THE SHRINKING RENAL REPLACEMENT THERAPY "BREAK-EVEN" POINT

Abstract

17 Kidney transplantation has a high initial cost followed by the low maintenance cost of a functioning graft. Dialysis costs are also high, but tend to be stable over time. The time it takes for the initial cost of transplantation to be recovered by saving the cost of dialysis has been termed the "break-even" point. While a kidney transplant produces a net fiscal loss to the health care system during the time before the break-even point, savings accrue during the time the graft survives beyond then. Private third party payers thereby have a financial disincentive to encourage referral for transplantation in a setting where they are bearing the costs before, but not beyond, the break-even point. This is currently the case for health insurance carriers covering patients who develop kidney failure, since the latest Federal budget stipulates that Medicare does not become the primary payer for ESRD costs until 30 months later. While the break-even point has been estimated in the past to be around 3-5 years, recent developments in kidney transplantation have shrunk it to well below the 30 month mark for low-risk patients. METHODS: Recent trends in the management, outcome and cost of 123 live donor (LD) kidney transplants performed over the last 12 months at a single institution were compared with published reports on the cost of maintenance dialysis. RESULTS: Routine use of the tacrolimus and/or mycophenolate mofetil as maintenance immunosuppression has reduced the need for antilymphocyte immune induction from 85% to < 10% in LD recipients, for an estimated average savings of over $8,400 per recipient. These medications have also reduced the need to use antilymphocyte antibody for treatment of acute rejection from 40% to 20% of recipients, for an additional savings of over $2,300 per patient. Efforts to transition to outpatient management of LD kidney recipients by postoperative day #2 has significantly reduced our length of stay from 9 to 2.4 days, for savings of at least $6,000 per patient. The total cost of managing uncomplicated LD kidney transplant recipients for the first year is estimated to be less than $58,000. This compares favorably to the $44,200 annual Medicare payments per patient on hemodialysis for years 1991-1993 (USRDS 1996 Annual Data Report). Estimating the cost of transplantation for subsequent years at 20% of the first year, these data indicate that the break-even point for LD transplants is now between one and two years. CONCLUSION: Modern LD kidney transplantation results in a net savings over dialysis to third party payers within the time frame that they are responsible for ESRD costs. There is a strong financial incentive to refer patients for pre-emptive laparoscopic LD kidney transplantation before dialysis is initiated.