Author + information
- Received September 3, 2018
- Revision received October 1, 2018
- Accepted October 2, 2018
- Published online December 31, 2018.
- Ersilia M. DeFilippis, MDa,∗,
- Muthiah Vaduganathan, MD, MPHa,∗,
- Sara Machado, PhD, MScb,
- Josef Stehlik, MDc and
- Mandeep R. Mehra, MDa,∗ (, )@MRMehraMD
- aBrigham and Women’s Hospital Heart and Vascular Center, and Harvard Medical School, Boston, Massachusetts
- bDepartment of Health Policy, London School of Economics and Political Science, London, United Kingdom
- cDivision of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- ↵∗Address for correspondence:
Dr. Mandeep R. Mehra, Brigham and Women’s Hospital Heart and Vascular Center, Center for Advanced Heart Disease, 75 Francis Street, Boston, Massachusetts 02115.
Objectives This study examined longitudinal trends in types of payers for adult heart transplantations in the United States.
Background In the last decade, volume of heart transplantations in the United States has substantially increased, a trend that has coincided with Medicaid expansion and greater insurance coverage in the general U.S. population. Limited data are available characterizing the changes in payer mix supporting these recent increases in heart transplantation activity.
Methods De-identified data were obtained from the Organ Procurement and Transplantation Network for heart transplantation recipients 18 to 64 years of age in the United States between 1997 and 2017. Primary sources of insurance payment were determined at the time of transplantation in aggregate and stratified by sex and race. Changes in volume and payer mix of patients added to the candidate waitlist between 1997 and 2017 were also examined.
Results A total of 36,340 adults from 18 to 64 years of age underwent heart transplantations between 1997 and 2017. Support by public payer insurance increased from 28.2% (in 1997) to a peak of 48.8% (in 2016). Medicaid coverage increased from 9.4% in 1997 to 15.5% in 2007 and remained stable to 2017 (14.7%; β-coefficient: +0.23% [0.04]; p < 0.001 for trend). Medicare beneficiaries accounted for 18.2% of recipients in 1997, 22% in 2007, and 30.3% in 2016 (β-coefficient: +0.60% [0.06]; p < 0.001 for trend). The proportion of transplantation candidates receiving Medicare coverage increased over time across all races and both sexes. Similar aggregate patterns were observed in waitlist trends for adult heart transplantation candidates.
Conclusions Public payer insurance has emerged as an increasingly dominant source of funding for adult heart transplantations in the United States, supporting nearly half of all transplants in 2017.
The United States has noted a substantial increase in volume of adult heart transplantations in the last decade. Compared with 2008, 1,016 more transplantations were performed in 2017, totaling 2,813 adult heart transplantations (1). This increase has been attributed to increased availability of organs from victims of the opioid crisis within the United States (2), acceptance of donors at increased risk for disease transmission (3), an increasing candidate pool of listed patients, and better survival with the use of durable mechanical circulatory support (4). One important change in the health care arena within the United States has been greater insurance coverage provided for those previously uninsured (5). The ability to afford transplantation and associated medical care is an essential coverage element during the evaluation of patients to determine transplant candidacy.
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 (and therefore eligible for non–age-dependent Medicare coverage) prior to transplantation.
This investigation sought to examine longitudinal trends in payer mix supporting the financing of adult heart transplantation in the United States from 1997 to 2017, with a particular focus on demographic trends.
Organ procurement and transplantation network
De-identified data for heart transplantation recipients were obtained from the Organ Procurement and Transplantation Network, a data system overseen by the U.S. Department of Health and Human Services. Adults 18 to 64 years of age receiving heart transplantations in the United States between 1997 and 2017 were included. The mix of payer types supporting heart transplantation in aggregate and stratified by sex and race was determined. In order to separate insurance qualifications for Medicare by age alone, aggregated patterns of insurance status were examined for patients over 65 years of age separately. Primary sources of insurance payment at the time of heart transplantation were recoded as private, public, other types (e.g., donations, foreign government, free care, pending insurance, self-pay, United States government, or state government agency), or unknown. Public payer insurance was further divided into Medicare, Medicaid, and other. Finally, to better understand whether national trends in payer mix primarily reflected patterns in patients added to the wait list, changes in volume and payer mix (at the time of listing) of patients added to the candidate waitlist between 1997 and 2017 were also examined.
We evaluated data quality, availability, and distributions of health insurance payer type. We estimated trends using linear regression of each payer type over time separately for patients undergoing heart transplantation and patients added to the candidate waitlist. β-coefficients (and White-Huber robust SEs) of each linear trend represent the average annual change in payer share over time. A 2-tailed p value of <0.05 was considered significant. Statistical analyses were performed using STATA version 15.1 software (College Station, Texas).
