Mike Rees and reverse transplant tourism in the Toledo Blade

REVERSE-TRANSPLANT TOURISM: Kidney doctor pairs foreign, U.S. recipients
UTMC surgeon says program will save money in long run

Published: Sunday, 2/8/2015 

BY MARLENE HARRIS-TAYLOR
BLADE STAFF WRITER

image: http://www.toledoblade.com/image/2015/02/07/300x_b1_z/08n1rees-8.jpg

Dr. Michael A. Rees helped a man from the Philippines who could not afford a transplant get a new kidney from an American donor.
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Dr. Michael Rees, a University of Toledo Medical Center kidney transplant surgeon, has spent more than a decade developing ways to increase the number and quality of kidney transplants in the United States through a program he founded, the Alliance for Paired Donation.

Now Dr. Rees, who is also a professor of urology and pathology at the former Medical College of Ohio, is taking his expertise to focus on finding people in developing countries who don’t have the financial means for transplants, while increasing the number of kidneys available for U.S. patients.

Dr. Rees calls his new program reverse-transplant tourism.

A husband and wife from the Philippines, Jose and Kristine Mamaril, are the first participants to benefit from this innovative system that allowed Mr. Mamaril to receive a life-saving transplant in Toledo from an American donor in Georgia. His wife, who has a coveted blood type, reciprocated by donating a kidney to a man in Minnesota who previously would have had to wait years for a match.

According to the website Kidneylink, the average wait for people who need transplants and lack matching donors from their families varies between three and five years.

“In rich countries there’s not enough kidneys for people who have kidney failure, but there is plenty of money to pay for all the transplants. In poor countries, there’s lots of people that need kidney transplants and lots of available donors, but in poor countries they don’t have enough money,” Dr. Rees said.

This new program breaks down some of those barriers and helps bring people with the universal Type O blood into the U.S donor system, while helping someone from another country get access to free medical care.

One year of a kidney patient’s dialysis costs Medicare about $90,000, or nearly triple the $33,000 cost of a kidney transplant, Dr. Rees said. He argues his donor-matching system will ultimately save the federal government and private insurers money because it moves patients with kidney failure, also known as end-stage renal disease, off dialysis sooner.

“It is what health-care reform is all about. It increases access, so now poor people are getting access to transplantation. It reduces the cost of care and it improves the quality of care because a transplant’s a lot better than dialysis. The average person who gets a kidney transplant lives 10 years longer than if the same person had they remained on dialysis,” Dr. Rees said.

‘A miracle’

Mr. Mamaril, 31, had nearly given up hope of ever being able to afford a kidney transplant at home in San Pablo, in the Philippines’ Laguna province. He told his wife they could afford neither the transplant nor dialysis and tried to persuade her to give up on him and save their meager money to take care of their 8-year-old son.

The Mamarils are not poor by Philippine standards. Both college-educated, she is an accountant for Dunkin’ Donuts in Laguna while Mr. Mamaril had been operating a taxi business that transports passengers using motorcycles with trailers.

Everything changed for the family when he began to feel weak and dizzy in October, 2013 — a symptom of his kidneys failing. By the following January he started dialysis, but the couple had to borrow money from relatives to pay for it.

Mr. Mamaril, often speaking through an interpreter, said he worried constantly about how to pay for his expensive medical care. Dialysis or a transplant cost 10 times the family’s income, Dr. Rees said, and the Philippines has no public health system to help pay for transplants.

image: http://www.toledoblade.com/image/2015/02/07/300x_b1_z/08n1kidney-5.jpg

Jose Mamaril received a kidney from a donor in Georgia through the ‘reverse transplant tourism’ program. In return, his wife, Kristine, donated one of her kidneys, which did not match her husband, to a recipient in Minnesota.
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Mr. Mamaril sold his taxi, and he and his wife sold every piece of furniture in their home. His wife took her bank card to a pawn shop and agreed to have her future wages garnished to get money for his care. But it still wasn’t enough.

“They never gave up on me,” he said.

During one of his hospital visits Mr. Mamaril, who is Catholic, called out to God: “I’m going to go with you now.”

The only thing that kept him going was the thought that “my son needs me,” he said.

Then fate intervened.

