Federal regulators have threatened to pull funding from three more heart transplant programs, continuing a national crackdown on substandard programs that began last year.
In letters sent Friday, the U.S. Centers for Medicare and Medicaid Services gave hospitals in Texas, Minnesota and Indiana 30 days to submit acceptable plans to overhaul their programs. If they are unable to do so, they will lose federal funding.
A fourth heart transplant program, at University of Kentucky Chandler Hospital, has agreed to withdraw from Medicare.
In 2005 and 2006, each of the four programs performed fewer than the 12 heart transplants annually that Medicare required to ensure proficiency. (Experts generally agree that the more a program performs specialized procedures, the sharper its performance.)
The Medicare agency increased scrutiny of programs nationwide after a Los Angeles Times investigation in June 2006.
The Times found that a fifth of the 236 federally funded heart, liver and lung transplant centers had substandard patient survival rates or performed too few operations.
Since last year, eight transplant programs have agreed to forgo federal money, another five are operating under corrective plans approved by Medicare, and one, BryanLGH Medical Center East in Lincoln, Neb., has had its funding pulled.
Without the Medicare agency's approval, it can be difficult for a transplant center to secure private insurance contracts or even stay open.
Indeed, BryanLGH decided to deactivate its program after losing federal funds. Officials said they couldn't envision a scenario in which they would be able to perform 12 transplants a year.
"We think we did a very good job," said Lawrence Elliott, a hospital vice president. "But at the same time, we've always said if we can't really ... meet the requirements then we shouldn't be doing it."
The notified hospitals are Christus Santa Rosa Hospital-Medical Center in San Antonio, Abbott Northwestern Hospital in Minneapolis and St. Vincent Indianapolis Hospital.
The programs can maintain certification -- and funding -- by submitting acceptable corrective plans. These must include explanations of why the programs failed to meet Medicare standards, as well as the short- and long-term measures that would be taken to ensure continued compliance with U.S. standards.
Although the programs drew Medicare's attention by performing fewer than 12 surgeries annually, the government has since issued new standards that will reduce the annual requirement to 10.
Jennifer Milton, director of the Christus Transplant Institute, said Medicare's letter was not a surprise. The program performed five heart transplants in 2006.
"We knew we weren't meeting the volume criteria," Milton said. "We had already recognized that it was an issue."
Milton said the hospital was committed to keeping the program open and had formed partnerships with the University of Texas Health Science Center at San Antonio to develop more comprehensive services.
In a written statement, University of Kentucky Chandler Hospital said it volunteered to temporarily forgo Medicare funding for its heart transplant patients while it works to build its volume. The hospital said it would continue to perform surgeries for non-Medicare patients.
Dr. David Moliterno, director of the hospital's heart institute, said many hospitals had seen their transplant numbers decline because of the increased popularity of less-invasive procedures and other medical therapies. Even so, he said, "we have a very high rate of cardiovascular disease in this part of the nation and it is important that we continue to provide access to the full spectrum of services for heart patients, including transplants."
Officials at St. Vincent and Abbott Northwestern did not respond to requests for comment.
To read previous Times stories on organ transplants, go to www.latimes.com/transplants.