The New Transplant Patient Older, sicker patients are now eligible. ALSO INSIDE: Marrow Matchmaker The Barbershop Project Hand Transplantation PLUS: Minnesota’s Transplant Firsts MINNESOTA MEDICAL ASSOCIATION MAY 2011 MINNESOTA MEDICAL ASSOCIATION MAY 2011 TABLE OF CONTENTS COVER STORY The New Transplant Patient By Kate Ledger Older, sicker patients are becoming eligible for organ transplantation, increasing the need for 24 organs and raising new questions about who should get priority on waiting lists. FEATURE 29 Minnesota Firsts A timeline of transplant milestones. PERSPECTIVE Illustration by Andree Tracey Andree Illustration by 32 The First and Last Days of Medicine Better drugs and protocols have enabled transplant centers to offer transplantation to a wider By Maura Scanlon spectrum of patients. On a busy morning, a doctor stops to ask what a patient really wants—and finds out it isn’t more treatment. CLINICAL & HEALTH AFFAIRS COMMENTARY 40 Hand Transplantation 34 Stem Cell Research in Minnesota: Here By Hatem Amer, M.D., Brian T. Carlsen, M.D., Today, Gone Tomorrow? Jennifer L. Dusso, Brooks S. Edwards, M.D., and Steven L. Moran, M.D. By Meri Firpo, Ph.D., and John Wagner, M.D. A bill moving through the Legislature threatens to 44 Regenerative Medicine: A Reality of disrupt progress on therapies that are already Stem Cell Technology helping patients. By Andre Terzic, M.D., Ph.D., Brooks S. Edwards, M.D., Katherine C. McKee, and Timothy J. Nelson, M.D., Ph.D. 36 Paying for End-Stage Renal Disease Treatment MEDICINE, LAW & POLICY Special Treatment—The Story of Medicare’s 48 The ACO Dilemma: Should We or ESRD Entitlement Shouldn’t We? By Richard A. Rettig, Ph.D. By Todd I. Freeman, J.D. Bundled Payment for ESRD—Including ESAs in Accountable care organizations are being touted Medicare’s Dialysis Package for their potential to make health care more efficient. Physicians, however, should be cautious By John K. Iglehart about joining these new entities. May 2011 • Minnesota Medicine | 1 MAY 2011 TABLE OF CONTENTS PULSE 6-18 minnesota MEDICINE A Network of Networks 2011 MMA Officers Owner and Publisher How organ distribution works. President Minnesota Medical Association Patricia J. Lindholm, M.D. Editor in Chief In His Own Words President-Elect Charles R. Meyer, M.D. Lyle J. Swenson, M.D. Managing Editor Transplant legend John Najarian on his life and Chair, Board of Trustees Carmen Peota David C. Thorson, M.D. Associate Editor work. Secretary/Treasurer Kim Kiser David E. Westgard, M.D. MMA News A Shave, a Haircut—and a Kidney? Speaker of the House Scott Smith Mark Liebow, M.D. Graphic Designers Barbers teach African-American men about organ Vice Speaker of the House Janna Netland Lover donation and the importance of attending to their Robert Moravec, M.D. Michael Start Past President Publications Assistant own health. Benjamin H. Whitten, M.D. Kristin Drews The Matchmaker MMA Chief Executive Officer Advisory Committee Robert K. Meiches, M.D. Zubin Agarwal Headquartered in Minneapolis, the National Maria Carrow MMA Board of Trustees Donald L. Deye, M.D. Marrow Donor Program has become the world’s Northwest District Mark Eggen, M.D. resource for patients needing a marrow, cord blood, Robert A. Koshnick Jr., M.D. Barbara Elliott, Ph.D. Northeast District Jon S. Hallberg, M.D. Neal Holtan, M.D. or peripheral blood transplant. Michael P. Heck, M.D. Peter J. Kernahan, M.D. Paul B. Sanford, M.D. Learning from Experience Robert K. Meiches, M.D. North Central District Gregory Plotnikoff, M.D. Wade T. Swenson, M.D., M.P.H. Martin Stillman, M.D., J.D. The government is exploring bundled billing—a Patrick J. Zook, M.D. Barbara P. Yawn, M.D. practice long used in organ transplantation—as a Twin Cities District Anjali Wilcox Michael B. Ainslie, M.D. Therese Zink, M.D., M.P.H. strategy for reducing health care costs. Beth A. Baker, M.D., M.P.H. Carl E. Burkland, M.D. Copyright & Post Office Entry Commonly Good Care Benjamin W. Chaska, M.D. Minnesota Medicine (ISSN 0026-556X) is V. Stuart Cox III, M.D. published each month by the Minnesota Fairview doctors are working to make early diag- Donald M. Jacobs, M.D. Medical Association, 1300 Godward Roger G. Kathol, M.D. Street NE, Suite 2500, Minneapolis, MN nosis and better management of chronic kidney Charles G. Terzian, M.D. 55413. Copyright 2011. Permission to disease routine and dialysis rare. David C. Thorson, M.D. reproduce editorial material in this maga- Southwest District zine must be obtained from Minnesota Cindy Firkins Smith, M.D. Medicine. Periodicals postage paid at Keith L. Stelter, M.D. Minneapolis, Minnesota, and at addi- Southeast District tional mailing offices. POSTMASTER, send address changes to Minnesota David C. Agerter, M.D. Medicine, 1300 Godward Street, Ste Daniel E. Maddox, M.D. MMA NEWS 21-23 2500, Minneapolis, MN 