We identified 36,340 adults 18 to 64 years of age who underwent heart transplantations from 1997 to 2017. The health insurance payer was unknown for 274 transplantation recipients (0.8%) during this interval. Annual adult heart transplantation volume increased from 1,824 patients in 1997 to 2,240 patients in 2017 in this age group of 18 to 64 year olds. In 1997, public payer insurance was responsible for 28.2% of transplantations. It has since increased to 41.3% in 2007 and to a peak of 48.8% in 2016 (Figure 1A). Specifically, Medicaid coverage increased from 9.4% in 1997 to 15.5% in 2007 and has remained relatively stable to 2017 (14.7%), with an average growth in coverage estimated at 0.23% (0.04) per year (p < 0.001). Medicare beneficiaries accounted for 18.2% of heart transplantation recipients in 1997, increased to 22% in 2007, and to a peak of 30.3% in 2016, an average growth in coverage estimated at 0.60% (0.06) per year (p < 0.001). Figure 2 summarizes the linear trends in payer types supporting heart transplantation over time (all temporal trends from 1997 to 2007; p < 0.001).
Over time, public payer-supported heart transplantation has increased for both sexes (Figure 1B). Notably, among women, rates of Medicaid coverage remained stable from 15.7% in 1997 to 15.9% in 2017, whereas female Medicare beneficiaries increased from 16.8% in 1997 to 23.8% in 2017. In men there were significant increases between 1997 and 2017 in both Medicaid (7.5% to 14.4%) and Medicare (18.6 to 27.1%) coverage.
The proportion of transplantation candidates receiving Medicare coverage increased over time across all races (Figure 1B). The proportion of black Medicaid beneficiaries decreased from 21.4% in 1997 to 18.3% in 2017. Among white patients, Medicaid beneficiaries increased from 7.1% in 1997 to 10.9% in 2017. Among other races, there was an increase from 15.7% to 25.4% over the last 2 decades.
From 1997 to 2007, 6,349 patients over the age of 65 (14.9% of all adult heart transplantation recipients) underwent heart transplantations. Over time, the number of patients over 65 undergoing heart transplantation has steadily increased from 192 transplantations in 1997 to 573 in 2017. Overall, Medicare supported 69.6% of all transplantation recipients above the age of 65, whereas private insurance supported 26.7%. During this time, Medicare increased from 67.7% in 1997 to 72.3% in 2017, whereas private insurance coverage decreased from 38.3% (at its peak in 1999) to 22% in 2017.
These findings were mirrored by the waitlist trends for adult candidates for heart transplantation (Figure 3). In 1997, 3,753 individuals were added to the heart transplantation list; this number increased to 4,536 in 2017, representing a 21% increase. In 1997, 64% of waitlist additions were covered by private insurance, with Medicaid supporting 11% of additions and Medicare supporting 19%. In 2017, only 48% of waitlist additions were covered by private insurance, whereas Medicaid supported 19% and Medicare 29% of additions, respectively. The estimated average growth in Medicaid and Medicare share supporting newly waitlisted patients was 0.29% (0.05) and 0.65% (0.09), respectively, per year from 1997 to 2017, whereas the share of private insurance declined at an average of 0.82% (0.04) per year during this time (all p < 0.001 for trend) (Figure 4).
Public payer insurance has emerged as an increasingly dominant source of funding for adult heart transplantation activity in the United States, supporting nearly one-half of all heart transplantations in 2017. This finding is largely attributable to increasing Medicare support (in age-based Medicare coverage and disability-based coverage) and is mirrored by the trends in mix of payer types in the candidate population listed for heart transplantation during the previous 2 decades.
Implications of changing patterns of health insurance coverage in heart transplantation
Health insurance coverage at the time of transplantation is correlated with long-term graft function and survival (6). Patients younger than 65 years of age supported by public health insurance experience worse long-term survival after transplantation than those with private insurance (6,7). Possible explanations for this include lower reimbursement rates, limited access to care and providers, limited medication coverage (6), and non–insurance-based socioeconomic determinants of health. It is also possible that gaps in public insurance coverage in patients with chronic heart failure prohibit patients from affording optimal medical therapies. Therefore, these patients may experience accelerated disease progression and more quickly meet the criteria for heart transplantation.
Empirical data regarding global variation in health insurance models may further the understanding of the potential health consequences of adequacy of transplantation access and coverage. Many European countries have universal health care access, unlike the United States, which relies on a mix of insurance payers. Recognizing variations in allocation systems that prioritize more urgent candidates, in Germany, 1-year survival rates are 76% compared with 89% in the United States (8). Similarly, lower survival rates have been observed in France as more donor hearts are allocated based on Special Urgency status (9).
Given the growing share of transplantation funding supported by public payer sources, national health care policies have potentially significant coverage implications. In a recent study of hospitalizations for durable left ventricular assist systems and heart transplantations from 2009 to 2014, annual expenditures nearly doubled, and Medicare and Medicaid consistently contributed to >50% of total costs of these hospitalizations (10). Together with our study through 2017, these data suggest that heart transplantation relies heavily on federal support and that there is an ongoing need to lower its financial burden and improve its cost efficiency.