Mr. Mamaril calls it a miracle. The doctor who had been treating him at the hospital in Manila, Dr. Siegfried Paloyo, had worked for a short time in the United States, where he met and befriended an associates of Dr. Rees. The mutual friend brought together the two kidney surgeons who were thousands of miles apart in different countries.

Finding right fit

Dr. Rees had developed the idea for his reverse-tourism transplant program, but he needed to find a developing country that had a medical structure in place to support ongoing care for kidney patients.

“The transplant infrastructure in the Philippines was well-developed and Don was an excellent doctor,” Dr. Rees said.

Dr. Rees asked Dr. Paloyo to find a couple who were struggling financially and whose kidney donor would have Type O blood, the universal-donor type that can be received by nearly anyone. He also preferred a kidney patient with Type A blood, because that person would match about 85 percent of the U.S. population.

Jose and Kristine Mamaril fit the description perfectly.

Dr. Rees raised $150,000 from private Toledo donors and invited the couple to come to UTMC to be his program’s first participants, but getting all the pieces in place for the exchange took several tries. After five different attempts to match Mr. Mamaril with an American donor, the couple finally arrived in Toledo on Dec. 3.

Mrs. Mamaril said there were several times during this harrowing ordeal that she thought, “This will never happen.”

Mr. Mamaril said his faith helped him get through the months of medical procedures, having his hopes dashed when donors didn’t match, and watching his family fall into abject poverty.

At 7:30 a.m. on Jan. 6, the three-way kidney exchange began. Mrs. Mamaril’s donor kidney was removed and sent to Minnesota. The kidney intended for Mr. Mamaril was removed from the man in Georgia and flown to Toledo.

By 4 p.m., Mr. Mamaril was in surgery receiving his new kidney. Sitting in a UTMC conference room two weeks later, he said he felt great.

“I’m so happy I get my new kidney. I still believe in God,“ he said.

Mr. Mamaril also had an opportunity to talk with his kidney donor via a video conference call between Toledo and Georgia.

“He said, ‘Thank you and I love you,’ ” Mrs. Mamaril said speaking for her husband.

Dr. Rees said he now has an even larger task ahead in trying to create a system where his reverse-transplant tourism program is sustainable.

He is working to convince private insurance companies this program will help more Americans get kidneys and save them money in the long term.

“The critical piece in all of this is I don’t yet have a commercial insurance industry who has agreed to give me $150,000 to do the next one. I have six commercial insurance companies who are interested, but this remains a simple act of charity until it becomes sustainable because the insurance industry recognized the value of the concept,” Dr. Rees said

Read more at http://www.toledoblade.com/Medical/2015/02/08/Kidney-doctor-pairs-foreign-U-S-recipients.html#sZwHDp26aqLsVF4F.99

An economist's perspective on transplantation--in Transplantation (the journal)

I have a paper in the latest issue of the journal Transplantation, discussing some approaches to current challenges facing transplantation.

I discuss ways to extend kidney exchange by initiating nondirected donor chains with some deceased donor organs, and by developing  international kidney exchange (along the lines of what Mike Rees calls  reverse transplant tourism). Reducing barriers to participation by transplant centers would also help (e.g removing financial barriers with some kind of standard acquisition fee) and removing barriers for enrolling easy to match pairs, including compatible pairs.  I also discuss ways to increase deceased donor registration, including priorities for donors, and providing other kinds of incentive for donation.

Roth, Alvin E., “Transplantation: One Economist’s Perspective,” Transplantation, February 2015, 99, 2, 261–264

(this link will only get you to the first page; )

Here are some relevant passages from the rest of the paper:

"Extending the reach of kidney exchange

"One way to make kidney exchange accessible to more patients would be to simplify participation. Developing a standard acquisition charge for living donor kidneys  would remove some barriers that arise e.g. from different costs of nephrectomies at hospitals that may need to ship each other kidneys. And matching algorithms could be adjusted to guarantee hospitals that they and their patients won’t lose transplants or sacrifice patient care if they enroll all pairs in exchange (and not just hard-to-match pairs).17 Enrolling easy-to-match pairs, including compatible pairs, can be organized to help those pairs find better matches, and also makes it much easier to find matches for hard-to-match pairs.9, ,  Incentives for transplant centers to enroll their non-directed donors are already being implemented (a chain typically is terminated with a patient on the waiting list of a center that enrolled a non-directed donor).

