Publicly insured more likely to drop off liver transplant waitlist, study finds

Cancer patients with public health insurance were more likely to drop off the waitlist for a liver transplant than patients with private insurance, according to a study published Friday in JAMA Network Open.

Among 705 patients with a common type of liver cancer waiting for a transplant at the University of California, San Francisco, 46.7% of patients with public insurance dropped off the waiting list over a seven-year study period.

That compared with 28.7% of patients insured by Kaiser Permanente and 33.8% by other private insurers despite similar tumor-related characteristics, according to the study. In total, 246 patients dropped off the wait-list during the period that lasted from Jan. 1, 2010 to Dec. 31, 2016.

“When we think about patients with liver cancer who are listed for transplants, we typically think about the main reasons they don’t make it to transplant being clinical characteristics,” explained study author Dr. Neil Mehta, an associate professor medicine at UCSF. “But this study suggested that even though patients in all the different insurance categories had similar clinical characteristics, they had very different rates of dropping off the waitlist, specifically patients with public insurance.”

Of the 705 patients in the study, about a quarter of patients dropped off the waiting list specifically because of tumor progression or death. That included 19.2% of patients in the sample with Kaiser Permanente insurance, 26.1% of patients with private insurance and 33.2% with public insurance.

The study found that 416 patients received liver transplants from deceased donors, including 65.6% of patients with Kaiser Permanente insurance, 63.1% with other private insurance and 44.2% with public insurance. Others may have gotten liver transplants from live donors or a center outside of the study.

Researchers speculated that socioeconomic factors were to blame for public insurance being associated with a higher risk of dropping off the waitlist. Patients on Medicaid were more likely to be poor and unemployed and lack stable housing and social support, which could impact the patient’s ability to attend follow up appointments, for example.

Mehta explained that to remain eligible for transplant, liver cancer patients must get imaging done every three months to make sure the tumor stays within transplant criteria. Organizations such as Kaiser Permanente have care coordination programs to help patients navigate the testing and challenges that come with being on the waitlist, while publicly insured patients may not have that benefit, he said.

“Our main hypothesis is that if we can actually improve healthcare coordination delivery for these patients, that can hopefully reduce these disparities,” Mehta said.

In an emailed statement, Dr. Joanna Ready, chair of the Kaiser Permanente Liver Transplant Advisory Board for Northern California, said Kaiser Permanente ensures patients with chronic conditions have timely access to care.

“For our liver transplant patients, we provide comprehensive pre- and post-transplant services, including nurse coordinators, physicians, and sub-specialty care, such as radiology, oncology, and cardiology. This ensures critical conditions such cancer are identified early and managed efficiently throughout the transplant journey,” she said.

Half of the patients in the study sample had Kaiser Permanente insurance because UCSF has a contract with Kaiser Permanente in Northern California, but that organization did not sponsor the study, Mehta said.