Introduction
    Recovery following major illnesses and/or surgical procedures can be positively and negatively effected by the role that the patient and the physician take during the illness and recovery process (Wallston & Wallston, date unk; Leigh & Reiser date unk).  Organ transplant patients and their physicians use a combination of the natural healing processes of the body and the technological advances of medicine to successfully replace diseased organs and replace them with healthy donor organs.  However, unless the transplant recipients have the option to return to work, their self-esteem and confidence could be adversely effected.  Because an inner sense of stability and security is more difficult to achieve, people become emotionally attached to symbols, material goods, or a particular job or social position - all which help to define who they are.  The loss of any of these symbols,, which have become an important source of meaning in life, can be a terrible blow (Jaffe, 1980, p.83).   Health-care benefits protocols, for organ transplant recipients, need to be improved to include medical, vocational rehabilitation, and financial support which incentivize the individual, benefits underwriter, and employer to return the recipients to work.
    Under current social security and many private medical and financial benefit plans, individuals who are considered well enough to return to work, may never return to the work place due to the fear of losing his/her medical and cash benefits (GOA, 1988, p.5).  Suggestions to modify current benefits programs in order to be able to return an organ transplant recipient to vocational productivity is the topic of this paper.  I will discuss the current benefits protocols, for individuals with long term disabilities -  who have recovered, and contrast the current programs with opinions to change the benefit protocol, for organ transplant recipients, in order to facilitate a higher return to work rate for these disability clients.
    The cost of successfully returning organ transplant recipients to vocational productivity effects the individual transplant recipient, the taxpayers, employers.  By an individual returning to work, he/she becomes an independent wage earner, who contributes to the tax and benefits program base, and becomes a productive member of the world of work and not a recipient of social programs.  Employers can benefit by reducing turnover costs, by employing a good employee, and by taking advantage of the tax incentives for hiring the disabled.
    The current system of private and social financial and medical benefit programs disincentivize the disabled individual to return to work.  Modifying the existing program to provide for financial and medical benefits safeguards, will enhance the recovery process of the transplant individual and have a positive impact on private and social benefits programs.

Discussion
    A rising number of organ transplant recipients are successfully recovering from the disease that caused the need for an organ transplant and are ready, willing, and able to return to work.  The many unemployed transplant recipients are hesitant to return to work due to the potential of losing his/her social security medical and financial benefits and not having any medical insurance to cover the high cost of post transplant medical care and medication.  The projected post-transplant medical costs are estimated to be between $12,000. and $15,000. a year per transplant recipient (Gutkind, 1988, p.343).  The current social security system only allows the individual a limited trial work period before all financial and medical benefits are discontinued.  A number of private insurance companies do not provide sufficient coverage or incentive for transplanted individuals to return to work.  It is ironic that federal and state assistance programs, private insurance companies, and Blue Cross and Blue Shield organizations will invest as much as a half a million dollars to save the life of a dying person but will provide absolutely no assistance to help the individual, whose lives they have paid to preserve, return to the mainstream of productive life (Gutkind, 1988, p.337).
    The projected cost of maintaining and individual on a social and insurance benefits programs, without returning to work, is costly to the U.S. taxpayers and industry.  Returning the individual to work will save the individual taxpayers and businesses money, by permitting him/her to earn an income and contribute to the social security and insurance programs, and still be eligible to receive adequate medical and financial coverage.
    In many cases, the organ transplant recipient may develop a feeling of lack of self-worth and purpose when he/she begins to feel well enough to begin working.  He/she may find that he/she is unable to return to work due to a lack of experience for a new job, if he/she is unable to return to his/her former occupation.  It may also be infeasible to return to work because the new occupation may pay the worker less than what he/she was receiving from private and social benefit programs.  Economic conditions can also adversely effect the transplant recipient's ability to find a suitable position.  Several benefits to the organ transplant recipient, by returning to work, is the feeling of usefulness and productiveness, the sense of independence and not dependent on subsistence programs, and the acceptance of being "normal" again after an illness and receiving a "non-conventional" treatment modality.
    The role of the vocational rehabilitation professional is to access, educate, and assist the organ transplant recipient to return to work.  According to a December 1988 GAO report to the Chairman of the subcommittee on Social Security, in the U.S. House of Representatives, over 90% of the vocational rehabilitation counselors surveyed said that more social security beneficiaries would try to work if their Medicare coverage were continued and their cash benefits were based upon a sliding scale related to earned income.  In many cases, the transplanted individual is unable to return to the work he/she performed prior to his/her illness and transplant, but is capable of performing a different occupation that may have a lesser wage earning potential and/or cash benefit level.  The report to the House of Representatives subcommittee pointed out that the number of beneficiaries who returned to work could possibly be increased through some changes in the benefit payment structure (GAO, 1988, p.14).  A sliding cash benefit plan would protect the worker from earning less than what had been received in cash social security benefits.  If private insurance companies also adopted this point of view, this could facilitate more organ recipients to return to work thereby reducing benefits claims costs.
    Currently there are more potential recipients than there are available donors, however, more recipients are surviving the transplant procedures and are physically, cognitively, and emotionally capable of returning to work.  According to UNOS (1990), in 1989 there were 8,935 kidney transplants performed, 1,687 heart transplants, 2,188 liver transplants, 416 pancreas, 66 heart/lung transplants, and 92 lung transplants performed.  The survival rates for kidney, heart, and liver transplants are significant.  More than 8 out 10 heart recipients live more than a year after their transplant.  More than 90% of kidney transplant recipients survive for more than a year (Gorman, 1991; Gutkind,1988).  As of August 1990, there were 17,712 people waiting for kidney transplants, 1,747 people waiting for a heart, 959 people waiting for a liver, 251 waiting for a heart/lung, 414 people waiting for a pancreas, and 225 people waiting for a lung transplant (UNOS,1990).
 There are a number of employment barriers that effect an individual's ability to return to work after an organ transplant.  Aside from the potential loss of financial and medical subsistence benefits, the transplant individual must also overcome employer bias regarding hiring individual's with perceived disabilities.  An individual who has had a transplant may have some special medical and environmental needs, but this should not impact the majority of the businesses that have light and sedentary, inside jobs.  Many employers fear the potential loss in production - due to potential sick time by the employee, inability to perform the job tasks due to physical restrictions, and the possible increase in health insurance premiums.
    There are several special employment problems that impact the ability for a disabled individual to return to work, according to the 1988 GAO study, which reflects the opinion of the surveyed vocational rehabilitation counselors.  The transplant person may also encounter these issues since he/she is also considered disabled, particularly if he/she is receiving social security benefits.