"Another way to accomplish more transplants through exchange would be to allow some non-directed donor chains to be initiated with deceased donor kidneys1 which, properly organized, could facilitate more transplants and shorten the wait for deceased donor kidneys for all patients.

"Kidney exchange in the developed world could also be extended to patient-donor pairs from countries in which treatment for ESRD is essentially unavailable for large parts of the population.  Such patient-donor pairs could, for example, be invited to come to the U.S. to participate in kidney exchange , financed by the American taxpayer from the savings that result from removing an American from dialysis through receiving a transplant, which are more than sufficient to finance the additional surgeries.  (The bureaucratic obstacles to such exchanges and financial arrangements will be formidable, but the potential to aid both domestic and foreign patients is substantial.)

How else to increase donation?

"There remain many avenues other than kidney exchange through which the shortage of transplantable organs might be reduced.

"In the U.S., the scope for recovering many more transplantable organs from deceased donors seems somewhat limited for most organs, given current technology and recovery rates. But there is suggestive evidence that more frequent opportunities to register as a deceased donor would increase registration, and that the manner in which registration is solicited can influence rates of family consent for donation.

"There is growing consensus that donors should not face financial disincentives from donating, ,  and recent evidence that the costs borne by living donors are substantial enough to reduce donation in recessions. ,  There is consequently great interest in exploring ways to remove disincentives or provide inducements for donation.

"Several novel features of recent Israeli legislation are worth study.  Deceased donation is encouraged by giving registered donors and next-of-kin of deceased donors some priority to receive deceased donor organs. Living kidney donors are also reimbursed 40 days wages, at their own wage rate, to offset the costs of donation. Initial indications are that the new Israeli law is increasing donation.

"The most contentious part of the discussion of how to increase donation concerns cash compensation to donors, particularly living kidney donors. With the prominent exception of Iran, which specifically permits cash payments for kidneys , there does not appear to be a legal market for the purchase and sale of organs for transplant anywhere else, although illegal black markets are widely reported, and occasionally prosecuted.

"However the critical shortage of transplantable organs around the world prompts continual discussion of whether to relax the ban on cash compensation. For example, the March 2014 issue of the Journal of Medical Ethics devoted five articles to the subject, all by philosophers. While this discussion is too important to be left only to philosophers, neither can it be confined to the ongoing debate among transplant professionals, given the public resources devoted to transplantation and the important implications transplantation has for health policy.

"The arguments, pro and con, will already be largely familiar to those who follow this debate.  I will simply try to add some context to the discussion by noting that the ban on organ sales is not unique: other kinds of markets have also been banned in the past, and presently, and laws have changed over time.

"Of course, banning markets does not always end them: black markets for narcotics make clear that outlawing markets is simpler than abolishing them. In the United States, the manufacture and sale of alcoholic beverages was illegal from 1920 to 1933, during which time black markets for alcohol thrived. Less familiarly, an 1824 editorial in The Lancet comments on the black market in which medical schools bought cadavers for dissection from grave robbers, known as “resurrection men,” because the only cadavers that could legally be dissected were from executed murderers.  (The Anatomy Act of 1832 expanded the sources of legal cadavers for dissection in Britain.)

"Let’s call a transaction repugnant if some people want to engage in it, and others, who aren’t materially affected, don’t think they should be allowed to .

"By this definition, sales of kidneys are widely repugnant, as are (or were) the sale of narcotics, alcohol, and cadavers. But note that the ban on kidney sales is different from these other bans, since there is, or was, general disapproval of narcotics, alcohol, and dissection. But there is no similar disapproval of kidney donation and transplantation; it is only sales that are repugnant.

"This turns out not to be too unusual: a transaction that is not otherwise repugnant sometimes becomes so when money is added to the mix. For example, charging interest on loans was largely banned in medieval Europe, although loans were permitted. (The relaxation of that ban has had profound effects on the modern economy.)  Note that repugnance doesn’t only change in one direction—some transactions that used not to be repugnant are widely banned today. Indentured servitude, for example, is no longer legal in the U.S., although it was once a common way of purchasing passage across the Atlantic.41

"Some transactions are banned in some places and not others, e.g. those concerning sale of blood and blood products, and reproductive goods and services such as sperm, eggs, and surrogacy. Legal markets in some places and not others give rise to “fertility tourism,” and many countries that ban payment for blood plasma import plasma products from the U.S., where such payments are legal.

