Transplants and other high-cost care: What payers need to know

As transplant and cell therapy costs continue to increase, payers will need to focus on finding the right approach to drive better health outcomes while containing costs. Here are 3 developments that health plans should keep an eye on.

Organ transplant costs keep growing. More than 46,000 Americans received a new organ from both living and deceased donors in 2023.¹ This new record constitutes a nearly 9% increase over 2022 and a surge of more than 25% over the last 5 years.²

The rise in transplantation brings hope and increases the chance of lifesaving treatment to the more than 100,000 Americans currently waiting for a new organ.³ Thanks to improvements in medical care for end-stage organ disease, more patients are living long enough to make it onto a transplant list.

Due to breakthrough cures for hepatitis C, more organs are now usable for transplant. And as bioengineering achievements progress, organ availability may further increase as researchers create new organs from human tissue, animal organs, 3-D printing and even human stem cells.

Breakthroughs in ex vivo gene and cellular therapy are also creating a new frontier in the battle against cancer and other serious illnesses. These treatments extract and genetically modify a patient’s cells outside of the body, then return them to the patient to fight disease.

But transplants are also very expensive, with costs averaging $743,000 per transplant and ranging from $500,000 to more than $1 million.⁴ Costs can also be unpredictable, varying widely depending on the type of transplant, clinical complexity and where it’s performed geographically.

Advances in treatment for congenital heart problems mean more patients are living into adulthood. Today, more than 2 million adults live with congenital heart disease (CHD), and that population grows by 5% each year.⁵ But this medical success story also has a downside, as more adults with CHD are developing heart failure as they age.

A recent study found that the proportion of hospital admissions for adult CHD patients related to heart failure more than doubled from 6.6% in 2010 to 14% in 2020.⁶ These patients with heart failure also fared worse after hospitalization, with an 86% higher risk of death, a 73% higher risk of major heart and brain complications, and a 26% higher risk of readmission.

“Adult congenital patients are not an emerging heart failure subgroup but one that has fully emerged, and they are in need of specialized heart failure care now,” said Luke Burchill, senior author of the study and a cardiologist at the Mayo Clinic.

To provide the specialized service that this patient population requires while managing the financial risk, payers should find solutions that combine best-in-class CHD Centers of Excellence with competitive contracting. Together, these offerings can reduce the average length of hospital stay for CHD patients by 40% while driving 39% in contractual savings.

As targeted cancer therapies and immunotherapies continue to revolutionize the treatment of cancer, researchers are looking for ways to reduce both side effects and financial exposure.

Growing evidence shows that lower doses or shorter treatments could save money while reducing toxicity, but more clinical trials are needed.⁷

Another study found that patients with advanced melanoma and carcinoma who received a reduced frequency dose of immune checkpoint inhibitors demonstrated slightly favorable outcomes compared to patients who received standard dosing. By using a reduced dose on 23 patients, the study authors calculated savings of $1.74 million in drug costs.⁸

This ongoing research into lower doses could offer a meaningful response to the astronomical cost of new cancer treatments that strains both payers and patients. As more patients use immune checkpoint inhibitors, CAR T-cell therapies and other lifesaving, high-cost treatments, cancer costs are skyrocketing and could reach $246 billion by 2030.⁹

The kidney is the most transplanted organ in the United States, with more than 27,000 kidneys placed in 2023.1 That figure is expected to increase, as more than 800,000 Americans currently live with end-stage renal disease (ESRD).¹⁰

Insurance coverage for ESRD is also evolving, bringing with it a greater imperative to improve patient outcomes while managing medical spend. As part of the 21st Century Cares Act, patients with permanent kidney failure were allowed to enroll in Medicare Advantage plans beginning in 2021. This shift brought tens of thousands of patients to these plans for the first time and created a 20% increase in kidney transplant referrals.¹¹

To effectively manage this influx of patients with a costly disease, health plans should consider managed care programs that proactively manage patients with ESRD, engaging with them early to preserve remaining kidney function, manage comorbidities and adhere to medications.

At the same time, these programs offer trained coordinators who can help patients begin the complex path to transplantation earlier. This helps drive preemptive kidney transplants before dialysis that have been shown to improve patients’ quality of life while potentially saving hundreds of thousands of dollars of care over each patient’s ESRD journey.¹²

When it comes to organ transplants, patients and payers alike benefit from working with hospitals that have demonstrated skill in performing a high volume of these surgeries with excellent outcomes. 

Payers, then, should look to third-party solutions that invest in identifying and qualifying these superior providers to develop a robust Centers of Excellence network. Using these networks can improve survival rates for solid organ transplant patients while also reducing hospital stays and lowering costs.¹³ With the right approach, health plans can facilitate transplants and other extraordinarily high cost areas of care that can usher in a new era of hope and healing for seriously ill patients.

Learn more about Optum Transplant Resource Services.