We appreciate the Office of Special Counsel's concerns, but we feel OSC's assessment is ill informed due to a lack of understanding of the general standards and practices regarding organ transplants throughout the U.S. medical community. A point-by-point response to OSC's concerns is below.

OSC allegation: Mr. McBride disclosed that the structure and procedures for referring VA patients for organ transplants to a limited number of VA transplant facilities restrict patients' access to life-saving treatment.

VA response: All patients undergoing transplants must be thoroughly evaluated prior to transplantation to ensure that they are appropriate candidates for the planned surgical procedure and required peri- and post-operative management.

VA Transplant Centers are certified by the United Network for Organ Sharing (UNOS), requiring compliance with Organ Procurement and Transplantation Network (OPTN) policy, as required by all U.S. transplant centers. OPTN policies govern the operation of all member transplant hospitals, organ procurement organizations (OPO), and histocompatibility labs in the United States. Furthermore, OPTN tracks VA Transplant Center services and outcomes through the Scientific Registry of Transplant Recipients (SRTR), along with all US transplant centers.

OSC allegation: The structure also causes financial and other hardships to veterans and their families by requiring them to relocate for months to receive treatment.

VA response: This is a national issue and is not unique to VHA. Transplant programs are not located in every state. There are numerous advantages for Veterans in having access to a robust VA Transplant Program for lifelong complex care, which includes an integrated healthcare system, travel/lodging benefits, telehealth, and secure messaging.

OSC allegation: The transplant centers apply inconsistent and overly restrictive eligibility criteria for liver and kidney transplants; the medical centers lack the level of specialty care required to care for post-transplant patients; and the VA's unwillingness to perform living donor kidney transplants denies patients timely, life-prolonging treatment options.

VA response: VA transplant Centers followstandards of care consistent with OPTN policy; VA’s integrated health care system provides 24/7access to VA Transplant Centers and subject matter experts as needed for advice and consultation regardless of where the Veteran is located; and the VA Transplant Program actively performs living donor transplant procedures utilizing both Veteran and non-Veteran living donors. VA policy supports living donor costs for donor-related testing and care as well as travel.

OSC Allegation: VA did not address the conflicting information regarding the availability of transplant care in the community and the coverage of organ harvesting and donor care through the Choice Program, which Congress created to allow veterans to seek care outside of the VA system when needed.

VA response: When VA provides transplant care in the community, VA typically uses the authority in 38 U.S.C. 8153 to obtain surgical and related services. When purchasing the donor’s associated care under a sharing agreement, all the associated clinical donor-related costs can be identified and purchased at a negotiated, mutually agreed-upon rate. While VA is authorized to use the Choice Program to provide transplant care (including for the donor), the law generally caps the payment at Medicare rates which community providers have been less willing to accept.

OSC allegation: VA did not address the full scope of the allegations, such as the cause of the VA's low rate of living donor transplants and communication problems among multiple VA facilities.

VA response: We stand ready to address any of OSC’s remaining concerns.

OSC allegation: For some findings, VA did not acknowledge the consequences and potential harm to veterans, such as the delay veterans experienced while appealing and seeking second opinions in cases where a VA transplant center applied overly restrictive criteria, and for post-transplant patients who receive care from physicians who do not believe they are capable of providing proper care.

VA response: This allegation disregards the facts and outcomes of the cases in question. For the period of October 1, 2016, to September 30, 2017, the VA Transplant Program received 2,602 referrals, performed 1,660 evaluations, placed 834 Veterans on the transplant waiting list, and performed 631 solid organ and bone marrow transplants. VA’s National Surgery Office monitors survival statistics for all VA Transplant Centers on a quarterly basis. For transplants performed between 2007 and 2017, three year Kaplan-Meier survival rates are: Bone Marrow: allogeneic 49.5%, autologous 71.0%; Heart, 86.7%; Kidney 92.2%; Liver 80.8%; and Lung 78.6%.

OSC allegation: Aside from travel reimbursement, VA did not address the other significant hardships and barriers to care imposed on veterans who must travel long distances for months to VA transplant centers.

VA response: This is a national issue and is not unique to VHA. Transplant programs are not located in every state. There are numerous advantages for Veterans in having access to a robust VA Transplant Program for life-long complex care, which includes an integrated healthcare system, travel/lodging benefits, telehealth, and secure messaging.

OSC allegation: VA identified only one transplant in the community covered under the Choice Program allowing veterans to receive care outside of VA facilities, and a small number through other contracting arrangements, yet offered no recommendations to improve veterans' access to community care.

VA response: Utilization of the Choice Program for transplants is governed by current legislation and is summarized in the attached letter from the VA Secretary to then-HVAC Chairman Miller. If Congress – or anyone else – is interested in expanding access to transplants through the Choice Program, we recommend they look into changing the law.

Lydia B Blaha

Deputy Press Secretary

Department of Veterans Affairs