The costs of caring for patients with end-stage kidney disease (ESKD) appear to be rising. Expenditures for pre-transplant medical care besides dialysis services increased 4% per year from 2012 to 2017 in the US, and only 36% of that increase was attributable to deceased-donor organ procurement, a new study finds.

As the kidney waiting list expands, investigators expect substantial cost increases. Other research indicates that medical billing for dialysis is far higher for private insurers than for Medicare.


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Medicare reimburses kidney transplantation programs for costs attributable to kidney transplantation evaluation and waiting list management via The Organ Acquisition Cost Center (OACC). Medicare’s share of OACC costs increased from $950 million in 2012 to $1.32 billion in 2017, which was 3.7% of total Medicare spending on the ESKD program.

Median OACC costs per kidney transplantation increased from $81,000 in 2012 to $100,000 in 2017, Xingxing S. Cheng, MD, MS, of Stanford University in Stanford, California, and colleagues reported in JAMA Network Open. The investigators calculated that for a median-sized transplantation program, costs per transplantation significantly increased $4400 annually, $1900 per 10-point increase in local price index, and $3100 per 100 patients listed “active” on the waiting list. Comorbidity burden significantly increased costs: $1500 per 1% increase in the proportion of waitlisted patients with the highest comorbidity score.

Patient factors appear to be the main drivers of rising costs. From 2012 to 2017, transplantation hospitals experienced increases in kidney waiting list volume, kidney waiting list active volume, and comorbidity burden, according to the investigators. Greater kidney transplantation volume offset costs. For a median-sized program, mean OACC costs per transplantation significantly decreased $3500 for every 10 transplants performed.

“These findings highlight the importance of efficiency—or how quickly transplantation programs aid a patient in moving from evaluation to waiting list to the actual transplant—as a key factor in OACC cost,” Dr Cheng’s team wrote. They highlighted that measures to increase waiting list access must be accompanied by measures to improve organ availability to increase the number of kidney transplants.


In a second study published in JAMA Network Open, Riley J. League, MA, of Duke University in Durham, North Carolina, and colleagues examined the prices that private insurers actually paid for dialysis using data from the Health Care Cost Institute.

Prices paid by private insurers varied widely by geography. Based on 1,987,439 claims for hemodialysis sessions from 2012 to 2019, the mean and median prices that private insurers paid per session were $1287 and $1476, respectively. These prices were substantially higher than the Medicare base rate per session ($240 with a maximum possible cost of $1081).

“Lowering the prices paid by private insurers to Medicare rates and discouraging steering patients onto private plans could bring about substantial savings in spending on hemodialysis,” League and colleagues concluded.


Cheng XS, Han J, Braggs-Gresham JL, et al. Trends in cost attributable to kidney transplantation evaluation and waiting list management in the United States, 2012-2017. JAMA Netw Open. Published online March 10, 2022. doi:10.1001/jamanetworkopen.2022.1847

League RJ, Eliason P, McDevitt RC, Roberts JW, Wong H. Variability in prices paid for hemodialysis by employer-sponsored insurance in the US from 2012 to 2019. JAMA Netw Open. Published online February 1, 2022. doi:10.1001/jamanetworkopen.2022.0562