access to organs and harm their patients and their centers, he said. There also was the belief that if local organs could be transplanted locally that would benefit the community and encourage more donations.
The economics are obviously important, Meltzer said. The small centers, which often were not very profitable to begin with, felt they could not survive if they were forced to share their organs.
Meltzer and his colleagues found that the fears were probably unfounded since many small transplant centers managed to survive despite being part of very large sharing areas. In addition, we saw that there is a very well-established volume/outcome relationship, Meltzer noted. So it may be much better for people to have to travel a little farther to get a transplant at a larger center that performs significantly more procedures.
Organs for transplantation also differ in their mobility, which limits how broadly they may be shared. While kidneys can be safely transplanted after more than two days of transport time, livers should be transplanted within eight hours and hearts and lungs have a very short viability. We decided to focus our study on livers and asked a series of questions to see whether patients would be better off in the end if organs were shared regionally or nationally as opposed to locally, Meltzer explained. Its essentially a public policy question that depends on the medical facts.
The groups key finding was that when the allocation areas are smaller, patients with less-advanced diseases were likely to receive a larger percentage of organs. As allocation areas grew geographically, organs tended to be more available when needed urgently and more often used for the most severely ill patients with the greatest need for transplantation.
The committee also found that there was not a large downside to increased organ sharing in terms of reduced donors.
More human organs will be needed for transplantation than will be available for the foreseeable future. Meltzer suggested that another way to increase the organ supply would be a public policy that fosters enhanced family involvement in donations. We do not have enough family awareness, he noted. We need to focus on families rather than individuals, and try to encourage a family decision on organ donation that will be a positive memory for everyone.