Kidney Transplants

New research points to something that doesn't surprise most transplant surgeons: You're far less likely to receive a kidney if you're unemployed, even if you're near death.

They say this is not a form of discrimination, but rather an issue of “non-compliance.” It's economic reality, they argue.

Robert Woodward, a professor in the departments of health management and policy as well as economics at the University of New Hampshire conducted the study, along with doctors from three transplant hospitals in the Northeastern U.S. It appears this month in the journal Clinical Transplantation.

The researchers culled data from the U.S. Renal Data System (USRDS), including data provided directly to the United Network for Organ Sharing (UNOS), a private, non-profit organization that manages the U.S. organ transplant system under contract with the federal government. They examined the records of about 430,000 patients with end-stage kidney disease.

Of that group, 54,000 people were put on a waiting list for a kidney, and 22,000 actually received one. Patients working full-time were almost two and a quarter times more likely to receive a transplant than those not working or working only part-time, the researchers found.

Does Compliance Equal Income?

“In my experience, compliance is the issue, not employment,” Woodward told Healthline. “While we report a correlation between employment and wait-listing and transplantation, we have no evidence to suggest that employment or unemployment is a factor itself in the evaluations.”

However, Woodward said that the ability to pay $12,000 or so every year for immunosuppressive medications is an important factor to some, but not all, medical centers when they try to predict a patient's future compliance with their treatment.

“There's no easy answer in the conflict between ethics-based equal access and practical considerations required to make sure that each of the scarce kidneys available for transplant have as long an impact on the recipient's life as possible,” Woodward said.

In the case of end-stage kidney disease only, Medicare and Medicaid pay almost the entire cost of transplant surgery and immunosuppressive medications for life. For younger patients, however, the payments for medication end three years after the transplant.

Woodard said he would like to see Medicare extend the benefit of paid immunosuppressive drugs for life to everyone, regardless of age, unless they are in the top 25 percent of incomes nationwide.

Hospitals Can Make it Possible

“Employment status could potentially be considered a marker of overall physical and mental health of an individual, reflecting not only motivation and health consciousness, but also the likelihood of following health advice,” the researchers hypothesized in the study.

Jim Gleason, a member of the board of directors of UNOS and president of Transplant Recipients International, told Healthline he disagrees with that theory. “Unemployment has nothing to do with the ability to be compliant,” he said.

Gleason, who received a donated heart 19 years ago, stressed that having the financial resources to take care of one's self after the transplant is essential, however. “Life is not fair that way. Just because something is life-threatening doesn't change that fact,” he said.

Medicare does not pay for medications that are not immunosuppressives, so some hospitals also require secondary private insurance.

Still, Gleason maintained that Medicare recipients are not at a disadvantage when it comes to receiving kidneys and noted that transplant hospitals employ social workers and financial officers who help transplant candidates pay for their medications and stay compliant.

Gleason said he's even heard of surgeons performing life-saving transplants for free on people with good odds of long-term survival. In one case, a hospital paid a person's private insurance premiums instead of allowing him or her to become a state-funded emergency case. “They go to extraordinary efforts to save a person's life,” Gleason said.

Not Worth the Risk?

Dr. Amit Tevar, surgical director of kidney and pancreas transplantation at the University of Pittsburgh Medical Center, said employment status alone plays no role in the decision to place a candidate on the transplant waiting list.

“The system for transplantation in the U.S. is very fair, very equitable, and very transparent,” he told Healthline. “If there's something we can do to help [patients] overcome hurdles, we provide assistance to them.”

Dr. Mikel Prieto, surgical director of kidney transplantation at the Mayo Clinic, agreed. He told Healthline that most hospitals will go far as making sure a transplant candidate has money for bus fare after the surgery so he or she can get follow-up care.

In some cases, a hospital will even direct a patient to a different medical center better suited to meet their needs, he added. In Prieto's opinion, the people truly left behind when it comes to transplants are the very, very sick who have little chance of survival.

Prieto said most hospitals tout their transplant mortality rates on their Web sites. What's more, insurance companies are generally more willing to pay when a patient goes to a hospital with a high success rate. “Outcomes have dramatically improved," he said. "That's because we are cherry-picking who gets a transplant now.”

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