 1. Smaller companies, which otherwise might be good prospects for hiring transplant recipients, are afraid of the effect on their health insurance premiums.

 2. Many health insurance plans specifically exclude preexisting conditions from coverage.

 3. Many part-time, temporary, or contractual jobs which the transplant recipient might qualify do not offer health insurance benefits.
 4. The loss of the cash benefits may not benefit the transplant recipient to return to work.

    Sixty-eight percent of the vocational rehabilitation counselors surveyed in the GAO (1988) study, indicated that social security disability recipients were less likely to succeed in rehabilitation programs than other types of clients.  They cited that the reason for this was the lack of financial and medical benefits security if they were to return to work.
    Federal and state government agencies, private insurance companies, and Blue Cross and Blue Shield organizations need to develop programs that will invest dollars into providing guaranteed medical, rehabilitation, and financial benefits to transplant recipients in order to assist them in returning to maximum productivity.  They need to insure medical benefit protection, provide medical and vocational rehabilitation services, and protect the financial integrity of working transplant recipients by providing a protocol for a sliding scale wage/financial protection program.  Employers need to be educated to the value of the transplant recipient worker in order to enhance the employment prospects for the transplant recipient.  Organ transplant recipients need to be educated about their medical, rehabilitation, and financial benefits and assessed for alternative employment prospects that are within their physical, cognitive, and emotional capabilities.
    Current health-care protocols must be changed to provide more efficient and cost effective health care and rehabilitation services to return transplanted individuals to work and thereby reduce on-going benefits cost.  Private companies should take the initiative and not wait for the public programs to be developed and enacted.  According to Susan Dentzer (1991), an effective health-care reform must be based upon seven key principles.  Among them: Business must confront the real forces that are driving up costs, such as the absence of economic incentives for truly cost effective health care.  Firms must also become intelligent health care buyers, searching far more diligently for the best deals around.  Companies must accept the job of providing most of the nation's health insurance in exchange for powerful new tools to contain health costs.  And above all, firms must recognize that new laws or national policies alone won't get the job done.  Just as companies have coped with global competition by overhauling manufacturing or switching strategies, effect health-care reforms will mean changing the way business does business (p. 51).

