Introduction: Proposed kidney allocation changes in the US are expected to increase average survival. This system would provide first access for candidates in the top 20% of expected survival to top twentieth percentile kidneys in the kidney donor profile index (KDPI). Candidates with high CPRA will also be prioritized. The outcome and economic implications of this proposal for wait-listed candidates have not been assessed.

Methods: We simulated the allocation of kidney allografts based on the proposed allocation system and compared the results with the current system and actual transplants in 2010. A Markov model was applied to to estimate differences between the existing and proposed systems in total lifetime cost of care and quality-adjusted life-years (QALY).

Results: Under current allocation policy, average lifetime outcomes per listed patient discounted to present value were $342,799 and 5.42 QALY, for an incremental cost effectiveness ratio (ICER) of renal replacement therapy of $63,775 per QALY gained. Under the proposed policy, lifetime cost and QALY were reduced by $1,764 and 0.03. The ICER for the proposed policy change was $60,540 per QALY lost. Increased access for top-20% candidates will increase private insurance coverage of kidney transplant and Medicare coverage of dialysis. However, less conversion to Medicare primary coverage at the end of the Coordination of Benefits period is expected among top-20% candidates, coupled with lower payments to centers for the transplant portion of the Medicare Cost Report. Total annualized savings in ESRD care from the policy change is expected to be $232,000,000, and is expected to accrue to Medicare primarily. Medicare savings may exceed total savings with a small or modest increase in total private payer ESRD costs.

Conclusion: Proposed changes to the kidney allocation system, if implemented, are expected to reduce both cost and QALYs in the US ESRD system. Most cost savings are expected to accrue to the Medicare ESRD system while most increased access is expected in private payer populations. The money saved per QALY lost is similar to the cost per QALY on dialysis in the wait-list population. Motivations beyond simple economic gains are required to justify this system.

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