*Purpose: Despite innovations in clinical care, liver transplant (LT) remains highly resource intensive due to medical complexity and organ quality. National allocation systems prioritize access to the deceased donor organ supply based on medical urgency, resulting in increasing numbers of LTs performed in patients with high model for end-stage liver disease (MELD) scores, and increasing prevalence of organs imported from distant allocation regions. Despite the shift in transplant demographics, reimbursement is not directly tied to illness severity or to organ origin

*Methods: LT registry data from the Scientific Registry of Transplant Recipients (SRTR) were linked to the Vizient clinical database to assess the total cost and total direct cost of 4856 LTs in 51 transplant programs performed from 2006-18. Reimbursement data were derived from a dataset linking SRTR to Medicare Part A (facilities) payments for 7432 LTs. LT recipients were excluded if the pretransplant period exceeded 7 days. Medicare payments via the cost report were not included in this analysis. Laboratory MELD score at LT was used as a marker of illness severity.

*Results: The average cost of LT increased by 29% over the past decade ($148,721 to $191,927). The cost of LT varied significantly by MELD score (Figure) and donor location (local: $179,215; shared: $223,545). While mean Medicare payments increased by 34% for high MELD patients ($88,429 to $134,867, P<.0001) and 31% ($93,417 to $136,070, P<.0001) for imported organs, this was significantly less than the reported increase in cost per case.

*Conclusions: LT care has become more financially challenging as the population of patients undergoing LT evolves. Recent shifts in allocation in addition to higher transportation costs and organ import fees are likely to intensify financial pressure on program finances. Novel strategies to lower costs and increase reimbursement are needed to preserve the financial viability of LT programs.

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