Health Insurance as a Requirement to Undergo Cardiac Transplantation: A National Survey of Transplant Program Practices

doi:10.1016/j.transproceed.2012.05.074

Transplantation Proceedings

Volume 45, Issue 1, January–February 2013, Pages 360-363

https://doi.org/10.1016/j.transproceed.2012.05.074 Get rights and content

Abstract

Background

Recent limitations in Medicaid coverage of transplantation in Arizona jeopardized transplantation of potential recipients in that state and called attention to financial barriers inherent in the present organ allocation system. Policies of cardiac transplant centers regarding insurance requirements for transplantation have not been previously assessed. We sought to determine the policies of adult cardiac transplant programs nationwide regarding insurance requirements for evaluation and listing for cardiac transplantation.

Methods

From December 15, 2008 to November 16, 2010, all active adult cardiac transplant programs in the United States were surveyed regarding insurance requirements for evaluation and listing for cardiac transplantation.

Results

Surveys were completed by 62 of 101 programs, accounting for 71% of adult cardiac transplants in 2007. Only 2% of recipients were uninsured. Insurance was required by 48% of programs to evaluate and 84% to list for transplantation. For uninsured patients, 81% of programs required a large amount of money upfront (median, $200,000; interquartile range, $10,000–$300,000) to list for transplantation and often (84%) educated patients about fundraising to acquire these resources.

Conclusions

Adult cardiac transplant programs generally require candidates to have adequate health insurance to undergo transplantation. Uninsured patients typically need a significant amount of money upfront to be listed for transplantation and often are advised to fundraise to gather such resources.

Section snippets

Participants

All active adult cardiac transplant programs nationwide were included. A list of programs was obtained from the United Network for Organ Sharing (UNOS) Member Directory.⁵ Programs were excluded if they were listed as inactive by the UNOS Member Directory when queried in November 2008 (n = 6), pediatric programs (n = 8), or located outside of the United States (n = 1). The remaining 101 active adult cardiac transplant programs were included. The Institutional Review Board of the University of

Results

Of the 101 active adult cardiac transplant centers, 62 (61%) responded (Table 1). These programs performed 1,314 of the 1,847 (71%) adult cardiac transplants performed by active cardiac transplant centers nationwide in 2007. Most were academic centers (71%) and small-volume programs (68%). There were no differences between responders and nonresponders when characterized by transplant volume (P = .32) or UNOS region (P = .55).

Survey responses are summarized in Table 2. Seventeen programs (27%)

Discussion

To our knowledge, our study is the first to evaluate policies of transplant programs nationwide and to quantify cardiac transplant volumes to insured and uninsured recipients. Our findings extend previous data demonstrating that few uninsured patients receive transplanted organs.⁷ We demonstrate that not only are uninsured patients rarely recipients of cardiac transplants, but most programs require insurance coverage to list for transplantation. In addition, patients generally need not only

Conclusion

In conclusion, most adult cardiac transplant programs nationwide require transplant candidates to be adequately insured before listing for transplantation, resulting in few transplants to uninsured recipients. Programs utilize various strategies to address this problem, including allowing uninsured patients to provide funding upfront and advising uninsured candidates to fundraise to acquire resources.

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Cited by (19)

