Kaiser Denied Transplants of Ideally
HMO would not authorize some patients to receive organs from outside
its new program.
Twenty-five Kaiser Permanente
patients in Northern California were denied the chance for new kidneys
that were nearly perfectly matched to them last year during the
troubled start-up of the giant HMO's kidney transplant program in San
Francisco, a Times investigation has found.
missed this opportunity because they were in effect
stranded between two transplant programs.
never properly completed the paperwork to transfer the patients'
cases to its program from UC San Francisco Medical Center, which had
been under contract to care for them until September 2004. At the same
time, Kaiser would not authorize UC San Francisco to continue accepting
kidneys and transplanting them into Kaiser patients, according to
interviews, internal memos and transplant records.
Francisco transplant officials said they asked Kaiser if they
could transplant some of the offered organs and Kaiser representatives
told them no, said Dr. Stephen Tomlanovich, medical director of the
university's renal transplant service. An e-mail from Tomlanovich to a
UC San Francisco colleague in February 2005 confirms his account.
several of these turndowns, Tomlanovich said, UC San Francisco
automatically declined the organs — though no one told the
it was frustrating," he said. "If the offer goes by, the
question is, 'Would they ever get another one?' "
As late as
Wednesday afternoon, Kaiser officials adamantly denied that
they had ever instructed UC San Francisco to turn away such organs.
being confronted with evidence to the contrary by The Times,
the officials called back to say that they could not stand by that
position. One of Kaiser's own kidney specialists had confirmed that he
directed UC San Francisco to turn down at least one of the
near-perfect-match kidneys, they acknowledged.
statement to The Times, that doctor, W. James Chon, said he paged
Kaiser's transplant medical director, Dr. Sharon Inokuchi, when he
received one such offer from UC San Francisco more than a year ago.
"I was told by her that she would not give
permission for this
transplant to take place and was instructed to relay that message to
UCSF," said Chon, who was placed on administrative leave in February
after criticizing the way the program was run.
Inokuchi said through a Kaiser spokeswoman Wednesday that she does not
recall such a conversation with Chon.
The 25 rejected kidneys were offered between January and December 2005,
according to the California Transplant Donor Network, which oversees
the distribution of organs in the San Francisco area.
When matching a donated organ to a patient, transplant specialists look
at six antigens, molecules that help define a person's immune response.
In the organs offered for the Kaiser patients, none of the antigens
These "zero mismatch" organs from cadavers are prized, because they
offer patients a greater chance of long-term survival and minimize the
risk of rejection. They are generally the best possible option in a
transplant, aside from a living donor's kidney. And they allow patients
to get their transplants immediately, no matter where they are on the
But these organs are relatively hard to come by; fewer than one in five
kidney transplants involves one. An offer does not guarantee a
transplant, because other factors, besides antigens, might make the
organ a bad fit. Often, the donors are too old or their organs too
damaged. Even so, the head of the California Transplant Donor Network
called the blanket turndowns "alarming."
"That's really significant," executive director Phyllis Weber said this
She said it would be hard to track what happened to the rejected organs
or the patients to whom they were first offered.
The Times reported Wednesday that Kaiser patients were imperiled by the
massive start-up of the HMO's first kidney transplant program, which
now has a waiting list of more than 2,000. Since Kaiser took over, the
number of transplants has plummeted. Patients have complained of
inexplicable delays. And paperwork snafus have left hundreds of
patients stuck between programs with no hope of receiving a life-saving
The Times could not determine whether any Kaiser patients died as a
direct result of the transition. However, the shift has meant that
hundreds of patients have remained on dialysis, an often grueling
regimen that removes impurities from the blood. Prolonged dialysis can
lead to deadly complications and decrease the chances of a successful
But a Kaiser official said dialysis is
manageable. "It isn't as if
waiting another six months or nine months for a transplant is a death
sentence," said Dr. Sharon Levine, associate executive director of the
Permanente medical group in Northern California. "There are patients
who choose to stay on dialysis rather than going through a transplant."
UC San Francisco struggled internally over how to handle the organ
offers for Kaiser patients left on their list. In one February 2005
e-mail reviewed by The Times, medical director Tomlanovich wrote that
he had spoken with Inokuchi, his Kaiser counterpart, and that she said
"she will not authorize 0-mismatch transplants at UCSF. I think the
best way to handle this issue is to let Kaiser work it out."
Inokuchi told The Times earlier this week that she had never told UC
San Francisco not to perform a transplant.
Transplant experts and bioethicists said the emerging problems at
Kaiser, the nation's largest HMO, are disturbing.
"Something is simply out of whack with the health plan's priorities,"
said Arthur Caplan, director of the University of Pennsylvania Center
Before Kaiser opened its program in 2004, it sent letters to more than
1,500 members receiving care at UC San Francisco and UC Davis,
informing them that they had to move to Kaiser's new center if they
wanted their transplants covered. Kaiser's Northern California region
serves 3.2 million members from Fresno to Sacramento.
The patients had little choice. Kaiser members are part of a unique
healthcare entity that runs both a health plan and a hospital system.
Except in rare circumstances, members get their care only from Kaiser
hospitals and affiliated Permanente medical group doctors.
But the transition did not go as expected. Delays and paperwork errors
by Kaiser left hundreds of patients in limbo.
When patients switch from one transplant program to another, it is
essential they get credit for the time they've already spent waiting.
Otherwise it will appear they are new additions to the list with no
seniority, and their waits will start from scratch. UC San Francisco
continued to receive offers for the Kaiser patients whose waiting time
hadn't been transferred.
The United Network for Organ Sharing, the national group that
coordinates such transfers, said the forms Kaiser submitted to transfer
the time were full of "errors or inconsistencies."
On Wednesday, a top Kaiser official in Northern
California said the
program plans to contact all 2,000 patients on its waiting list in
coming weeks to assuage their concerns. The HMO also vowed to look for
an independent third party to evaluate the transplant program and plans
to disclose the results publicly, said Levine of the Permanente medical
"Our goal is to deliver the highest quality care pre-transplant, during
transplant and post-transplant to our members," she said.
Separately, the state Department of Managed Health Care, which
regulates Kaiser, said it is investigating the HMO's Northern
California operation. In Southern California, Kaiser continues to
contract with outside hospitals to provide transplant care for its
"We want to make sure that the plan is fulfilling its obligations and
make sure that they're sending people to places and treatment centers
where people can get the care," agency spokeswoman Lynne Randolph said.