Report of a consensus conference on transplant program quality and surveillance.

Public reports of organ transplant program outcomes by the US Scientific Registry of Transplant Recipients have been both groundbreaking and controversial. The reports are used by regulatory agencies, private insurance providers, transplant centers and patients. Failure to adequately adjust outcomes for risk may cause programs to avoid performing transplants involving suitable but high-risk candidates and donors. At a consensus conference of stakeholders held February 13-15, 2012, the participants recommended that program-specific reports be better designed to address the needs of all users. Additional comorbidity variables should be collected, but innovation should also be protected by excluding patients who are in approved protocols from statistical models that identify underperforming centers. The potential benefits of hierarchical and mixed-effects statistical methods should be studied. Transplant centers should be provided with tools to facilitate quality assessment and performance improvement. Additional statistical methods to assess outcomes at small-volume transplant programs should be developed. More data on waiting list risk and outcomes should be provided. Monitoring and reporting of short-term living donor outcomes should be enhanced. Overall, there was broad consensus that substantial improvement in reporting outcomes of transplant programs in the United States could and should be made in a cost-effective manner.

Call to develop a standard acquisition charge model for kidney paired donation.

We propose a Medicare Demonstration Project to develop a standard acquisition charge for kidney paired donation. A new payment strategy is required because Medicare and commercial insurance companies may not directly pay living donor costs intended to lead to transplantation of a beneficiary of a different insurance provider. Until the 1970s, when organ procurement organizations were empowered to serve as financial intermediaries to pay the upfront recovery expenses for deceased donor kidneys before knowing the identity of the recipient, there existed similar limitations in the recovery and placement of deceased donor organs. Analogous to the recovery of deceased donor kidneys, kidney paired donation requires the evaluation of living donors before identifying their recipient. Tissue typing, crossmatching and transportation of living donors or their kidneys represent additional financial barriers. Finally, the administrative expenses of the organizations that identify and coordinate kidney paired donation transplantation require reimbursement akin to that necessary for organ procurement organizations. To expand access to kidney paired donation for more patients, we propose a model to reimburse paired donation expenses analogous to the proven strategy used for over 30 years to pay for deceased donor solid organ transplantation in America.

Kidney paired donation: a payer perspective.

Kidney transplantation is the most cost-effective and clinically effective form of renal replacement therapy. Due to long wait times for deceased donors, kidney transplantation is not available to many patients with incompatible living donors. Increased access to kidney transplantation is a shared goal that can be achieved through kidney paired donation (KPD). A single, national system of KPD administered to a set of clinical and ethical standards determined by a consensus of stakeholders including recipients, donors, providers, payers and the United States federal government will provide the best opportunity to offer kidney transplantation to the most people and particularly to those currently unlikely to receive a transplant. We propose that this system will use uniform tissue typing algorithms and a computerized donor and recipient matching program using a national pool of willing donors. The proposed system can be managed best through a single administrative structure that takes advantage of uniform donor evaluation and management with a standardized organ acquisition charge that recognizes that the current lack of standardization contributes to delays in transplantation and payment to programs. This program will use the existing Organ Procurement Organization infrastructure to manage the logistics of organ acquisition, transportation and billing.