Conclusion
    A reassessment of current private insurance benefit programs and social security financial and medical benefits rules and regulations should be initiated to provide the potential employee and employer with appropriate financial and medical insurance coverage that will protect the employee and employer from exorbitant post-transplant medical costs and enhance the return to work potential of the worker.
    Organ transplant recipients make good, effective employees.  They do not have any higher work absences than non-disabled individuals (Gutkind, 1988, p.343).  Work is therapeutic physically, cognitively, and socially for disabled individuals.  However, without the financial and medical benefit coverage assurance, vocational rehabilitation services, to assist the transplant recipient to return to work, would not be effective.    With guaranteed health-care and financial support, vocational rehabilitation services can be effective in educating employers to the benefits of hiring disabled/transplanted individuals.   The benefits to the employer, for retaining an individual who has had an organ transplant, is that the employer gets back a trained, qualified worker that does not have the learning curve that a new employee may have.  The company morale can be positively effected by the other employees seeing that the company does support its workers.  The company also gets back an employee who will probably be very loyal and grateful to the company.  Another benefit of returning the organ transplant recipient to work, as soon as is medically feasible, is a possible reduction in the company's short-term and long-term disability insurance rates.  Medical and vocational rehabilitation case management services can be a helpful and cost effective services to the employer, in coordinating an earlier return to work of the disabled individual.
    According to my clinical experience, employers who hire individuals who have successfully undergone an organ transplant and are ready to return to work will benefit by the hiring these individuals.  They will get a loyal employee who will not incur any additional costs and/or lost work time than non-disabled employees.  In many cases, employees who have been organ transplant recipients, are healthier than their non-disabled fellow workers due to their regular medical consultations.  Organ transplant recipients are generally more aware of their health care and practice continuous preventative medical care.  They are also are seen regularly by a physician.  New employers are not effected by the health insurance requirements, associated with the transplant procedure and post-operative care, since the condition was pre-existing to the employment of the transplant recipient.  Another benefit to the employer may be the eligibility of Targeted Job Tax Credits (TJTC), which provide economic incentives for employers to hire disabled workers.  Case management professionals can assist employers and potential employees in qualifying for this federal program.
    Employers who hire or retain employees who have had an organ transplant do not incur any additional expense for modifying a job to suit the transplant recipient.  Individuals who previously had jobs that were physically, emotionally, and/or environmentally more demanding than what the transplant recipient can perform post-transplant, will need to change jobs, and in some cases employers.  However, in most cases, no modifications to the job site are required to accommodate and organ transplant recipient.
    Providing vocational rehabilitation services to transplant recipients can assist them in analyzing occupational alternatives and developing work search techniques. The role of vocational rehabilitation should be to educate and guide potential employers and employees to the effectiveness of returning the individual to work.
 The possible long-range consequences associated with the improvement of private insurance programs and the social security benefits programs are:

 1. More transplant recipients will be able to afford to return to work.

 2. Employer costs for hiring and training replacement workers will be reduced by the return to work of transplant recipients

 3. Medical costs will be better controlled as a result of the medical cost containment procedures put in to place to manage the catastrophic medical care program.

 4. Social security costs should be reduced as a result of the organ recipient returning to work and contributing to the Social Security System.

 5. More individuals will donate their organs as a result of the increased visibility of the individual who has returned to productive living as a result of another individual's organ donation.

    The current private and social financial and medical benefits programs are antithetical to the concepts of rehabilitation.  The prime purpose of rehabilitation is to help the patient/client achieve his/her maximum physical, cognitive, and emotional capabilities.  The focal concept of vocational rehabilitation is that work is therapeutic in returning the disabled/injured worker to maximum productivity (Romano, 1984, p.43).
    If the current private and social financial and medical benefit programs can be ameliorated to improve the coverage for the organ transplant recipients, more recipients will be able to return to work and be productive members in the work place.  The private and public benefits programs can save money by returning organ transplant recipients to work, thereby reducing benefits costs, and by implementing recommended medical cost containment services.
    As the techniques and medication associated with organ transplantation are improved, more individuals are going to be able to return to work.  Tom Starzl, the dean of American transplanters voices concern over the impact of the medical advancements in transplantation science, "The consequences of changing human ecology are well known to those who have studied the amplifying effects of antibiotics on the population explosion that is said to threaten the earth or at least the quality of life of its inhabitants," (Dowie, 1988, p. 242).  In order to meet the needs of these returning to work individuals, medical and financial benefits programs need to be modified to insure continued coverage and financial support.

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