Non–age-dependent medicare support in heart transplantation
Our observations of increased Medicare support of heart transplantation are similar to current and projected payer trajectories for overall prescription drug spending across the nation (11). Indications for Medicare coverage in the United States that are not age-dependent include disability and end-stage renal disease. Patients who are permanently disabled and who have been receiving disability benefits for at least 2 years are automatically enrolled in Part A (inpatient services) and Part B (outpatient services) coverage. Because we examined patients under the age of 65 years receiving heart transplantation alone (and not dual organ transplantations), increased Medicare coverage in this age group may be related to relative increases in transplantation recipients on long-term disability. Indeed, a significant number of patients do not work full-time after heart transplantation and depend on permanent disability status (12,13). Increasing the share of Medicare coverage may reflect greater awareness of disability in patients with heart failure and/or development and refinement of social work and support systems within transplantation programs. Hospital systems with care providers and structured teams that include social workers and financial counselors may be achieving greater access to public coverage.
However, increased access under Medicare may lead to different levels of coverage for post-transplantation care. Organ transplantation coverage includes necessary imaging and laboratory tests, follow-up care, and procurement of organs. Transplantation drugs such as immunosuppressive agents are covered under Medicare Part B rather than Part D if Medicare covered the heart transplantation, and Part D may provide relatively more complete coverage. Furthermore, Medicare requires a 20% copayment for immunosuppressive medications, which is frequently higher than other private health insurance plans (13). Subsequently, patients on disability may be unable to afford copayments for these essential medications; the potential post-transplantation health implications of these recent shifts in coverage require further attention.
Expansion of medicaid coverage
In 2014, the Affordable Care Act expanded Medicaid coverage and the insurance market, leading to a significant reduction in the number of uninsured in the United States. Nevertheless, patients with Medicaid coverage continue to account for a small proportion of total patients undergoing heart transplantation, and this share was relatively unchanged from 2007 to 2017 (∼15%). However, relative shifts in longitudinal Medicaid support of heart transplantation appeared to vary by sex and race. Over the last 2 decades, the share of Medicaid support remained stagnant in female transplantation recipients and nearly doubled in male transplantation recipients. Although prior data have shown that the Affordable Care Act led to an increase in the number of black Medicaid beneficiaries undergoing heart transplantation (5), 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. 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. Indeed, a number of states limit access to transplantation under their Medicaid programs (e.g., Nevada covers transplantation only for children).
We analyzed insurance status at the time of transplantation, which may dynamically change in the post-transplantation period. In addition, we did not have access to supplemental or secondary insurance status.
These findings have several implications. First, overall payer trajectories supporting transplantation mirror that observed for prescription drug spending across the nation. Indeed, solid organ transplantation may provide a vivid lens for analyzing use of health resources in the United States. Second, recent increases in heart transplantation volume in the United States have been largely supported by public sources (especially Medicare) across age, sex, and race/ethnicity. This increased reliance on federal sources of support makes the transplantation system vulnerable to potential federal cuts in coverage. The Centers for Medicare and Medicaid Services will become increasingly important in negotiating prices surrounding heart transplantation and post-transplantation care (including prescription drug coverage). Third, non–age-dependent Medicare enrollment may reflect increased coverage from heart failure-related disability. Disability may be more broadly recognized as patients with chronic heart failure are living longer with mechanical circulatory support. Standardized pathways for Medicare enrollment and access to disability resources should be integrated in all transplantation programs. Fourth, although these trends in federal insurance support are encouraging, gains in Medicaid access were not observed in certain demographics (e.g., women and blacks subjects), which requires further attention and scrutiny.
COMPETENCY IN MEDICAL KNOWLEDGE: Recent increases in volume of adult heart transplantation in the United States have been largely supported by public sources across age, sex, and race/ethnicity. Despite Medicaid expansion, this has largely been driven by increases in non–age-dependent Medicare beneficiaries.
TRANSLATIONAL OUTLOOK: Further studies are needed to explore the impact of increased recent reliance on federal sources of support on adequacy of coverage, access to care, and health outcomes after heart transplantation.
↵∗ Drs. DeFilippis and Vaduganathan contributed equally to this work and are joint first authors.
The contents are the responsibility of the authors alone and do not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. Supported by Health Resources and Services Administration contract 234-2005-37011C. Dr. Vaduganathan is supported by the KL2/Catalyst Medical Research Investigator Training award from Harvard Catalyst, Harvard Clinical and Translational Science Center (National Center for Advancing Translational Sciences, U.S. National Institutes of Health award KL2 TR002542); and serves on advisory boards for Bayer AG and Baxter Healthcare. Dr. Stehlik consults for Medtronic. Dr. Mehra consults for Abbott, Medtronic, Janssen, Mesoblast, NupulseCV, Bayer, and Portola. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- Centers for Medicare and Medicaid Services
- United Network for Organ Sharing
- Received September 3, 2018.
- Revision received October 1, 2018.
- Accepted October 2, 2018.
- 2019 American College of Cardiology Foundation
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