Magazine article The Alcoholism Report

Medicare to Cover Liver Transplants for Alcoholic Cirrhosis

Magazine article The Alcoholism Report

Medicare to Cover Liver Transplants for Alcoholic Cirrhosis

Article excerpt

HHS Secretary Louis Sullivan approved a final rule making liver transplants eligible for Medicare reimbursement for alcoholic cirrhosis and six other end-stage liver diseases on grounds the procedure is "safe and effective" under certain conditions and when performed in facilities meeting specified criteria.

In including alcoholic cirrhosis, HHS and its Health Care Financing Administration (HCFA) rejected various arguments against such coverage, including that the condition is a "self-inflicted complication resulting from a chosen lifestyle" and would be a "misallocation of government funds." In its notice of proposed rulemaking last year, HCFA had proposed coverage for transplants for alcoholic cirrhosis, but noted that such coverage "might be considered controversial by some."

In responding to comments on its earlier notice, HCFA declined to specify that there be no required period of abstinence for those diagnosed as having alcoholic cirrhosis. The National Council on Alcoholism and Drug Dependence (NCADD) and the American Society of Addiction Medicine (ASAM) had both opposed setting arbitrary periods of abstinence for alcoholics requiring organ transplantation (AR, August).

HCFA appeared to accommodate NCADD's proposal that decisions about abstinence should be clinical in nature and reside with the transplant team, rather than the hospital and the transplant team as originally proposed. "We believe the transplant surgeon and the rest of the team are best qualified to determine the suitability of a patient to receive a transplant, and this includes making a decision regarding the need for a period of abstinence," HCFA said in response. However, the language of the final rule, published in the April 12 Federal Register, states:

"Although the center should require abstinence at the time of the operation, we do not specify how long the patient should be abstinent prior to the operation. We believe the hospital and the transplant team should establish such guidelines. Facilities will be required to submit, as part of their application, the period of time they require for abstinence in patients with end-stage disease due to alcoholic cirrhosis."

Patients with alcoholic cirrhosis in need of a liver transplant must also show "evidence of sufficient social support to assure assistance in alcohol rehabilitation and in immunosuppressive therapy following the operation," according to the final Guidelines for Patient Selection Criteria. NCADD had objected to this language, on grounds that "it is unclear as to why such a requirement would not be applied to other potential recipients of liver transplants." In addition, NCADD had argued that the term "sufficient social support" was vague and could be "subject to misinterpretation." NCADD joined ASAM in urging that the language be refined to reflect the importance of ongoing participation in a "program of recovery."

At the same time, HCFA disagreed with proposals that hospitals be required to include a physician who is an expert in alcoholism and/or a psychiatrist on the transplant team, explaining: "We have no objection to a hospital including a physician who is an expert in alcoholism or including a psychiatrist but we do not believe it should be required to do so. …

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