Law jeopardizes transplants for foreigners, hospitals' fees.

Congress may soon ban foreign transplant patients from receiving scarce donated U.S. organs, a move that could impact local hospitals that increasingly market abroad for wealthy patient referrals.

The House Subcommittee on Health and Environment this month approved a measure that will require organ transplant centers to place non-U.S. residents on a second, lower-priority waiting list. Only after the main list is exhausted could an organ be offered to a foreigner.

Part of the reauthorization bill for the National Organ Transplant Act, the legislation would effectively close the door on foreign patients who come here for life-saving transplants since there are not enough organs now to meet the needs of U.S. residents.

Current policy allows the nation's 811 transplant programs to perform up to 10 percent of donated organ transplants on non-U.S. residents. Congress is expected to pass the reauthorization bill before the end of the summer.

Though the portion of transplants performed on non-U.S. residents last year was miniscule -- between 1 percent and 4 percent for various types of donated organs -- the issue has become a charged one as the nation's organ transplant waiting list grows.

31,000 On Waiting List

There are now some 31,000 people in the United States waiting for donated organs, according to the United Network for Organ Sharing (UNOS), which runs the nation's organ-sharing system under federal contract. Last year, there were about 25,000 on the waiting list, of which about 14,000 received organ transplants. Of that 14,000, about 400 were either non-U.S. residents or foreigners of "undeterminable" residency, according to UNOS statistics.

"Foreign patient transplants may seem a small number, but it is a very significant one for those families whose loved ones die waiting for an organ," said a spokesman for the House subcommittee, who asked not to be identified.

Yet some local transplant programs argue that eliminating the 10 percent foreign-transplant patient limit could pose a financial hardship on hospitals -- and on poor U.S. patients whose transplants are, to some extent, underwritten by cash-paying foreign transplant patients.

Scripps Health and Sharp HealthCare, entities that operate two of San Diego's three certified transplant programs, are aggressively seeking foreign patient referrals for pricey procedures such as bypass surgery and organ transplants.

Scripps Health has a pending agreement to develop and manage a community hospital in the Mexican city of Aquascalientes, and part of the benefit of the contract will be foreign patient referral to Scripps hospitals.

Sharp HealthCare and Childrens Hospital jointly fund a business development entity called International Services (IS), which provides extensive free consulting and development services to physicians and hospitals in Mexico, Micronesia, Japan and Hong Kong in return for foreign patient referral.

The Commonwealth of the Northern Mariana Islands signed a patient-referral contract with IS last year, and another is being negotiated with the Marshall Islands. Sharp HealthCare expects to reap $10 million in hospital revenues alone from patient referrals that flow through IS.

Cash Customers

Sharp HealthCare officials note that all four of the U.S. donor organ transplants it has performed on foreign patients since 1990 were cash customers.

"You may get someone who is a full cash-paying patient, and that patient allows the hospital to perform transplants on other patients whom the hospital would otherwise lose money on," said Dr. Auturo Martinez, a transplant surgeon with Sharp Memorial Hospital and a member of UNOS' foreign relations committee.

"One full cash-paying patient will allow you to do four additional Medicaid patients," said Martinez. "It (foreign patient transplants) is an important capital source that allows you to take care of your own population. We take a loss on some and regain it on others."

The House subcommittee spokesman said such financial "trade offs" only serve to undermine the credibility of the U.S. transplant program.

"Too many hospitals regard foreign transplant patients as a cash cow," he said. "To perform a transplant on a foreign patient because they are wealthy enough to pay for it denies a chance to a U.S. citizen. Ask the families who have lost someone who was waiting for an organ if they are willing to make that trade off."

Debate Not New

The debate is not a new one, local transplant program experts note. In years past, some U.S. hospitals aggressively marketed transplant programs in foreign countries, in some cases promising preferential treatment for cash-paying patients. As a result, the 10 percent limit on transplants for non-U.S. residents was imposed in 1986.

"This new legislation is the result of transplant centers that got into the business of bringing in wealthy people from outside the U.S. who use U.S. resources," said Dr. Nicholas Halasz, director of the kidney transplant program at UCSD Medical Center. "Organs are a national resource.

"We have more than 30,000 people waiting for organs in this country, and something like one-quarter to one-third of them die while waiting," said Halasz. "I hate to be nationalistic, but there is something to the idea that donated organs in this country should go to people in this country."

San Diego's three transplant programs last year performed a total of four transplants on foreign patients using donated U.S. organs.

Green Hospital of Scripps Clinic performed 15 liver transplants last year, one of them on a Mexican national. This year, Green performed 16 transplants, one of them on a Mexican national.

Sharp Memorial Hospital performed 73 organ transplants last year, one of them on a Japanese national. This month, Sharp performed a kidney transplant on a citizen of Saudi Arabia.

The UCSD Medical Center performed 110 organ transplants last year, two of them on foreign patients. This year it performed one heart transplant on a non-U.S. resident.

Makes Compliance Mandatory

In addition to eliminating the 10 percent foreign patient transplant limit, the proposed reauthorization bill would force transplant programs to comply with UNOS bylaws and policies. At present, compliance is voluntary.

For instance, there were at least four transplant programs last year that exceeded the 10 percent limit on foreign patient transplants. UNOS has no power to punish or remove a transplant program from the network, though it can refer offenders to the U.S. Department of Health and Human Services, which can impose penalties. UNOS has never referred a program to federal authorities.

The bill would also force UNOS to increase the number of transplant recipients and donor family members serving on its board to at least one-third of its membership. UNOS board membership has been criticized for relying too heavily on transplant professionals who have a financial stake in its policies.

UNOS officials said they have a high rate of policy compliance through peer pressure, despite a lack of regulatory power. However, there are indications that some transplant programs regularly cross ethical lines when it comes to organ allocation and procurement.

A General Accounting Office study released in April found that a majority of organ banks serving more than one transplant program allocated some organs by hospital, not by patient. Another recent study by the Mayo Clinic questioned the wide variation in the prices hospitals and organ banks charge for procurement.

Last year, an UNOS audit of liver transplants showed a 15 to 20 percent rate of non-compliance with UNOS policies. In most cases, transplant programs listed patients as more critical than they apparently were, allowing them to move to the head of the transplant list.

The recent case of Pennsylvania Gov. Robert Casey, who shot to the front of the waiting list at the University of Pittsburgh Medical Center for a heart and liver transplant, also raised questions of preferential treatment. UNOS is preparing a report on the incident for the Department of Health and Human Services.

The proposed reauthorization bill will increase compliance among transplant programs in the nation's organ-sharing network and restore some its lost credibility, said the House subcommittee spokesman.

"The need for organs is increasing, but organ donation is static," he said. "The system works only when the public has faith in the equity of organ allocation."