Measuring out medicine (book excerpt: The Surgeons: Life and Death in a Top Heart Center)

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While the match is made by a computer, the decision whether someone actually gets on a list, and his medical urgency classification, is made by local transplant committees. At Columbia-Presbyterian, the adult transplant coordinating committee meets every Friday morning, chaired jointly by Yoshifumi Naka [MD, PhD], the transplant surgery program director and Donna Mancini [MD], a professor of medicine and director of the Center for Advanced Cardiac Care, who oversees transplant cardiology. There are usually about 30 people around the table -- transplant cardiologists, social workers, psychiatrists, infection specialists, neurologists, surgeons, transplant nurses and others. Most of the cardiologists are from Mancini's section, but very occasionally an outside cardiologist may attend as well, to help advocate a listing for one of his patients.

Committee meetings open with a review of the current waiting list, followed by an intense case review of recent transplants. Few patients are ever the focus of so much concentrated medical brainpower. Transplant X has an intestinal infection: is that resolving itself or are we overdoing the immunosuppressants? Transplant Y is refusing to get out of bed: is she depressed? The psychiatrists will follow up. Here are Transplant Z's blood chemistries, and last week's trends: what does the group think? The lavishness of the resources partly reflects the value of the sunk investment. It's not just money -- although at $200,000 to $300,000 per patient, transplants are stunningly expensive. The "most precious resource of all," in Naka's words, is the donated heart, which is quite literally priceless. An early death of a transplant patient is therefore uniquely tragic -- not only has a patient died, but a rare gift has been wasted, a donor's good intentions flouted, and another patient who might have been more suitable may now die as well.

Finally, the meeting focuses on new candidates for listing -- there were two or three at each of the meetings. The twin questions were: Should this person be listed for a transplant? And what urgency level should she be assigned? The medical criteria seemed the easiest to apply. People are disqualified for transplants if they're "too sick or too well," in Naka's words. The "too sick" hurdle is quite a high one -- a presentation at one committee involved a patient with both heart failure and renal failure. He had received his new heart the previous night and was scheduled for a new kidney that afternoon. He was doing fine.

The hardest discussions involved a candidate's psychosocial status. Put baldly, the question was: can this patient be trusted with a new heart? Substance abusers -- drug addicts, alcoholics, smokers -- were automatically out. Obesity was another disqualifier, although the threshold is high -- a person five and a half feet tall would have to weigh over 216 pounds to be denied listing. Getting off the drugs or losing weight, however, could move a patient onto the list, but the committee had to be convinced that the patient would stick with it. (I sat in on a review, at another committee, of a lung transplant case involving a former polysubstance abuser. He had suffered an overdose of fentanyl, the powerful opioid used in surgery. The hospital had dosed him correctly, but his parents were smuggling in "fentanyl lollipops." And then there was the heart transplant patient caught hiding bags of Cheetos in his intensive care bed).

Discussions focused hard on evidence of personal discipline. In one case, a cardiologist blurted out in exasperation about a candidate, "He has lousy teeth. He won't go to the dentist!" He was not listed. Not having health insurance is usually disqualifying. "It's not that the hospital won't get paid for the surgery," Naka said, "but a patient without insurance won't maintain his medications or his follow-up program." (I believed him on the payment question: Columbia-Presbyterian performs a lot of uninsured surgery, and an outside cardiologist told me he'd sent them seven Medicaid transplant patients within the past two years, all guaranteed money-losers).

There is an uncomfortable edge of class bias in those decision criteria, even though surgeons tell you that they don't make moral judgments on their patients. Mehmet Oz [MD] told me a story from his days as a Columbia surgical resident. He was a superb ER surgeon, and so naturally fell into the triage role. This was the high-crime "Fort Apache" era in New York City, when ERs were overwhelmed, and it was up to Oz to decide who got cared for and in what order. One night the police brought in three shooting victims. "There was a dead cop," Oz said. "Next to him was the shooter, who was in critical condition, and then there was a pregnant woman who was caught in the cross fire. She was badly hurt but stable. I saw the three of them and realized that I wanted the shooter to die. At the same time, the staff are looking at me to decide -- this all took seconds. And I pointed at the shooter. He's next. We can't help the cop, and the woman's stable, so we save the shooter. The next day," Oz went on, "the police discovered that the woman was the shooter -- she was running a drug den -- and the man was just some guy walking by. That case had a profound effect on me. We can't make judgments about who deserves to live."

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This next excerpt looks at technological advances and health care costs.

Few people seem to realize what a dynamic sector of the American economy health care has become. Companies like GE Healthcare (imaging, diagnostics, pharmaceutical manufacturing systems, patient monitoring systems, 45,000 employees, $15 billion in sales) are world leaders. Health care is an important driver of advances in electronics and biotechnology, is not especially susceptible to outsourcing, and is a positive offset to America's international fiscal deficits. It is also a generally good employer that pays above-average wages. The perfusionists at Columbia-Presbyterian are just one example of the burgeoning new professional and semiprofessional careers in health care, which include physicians' and surgeons' assistants, many varieties of imaging technicians, inhalation therapists, physical therapists, nurse-anesthetists, dental hygienists, and many, many more. One sign of the times: Some of the deepest coverage of the late-2006 flap over possible complications from drug-eluting stents was in the business press rather than the science and health sections.

Despite the lamentations over "rising health care costs," procedure by procedure, technological advances are generally reducing costs, often by quite striking amounts, while bringing very large benefits in terms of extended, active, life spans. The very sharp drop in the death rate from heart attacks, for example, is substantially attributable to improvements in the technology of cardiac interventions. Modern pharmaceuticals are making major inroads in the treatment of depression, hypertension, diabetes, arthritis, and other chronic diseases, as well as steady advances against cancer. Surgical interventions to remove cataracts, or to replace hips, knees, or eye and ear parts, help people stay active and live longer. At the same time, laparoscopic and other microsurgical techniques make interventions cheaper, quicker, safer, and shorten recovery times. MRIs have replaced older invasive, often dangerous, diagnostic procedures, while advanced PET- and CAT-scanning systems facilitate far more informed interventions against cancers and heart and brain disease.

Just as in other markets, however, better, cheaper health care products almost always increase total spending. Most gallbladder surgery, for example, is now performed on an outpatient basis: It's cheaper, requires minimal incisions, and gets you back to work sooner. Doctors are therefore more apt to recommend it, so total gallbladder spending is now higher than with the old, "expensive," full-surgery, inpatient methods. That same cycle whereby lower prices and better results increase spending can be seen in a long list of other standard therapies -- cataract surgery is now a simple outpatient procedure that costs a fraction of what it used to, so millions of Americans have had it. Hip operations are surer, safer, with rapidly improving recovery times, so they are almost a rite de passage for senior golfers. LVADs and other heart-assist devices will soon be moving along a similar path.

The hard truth about health care is that death is usually the lowest-cost outcome. Twenty years or so ago, people in their 70s and above were considered too old for heart surgery; now they make up most of the patients, with very high success rates. Similarly, the raw number of annual deaths from cancer has been falling in the United States, even as the vulnerable population increases apace. But every victory that health care wins over traditional killers like heart disease and cancer preserves its best customers, and leads to years of more spending. The quickest way to reduce future Medicare costs would be to induce a lot more Americans to take up heavy smoking.