Who’s paying the cost of lung transplants for work-related lung diseases?

**Update below (1/30/2016)

A new paper by NIOSH researchers explores the use of lung transplants for individuals with work-related pneumoconiosis, including black lung disease. Using data from the United Network for Organ Sharing (UNOS) for the period 1996-2014, Blackley and colleagues identified 47 lung-transplant cases in which the patient’s primary diagnosis was “coal workers’ pneumoconiosis” or pneumoconiosis unspecified.” Thirty four of the lung transplants (72%) were performed since 2008.

The medical costs for a bilateral lung transplant are substantial. In 2014, the average cost of treatment was $1.04 million for the period covering 30 days prior to the surgery through six months after the transplant surgery.

The authors conclude:

“These transplants reflect the use of a scarce resource for an entirely preventable disease, and highlight the need for enhanced efforts to reduce coal mine dust exposures.”

I couldn't agree more.

One of the things that jumped out to me in the paper were a few sentences about the payers for these 47 lung transplants. The phrase "workers' compensation insurance" is noticeably absent although these surgeries and related costs are clearly for a work-related disease. The authors report that 34 percent (n=16) were paid by private insurance and 30 percent (n=14) were paid by Medicare.

The authors write “other government insurance schemes” paid for 36 percent (n=17) of the lung transplants. I contacted the authors for clarification about this category of payer. They indicated that the dataset identified these other payers as “public insurance” or “US/State Govt Agency.”**

One of these "other government insurance schemes" might be the Federal Black Lung program which is managed by the US Department of Labor. In order for a lung transplant to be covered by the program, however, a coal miner must already have an approved claim. In other words, he must already be enrolled in the program. As we learned in the Pulitzer Prize winning series by the Center for Public Integrity, “Breathless and Burdened,” some mine operators go to extreme measures fighting coal miners’ claims for black lung benefits.

Under Medicare rules, the Federal Black Lung Benefits Program is supposed to be the first payer for any healthcare related to a miner’s black lung disease. NIOSH researchers found however that 30 percent of the lung transplants were paid for by Medicare. It’s not hard for me to imagine why a person with a gravely serious lung disease would prefer the Medicare payment route than the Federal Black Lung Benefits route. (An upside of coverage under the latter is that costs are covered 100%, while under Medicare the miner could have a 20% co-pay.)

Even if a coal miner is already approved for the Federal Black Lung program, he needs special pre-evaluation and approval for a lung transplant. This includes approval by his former employer. The same rigmarole and stumbling blocks the miner faced securing other black lung benefits may likely be even worse when the request is for a costly lung transplant. The Labor Department’s Division of Coal Mine Workers' Compensation (DCMWC) may determine that a lung transplant is medically warranted and the miner meets the other eligibility requirements, but the transplant request may still be challenged by the coal company. In such a case, the Federal Black Lung program would pay the medical bills and then work to recoup the cost from the coal miner’s former employer(s).

"Lung Transplantation Is Increasingly Common Among Patients With Coal Workers’ Pneumoconiosis" makes an important contribution to the literature. I tip my hat to the NIOSH researchers for probing the UNOS data. Who pays for work-related injury and illness is an important policy issue. It's one that's been investigated (e.g., here) and a topic of interest to OSHA's administrator David Michaels, PhD, MPH. These and other analyses indicate there is significant and inappropriate cost-shifting from workers' compensation to other payers, including Medicare, Medicaid, and families. The paper by Blackley and colleagues peeks at that idea, but it is not explored further. An opportunity for them to write a follow-up paper? On my end, I've submitted a FOIA request to the Labor Department for their data on lung transplant cases covered by the Black Lung benefits program.

A lung transplant has a $1 million price tag. Lungs for transplantation are a scarce resource, with more than 1,600 individuals in the US on the waiting list. We've know for decades how to prevent coal-dust related lung diseases---unlike other illnesses for which individuals need lung transplants. This underscores the need for more vigorous efforts to make sure coal miners are protected from respirable coal dust. But coal mine operators are fighting those efforts.

In May 2014, the Mine Safety and Health Administration (MSHA) issued a new regulation to address the problem of coal-dust related lung disease. The rule will take full effect later this year when coal mine operators will have to use continuous personal dust monitors to assess concentrations of respirable dust and to reduce these exposures from 2.0 mg/m3 to 1.5 mg/m3. The National Mining Association, Murray Energy and a slew of other coal companies filed a legal challenge against the rule, and just recently ask the US Court of Appeals for the Eleventh Circuit to halt a provision of the rule set to take effect next month.

I think their money would be better spent on controlling respirable coal mine dust than on lawyers' fees. But if coal companies aren't held accountable for the full cost of black lung disease, including $1 million lung transplants, why would they?

**In response to my FOIA request the Department of Labor's Division of Coal Mine Workers' Compensation reported the following: "We have thoroughly researched our records pursuant to your request and have determined that since 1996 the Federal Black Lung benefits program has approved and authorized payment for seven (7) lung transplants. The lung transplants which were approved and authorized for payment are as follows: 2008 (1); 2009 (1); 2012 (2); 2013 (1); and 2014 (2)."