The economic implications of HLA matching in cadaveric renal transplantation.

Abstract Background: The potential economic effects of the allocation of cadaveric kidneys on the basis of tissue-matching criteria are controversial. We analyzed the economic costs associated with the transplantation of cadaveric kidneys with various numbers of HLA mismatches and examined the potential economic benefits of a local, as compared with a national, system designed to minimize HLA mismatches between donor and recipient in first cadaveric renal transplantations. Methods: All data were supplied by the U.S. Renal Data System. Data on all payments made by Medicare from 1991 through 1997 for the care of recipients of a first cadaveric renal transplant were analyzed according to the number of HLA-A, B, and DR mismatches between donor and recipient and the duration of cold ischemia before transplantation. Results: Average Medicare payments for renal-transplant recipients in the three years after transplantation increased from $60,436 per patient for fully HLA-matched kidneys (those with no HLA-A, B, or DR mismatches) to$80,807 for kidneys with six HLA mismatches between donor and recipient, a difference of 34 percent (P\u3c0.001). By three years after transplantation, the average Medicare payments were $64,119 for transplantations of kidneys with less than 12 hours of cold-ischemia time and$74,997 for those with more than 36 hours (P\u3c0.001). In simulations, the assignment of cadaveric kidneys to recipients by a method that minimized HLA mismatching within a local geographic area (i.e., within one of the approximately 50 organ-procurement organizations, which cover widely varying geographic areas) produced the largest cost savings ($4,290 per patient over a period of three years) and the largest improvements in the graft-survival rate (2.3 percent) when the potential costs of longer cold-ischemia time were considered. Conclusions: Transplantation of better-matched cadaveric kidneys could have substantial economic advantages. In our simulations, HLA-based allocation of kidneys at the local level produced the largest estimated cost savings, when the duration of cold ischemia was taken into account. No additional savings were estimated to result from a national allocation program, because the additional costs of longer cold-ischemia time were greater than the advantages of optimizing HLA matching

A Gift of Life Deserves Compensation: How to Increase Living Kidney Donation with Realistic Incentives

Treatment for end-stage renal (kidney) disease (ESRD) is the only government-funded health care in the United States that has no financial need- or age-based criteria; inclusion in the program (Medicare) is solely based on diagnosis. If a person has ESRD, treatment is covered by Medicare. No other criteria must be met, but the best treatment option, a transplant, is not available for most patients. Compared with dialysis, a kidney transplant significantly prolongs life and improves quality of life, but kidneys are scarce in large part because federal law prohibits the buying and selling of organs. The average waiting time for a kidney transplant in the United States approaches 5 years; in some parts of the country, it is closer to 10 years. A significant number of transplant candidates die while waiting for an altruistic donation that never comes. Allowing the sale of kidneys from living donors would greatly increase the supply of kidneys and thereby save lives and minimize the number of patients suffering on dialysis. The National Organ Transplant Act of 1984 was passed to, among other things, prohibit the sale of organs in the face of apprehension that the growing commercialization of medicine would result in human beings being treated as commodities rather than individuals. Whether such concerns were well founded or not, the act was clearly overbroad in its prohibition of the sale of organs. It's time to loosen those restrictions in order to save lives. The best way to increase the supply of kidneys without drastically changing the existing allocation system is to legalize a regulated system of compensation for living kidney donors. Such a system could be established using the infrastructure already in place for evaluating deceased donors and allocating their organs. The only change required to ease and probably even solve the organ shortage is some form of payment for donors. The potential practical and theoretical concerns with compensated donation can be overcome, and alternative proposals will not do enough to solve the shortage. Upon careful analysis, it is clear that the benefits of a regulated system of compensated donation (chiefly, increasing the number of donated kidneys) outweigh any risks

A study on the optimal aircraft location for human organ transportation activities

