State Won’t Pay Hospital for Heart Transplants

The state Medi-Cal program has decided to stop paying for heart transplants at a Northern California hospital, the latest sign of stress in the state’s organ transplantation system.

California health authorities have pulled the certification of Sutter Memorial Hospital in Sacramento, the only heart transplant center serving a region that sprawls from Modesto to Redding, saying it performs too few transplants to maintain its expertise.

The decision means that patients on Medi-Cal, the state’s health insurance program for the poor, probably will have to seek transplants at far busier hospitals in the San Francisco Bay Area. Some consider such travel inconvenient and possibly dangerous to their health.

The Nov. 10 action by the state Department of Health Services marks just the third time in five years that an organ transplantation program has lost its state approval, according to documents obtained by The Times under the state Public Records Act.

Sutter said it would appeal, and in the meantime would try to keep the program running. That could prove difficult, however, because private insurers tend to follow the government’s lead.

At least two insurers had already dropped coverage for the program, opting to send patients to the Bay Area, about 90 miles away, because of the low number of transplants performed at Sutter.

The decertification follows scandals at two Southern California liver transplant programs. St. Vincent Medical Center and UCI Medical Center recently announced their closure following allegations of wrongdoing. No such claims have been made against Sutter. UCI, however, lost its state certification two years ago in part for performing too few liver transplants.

At Sutter, it was a simple case of numbers. Sutter performed just five transplants in each of the last three complete years, well below the state requirement of nine per year. Only three have been done so far this year.

Hospital officials had kept state regulators at bay since 2003 with promises that the numbers would improve. They also argued that the Sacramento area needed its own heart transplant center and that patient survival rates were at least as good as those at larger transplant centers in the state.

“If I thought we weren’t doing a good job from a quality standpoint, I wouldn’t be here talking to you,” said Dr. John Chin, medical director of Sutter’s heart transplant program.

Indeed, 90% of patients who received transplants from July 2001 to December 2003 were alive one year after surgery, according to data kept by the Scientific Registry of Transplant Recipients. That is about the rate expected for a program like Sutter’s.

But that success comes, in part, because small transplant programs, like that at Sutter, often disqualify the sickest patients, said Dr. Michael Acker, chief of cardiothoracic surgery at the University of Pennsylvania.

Since 2001, none of the 21 transplant recipients at Sutter were classified as the most severe status, according to data kept by the United Network for Organ Sharing, which oversees the national transplant system. By comparison, 42 of the 77 recipients at UCLA last year had the highest status.

“They’re cherry-picking,” Acker said of Sutter. “How many patients never get listed because of their very specific approach?”

Chin acknowledged that the sickest patients are often sent to San Francisco but said the hospital was considering ways to treat them there.

All told, the 11 adult heart transplant programs in California performed 268 transplants last year and 196 so far this year. The two largest centers are UCLA and Stanford University Medical Center.

Currently, six patients are on the waiting list at Sutter -- three men and three women. Three have been waiting less than three months for a heart.

Margaret Mette, the hospital’s assistant administrator, said the state’s decision affects one patient already on the list -- and another who was expecting to join the list within weeks.

Eugene Wilson, 19, suffered heart damage last spring when he contracted a virus while participating in the Job Corps in Sacramento, said his mother, Onika Jackson.

Because Wilson is on Medi-Cal, he will have to find another hospital in which to receive a transplant. But Jackson said she hopes state officials will change their mind because travel to the Bay Area would be extremely inconvenient and expensive.

“What about the people who cannot commute back and forth like that?” Jackson asked. “Are they going to pay for a car? Are they going to pay for us to go back and forth to doctors’ appointments in the Bay Area? I don’t have the funds.”

The hospital still receives reimbursement from Medicare and several insurers, including Health Net and Blue Shield of California. But that could change.

Tom Epstein, a spokesman for Blue Shield, said the insurer requires hospitals to report the loss of government funding, and such an action would be reviewed to determine if the health plan’s patients should be moved.

Federal standards governing Medicare reimbursement are even more stringent than those of Medi-Cal. Medicare requires hospitals to perform 12 heart transplants a year to remain certified.

It is unclear why Medicare has not taken action against Sutter. Federal health officials could not be reached for comment.

In recent years, at least two insurers have dropped coverage for heart transplants at Sutter.

Blue Cross of California stopped in August 2003.

“If you have a low volume [of patients], you can see how a surgeon would lose expertise pretty quickly,” said Dr. Jeff Kamil, the chief medical officer.

PacifiCare ended its coverage in January. “There are many other alternatives with established programs throughout California, including Northern California, where they have large numbers, positive outcomes and good patient experiences,” said Dr. Sam Ho, executive vice president and chief medical officer for PacifiCare Health Systems.

Opened in 1989, Sutter’s heart program performed its 100th transplant in April.

It is planning a reunion for its transplant patients early next month.