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Policies that increase access to waiting lists for kidney transplant are likely to substantially increase administrative and medical costs without providing any benefit, said authors of a new study.

An examination of cost reports from all certified U.S. transplant hospitals from 2012 to 2017 indicated that Medicare reimbursements for transplant evaluation and waiting list management increased from $0.95 billion to $1.32 billion, according to researchers led by Xingxing Cheng, MD, of Stanford University School of Medicine in California.

In addition, the evaluation and management costs per transplant increased from $81,000 to $100,000 during that time, they reported in .

"Blanket policies to increase waiting list access without increasing organ availability could not only overwhelm transplantation program workforces but also threaten the solvency of the entire Medicare End-Stage Kidney Disease program," argued Cheng and colleagues.

Factors associated with higher costs included the number of patients on an active waiting list ($3,100 per 100 patients, P<0.001) and patients on the waiting list with high comorbidities ($1,500 per 1% increase in proportion of patients with the highest comorbidity score, P=0.002).

However, costs decreased when more transplants were performed (-$3,500 per 10 transplants, P<0.001), Cheng's group noted. During the study period, transplantation hospitals experienced increases in kidney waiting list volume, kidney waiting list active volume, kidney transplantation volume, and comorbidity burden.

"Our finding has major implications for the recent policies to increase kidney transplantation referral and waitlisting," Cheng and colleagues wrote.

"The fact that a waiting list even exists is evidence that the shortage of kidneys, not a shortage of patients eligible for transplantation, is limiting the volume of kidney transplantation in the United States," they continued. "Measures solely to increase waiting list access, unaccompanied by measures to improve organ availability, are unlikely to succeed in increasing the number of kidney transplants."

Because of the kidney shortage, many patients on waiting lists die or are removed before a kidney becomes available, the researchers explained. They incur costs during the evaluation and list maintenance process but accrue no benefit of transplantation. The costs of patients on a waiting list who do not receive a transplant are shifted to the hospital's Organ Acquisition Cost Center (OACC), which reports the allowable costs of pre-transplant care to Medicare for reimbursement.

"It is therefore unsurprising that the OACC cost per kidney transplantation increases with measures of waiting list size, waiting list case-mix, and the waiting list-to-transplant ratio and decreases with actual transplants performed," Cheng's group said.

Asked for his opinion, Joseph Vassalotti, MD, chief medical officer of the National Kidney Foundation in New York City, told MedPage Today: "The investigation seems to add a financial efficiency burden to improving kidney transplant access. Although access to the kidney transplant deceased donor waitlist will increase expenditures initially, the U.S. still has to advance access."

However, "The point that we must ensure that waitlist access culminates in increased kidney transplant rates is important," Vassalotti noted. "We should not be surprised that driving health equity to reach socioeconomically disadvantaged populations will increase costs at least initially. We don't say or complain that chemotherapy costs too much to preclude treating cancer patients," he said.

Finally, "As a society we have to do right by Americans living with kidney failure," Vassalotti said. "In addition to improving quality and duration of life compared to dialysis for most patients, kidney transplant is also ultimately cost effective when compared to dialysis treatment as pointed out by the authors in the paper. estimate the benefit of each kidney transplantation at approximately $1.1 million, using a cost-benefit analysis framework."

A limitation of the study noted by the authors is that by focusing on Medicare reimbursement to OACCs, it may underestimate the actual costs incurred by patients on waiting lists. One example is a waiting list patient with no cardiac symptoms who undergoes a stress test, as per standard practice. The costs of the stress test may be assigned to the OACC, but follow-up care, including repeated testing, coronary angiogram, revascularization, and treatment of any complication that arises, becomes the standard of care for a patient and is billed to the patient's insurance, the study authors explained.

In addition, there is substantial variability in how hospitals assign costs to the OACC and report them, they noted. "For instance, a patient who needs to undergo a stress test for a kidney transplantation evaluation may choose to undergo testing at a local facility, which bills it to the patient's insurance directly, thereby bypassing the OACC mechanism completely. This is a second way in which the OACC underestimates the true cost of pre-transplant care," they said.

Even if transplant programs wanted to reduce OACC costs by deferring work-ups and waitlisting until patients without living donors had enough dialysis time to be within reach of a deceased donor transplant, these practices run counter to recent policy changes intended to increase waiting list access, and the measures would likely be resisted by referrers, Cheng's group said.

"The value of pre-transplant screening practices need to be rigorously evaluated in light of their cost implications. As one of the most successful of all modern medical interventions, the value of a kidney transplantation cannot be overstated, but the relative values of services and policies in its run-up phase need to be better defined," the study authors concluded.

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