SUPPORTING FUTURE SURGICAL INNOVATION - LUNG TRANSPLANTATION AS A CASE-STUDY

Objective Using lung transplantation as a case study, this article add ressed the problem of supporting innovative clinical surgery in an era of increasing pressures for cost containment. Summary Background Data After sporadic attempts at lung transplantation during the 1960s and 1970s, its clinical development began in earnest during the early 1980 s. As a result of a wide range of incremental advances, the results ha ve improved significantly. The Health Care Financing Administration, h owever, has not yet issued a national policy covering lung transplants and has left the coverage decision to the discretion of its regional contractors. Methods The authors surveyed the major commercial insurer s, the Blue Cross Blue Shield Association, and a sample of Medicare in termediaries to evaluate the coverage of lung transplantation. They al so interviewed the National Heart, Lung, and Blood Institute and indus trial firms about their support for clinical research. Results Governm ent and industry funding were limited, and the development and assessm ent of lung transplants have been financed predominantly by academic i nstitutions through cross-subsidization from patient care and teaching funds. The major private payers and Blue Cross Blue Shield decided to cover this procedure in the early 1990s. Coverage decisions by Medica re intermediaries, however, revealed considerable variability. Moreove r, the absence of a specific diagnosis-related group for lung transpla nts had considerable consequences for institutions in all-payer states , in which payments appeared to be considerably lower than the mean co sts of a transplant procedure (about $110,000). Conclusions This analy sis indicated that there was a growing disparity between the increasin g demand for outcomes data about new procedures and the limited resour ces available for supporting the development and assessment of new ope rations. If this disparity is not addressed, the rate of surgical inno vation may be jeopardized, and timely outcomes data may not be acquire d. It was concluded that provisional coverage within a predetermined r esearch protocol may be a promising mechanism to remedy this situation , providing timely assessment of new procedures before widespread appl ication.