Reply: Liver transplantation costs in the era of a health care crisis

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We would like to respond to Dr. Haque's recent letter1 regarding our article on health care charges incurred by liver transplant recipients beyond the transplant admission.2 In his letter, he addressed the need for health care cost curtailment across medical specialties. He stated that analyzing the real cost in terms of the paid amount would have been more helpful for guiding specific interventions for cost containment in this population. Although we agree that actual payments would be interesting, we were limited to the available data. Unlike kidney transplantation, there is no national registry of payments following liver transplants. Thus, access to a national, private payer database offered a unique and valuable opportunity for comparing relative costs and the factors that influence transplant payments across many providers. There is ample evidence that charge data are highly correlated with actual costs and can be used to accurately describe relative differences in health care expenditures following liver transplantation as a function of the Model for End-Stage Liver Disease score. Liver transplantation remains the only life-saving therapy for patients with end-stage liver failure and must be considered in the context of other, expensive life-saving treatments such as implantable cardiac assist devices and multi-agent chemotherapy, both of which are associated with significantly less survival benefit. In addition, the cost of liver transplantation is only partially within the control of providers. The cost of liver transplantation is directly linked to the interplay of the recipient's disease severity, the local allograft supply, and the donor quality.2, 3 Therefore, centers in geographic areas with a very high demand for organs with respect to the supply are able to provide transplants to substantial proportions of their candidates only at advanced stages of disease severity, and they use higher risk organs in order to reduce the risk of certain death from untreated liver failure. As shown in our articles, these factors, more than the process of care, drive the cost of this treatment. We certainly agree that appropriate cost containment measures such as avoiding unnecessary investigation and minimizing the practice of defensive medicine should be pursued where possible. We disagree with the assertion that liver transplant costs are significantly inflated by clinical practice. Transplant specialists are limited in what they can do to minimize costs under an organ allocation system that requires the sickest transplant candidates to undergo transplantation first and is characterized by marked regional differences in the organ supply. We believe that resolving geographic disparities in the organ supply to allow earlier transplantation is vital to the economic sustainability of transplantation in an era of limited health care resources. We thank Dr. Haque for his comments and encourage exploration of other data sources to advance our knowledge of modifiable factors that may help us to manage transplant-related costs without worsening disparities in underserved populations. It is equally important to consider the fact that liver transplantation routinely produces 5-year survival rates in excess of 70% for patients destined to die without treatment. Paula M. Buchanan*, Nino Dzebisashvili*, Krista L. Lentine*, David A. Axelrod* , Mark A. Schnitzler*, Paolo R. Salvalaggio* , * Center for Outcomes Research, Saint Louis University School of Medicine, Saint Louis, MO, Department of Surgery, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire, Department of Surgery, University of Washington, Seattle, WA.