~~~
..  .. 
THE ACCESS 
OF DIALYSIS PATIENTS

TO KIDNEY TRANSPLANTATION

':1.H' I(IS 
OFFICE OF INSPECTOR GENERAL 
OFFICE OF ANAL YSIS AND 
INSPECTIONS 
MA 
1987  , ,

THE ACCESS OF DIALYSIS PATIENTS

TO KIDNEY TRASPLATATION 
RICHAD P. 
KUSSEROW  DATE OF INSPECTION 
INSPECTOR GENERAL  1-.ACp. 1987 
CONTROL #OAI-Ol-S6-00107
 Office of Inspector General

The mission of the Office of Inspector General 

promote the efficiency, effectiveness and integr(iOtIyG )o fi sp rtoog
 rams

HthSe )C.n iI tted states Department of Health and Human Services
does this by developing methods to detect and prevent 
waste and abuse. 
fra  Created by statute in 1976 
Inspector General keeps both the Secretary and the C,o ntghree
 ss fully

and currently informed about programs or management problems and

recommends corrective action. 
conducting audits  The OIG performs its mission by
, investigations and inspections with 
capporoxiumatenly try.  200  staff strategically located arounQ the 
Office of Analysis and Inspections

This report is produced by the Office of Analysis and Inspections

(OAI), one of the three maj  thin the OIG. 
or offices wi 
two are the Office of Audit and the Office of  The other
Investigations.
OAI conducts inspections which are 
typically, short-term studies
designed to determine program effectiveness

vulnerability to fraud or  , efficiency and

abuse. 
This Report

Enti tIed "The Access of Dialysis Patients to Kidney Transplan

tation 
" this report is based on a comprehensive study conducted

to help the u. S. 
Department of Health and Human Services and

other interested parties gain a better understanding of the
effectiveness 
, efficiency and equity of organ acquisition
practices in the 
U. S. 
The study was prepared by the Regional 'Inspector General

of Analysis and Inspections , Boston Region.  , Office

proj ect  Participating in the
were the following pe ple: 
Boston Reqion

Headquarters Office 
Mark R. Yessian
, Ph.
 Betty 
(proj ect Leader)  S. Burrier 
Barry McCoy 
Eleanor Ellis  TABLE OF CONTENTS

MAJOR FINDINGS 
. ii 
RECOMMENDATIONS 
INTRODUCTION 
THE PROBLEM

THE CAUSES

THE IMPLICATIONS 
I ,	
RECOMMENDATIONS 
APPENDIX I 
BACKGROUND AND METHODOLOGY

APPENDIX II

METHODOLOGY FOR MEDICARE

COST SAVINGS ESTIMATES

APPENDIX III

HCFA, ASH, AND ASPE COMMENTS ON

THE DRAFT REPORT AND OIG RESPONSES.
 .. ) 
MAJOR FINDINGS 
Al though kidney transplant surgeons report that at 
least 20 to 25 percent of the dialysis population is

medically suitable for a transplant, only 10 to 11

percent of that population is on a transplant waiting

list. 
A maj or factor contributing to this differential is the

failure of some dialysis facilities to provide their

patients with a full and fair opportunity to receive a

transplant. 
Across the country, a number of dialysis facilities

have transplant referral rates well below the national

average. 
Some of these are large facilities with SO or 
r !	
more patients. 
Under Medicare conditions of coverage, dialysis

facil i ties 
are required to develop patient long-term 
care plans that designate suitable treatment modalities

for patients. The oversight of this requirement by

state survey agencies and ESRD network organizations

has been spotty and often ineffectual. 
A Medicare requirement notwithstanding , it appears that

transplant surgeons are not regularly involved in

reviewing patient long-term care programs. Further, 
the patients' own role in this process tends to be

minimal and passive. 
A number of considerations support the case for 
significantly increasing the number of referrals for 
kidney transplantation, even at a time when close to
10, 000 individuals are already reported to be awaiting 
a transplant. Among them are the following: 
Precluding a patient the opportunity for a

transplant is unethical, regardless of the

list. 
length of a waiting 
Non-sensitized dialysis patients are likely 
to receive a transplant quickly. 
Increased waiting lists would reduce the

likelihood of cadaver kidneys being discarded

or provided to foreign nationals. 
The supply of cadaver kidneys may increase 
future. 
significantly in the near 
costs. 
Low referral rates can add to Medicare  RECOMMENDATIONS

HCFA should require that network organizations prepare

and disseminate 
, annually, a report that indicates
dialysis facility, the proportion of patients on a , by

list. 
transplant waiting 
HCFA should ensure that intensive oversight is given 
to dialysis facilities having transplant referral rates 
appreciably below the network. average. 
