Introduction

Living donor kidney transplantation not only offers the best treatment option to patients in need of renal replacement therapy but also provides cost-savings to the healthcare system, compared to both dialysis and deceased donor transplantation. A contemporary discrete event model analysis of a hypothetical cohort of 20,000 end-stage renal disease patients found that almost all living donor kidney transplants result in cost savings, ranging from $13,000 USD to $30,000 USD, and even higher risk transplants from HLA-incompatible donors were cost-effective [33].

Some transplant programs may have misinterpreted the CMS manual and sought to recover LKD follow-up care costs via the MCR or recipient Medicare billing to fulfill the OPTN mandate and recover associated costs. Billing the recipient’s Medicare and using the MCR tend to occur more at smaller compared to larger volume programs, and at centers with lower vs. higher baseline follow-up performance. Thus, broader-reaching education for transplant programs is needed on billing practices that are compliant with the CMS manual. We recently outlined appropriate mechanisms for recovery of follow-up care costs [34], which include (1) billing recipient non-Medicare insurance unless excluded in the insurer's contract, (2) covering costs with institutional or charitable funds [33, 35], (3) allowancing or writing-off at the transplant center level, and (4) billing donors or donor insurance (for services either at the transplant program or at a primary care physician’s office).

Future Directions for Managing Living Donor Follow-up Costs

Living donor candidates must be counseled in detail about the potential financial consequences of donation during the evaluation. Failing to counsel appropriately on financial risks may compromise the ability of donor candidates to provide informed consent. Living donors should also be educated on and assisted in accessing reimbursement programs for donation-associated costs, such as the US federally-funded Living Donor Assistance Center (NDLAC), and the National Kidney Registry’s “Living Donor Shield” when applicable [36, 37]. We also contend that universal access to living donor follow-up is important in the first few years to monitor health and to instill in donors the value of engaging in long-term routine screening. As such, there is a rationale to include living donor follow-up care as a covered benefit under OACC. Uniform access to follow-up care is especially important in the USA, where there are significant disparities in access to healthcare and living donor outcomes based on social determinants of health and other factors [14]. Provision of donor follow-up care may also reduce financial burdens on donors, and provide early warning systems for donors at increased risk of long-term complications [38].

We also support the concept of national tracking of donor outcomes and posit that gaps in funding mechanisms may limit such efforts in the USA. Successful models to acquire information on living donor outcomes exist elsewhere, particularly in countries with socialized medicine. For example, all living donors in Switzerland are registered in the Swiss Organ Living Donor Health Registry, which collects information from general practitioners at 1-year after donation and biennially thereafter [39]. Australia and New Zealand have a similar universal system [40]. In the USA, the Living Donor Collective is a Health Services Research Administration (HRSA)-supported initiative of the SRTR to create a lifetime registry for all donor candidates evaluated at US transplant centers [41, 42], for which pilot phase experience (June 2018–September 2020) was recently published [43]. Under the Living Donor Collective model, centers register donor candidates, and the SRTR is responsible for follow-up. Development of a government-supported national living donor follow-up registry like the Living Donor Collective may provide solutions for aspects of postdonation follow-up, but requires transplant program commitment to register donors and donor candidates, as well as donor engagement with follow-up outreach contacts after donation.

Conclusion

A path towards mitigating health and financial risks of living kidney donation includes maintaining a high level of adherence to complete living donor follow-up without financially burdening donors. We advocate for the revision of OACC policy to include follow-up costs as part of the commitment necessary for living donor care and safety, rather than solely for data collection. The SRTR Living Donor Collective may also provide a solution for long-term follow-up [41, 42], but requires a partnership of transplant centers in registering donors and donor engagement to be successful. Ongoing efforts to support follow-up for all living donors, including attention to covering necessary costs and removing financial barriers, are vital to help ensure opportunities for safe donation, especially among vulnerable groups.