"The repugnance to kidney sales involves concerns about the identity and welfare of potential sellers. The same concerns cause many proposals for allowing some forms of compensation to address the need to avoid exploiting the poor and vulnerable, as existing black markets for kidneys are widely seen to do.  The debate on how to proceed seems likely to focus on removing disincentives to donate and providing incentives that are not seen as leading to coercive or exploitative situations. The debate can be furthered by identifying specific sources of repugnance, and considering how inducements could be structured to avoid them. , ,

"In the meantime, kidney exchange has proved to be a way of bringing some of the benefits of exchange to transplantation without running into the barrier of repugnance. So it seems promising to consider ways of extending its reach, as discussed above."

Mike Rees launches "Reverse transplant tourism" at the Alliance for Paired Donation

Philippine couple receives first operation in Reverse Transplant Tourism

NBC videos: https://www.youtube.com/watch?v=f1ZA3uQslFc 

"TOLEDO -- A couple from the Philippines is preparing to return to their country after undergoing life-saving transplant surgery here in Toledo.

They have been through an amazing journey so far. But the biggest accomplishment from their ordeal may be yet to come, and may benefit thousands of people around the world.

Jose is undergoing one of his last dialysis treatments before his kidney transplant. He is the first organ recipient in a pioneering program developed by University of Toledo Medical Center surgeon Dr. Mike Rees.

Being the first person to benefit from Revese Transplant Tourism, Jose is almost the ultimate lottery winner. "This has never happened before," said Dr. Rees. "And through a series of chance encounters, he’ll be the first to benefit from this."

Those encounters all began in the city of San Pablo, in the Philippines. In October, 2013, Jose’s kidneys began to fail. Dialysis or transplantation would cost ten times Jose’s income as a debt collector combined with that of his wife, Kristine, an accountant.

Jose was ready to stop treatments and resign himself to death. But his son, eight-year-old John, insisted he hold on.

“He asked, if you go through this surgery maybe we will be father and son again," Jose told NBC 24. "And you had to keep on going.”

In their hometown of San Pablo in the Philippines, Jose and Kristine sold their possessions. They sold their house. They even pawned their ATM card to pay for his treatments. And then, when they had used up all their resources, something like a miracle happened.”

Dr. Don Paloyo, Jose’s doctor in Manila, had been introduced to Dr. Rees through a mutual friend. Jose and Kristine had just the right pairing of blood types, and just the economic circumstance, to benefit from Dr. Rees’s program. “I said, you know, I think that’s the way for one of my patients to go," said Dr. Paloyo.

It took months to raise the needed 150-thousand dollars to pay for Jose and Kristine’s trip to America and arrange a series of organ donations.

Ultimately, Jose would receive a kidney from a donor in Georgia, Kristine would donate her kidney to a recipient in Minnesota. The Minnesota recipient had a willing kidney donor, been offered a kidney by an acquaintance, but they had at was an incompatible tissue match. So, instead that donated kidney will go to a recipient in Seattle.

The unique twist in Dr. Rees’ program is what makes it affordable. He is working to convince American insurance companies to pay for a transplant and follow-up care because the insurance companies will actually save money.

"You can pay for three kidney transplants for the cost of one patient to get dialysis," said Dr. Rees.

And recruiting a foreign donor makes sense because the cost of follow up care is less in countries like the Philippines.

"So the amount of money that we would have to put up to pay for an American to get a transplant would be significantly more than we would have to pay for a recipient in the Philippines," said Dr. Rees.

Dr. Rees calls his program Reverse Transplant Tourism. And in addition to saving private insurers enough to pay for itself, it could reduce the cost of treatment through Medicare by billions. "We’ve actually achieved a holy grail of health care reform," said Dr. Rees.

"It’s revolutionary," said Dr. Paloya. "It’s a game changer I think."

And for the poorest of poor patients around the world, it could also be a life-saver.

Dr. Rees’s Reverse Transplant Tourism program could require changes in current transplant laws, especially when it comes to making it eligible for Medicare or Medicaid insurance. But Rees and his foundation, the Alliance for Paired Donation, are working to lay the groundwork for that."