The impact of Medicaid expansion and travel distance on access to transplantation
2024, Journal of Health Economics
Most transplant centers require candidates be insured before they can join the waitlist for a deceased donor organ. After the Affordable Care Act, many uninsured Americans gained improved access to Medicaid. I examine the effect of this increase in access to insurance and find that Medicaid expansions significantly increase Medicaid-insured waitlist registrations by 39% and deceased donor transplants received by 44%, but the increase in registrations is larger for candidates who live closer to a transplant center. Additionally I show that most of these registrations would have been privately insured otherwise but provide suggestive evidence that this is better explained by improved access to subsidized private coverage due to other ACA reforms than from candidates with private coverage before the ACA switching to Medicaid coverage after expansion. This suggests that although the ACA improved access to the transplantation system, access is still limited for candidates who live far from centers.
Increased disparities in waitlist and post-heart transplantation outcomes according to socioeconomic status with the new heart transplant allocation system
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The study objective was to assess disparities in outcomes in the waitlist and post-heart transplantation (HT) according to socioeconomic status (SES) in the old and new U.S. HT allocation systems.
Adult HT candidates in the United Network for Organ Sharing database from 2014 through 2021 were included. Old or new system classification was according to listing before or after October 18, 2018. SES was stratified by patient ZIP code and median household income via U.S. Census Bureau and classified into terciles. Competing waitlist outcomes and post-transplantation survival were compared between systems.
In total, 26,450 patients were included. Waitlisted candidates with low SES were more frequently younger, female, African American, and with higher body mass index. Reduced cumulative incidence (CI) of HT in the old system occurred in low SES (53.5%) compared to middle (55.7%, p = 0.046), and high (57.9%, p < 0.001). In the new system, the CI of HT was 65.3% in the low SES vs middle (67.6%, p = 0.002) and high (70.2%, p < 0.001), and SES remained significant in the adjusted analysis. In the old system, CI of death/delisting was similar across SES. In the new system, low SES had increased CI of death/delisting (7.4%) vs middle (6%, p = 0.012) and high (5.4%, p = 0.002). The old system showed similar 1-year survival across SES. In the new system, recipients with low SES had decreased 1-year survival (p = 0.041).
SES affects waitlist and post-transplant outcomes. In the new system, all SES had increased access to HT; however, low SES had increased death/delisting due to worsening clinical status and decreased post-transplant survival.
An Organizing Opportunity to Change the World
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Organ Donation and Transplantation among Non-US Citizens: Opportunities to Improve Global Equity in Heart Transplantation
2023, Journal of Cardiac Failure
Non-US citizens/non-US residents (NCNR) are a unique and growing population. Patterns of heart donation and heart transplantation (HT) within this subgroup have not been described fully. The purpose of this study was to evaluate the use of organs from NCNR donors and the characteristics and outcomes of NCNR HT recipients.
All adult donors whose hearts were recovered for HT and all primary adult HT recipients from 2013 to 2020 were identified using the United Network for Organ Sharing. Donors and recipients were categorized as citizens, residents, or NCNR. NCNR were further categorized by reason for travel to the United States. Outcomes included mortality, infection, and rejection at 1-year after transplantation.
NCNR accounted for 0.4% (n = 77) of heart donors. Most NCNR donors identified as Hispanic (61%), were predominately recovered from the South and Southwest United States, and were less likely to express written documentation to be a donor compared with citizens and residents. NCNR accounted for 0.7% (n = 147) of all HT recipients. The majority identified as non-Hispanic White individuals (57.1%). Compared with citizens and residents, NCNR recipients seemed to be sicker, as evidenced by higher intra-aortic balloon pump use before HT and higher priority United Network for Organ Sharing status. Of NCNR recipients, 63% traveled to the United States for HT, predominately from Kuwait (29.9%) and Saudi Arabia (20%). At 1-year after transplant, there were no differences in mortality, infection, or rejection between the groups.
A growing subgroup of NCNR travel from countries with low HT rates to the United States for HT. This finding highlights the need for strategies to improve equitable access to HT domestically and abroad.
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Marginalized communities are at risk of receiving inequitable access to surgical care. We aimed to examine the barriers and facilitators to access to surgery in underinsured and immigrant populations.
A systematic review of disparities in access to surgical care was performed between January 1, 2000–March 2, 2022. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A convergent integrated approach was used to code common themes between studies.
Of 1315 publications, a total of 66 studies were included for systematic review. Eight studies specifically discussed immigrant patient populations. Barriers and facilitators to surgical access were categorized by patient and health systems related factors.
Established facilitators to improve surgical access are centered on patient-level factors while interventions to address systems-related barriers are limited and may be an area for further investigation. Research focused on access to surgery in immigrant populations remains sparse.
The effects of demographic, psychosocial, and socioeconomic characteristics on access to heart transplantation and left ventricular assist device
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This study aims to better understand how demographic, psychosocial, and socioeconomic factors influence the selection of patients for advanced therapies for heart failure (heart transplant and left ventricular assist device (LVAD)).
Patients evaluated for heart transplant or LVAD at a large, Midwestern hospital system were assessed retrospectively. Three outcomes were analyzed: 1) Patients who were evaluated and approved to receive a transplant or LVAD were compared to patients who were not approved for transplant or LVAD; 2) Patients who were listed for transplant were compared to patients not listed; and 3) Patients who received a transplant or LVAD were compared to patients who did not receive a transplant or LVAD. ANOVA was used for continuous variables and Chi-squared test for categorical variables. Significant variables were further analyzed by logistic regression.
Four hundred fifty-nine patients were included. Marital status (p = 0.004), race (p = 0.008), social support (p < 0.001), mental health (p = 0.006), and substance use (p < 0.001) were associated with whether patients were approved for transplant or LVAD. Patients with public insurance were half as likely (OR 0.495) to be listed for transplant once approved.
Financial, psychosocial, and demographic characteristics all play a role in selection for advanced therapies for heart failure. These insights can help guide future work on interventions to address the social disparities in access to heart transplant and LVAD.

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Thoracic transplantationHeart: CandidatesHealth Insurance as a Requirement to Undergo Cardiac Transplantation: A National Survey of Transplant Program Practices

Abstract

Background

Methods

Results

Conclusions

Section snippets

Participants

Results

Discussion

Conclusion

Am J Transplant

J Heart Lung Transplant

J Am Coll Cardiol

Am J Transplant

Soc Sci Med

Patient Educ Couns

Changes to transplant coverage

Arizona Medicaid cuts seen as a sign of the times

The New York Times

Benefit changes

Resources: member directory

Organ Procurement and Transplantation Network: Data: build advanced data reports

Insurance status of U.S. organ donors and transplant recipients: the uninsured give, but rarely receive

Int J Health Serv

Thoracic transplantation
Heart: Candidates
Health Insurance as a Requirement to Undergo Cardiac Transplantation: A National Survey of Transplant Program Practices