by Judy Melinek, MD 

Back when I was a medical student I learned a lesson about who was expendable. I was doing research for the liver transplant team at UCLA, one of the largest organ-transplant centers in the U.S., and one of the surgeons gave me an assignment: can you track how sick the patients are before they come to our operating tables for transplant surgery based on what health insurance policy they have?

He had noticed that the patients insured by one particular HMO (health maintenance organization) were arriving sicker than the others. This was easy enough for him to quantify because we had a patient-status grading system. People who were well enough to be waiting at home for the call that their donated liver had been procured were a stage 1. Those who were hospitalized were a 2. Those who needed critical care were a 3, and the people in the ICU on a ventilator fighting for their lives were the stage 4 liver patients. As a student researcher, I kept a spreadsheet on the patients in several clinical studies we were tracking. All I had to do was enter in their insurance data. The surgeon was convinced that the patients enrolled in that one plan were more likely to receive their liver transplant when they were in a more deteriorated state, like stage 3 or 4. We knew well that patients who were more critically ill when the time came for them to receive their transplant were less likely to survive the operation than the stage 1 and 2 patients. The surgeon thought that if we showed the insurance executives the data, their HMO would incentivize their primary care physicians to refer patients sooner, when they were healthier, and so those patients — their paying customers — would enjoy a higher survival rate and overall better outcomes.

We were naive.

I collected the data, and as far as I know the transplant team shared the results with the HMO’s executives. They asked that the HMO change its protocols to make sure they could refer their patients for liver transplantation sooner than they had been doing.