55413. Gabriel F. Sciallis, M.D. • Physicians Generate Jobs in Minnesota Douglas L. Wood, M.D. Subscriptions At-Large Annual subscription - $45 (U.S.), $80 (all Fatima R. Jiwa, M.B. ChB. international) • Annual Meeting Gets a New Look Resident Maya Babu, M.D. Missing Issues and Back Issues • MMA and TCMS Launch Insurance Agency Missing issues will be replaced for paid Student subscribers at no additional charge if Carolyn T. Bramante notification is received within six months • Meet a Member: Ed Ratner, M.D. of the publication date. Replacement AMA Delegates of any issues more than six months old Raymond G. Christensen, M.D. will be charged the appropriate single Kenneth W. Crabb, M.D. back issue price. Single back issues of ALSO INSIDE Stephen F. Darrow, M.D. Minnesota Medicine can be purchased Anthony C. Jaspers, M.D. for $25 (U.S.) and $30 (Canada, Mexico, 4 . Editor’s Note Sally J. Trippel, M.D., M.P.H. and other international). Send a copy of John M. Van Etta, M.D. your mailing label and orders to Kristin Drews, 1300 Godward Street, Ste 2500, 20 . Viewpoint Minneapolis, MN 55413 or fax it to AMA Alternate Delegates 612/378-3875. John P. Abenstein, M.D., M.S.E.E. 51 . Index of Advertisers Blanton Bessinger, M.D., M.B.A. Maya Babu, M.D. 51 ..................... Employment Opportunities David L. Estrin, M.D. To Advertise Paul C. Matson, M.D. Contact Jocelyn Cox at 58 . MMA Awards Form Benjamin H. Whitten, M.D. 612/623-2880 or [email protected]. 60 .................................. End Notes MMA Alliance To Submit an Article Co-presidents Contact Carmen Peota at Candy Adams [email protected]. Minnesota Medicine is intended to serve as a credible Dianne Fenyk forum for presenting information and ideas affecting The editors reserve the right to Contact Us reject editorial, scientific, or adver- Minnesota physicians and their practices. The content of Minnesota Medicine, 1300 Godward Street, tising material submitted for publica- articles and the opinions expressed in Minnesota Medicine Ste 2500, Minneapolis, MN 55413. Phone: tion in Minnesota Medicine. The 612/378-1875 or 800/DIAL MMA views expressed in this journal do do not represent the official policy of the Minnesota Email: [email protected] not necessarily represent those of Website: www.mnmed.org the Minnesota Medical Association, Medical Association unless this is specified. The its editors, or any of its constituents. publication of an advertisement does not imply MMA endorsement or sponsorship. 2 | Minnesota Medicine • May 2011 editor’s note | Fixes for Failing Organs e’re all searching for a solution miracles. Not only are more organs being to wearing out. Time’s relent- transplanted and more uses for stem cells Wless nipping off of neurons, being found, but more people are “qualify- gelling of joints, and flopping of flesh have ing” for the treatments. In a trend repeated provoked patients to invest in potions, countless times with other medical proce- health club memberships, and facelifts, dures, as physicians get better at doing and have prompted medical science to them, age limits get liberalized and con- seek preventives for organ decline and fixes traindications melt away. More patients for organ failure. getting transplants means more costs, Borrowing from the car repair in- and the upward, unsustainable cost spiral Photo by Scott Walker Scott Photo by dustry’s mantra of “if it’s broke, replace continues. Even dramatic future medical it,” medicine’s answer to organ failure for miracles won’t likely find a government Transplants are 50 years has been transplantation. Those “white knight,” as the dialysis program did expensive, and in five decades have seen startling progress in 1972. in what can be replaced and how well it And money is not the only limited our era of limited works after it is replaced. Yet, with that resource. The supply of donor organs will technological progress have come finan- not likely meet the demand in our lifetime resources ... tough cial and ethical challenges that mirror the even if all current recruitment ideas suc- dilemmas of health care at large in the ceed. So we will be left with tough ethi- questions about United States. cal choices that will get even tougher. As Transplantation medicine’s techno- people live longer, healthier lives, will what we can afford logical strides have been seven-league. there be an upper limit on who gets an Kidney transplants, treacherous treks organ? Will we eventually ration accord- tarnish the hype through perilous rejections and toxic im- ing to chronological or physiological age? about medical munosuppressives during the 1960s, Does everybody have a right to the best are near-routine procedures today, with and latest medicine has to offer, or do we miracles. minimal mortality and impressive survival as a society have to figure out how to say rates.