In particular,
the network organizations should be required to conduct 
thorouah medical records reviews of 
 uch facilities and

be authorized to prescribe corrective action 

plans. 
HCFA should ensure that State survey agencies conduct a 
thorough and more outcome oriented review of the Medi
care condition of coverage concerning patient long-term 
programs and patient care plans. 
HCFA should require that as a condition of reimburse

ment for routine dialysis
, a facility must have for

each patient a written long-term program and a written

patient care plan signed by the 

patient, a nephrologist 
and a transplant surgeon. 
HCFA should work with the Public Health Service to

encourage the American Society of Transplant Surgeons

(ASTS) to provide some guidance on which dialysis

patients are medically suitable candidates for kidney

transplants.  .:-
INTRODUCTION

Doinaley.s is is a life-saving process. It is also a debilitating
Each year it exerts a signifi ant toll on the physical 
social, psychological, and financial well-being of patients.
Each year close to one-fourth of those taking the three-times
week treatment die. 
In a 1980 study, we examined the impact that dialysis has on the
life style of patients. 
We heard patients describe the loss of 
physical strength, the dietary restrictions, the disruptions to 
their marriages and social life in general, and the weariness
associated with their continued dependence on a machine. 
Further, we found that the impact on their employability was
"dramatic and far-reaching. 
Of 160 patients we met who were
working full-time when their kidneys failed, only 29 (18 percent)
were working full time and 22 (7 percent) part time at the time
of our discussions.

It is understandable then, why the dialysis patients expressed 
considerable interest in kidney transplantation. Even the most 
skeptical and cautious among them tended to see in transplan
tation the possibility of a "cure-all, 
" of a chance for a normal 
life once again. 
In recognition of the opportunity transplantation afforded for

improving the quality of life for renal patients and for reducing

long-term costs for the Medicare-funded End Stage Renal Disease

(ESRD) program, Congress, in 1978, passed legislation providing

greater financial incentives for transplantation. In particular,
this involved the enactment of provisions 
(1) authorizing payment 
full for the reasonable expenses of kidney donors and 
in  (2)
extending program coverage for kidney recipients from 12 to 36 
months following transplantation. 
These provisions did provide some stimulus. But the maj 

transplantation came a few years later in response to 
increase  in 
significant advances in transplantation technology and immuno
therapy. 
Particularly notable was the widespread introduction in 
November 1983 of cyclosporine, a powerful immunosuppressive
drug. 
These developments led to considerable improvements in trans
plantation results 
, particularly with respect to transplants 
involving the use of cadaver kidneys. By the mid 1980s , the one 
year patient survival rate for those having a cadaver kidney 
transplant was averaging about 93 percent; the one year graft-
survival rate about 75 percent. For those having living related
transplants 
, the comparable averages were about 96 and 88
percent.  Accordingly, for many individuals whose kidneys have failed 
option. Al 
transplantation provides a viable treatment  though 
there are still risks and limitations, they are much less

pervasive than was the case when we conducted our study only 

years ago.

Since then the interest in transplantation has increased greatly

among both the professional and patient communities. From 1980

idney transplantation increased 
to 1986, the annual incidence of

63 percent, from 4, 697 to 7 695. 
Yet, in the midst of this change, 'we have found 
that across the 
country there are still a number of dialysis facilities that do 
not afford their patients with a full and fair opportunity to 
pursue the option of transplantation. This is 
so despite the
fact that Medicare ESRD program regulations require each dialysis 
facility to develop a "written long-term program representing the
selection of a sui table treatment modality (i. e., 
dialysis or
transplantation) and dialysis setting (e.g., home, self-care) for

each patient.

In this report, the second in a series of reports concerning 
organ acquisition systems, we examine this problem of limiting 
patient access to transplantation, a practice which some refer to
as " sequestering. 
We address the nature and dimensions of the 
problem, the causes, and the implications. We close with some 
recommendations addressed to the Health Care Financing Adminis
tration 
(HCFA) in the U. S. Department of Health and Human
Services 
(DHHS). 
THE PROBLEM

. even more pressing than the problem of

non-Americans receiving kidneys is the

problem of many Americans being dialysized

who are not being considered for

transplantation. " 
The above comment was part of prepared testimony submitted by 
Paul I Terasaki, Professor of Surgery at the UCLA School of 
Medicine, to the House Subcommittee on Investigations and Over
sig  t of the Committee on Science and Technology. The testimony
was presented in November 1983 at hearings which the Subcommittee 
held on the procurement and allocation of human organs for
transplantation. 
In the nearly 3 years that have passed since those hearings 
remains. 
we have found that the problem  Although transplant 
surgeons report that at least 20 to 25 percent of the dialysis
population is medically sui 
table for a kidney transplant, HCFA 
data indicate that only 11. 5 percent of that population is on a  , ,
list. 
transplant waiting  Taking into account the duplications 
reflected in the waiting list data, the actual proportion of 
dialysis patients awaiting a transplant is probably closer to 10
percent. 
