Author + information
- Brett W. Sperry, MD,
- Antonio L. Perez, MD, MBA,
- Paulino A. Alvarez, MD,
- Kay Kendall, MSW, LISW-S,
- Eiran Z. Gorodeski, MD and
- Randall C. Starling, MD, MPH∗ ()
- ↵∗Department of Cardiovascular Medicine, Desk J3-4, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195
Health insurance coverage, particularly Medicaid, has been a focal point in the national debate. Medicaid was designed to provide health care for vulnerable patients with limited financial resources; now, ironically, the program itself has become vulnerable (1) due to increasing health care costs and state and federal budget deficits. Arguably the most medically vulnerable population comprises those with organ failure requiring evaluation for transplantation. Before consideration of transplantation, patients undergo a comprehensive multidisciplinary evaluation that includes a psychosocial assessment as a Class I guideline (2). The assessment of psychosocial impairment is important for clinicians and transplant committees to identify and remedy potential barriers to a successful outcome. We sought to assess the association between health insurance status and psychosocial impairment in patients undergoing evaluation for organ transplantation.
The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) scoring system was used to quantitatively assess psychosocial variables (3). The SIPAT evaluates patients according to several aspects of their psychosocial well-being. Subcomponents of the score relate to a patient’s readiness for transplantation, social support system, psychological stability and psychopathology, and substance use. The final score is categorized into suitability for transplantation, with ranges of 0 to 6 (excellent candidate), 7 to 20 (good candidate), 21 to 39 (minimally acceptable candidate), and ≥40 (high-risk candidate). Elevated scores have been associated with poor psychosocial outcomes (3,4) and a higher risk of rejection, hospitalization, and infection after transplantation (4). It is important to note that health insurance status is not a component of SIPAT. Results are presented as medians and interquartile ranges and compared using the Mann-Whitney U test. Ordered logistic regression analyses using separate models with SIPAT and its subcomponents as dependent variables were performed in Stata, version 13.0 (StataCorp, College Station, Texas).
There were 454 patients evaluated for organ transplantation between April 2013 and June 2017 at our institution who underwent comprehensive psychosocial assessments including SIPAT calculation. If more than one score was calculated (n = 37), only the most recent was used. All patients were evaluated for heart transplantation, with 35 evaluated for combined organ transplant. Mean age was 55 ± 12 years, 74% were male, and 78% were white. At the time of evaluation, there were 46 patients (10%) who had health insurance through Medicaid alone, 45 (10%) through dual eligibility (Medicare and Medicaid), 173 (38%) through Medicare or Medicare Advantage alone, and 190 (42%) through commercial insurers. Patients with Medicaid were more likely to be younger (p < 0.001), female (p = 0.014), and nonwhite (p < 0.001).
Median SIPAT score was 15 (range 0 to 71) in the overall cohort, 24 (interquartile range: 16 to 36) in patients with Medicaid, and 14 (interquartile range: 8 to 22) in patients without Medicaid (p < 0.001). Overall SIPAT and subcomponent scores by insurance type are seen in Figures 1A and 1B, respectively. Medicaid insurance was significantly associated with higher SIPAT scores after adjusting for age, sex, race, and coinsurance with Medicare (p < 0.001). This association persisted across all subcomponents of SIPAT score (all p < 0.001). Patients with Medicaid were 6 times more likely to be considered high-risk transplant candidates after adjustment.
In this analysis, we found that Medicaid insurance in patients undergoing evaluation for heart transplantation was associated with greater psychosocial impairment as compared with Medicare or commercial insurance. This higher degree of psychosocial impairment may make Medicaid patients with advanced heart failure especially vulnerable if they experience a loss of health insurance, because the uninsured report significantly greater unmet health needs than insured adults (5). Stable affordable health insurance coverage for this medically and psychosocially vulnerable population is crucial to provide access to life-saving organ transplantation.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
- Fiedler M.,
- Aaron H.J.,
- Adler L.,
- Ginsburg P.B.
- Maldonado J.R.,
- Sher Y.,
- Lolak S.,
- et al.