Liver Transplant Candidates with Public Insurance Have Worse Waitlist Outcomes Than Those with Private Insurance

By Scott Maier

Patients with similar liver cancer characteristics on the waitlist for a liver transplant had significantly worse outcomes with public insurance compared to Kaiser Permanente or other private insurance, according to a study by researchers at UC San Francisco.

Their findings appeared online Aug. 30, 2019, in JAMA Network Open.

Neil Mehta portrait
Neil Mehta, MD, senior author of the study. 

“Public insurance should be recognized as a risk factor associated with waitlist dropout, and necessary steps should be implemented to mitigate the increased risk of dropout among these patients,” said senior author Neil Mehta, MD, UCSF Health gastroenterologist and associate professor of gastroenterology at UCSF. “Our findings have increasingly meaningful implications as growing numbers of patients listed for liver transplant have public insurance.”

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and third leading cause of cancer-related deaths. The only curative treatment options are tumor resection, liver transplant or local ablation.

Liver transplant is the best treatment for HCC, though about 15-30 percent of candidates dropout from the waitlist within a year of being listed, primarily due to organ scarcity and cancer progression. In addition, transplant centers often are in urban areas, with patients from rural areas having to frequently travel long distances to attend appointments, undergo tests or receive multiple bridging tumor therapies. Lower education levels and language barriers also can make navigating the transplant waitlist more challenging. 

The racial/ethnic and socioeconomic disparities in access to health care among patients with HCC are known, but there is little data on the association of insurance type with liver transplant waitlist outcomes in these patients. African Americans have twice the HCC incidence rate as whites, but are also the least likely to undergo potentially curative treatment compared to whites and Hispanics. U.S. adults with HCC who are uninsured or on Medicaid have been found to have more advanced tumor stage at diagnosis, lower treatment rates and worse survival rates. 

In the JAMA Network Open study, Mehta and his colleagues reviewed insurance data for 705 adult HCC patients at UCSF Medical Center on the liver transplant waitlist from January 2010 to December 2016. Most patients were white and male, with 349 patients (49.5 percent) having Kaiser Permanente medical insurance, 157 (22.3 percent) other private medical insurance and 199 (28.2 percent) public medical insurance. 

Kaiser Permanente was singled out in this study mainly for its emphasis on preventive care, timely patient appointments and excellent care coordination, the researchers said. In the study, Kaiser Permanente patients were most likely to have a college or higher degree (47.9 percent) and the lowest proportion of non-U.S. citizens (5 percent).

Of the overall HCC patient group, 246 dropped out from the waitlist during the study, with 174 (24.7 percent) due to tumor progression or death. Dropout due to tumor progression or death within two years of being listed was 21.8 percent for Kaiser Permanente, 25.5 percent for other private insurance and 35.5 percent for public insurance. 

In all, 416 patients (59 percent) received a deceased donor liver transplant, including 229 Kaiser Permanente patients (65.6 percent), 99 private medical insurance patients (63.1 percent) and 88 public insurance patients (44.2 percent). Among those who received a liver transplant within two years, 67.3 percent were Kaiser Permanente, 64.1 percent other private insurance and 48.5 percent public insurance. 

If a waitlisted patient’s condition worsens, he or she can be given MELD (Model of End-Stage Liver Disease) exception upgrade, which improves the chances of a timely transplant. But those with public insurance had significantly longer periods between MELD exception upgrades compared to those with Kaiser Permanente or other private insurance, Mehta said. Only 5 percent of patients who received a liver transplant at another health care center had public insurance versus 68 percent with Kaiser Permanente.

To potentially diminish these disparities, the researchers recommend improved health care coordination and delivery for patients with public insurance to facilitate liver transplant. Additionally, the United Network for Organ Sharing recently enacted a policy assigning HCC exception points based on median MELD score at transplant minus 3 points, which may reduce the incentive for private insurance patients to travel to other regions.