Acuity circles (AC) liver allocation policy was implemented to eliminate donor service area geographic boundaries from liver allocation and to decrease variability in median model of end-stage liver disease (MELD) score at transplant and wait list mortality. A team of researchers at Baylor Scott & White Annette C. and Harold C. Simmons Transplant Institute found that the new policy also significantly increased transportation costs and acquisition fees.
Results of the study were published in JAMA Surgery in November 2021.
“Liver transplant is the most expensive treatment for chronic liver disease, and looking at costs will become essential in being able to maintain the treatment for everyone and not just the people who can afford it,” says Giuliano Testa, MD, MBA, FACS, chairman of Baylor Scott & White Annette C. and Harold C. Simmons Transplant Institute and chief of abdominal transplant. “Our strength as a transplant program is to look at not only the technical and clinical issues of transplant but also the financial implications.”
A single transplant institute with two liver transplant centers cost comparison study analyzed fees associated with acquisition of 213 organs before and after AC allocation implementation. The cost data were collected from the liver transplant centers at Baylor Dallas and Baylor Scott & White All Saints Medical Center – Fort Worth, which are located 30 miles apart in different donation service areas. Cost, recipient, and transportation data for all cases that included fees associated with liver acquisition from July 1, 2019, to October 31, 2020, were collected.
Post-AC, the two centers had a higher percentage of donors incurring an import fee of $10,000 or more and surgeons’ fee ranging from $2,500-$4,000, as well as increased total costs for accepted donors (+16%), declined donors (+55%), acquisition fees (+10%) and flight fees (+43%).
The authors reported no significant difference in the post-AC compared with pre-AC period in median MELD score at time of transplant or median match run sequence. Also, a distance and transport analysis found no significant difference in mean distance traveled or in the percentage of donors requiring flights.
“The unintended consequences of implementing broader sharing without addressing the higher fees associated with movement of livers between organ procurement organizations must be remedied to contain costs and ensure viability of transplant programs,” Dr. Testa says. “We worry that the increasing costs of liver acquisition will hurt smaller transplant programs that serve rural communities, are not close to a major airport or that don’t have the margins to absorb these costs. There is concern that now organ acceptance decisions will be based in part on the costs of the liver. If we want to eliminate geography, we have to eliminate the extra fees that transplant programs incur when we cross donor service area boundaries.”