Abstract The donation-transplant network's complexity lies in the need to reconcile standardized processes and high levels of urgency and uncertainty due to organs' perishability and location. Both punctuality and reliability of air transportation service are crucial to ensure the safe outcome of the transplant. To this scope, an Integer Linear Programming (ILP) model is here proposed to determine the optimal distribution of aircraft in a given set of hubs and under the demand extracted from the Italian transplant database. This is an application of uncapacitated facility location problems, where aircraft are facilities to be located and organ transportation requests represent the demand. Two scenarios (two hubs versus three hubs) are tested under the performance point of view and over different time periods to assess the influence of variations in demand pattern and time period length on the solution

Regression Discontinuity Designs with an Endogenous Forcing Variable and an Application to Contracting in Health Care

Regression discontinuity designs (RDDs) are a popular method to estimate treatment effects. However, RDDs may fail to yield consistent estimates if the forcing variable can be manipulated by the agent. In this paper, we examine one interesting set of economic models with such a feature. Specifically, we examine the case where there is a structural relationship between the forcing variable and the outcome variable because they are determined simultaneously. We propose a modi…ed RDD estimator for such models and derive the conditions under which it is consistent. As an application of our method, we study contracts between a large managed care organization and leading hospitals for the provision of organ and tissue transplants. Exploiting "donut holes" in the reimbursement contracts we estimate how the total claims filed by the hospitals depend on the generosity of the reimbursement structure. Our results show that hospitals submit significantly larger bills when the reimbursement rate is higher, indicating informational asymmetries between the payer and hospitals in this market.

Health Insurance and Cardiac Transplantation A Call for Reform

Cardiac transplantation is an accepted therapy for patients with end-stage heart failure (ESHF). Presently in the U.S., patients with ESHF need to have health insurance or another funding source to be considered eligible for cardiac transplantation. Whether it is appropriate to exclude potential recipients solely due to lack of finances has received considerable interest including being the subject of a recent major motion picture (John Q, New Line Cinema, 2002). However, one important aspect of this debate has been underappreciated and insufficiently addressed. Specifically, organ donation does not require the donor to have health insurance. Thus, individuals donate their hearts although they themselves would not have been eligible to receive a transplant had they needed one. By querying Siminoff’s National Study of Family Consent to Organ Donation database, we find that this situation is not uncommon as ∼23% of organ donors are uninsured. Herein we also discuss how the funding requirement for cardiac transplantation has been addressed by the federal government in the past, its implications on the organ donor consent process, and its potential impact on organ donation rates. We call for a government-sponsored, multidisciplinary task force to address this situation in hopes of remedying the inequities in the present system of organ allocation

Barriers to ideal outcomes after pediatric liver transplantation

Long‐term survival for children who undergo LT is now the rule rather than the exception. However, a focus on the outcome of patient or graft survival rates alone provides an incomplete and limited view of life for patients who undergo LT as an infant, child, or teen. The paradigm has now appropriately shifted to opportunities focused on our overarching goals of “surviving and thriving” with long‐term allograft health, freedom of complications from long‐term immunosuppression, self‐reported well‐being, and global functional health. Experts within the liver transplant community highlight clinical gaps and potential barriers at each of the pretransplant, intra‐operative, early‐, medium‐, and long‐term post‐transplant stages toward these broader mandates. Strategies including clinical research, innovation, and quality improvement targeting both traditional as well as PRO are outlined and, if successfully leveraged and conducted, would improve outcomes for recipients of pediatric LT.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151257/1/petr13537.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151257/2/petr13537_am.pd

Free Kidney For Sale? Substitution, the Shortage, and Procurement Policy

From 1989 to 2003 kidney transplant waiting lists have grown 247%. The effect of this growth and advances in kidney transplant technology has caused a shortage of available organs and the death of thousands waiting for their transplant. Current procurement policy based on altruism has failed to increase the supply of kidneys, yet many consumers and professionals are opposed to a market based system. This paper will examine the current altruistic procurement policy as well as presumed consent and a hypothetical open market approach. With the use of data from the United Network of Organ Sharing and the United States Renal Data System, I will discuss the economic and moral dilemmas of the shortage and argue for a market based procurement policy