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 $10,000. and $15,000. a year per transplant recipient (Gutkind, 1988).  The current social security system only allows the individual a limited trial work period before all financial and medical benefits are discontinued.
    The projected cost of maintaining and individual on a social benefits program, without returning to work, is costly to the U.S. taxpayers.  It will save the individual taxpayers and businesses money, by returning the individual to work, to earn an income and contributing to the social security program, 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 1987 GAO report to the Chairman of the subcommittee on Social Security, in the U.S.House of Representatives, over 90 percent 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).  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.  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 fora 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.

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.
    Work is therapeutic physically, cognitively, and socially for disabled individuals.  Organ transplant recipients make good,effective employees.  They do not have any higher work absences than non-disabled individuals (Gutkind, 1988).  Vocational rehabilitation services can be effective in educating employers to the benefits of hiring disabled/transplanted individuals. Transplant recipients can be assisted in analyzing occupational alternatives and developing work search techniques.  However,with out the financial and medical benefit coverage assurance,vocational rehabilitation services would not be effective.  The role of vocational rehabilitation should be to educate and guide potential employers and employees to the effectiveness of there turning worker.  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 assessed for alternative employment prospects that are within their physical, cognitive,and emotional capabilities.
 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.
    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.
 

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