By Mindy Kim, Intern
The large costs of kidney transplants are no secret; however, the impacts of insurance type on kidney transplant are often overlooked. Most patients in the United States have some form of public insurance (Medicare or Medicaid), private insurance, or are uninsured. In 2018, 32.3% of patients with prevalent end-stage renal disease only had Medicare coverage, 20.8% had non-Medicare insurance, and the remainder of patients had some form of dual or add-on Medicare insurance.1 Although the total estimated bills of kidney transplantation were approximated to be $442,500 in 2019, the total amount paid can differ significantly based on type of insurance.2 For instance, Medicare covers all hospital services, including the donor’s costs in living donation, and covers 80% of doctors’ services before and after transplant, while coverage from private insurance companies can vary widely.3 Beyond understanding the total costs of kidney transplants, it is crucial to consider a patient’s insurance status as it can be correlated with their access to kidney transplant.
Multiple studies have examined the correlation between insurance status and kidney transplant access, in examining various demographic characteristics of kidney transplant patients. For instance, a study conducted in 2020 aimed to determine if racial disparities in kidney transplant waitlisting could be accounted for by social determinants of health, such as insurance status, race/ethnicity, income, education, and perceived mistrust. The authors found that having public insurance, such as Medicare and Medicaid, compared to private insurance, decreased the probability of being waitlisted. While the racial disparities remained even after correcting for social determinants of health, insurance status was one social determinant that did contribute towards disparities in waitlisting. 4 Another study on preemptive kidney transplants (transplants that occur before starting dialysis) found that Medicare patients had a significantly lower probability of receiving preemptive transplantation compared to private insurance holders.5 Even after making it onto the waitlist, patients with Medicare and Medicaid as primary insurance were found to have higher rates of waitlist removal.6 Furthermore, patients without private insurance have a greater likelihood of not being assessed in the first place and thus lower likelihood of waitlisting.7 While these results shed light on the correlation between insurance status and kidney transplant access, it is also crucial to consider these results in a broader socioeconomic context, considering other factors that contribute to insurance such as income, race/ethnicity, and geographic area.
While there has not been extensive research looking to identify the root causes behind insurance-related disparities, multiple papers have proposed suggestions. Insurance status may simply be a function of socioeconomic status, such as race or ethnicity and income.8 Subjective biases against patients with public and no insurance, both from providers and from patients being flagged as having a longer evaluation process, may also contribute to these disparities.4,9 Furthermore, the Medicare policy is inflexible, not covering nuances and complexities of patient cases and requires a mandatory waiting period before receiving coverage, affecting eligibility for preemptive transplant listing.10,11 Future research identifying the extent to which insurance status is explained by other socioeconomic factors and other root causes for this disparity can better inform how to tackle this issue.
The question then remains of how we can mitigate the disparities between patients with private and public insurance. The same study that found that patients on public insurance were less likely to be put on the transplant waitlist also found that social support and transplant knowledge increased the probability of waitlisting.4 Digestible educational guides and education rooted in firsthand experiences and storytelling, found on the Explore Living Donation website, are examples of such education. Tailoring transplant education to serve patients with Medicare or Medicaid and making this education more accessible, by making materials more health literate, offering it in different formats (such as brochures at physical locations or digital formats), and including firsthand stories of patients of with varying insurance coverage, at Medicare/Medicaid-approved dialysis centers could further decrease these disparities. These educational resources could include specific information on Medicare coverage and emphasize differences in the transplant evaluation and waitlisting process for Medicare patients. Additional research could continue to examine the outcomes of kidney transplant with public and private insurance. In December of 2020, Medicare benefits were changed to cover lifetime supply of immunosuppressive medication after kidney transplant, whereas coverage only lasted up to 36 months after transplant before the end of 2020.12 Research examining possible disparities in outcome before and after this change and comparing outcomes to private insurance holders and those uninsured could provide insight on what changes to insurance benefits can be made to better support kidney transplant recipients. Addressing such demographic characteristics in the kidney transplant patient population can move us in the right direction to equalize kidney transplant access and outcomes.
- United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020.
- Bentley, T. S., & Ortner, N. J. (2020). United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020.
- Centers for Medicare and Medicaid Services, 2020, Medicare Coverage of Kidney Dialysis & Kidney Transplant Services.
- Ng, Yue-Harn et al. “Does Racial Disparity in Kidney Transplant Waitlisting Persist After Accounting for Social Determinants of Health?.” Transplantation 104,7 (2020): 1445-1455. doi:10.1097/TP.0000000000003002
- King, Kristen L et al. “Trends in Disparities in Preemptive Kidney Transplantation in the United States.” Clinical journal of the American Society of Nephrology : CJASN 14,10 (2019): 1500-1511. doi:10.2215/CJN.03140319
- Schold, J D et al. “Association of Candidate Removals From the Kidney Transplant Waiting List and Center Performance Oversight.” American Journal of Transplantation : Official Journal of the American Society of Transplantation and the American Society of Transplant Surgeons 16,4 (2016): 1276-84. doi:10.1111/ajt.13594
- Johansen, Kirsten L et al. “Association of race and insurance type with delayed assessment for kidney transplantation among patients initiating dialysis in the United States.” Clinical journal of the American Society of Nephrology : CJASN 7,9 (2012): 1490-7. doi:10.2215/CJN.13151211
- Schold JD, Srinivas TR, Kayler LK, Meier-Kriesche HU. The overlapping risk profile between dialysis patients listed and not listed for renal transplantation. Am J Transplant. 2008 Jan;8(1):58-68. doi: 10.1111/j.1600-6143.2007.02020.x. Epub 2007 Nov 2. PMID: 17979999.
- Laurentine KA, Bramstedt KA. Too poor for transplant: finance and insurance issues in transplant ethics. Prog Transplant. 2010 Jun;20(2):178-85. doi: 10.7182/prtr.20.2.xhu0678655331488. PMID: 20642177.
- Webb, Melissa J. “Speaker Suggests Medicare Reimbursement Strategy to Increase Kidney Transplantation.” Healio, Healio, 2 June 2020, www.healio.com/news/nephrology/20200602/speaker-suggests-medicare-reimbursement-strategy-to-increase-kidney-transplantation.
- Keith D, Ashby VB, Port FK, Leichtman AB. Insurance type and minority status associated with large disparities in prelisting dialysis among candidates for kidney transplantation. Clin J Am Soc Nephrol. 2008 Mar;3(2):463-70. doi: 10.2215/CJN.02220507. Epub 2008 Jan 16. PMID: 18199847; PMCID: PMC2390941.
- “Expanded Medicare Coverage of Immunosuppressive Drugs for Kidney Transplant Recipients.” National Kidney Foundation, National Kidney Foundation, Inc., 12 Feb. 2021, www.kidney.org/atoz/content/faq-expanded-medicare-coverage-immunosuppressive-drugs-kidney-transplant-recipients.