Impact of Medicare Coverage on Disparities in Access to Simultaneous Pancreas and Kidney Transplantation
Melancon JK, Kucirka LM, Boulware LE, et al
Am J Transplant. 2009;9:2785-2791
Summary
The authors analyzed retrospectively a national cohort of 22,190 patients with type 1 diabetes mellitus aged 18-55 years who were candidates for either kidney transplantation or simultaneous pancreas-kidney transplantation (SPKT) between 1995 and 2008. The United Network for Organ Sharing database was used as the source of patient information. Medicare coverage for SPKT became available in July 1999, and the purpose of the study was to determine the impact, if any, of this new policy on racial disparities in patient access to SPKT. Between 1995 and 1999, the racial distribution of type 1 diabetic patients with end-stage renal disease (ESRD) who were registered for either kidney transplantation or SPKT was 74.1% white, 15.6% African American, and 7.7% Hispanic. After 2000, the racial distribution was 64.7% white, 20.2% African American, and 11.6% Hispanic. In addition, the proportion of registrants aged 50-55 years increased from 11.5% to 18.8% after 2000. Moreover, the proportion of patients registered for SPKT vs kidney transplantation alone increased in the later era (42.1% of Medicare, 43.8% of Medicaid, and 61.2% of privately insured patients were registered for SPKT in era 1 compared with 53.7% of Medicare, 53.8% of Medicaid, and 65.3% of privately insured patients in era 2). Although insurance disparities were reduced after Medicare coverage for SPKT became available, racial disparities remained (in era 1, the racial distribution of patients registered for SPKT was 57.1% white, 36.2% African American, and 38.0% of Hispanic compared with era 2, in which racial distribution was 68.2% white, 44.8% African American, and 42.9% of Hispanic). In general, since 2000, 27% more patients with type 1 diabetes and ESRD who registered for a transplant were listed for SPKT. Such data indicate that Medicare coverage significantly improved access to this procedure. However, no statistically significant effect on racial disparities in access to SPKT could be identified. Even with Medicare coverage, African American and Hispanic patients had almost 30% lower SPKT registration rates than their white counterparts in both eras.
Viewpoint
Minority populations in the United States suffer disproportionately from ESRD and diabetes. Although it is generally accepted (and expected) that access to transplantation among suitable candidates should not be influenced by characteristics such as age, sex, race, socioeconomic status, or geographic location, the reality is that multiple complex socioeconomic barriers contribute to ethnic differences in access. In addition, the shortage of donor organs results in rationing with unequal and uneven allocation of a limited resource. The Medicare program ensures nominally equitable care for all persons with ESRD. However, the study by Melancon and colleagues highlights the substantial and persistent racial disparities that exist in access to SPKT, even when Medicare coverage is available for this procedure.
Limitations of the Melancon study include the possible misreporting of race and type of diabetes and the potential pitfalls of interpreting large registry data. To minimize misclassification bias, the authors adjusted for body mass index (BMI) in all regression models and still found that African American and Hispanic patients with a BMI of less than 30 kg/m had more than 20% lower access to SPKT than white patients. Although substantial strides have been made in addressing ongoing ethnic differences in access and outcomes, further study is needed to elucidate the underlying causes for these disparities so that appropriate interventions can be developed to ensure equitable access.
Abstract