In 1995, New York Yankee Hall of Fame baseball player, Mickey Mantle, lost his battle with cancer even though he received a liver transplant. While this might sound like discouraging news, the fact is that more than 27,000 solid organ transplants procedures are performed in the U.S. every year -- the majority with positive outcomes, according to the United Network of Organ Sharing (UNOS). And with science, medical technology and treatment protocols dramatically improving, over the years, a transplant recipient, depending on the type of transplant performed, has a better than 90 percent chance of survival. *

As the number of organ and bone marrow transplants steadily increase, managed care organizations and employers are considering ways to supplement health plans in order to minimize the financial impact of these expensive medical procedures while maximizing patient outcomes. Additional emphasis should also be placed on the quality of care, access to a network of qualified transplantation institutions, pre- and post-transplantation care (including how the patient's family is cared for), and finally, who will pay the catastrophic costs associated with organ transplantation?

Over the last ten years, there has been a slow movement to "carve out" transplant programs. The carved-out programs are usually designed to absorb the high cost health care treatments in high risk areas such as organ transplantation, neonatology, oncology, burn and cardiac care. The financial risk often associated with those treatments is transferred to a third party, typically an insurance provider. While the development of carve-out programs has been slow in neonatology, oncology, burns and cardiac care, development has been more rapid in the field of organ transplantation.

The precursor to a fully insured "carve-out" transplant program began in the early 1980s. The centers of excellence concept as it was called, analyzed performance statistics at transplant centers around the country and identified which centers had good patient outcomes. Employer groups and managed care organizations would then send their employees to the better centers and the underlying or sponsoring network would collect a small fee. This served as a key foundation in the development of carve-out programs like that offered by Zurich, one of the earliest carve-out transplant programs in the industry. A comprehensive transplant insurance program provides for quality patient outcomes and protects important employer group and managed care plan assets. A carved-out transplant program should include:

• First dollar coverage for all transplant related costs prior to transplantation through recovery---up to one year
  
• Payment for the cost of immunosuppressant drugs
  
• Access to a quality network of transplantation facilities
  
• Case management services
  
• Universal coverage for all employees thereby helping to mitigate employer liability
  
• Medical decision support
  
• Clinical/financial reporting

As Mickey Mantle's story proved, there are no guarantees in organ transplantation. But as public awareness increases, medical technologies improve and new medicines continue to develop, the one sure thing is that organ transplant frequency will increase. This will not only affect employees as patients, but the companies that sponsor and pay for healthcare in the United States.

* Kaplan-Meier Survival Rates
UNOS – June 21, 2005