The System of Health Insurance for Living Donors Is a Disincentive for Live Donation

Abstract

The health insurance system for living donors is derived from insurance policies designed to cover accidental death or dismemberment. The system covers only the direct consequences of organ removal, and recoups the costs of related medical services from the transplant recipient's health insurance provider. The system forces transplant programs to differentiate between health services that are, or are not directly attributable to donation and may compromise the pretransplant evaluation, postoperative care and longterm care of living donors. The system is particularly problematic in the United States, where a significant proportion of donors do not have medical insurance. The requirement to assign donor costs to a particular recipient is poorly suited to facilitate advances in living donation such as the use of nondirected donors and living-donor paired exchange programs. We argue that given the current understanding regarding the long-term risks of living donation, the provision of basic medical insurance is a necessity for living donation and that the system of attributing donor costs to the recipient's insurance is inefficient, has the potential to undermine the care of living donors and is a disincentive to the expansion of living donation.

The Canadian Kidney Paired Donation Program

“…11 The provision of lifelong donor health insurance also may be an advantage in increasing participation in KPD in Canada. In contrast, the current regulatory framework imposed by Health Canada and the lack of standardization between centers precluded shipping of live donor organs between centers and necessitated donor travel to the center performing the transplant.…”

The Effect of Race and Income on Living Kidney Donation in the United States

“…Unfortunately, information regarding donor health insurance is incompletely recorded in Organ Procurement and Transplantation Network/United Network of Organ Sharing (OPTN/UNOS) data and we did not adjust for this in our analysis. 15 Finally, the willingness of both ESRD patients and their prospective donors to participate in living donor transplantation may be lower in low-income populations. Mistrust of the health care system and a lack of knowledge about the safety of living donation have been associated with a reduced willingness to consider LKD 17,18 and may be more prevalent in low-income populations.…”

“…Although donor medical costs are covered by the transplant recipient's insurance, health insurance coverage is limited to medical claims that are directly related to donation. 6,15 Therefore, the cost of investigating and managing a medical problem identified during the work-up of a potential living donor is typically not covered by the recipient's insurance. Similarly, postdonation medical claims deemed unrelated to the donor surgery may not be covered by the recipient's insurance.…”

Critical Factors Associated With Missing Follow-Up Data for Living Kidney Donors in the United States

“…Complete follow-up at 6, 12, and 24 months was 67%, 60%, and 50% for clinical and 51%, 40%, and 30% for laboratory data, respectively, but have improved over time. Donor risk factors for missing laboratory data included younger age [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] (adjusted odds ratio [AOR] ¼ 2.03, 1.58-2.60), black race (AOR ¼ 1.17, 1.05-1.30), lack of insurance (AOR ¼ 1.25, 1.15-1.36), lower educational attainment (AOR ¼ 1.19, 1.06-1.34), >500 miles to center (AOR ¼ 1.78, 1.60-1.98), and centers performing >40 living donor transplants/year (AOR ¼ 2.20, 1.21-3.98). Risk-adjustment moderately shifted classification of center compliance with UNOS standards.…”