Medicare Advantage and Access to Living Donor Kidney Transplantation among Older Patients Receiving Dialysis.

Abstract

Key points: Medicare Advantage was associated with lower kidney transplant waitlisting among older adults initiating dialysis. After waitlisting, Medicare Advantage was associated with lower living donor kidney transplantation but not deceased donor transplantation. Findings suggest payer-related barriers may differ across transplant pathway steps and living donor processes.

Background: Medicare Advantage enrollment is rising among older adults with kidney failure. Compared with traditional Medicare, the contracted provider networks and utilization management of Medicare Advantage may introduce friction in transplant evaluation and living donor coordination, potentially restricting access for vulnerable beneficiaries. We examined whether Medicare Advantage is associated with access to living donor kidney transplantation and whether associations vary by rurality, age, or county-level social vulnerability.

Methods: Using the United States Renal Data System, we identified adults aged 65-80 years initiating dialysis in 2015-2021 with follow-up through March 15, 2024 ( N =284,166; analytic N =279,229 with complete covariate data). Payer was classified at day 90 after dialysis initiation for waitlisting and overall incident-cohort models and at waitlisting for postwaitlisting transplant models. Fine-Gray competing risks models estimated subdistribution hazard ratios (sHRs) for time to waitlisting (death as the competing event) and, among waitlisted patients, time to any transplantation (death and delisting as competing events) and to deceased donor kidney transplantation or living donor kidney transplantation (death, delisting, and receipt of the alternate donor type as competing events). We adjusted for demographics, dual eligibility, clinical factors, rurality, and county-level Social Vulnerability Index quartiles.

Results: Forty-two percent were enrolled in Medicare Advantage. Among 279,229 patients in adjusted models, 15,664 (6%) were waitlisted. Medicare Advantage was associated with lower likelihood of waitlisting versus traditional Medicare (sHR, 0.87; 95% confidence interval [CI], 0.84 to 0.90). Among waitlisted patients, Medicare Advantage was not associated with the incidence of any kidney transplantation (sHR, 0.99; 95% CI, 0.94 to 1.03) or deceased donor kidney transplantation (sHR, 1.04; 95% CI, 0.99 to 1.10) but was associated with a lower incidence of living donor kidney transplantation (sHR, 0.85; 95% CI, 0.77 to 0.94).

Conclusions: Among older adults with kidney failure initiating dialysis, Medicare Advantage was associated with lower waitlisting and lower living donor kidney transplantation after waitlisting but was not associated with deceased donor kidney transplantation or any kidney transplantation after waitlisting.