The U.S. Centers for Medicare and Medicaid Services has allowed 48 heart, liver and lung transplant centers to continue operating despite sometimes glaring and repeated lapses, the newspaper's review found. There are 236 approved centers nationwide.
Although many of the substandard programs treat small numbers of patients, their collective failings carry a significant toll.
FOR THE RECORD:
Organ transplants: A June 29 story in Section A about survival rates at the nation's organ transplant sites incorrectly said that the federal government was the only payer for heart transplants at Hartford Hospital in Connecticut. At least one transplant there last year was covered by a private insurer.
Consider the latest available statistics, for transplants performed between 2002 and 2004. Nine lung programs failed to meet the minimum Medicare standards for survival, number of surgeries or both.
These hospitals accounted for 21 more deaths than would be expected, based on a government-funded analysis of how all patients fare nationwide within a year of surgery. It is adjusted for the condition of the patients and the organs.
Three dozen heart transplant programs didn't meet federal standards for survival or volume. They accounted for 43 more deaths than expected.
Altogether, the programs examined by The Times had 71 more patients die than expected within a year of transplant.
"The bottom line message is that there are too many programs in the United States that need to be shut down," said Dr. Mark L. Barr, a cardiothoracic transplant surgeon at USC and president of the International Society for Heart and Lung Transplantation.
The disclosure of Medicare's failings follows a series of reports in The Times detailing dangerous lapses in oversight of the national transplant system. Three transplant centers in California have closed since September after their problems came to light.
Medicare, which funds most of the nation's transplant centers, requires programs to perform a minimum number of transplants and to achieve a specific survival rate to be certified for funding. The benchmarks vary by organ, and there are none for kidney transplants.
Should the programs later fall short, Medicare rules mandate no sanction, only that the programs turn themselves in.
The agency has the authority to pull certification — and therefore funding — from any center that does not meet its standards. But it rarely does.
It has cut off funding to 11 centers since 2000. In nearly all of those cases, it moved only after the programs had voluntarily ceased operations, according to federal documents reviewed by The Times. In one case, its decertification came eight months after the program shut down.
Only recently, after The Times began asking detailed questions, did the agency step up its scrutiny. In March, it sent letters to all its approved programs, asking for information about their staffing and performance.
It already has found about 25 programs that are "seriously out of compliance" with Medicare standards, said one agency official who spoke on condition of anonymity because the findings are preliminary. Some programs have problems so severe that the agency is considering immediate decertification, the official said. That could force closure.
Some transplant surgeons say Medicare has been too permissive, continuing to support poor-performing programs abandoned by private insurers.
"This is a continued artificial bolstering of the programs that shouldn't exist," Barr said. To decertify such programs, he said, "would have been the natural Darwinian process to occur. The weakest in the herd get weeded out."