Speaker suggests Medicare reimbursement strategy to increase kidney transplantation
Including adjustments for major complicating comorbidities in Medicare reimbursement policies for kidney transplantation could incentivize centers to utilize high risk kidneys, thereby increasing the number of transplants performed.
According to Issac R. Schwantes, of the University of Iowa, organ quality (as defined by the kidney donor profile index [KDPI]), has remained relatively constant since 2014, despite allocation reforms designed to promote the use of high KDPI organs.
In his presentation at the virtual American Transplant Congress, Schwantes argued that if the goal put forth by Advancing American Kidney Health of increasing access to kidney transplantation is met, higher risk kidneys must be used.
“Among the barriers to higher KDPI kidney transplant is the cost of these procedures to the transplant centers,” he said. “Kidney transplant with high KDPI organs has been demonstrated to result in significant financial losses.”
Further, he added, “Medicare reimbursement for kidney transplant is limited to a single diagnosis-related group, a payment system which does not allow for the adjustment of patient case complexity, incidence of delayed graft function or the need to use expensive induction medications at the time of transplant.”
This payment method differs from the reimbursement methodology used for both heart and liver transplantation which, Schwantes pointed out, includes one with and one without major complicated comorbidities.
“Patients undergoing liver or heart transplant with major complicated comorbidities receive substantially higher payments from Medicare for the complexity of their case,” he said.
For this study, researchers considered the potential revenue from the creation of a DRG with major complicated comorbidities in kidney transplantation. Noting the need for post-transplant dialysis was not considered a major complicated comorbidity, the researchers determined 52 of 270 recipients had a condition that would have qualified as a major complicated comorbidity.
After applying similar payment ratios for kidney transplant recipients with major complicated comorbidities as in liver and heart transplant, researchers found a DRG with major complicated comorbidity would have increased overall revenue by $2.1 million. Further observations determined that patients with major complicated comorbidities had been waiting almost a year longer for a transplant and had a higher incidence of delayed graft function than those without major complicated comorbidities. In addition, fewer kidney transplant recipients with major complicated comorbidities received a living donor transplant.
“Looking at this data, we can draw several conclusions,” Schwantes said. “The current single-diagnosis payment system does not reflect the complexity observed in current practice.”
Specifically, he added, “There is no compensation for delayed graft function, and there is equivalent payment for living and deceased donor transplant.”
Schwantes contended that kidney transplantation with major complicated comorbidities effectively identifies high cost transplants at risk of delayed graft function. He emphasized that the inclusion of major complicated comorbidities does not require novel payment methods to be developed, because CMS already has a list defining such diagnoses.
“By appropriately reimbursing programs adequately for high risk transplants, we could reduce the financial disincentive to use high-risk donor organs,” Schwantes said.