Medicare Extended to Heart Transplants

Medicare will now begin paying for heart transplants--once a highly risky and experimental procedure--with the designation recently of two medical institutions that meet government standards.

Stanford University Medical Center at Palo Alto and the Medical College of Virginia in Richmond received approval this month as the first Medicare heart transplant centers, nine months after the government announced that heart transplants were being added to the list of reimbursable medical procedures.

Another 15 to 20 medical institutions have applied for designation as transplant facilities, a Medicare spokesman said Thursday.

“These are the first two centers that have been reviewed and have met Medicare’s vigorous criteria,” said Dr. William Roper, director of the Health Care Financing Administration, which runs the Medicare program.

Costs Up to $45,000

Federal officials said they expect the program to pay for 98 heart transplants in the next year. The procedure costs $40,000 to $45,000 each, and Medicare patients’ bills will be paid under the regular claims process.

A transplant will be approved only after all other appropriate medical and surgical therapies have been tried or considered, according to Medicare rules. Patients will be eligible only if they have “a very poor prognosis, such as a less than 25% likelihood of survival for six months without the transplant,” the Health Care Financing Administration said in a statement.

Under Medicare rules, a beneficiary pays $520 for the first day in the hospital, and the government picks up the bill for the next 59 days. Since heart transplant patients usually are discharged in less than two months, patients’ out-of-pocket hospital expenses should be limited to that first-day charge, officials said.

Physician services outside the hospital, including the cost of drugs to prevent tissue rejection of the new heart, will be covered under Part B of the Medicare system. The government pays 80% and the patient 20% of the cost. The patient would be responsible for other costs such as shipment of the donor heart to the transplant center.

Reflects Advancement

The approval of Medicare coverage reflects the advancement of heart transplants from a pioneering, last resort procedure to a commonly accepted one. The first heart transplant was performed in 1967. There have been 3,182 such operations in the United States in the past five years. The insurance industry has been treating the procedure on a routine basis for several years.

In screening hospitals for the Medicare program, which covers 27 million people over age 65 and 3 million disabled persons of all ages, government officials sought institutions “with the necessary experience and expertise to perform this complex surgery successfully,” according to the Health Care Financing Administration.

To qualify, medical centers must have performed at least 12 transplants in each of the past two years and have average survival rates of 73% after one year and 65% after two years.