Expanding Kidney Transplant Waiting List Contributing to Higher Costs

Xingxing S. Cheng, MD, MS

Costs continue to increase related to kidney transplantation for patients with end-stage kidney disease (ESKD), which could be related to consorted effort to expand the kidney transplant waiting list in recent years.

A team, led by Xingxing S. Cheng, MD, MS, Division of Nephrology, Department of Medicine, Stanford University School of Medicine, described the temporaral trends in mean Organ Acquisition Cost Center (OACC) costs per kidney transplantation and to identify factors most associated with cost.

The Organ Acquisition Cost Center

The OACC is the mechanism where Medicare reimburses kidney transplantation programs at cost to identify the costs attributable to kidney transplantation evaluation and waiting list management.

In recent years there has been a push to improve access to kidney transplantations for patients with end-stage kidney disease. However, there has not been much research on the cost implications of expanding the kidney donor waiting list.There is an estimated benefit of approximately $1.1 million for each kidney transplantation using a cost-benefit analysis framework.

“Kidney transplantation is the preferred treatment for end-stage kidney disease,” the authors wrote. “Because of the expenses associated with the alternative, (ie, maintenance dialysis), kidney transplantation has been frequently lauded as a cost-saving treatment.”

Analyzing the Data

In the population-based study of cost center reports, the investigators analyzed data from all Center of Medicare & Medicaid-certified transplantation hospitals and evaluated costs for all kidney transplantation waiting list candidates and recipients in the US between 2012-2017.

The investigators sought main outcomes of the mean OACC costs per kidney transplantation.

Overall, there were 1335 hospital-years between 2012-2017 analyzed in the study. The costs related to Medicare for OACC increased from $950 million in 2012 to $1.32 billion in 2017 (3.7% of total Medicare End-Stage Renal Disease program expenditure).

In addition, the median OACC costs per transplantation increased from $81,000 ($66,000-$103 000) in 2012 to $100 000 ($82 000-$125 000) in 2017.

Transplantation hospitals also had increases in kidney waiting list volume, kidney waiting list active volume, kidney transplantation volume, and comorbidity burden.

Key Findings

In the median-sized transplantation program, the mean OACC costs per transplantation decreased with more transplants (-$3,500 per 10 transplants; 95% CI, -4,300 to -$2,700; P <.001) and increased with year ($4,400 per year; 95% CI, $3,500-$5,300; P <.001), local price index ($1,900 per 10-point increase; 95% CI, $200-$3,700; P <.001), and patients on the waiting list with high comorbidities ($1,500 per 1% increase in proportion of waitlisted patients with the highest comorbidity score; 95% CI, $600-$2500; P = .002).

“In this study, OACC costs increased at 4% per year from 2012 to 2017 and were not solely attributable to the cost of organ procurement,” the authors wrote. “Expanding the waiting list will likely contribute to further increases in the mean OACC costs per transplantation and substantially increase Medicare liability.”

The study, “Trends in Cost Attributable to Kidney Transplantation Evaluation and Waiting List Management in the United States, 2012-2017,” was published online in JAMA Network Open.