For many patients with advanced chronic kidney disease (CKD) or end-stage kidney disease (ESKD), the treatment that provides the longest and best quality of life is a kidney transplant. Recently, the U.S. transplant system achieved a record milestone, with performed in 2021. Despite this achievement, there are still many more people waiting years for a kidney than there are kidneys available. The transplant ecosystem, while functioning well, could be significantly improved with additional reforms.
For people living with CKD or ESKD, the path to a successful kidney transplant with a good long-term outcome is often winding and complex, making it easy to get lost along the way. Our system of care for these individuals is often uncoordinated, and many must rely on their own resources and sheer resilience to successfully navigate it. This complexity is a systemic problem that will not be solved by simply adding more "metrics" or "quality benchmarks" without a comprehensive structural solution. Here's what needs to change.
Reform Payment Models and Boost Transparency
CMS can and should build on existing to develop next-generation payment models that are more inclusive of transplant. These new models should include allowing nephrologists and dialysis providers to perform (and be reimbursed for) initial transplant waitlist testing for medically lower-risk referred candidates. This would streamline and shorten the listing process and allow for creation of a HIPAA-compliant patient data portal to facilitate sharing of patient data between pre-transplant providers and multiple transplant centers. A centralized data repository of patients' clinical evaluations, laboratory, and radiologic testing accessible by multiple transplant centers could reduce the time, expense, and waste of redundant or obsolete testing.
Quality outcomes for transplant programs should be pegged to the that really matters: Receiving a successful kidney transplant in the shortest period of time. A of patients with kidney disease regarding tradeoffs between being transplanted earlier and waiting for a "better organ" confirms that a wide majority of patients prioritize being transplanted sooner. "Transplant soon and well" should be the mantra for regulators and policy makers when considering nephrologist and dialysis provider-facing metrics to achieve the right outcomes for patients. Waitlist removals for deterioration or death should become vanishingly rare. Patient-facing transplant center dashboards should allow patients and families to easily identify the transplant centers that will get a transplant for "patients like me," the fastest. The Scientific Registry of Transplant Recipients is already , and this effort needs to be boosted, refined, and made broadly available to patients and patient educators.
Focus on Equity
Despite a record number of organs transplanted last year, in access to transplantation have persisted for 2 decades. The Medicare Innovation Center's recent adjustment to the ESRD Treatment Choices payment model to provide performance credit on quality metrics for patients dual-eligible for Medicare and Medicaid, and/or recipients of the Low-Income Subsidy, is a good model for more robust regulatory and payment reform. Social determinants of health (SDOH) that serve as barriers to access to transplant and post-transplant care is a systemic problem, requiring system-level care coordination solutions. Regulators and payors should consider required reporting of SDOH variables for risk adjustment in quality outcomes for transplant centers and in considering payment modifiers and regulatory dispensation for care delivery models designed to address SDOH barriers, like transportation, housing, food, and medication insecurity, as well as the digital divide.
Remove Barriers
We believe several reforms can be made to the transplant ecosystem to make it easier for transplant centers to be more aggressive in their organ acceptance behaviors. Changing the organ offer system to use the approach of "" can streamline organ placement timelines, placing higher-risk organs with more risk-tolerant centers more quickly and efficiently. Aligned with the goal of getting patients to transplant faster, regulators and payors (public and private) should prioritize shortening time to transplant over sky-high 1-year patient and graft survival thresholds. The lowest performing third of transplant centers are conferring to patients compared to any maintenance dialysis therapy. We should seek to remove regulatory and financial barriers to transplant centers seeking to safely make use of every gift of life. If we expect transplant centers to transplant higher-risk organs, we should recognize that it may cost more to perform those transplants successfully. The payment system for transplants should account for these higher costs so that transplant centers are not faced with losing money when transplanting higher-risk organs.
Reward Donors
A key component of the kidney transplant ecosystem is the generosity of living donors, and we should do more to support their decision to give the gift of life. This means protecting living donors from insurer efforts to exclude them from life or disability insurance coverage because of their donation. In addition, enhancing education efforts to increase living donor kidney transplants can help bridge the gap between organ need and supply. One pending solution to these challenges is the passage of the (H.R.1255/S.377). The bill would prohibit discrimination by insurers based on an individual's status as a living organ donor. Employers can also do their part through adjusting their paid leave policies for employees who become living donors, by joining the .
We stand ready to our part to advocate for policies and payment models that serve patients with kidney disease across the entire continuum of their disease. While there is much about the transplant ecosystem we can take pride in, there is much that can be improved, and more work to do.
is senior vice president and head of transplant medicine and emerging capabilities at Fresenius Medical Care. is associate chief medical officer at U.S. Renal Care. They are both members of Kidney Care Partners.