Public health insurance programs are covering an increasing number of heart transplant surgeries in the U.S., recent research suggests, meaning the outcomes of such procedures could hinge on decisions made by the federal government.
In a study published in the Jan. 1 issue of JACC: Heart Failure, Ersilia M. DeFilippis, MD, and colleagues scrutinized de-identified data from the Organ Procurement and Transplantation Network for adult heart transplant recipients between 1997 and 2017. The team assessed 36,340 patients’ primary sources of insurance payment at the time of their surgeries and tracked changes in volume and payer mix over two decades.
“The ability to afford transplantation and associated medical care is an essential coverage element during the evaluation of patients to determine transplant candidacy,” DeFilippis, an internal medicine resident at Brigham and Women’s Hospital, and coauthors wrote. “The transplantation candidate list is growing longer as more patients living with advanced heart failure become eligible for heart transplantation. This has led to increasing aggregate costs of managing this population and potentially a greater pool of those classified as disabled prior to transplantation.”
And the pool of potential transplant recipients continues to grow, they said. An increased availability of organs from victims of the current opioid crisis, greater acceptance of “risky” donors and better survival with the use of mechanical circulatory support have all contributed to a rise in heart transplants. Just under 3,000 adult transplants took place in 2017—nearly triple the number of surgeries in 2008.
Upon analysis, DeFilippis et al. found support by public payer insurance increased from 28.2 percent in 1997 to a peak of 48.8 percent in 2016. Medicaid coverage increased from 9.4 percent in 1997 to 15.5 percent in 2016, and Medicare coverage rose from 18.2 percent to 30.3 percent in the same window.
The proportion of transplant candidates receiving public coverage increased over time across all races and both sexes, but the authors reported the change was least noticeable in women and black populations. Medicaid coverage remained stable for women between 1997 and 2017 and Medicare coverage increased seven percentage points from 16.8 percent to 23.8 percent in the same period. On the other hand, men saw increases in both Medicaid and Medicare coverage—7.5 percent to 14.4 percent and 18.6 percent to 27.1 percent, respectively.
Among white patients, Medicaid beneficiaries increased from 7.1 percent to 10.9 percent, while the proportion of black beneficiaries dropped, from 21.4 percent in 1997 to 18.3 percent in 2017.
“Although prior data have shown that the Affordable Care Act led to an increase in the number of black Medicaid beneficiaries undergoing heart transplantation, similar increases in access were not observed over the 20-year period in our study; the percentage of black Medicaid beneficiaries nationally actually decreased over time,” DeFilippis and colleagues wrote. “Even among Medicaid expansion states, variation in state-specific coverage rules related to adult heart transplantation may explain less visible longitudinal changes in Medicaid support nationwide.”
What we do know is that Medicare and Medicaid are playing an increasingly important role in the future of heart transplant coverage, the authors said, putting CMS in the influential position to negotiate the prices of cardiac surgeries and post-transplant care, like prescription drug coverage.
In a related editorial, Khadijah Breathett, MD, MS, of the University of Arizona Health Sciences, pointed out that heart transplants cost an estimated $97,000 per quality-adjusted life-year, which is $57,000 higher than the cost per quality-adjusted life-year in patients with end-stage heart failure.
“Society must determine whether the value of heart transplantation is worth the cost of expanding public insurance,” she wrote. “Compared with private insurance, public insurance has been associated with reductions in survival but is hypothesized to be secondary to fixable issues such as limited coverage or high deductibles for immunosuppression medications and specialty care.”
Breathett said barriers to public insurance can be overcome. Still, that might require a single public payer that limits total deductibles based on income, is standardized across the U.S. and provides compensation close to what private insurers receive.
“Inequities in receiving heart transplantations may persist because factors expand beyond insurance, but insurance has a prominent role,” she wrote. “With the elections done, remember that patient advocacy and a political voice are powerful ways of influencing healthcare policy.”