Understanding Financial Hardship for Liver Transplant Recipients: A National Evaluation of Pre-Transplant Costs and Insurance Instability

Introduction: This study aims to examine the association between pre-liver transplant (LT) out-of-pocket costs (OOP) and post-transplant insurance instability among privately insured recipients, as financial strain from transplantation is significant and loss of private insurance post-transplant has been linked to increased risks of mortality and graft failure.

Methods: We included plan holders aged 18-63, continuously enrolled for at least 6 months pre-LT in employer-sponsored plans in MarketScan, a national private payer claims database. Insurance instability was defined as cessation of enrollment within 6 months post-LT. OOP admissions, outpatient, and pharmaceutical costs pre-LT were compared between patients who experienced insurance instability and those who maintained continuous coverage post-LT.

Results: Of 1706 LT recipients, 14% experienced a disruption in insurance coverage within 6 months of LT. Median time to insurance discontinuity was 2 months post-LT. Those with lower coverage retention after LT were more likely to have hepatic encephalopathy, hepatorenal syndrome, and biliary cirrhosis pre-LT and portal vein thrombosis post-LT (p< 0.05). Patients with insurance instability had 22.7% higher pre-LT OOP costs compared to those who maintained continuous coverage [$2999.83 IQR: ($1231.19 - $5500.84) vs $2444.55 IQR: ($1072.93 - $4331.64), p< 0.01].

Conclusion: Patients with greater severity of pre-LT liver failure and higher OOP costs are at the greatest risk of post-LT insurance instability. Targeted interventions aimed at improving insurance retention is crucial among this vulnerable group to mitigate risk of adverse post-LT outcomes.