Table 2.

Financial incentives and disincentives for various participants in the process of preemptive kidney transplantationa

ParticipantIncentiveDisincentive
RecipientLess disruptive to earning potential, employmentDifficult for patients with only Medicare coverage because of timing and out-of-pocket requirements
Maintain EGHP
Less impact on lifetime maximum (avoiding dialysis expenditures)
Living donorLost wages, travel expenses, and other associated costs (as with all LD scenarios)
The urgency of timing may add difficulty in dealing with lost wages, travel expenses, and other associated costs
Hospital/transplant centerLess costly (higher margin); less DGFAdministrative burden (EGHP) and potential risk (Medicare)
Decreased OAC; reduces waiting list expenseRecovering OAC for Medicaid-only patients
Better outcomes attract patients and contracts
Transplant surgeon/physicianGreater percentage of transplants paid by EGHP increases reimbursementLimited reimbursement from Medicare-only patients, particularly if no Part B coverage
Nontransplant physiciansNoneLack of financial support for educating patient with CKD regarding transplantation
Loss of dialysis revenue for patients who may not have had any coverage before initiation of RRT
Poor reimbursement for posttransplantation care relative to dialysis (50 to 80% less per patient per year)
Complexity of case overwhelms reimbursement benefit for PCP
EGHPAvoids costs of dialysis and its complications before transplant (greatest financial benefit accrues with least time in COB period spent on dialysis)Potential high "churn" reduces the savings opportunity (a "mythical" disincentive)
Lower costs of preemptive transplantFear of transplanting prematurely, given member churn
Fulfills obligation and social responsibility by affirming optimal patient care
Preserves other types of insurance (disability and reinsurance claims).
MedicareCost savings (particularly with LD transplants)Premature transplantation
MedicaidCost savingsPremature transplantation
  • a CKD, chronic kidney disease; DGF, delayed graft function; EGHP, employee group health plan; PCP, primary care provider; RRT, renal replacement therapy\