Why is there such a differential between the proportion of
sui table 
candidates and the percent actually awaiting a trans
plant?  factor. 
Certainly patient choice is a  Some patients, of 
their own volition, prefreirs knost.  to have a transplant, which, after 
all, does involve some  Some may be reluctant to give up 
treatments. 
their time slot for regular dialysis  Others may have 
some interest in a transplant, but because of the distance to the 
transplant center may conclude that it is not a realistic
ternative. 
al  Some studies carried out by ESRD network organ
izations suggest this factor as a possibility. 
But clearly a maj or factor responsible for the differential is 
the failure of some dialysis facilities to keep their patients 
adequately apprised of the transplantation option and to suggest 
candidates. 
that option to the appropriate  This assessment was 
offered to us by many surgeons, nephrologists, transplant 
coordinators, and network directors from different parts of the
country. 
Most were quick to clarify that in their areas the phenomenon was 
not widespread -- that most dialysis facilities and referring 
nephrologists were quite conscientious in informing patients of 
treatment options and in referring them for transplantation. The 
numer of facil
problem, they added, tended to involve a small 
i ties, 
some of which were quite large and some of which had 
years. In 
consistently low referral rates over the  a few cases, 
the problem appeared to be more widespread involving much of the 
locale. 
dialysis community in a particular 
To get a better sense of the scope of the problem, we examined 
data on referral patterns of each of the dialysis facilities 
located in three different ESRD networks. The networks are in 
three different parts of the country: New England, the South and
the West. In 
each case, we had visited one or more cities in the
network. 
In each of these areas we found extensive variation in the degree 
facilities. 
of attention given to transplantation by dialysis 
While some regularly had referral rates of 15 percent or more, 
others were consistently at levels well below the national 
5 percent. 
average of 11.  Following is some capsule information 
on the three networks and the findings concerning them.  Network 
:#4 
This network covers 
13 counties in southern

California, including Los Angeles and Orange

counties. As 
of December 1985
, it included

106 dialysis facilities, which had 6

patients  204
, 9 percent of whom were on trans
plant waiting lists. 
In 31 of the facilities
, 5 percent or less of
the patients were on transplant waiting 
ists . Ten of these facil i ties 
had 80 or
more patients.

One dialysis facility with 117 patients had

only one individual awaiting a transplant.

Another ,l iwistth.  181 patients had only 4 on a

waiting 
Since 1981 that facility

consistently has referred only 1 to 2 percent

of its patients for transplantation.

Network #18

This network covers Alabama 

(except for one

county), Mississippi, Tennessee, and selected

counties in Arkansas
, Georgia, Missouri, and

Virginia. As 
of December 1984, it included

79 dialysis facilities
patients  , which had 4 284

, 9 percent of whom were on trans

lists. 
plant waiting 
In 26 of the facilities

S percent or less of

tlhies tpsat.i ents are on transplant waiting

These include 5 of the 18 facilities

with 80 or more patients and 14 of the 22 in

Mississippi. 
One facility with 205 patients had only 5

awaiting a transplant. 
Network #28

This network covers Maine
Hampshire , Rhode Island, a,n dMa Vssearcmhuosnett.t sA,s  oNef w

December 1985, it included 40 operating
dialysis facilities 
patients.  , which had 2, 744
During 1985 , 9 percent of the
patients had a kidney transplant. 
(Data on

percentage of patients on transplant waiting 

ists were not readily available.
 In 8 of the facilities 
5 percent or less of 
the patients received a transplant in 1985. 
Two of these facilities had 80 or more 
patients. 
One facility , with 253 patients had only 8 of 
its patients receive a transplant in 1985. 
In another facility that maintained a patient 
census of about 50 in 1984 and 1985, none of 
the patients received a transplant during 
that period. 
It is important to recognize that the presence of some facilities 
having low transplant referral rates in these networks is not 
networks. 
unique to these  The same phenomenon is likely to be 
found in all or nearly all the networks. 
In some instances, of course, the medical condition and/or age of 
tfheer rpaatli.e nts may very well explain the low incidence of re
In many other facilities, especially larger ones having 
80 or more patients, patient characteristics are much less likely 
to provide a satisfactory explanation. 
THE CAUSES

Why, then, aren't more dialysis patients who are likely can
didates for transplants being considered for transplants? 
Indeed, in view of the widespread reports on the successes of
transplants  I t 
, why aren  the dialysis patients themselves urging 
that they be considered for transplants?

In actuality, dialysis patients are becoming more informed and

regard. 
assertive in this  That is in part responsible for the 
fact that from 1980 to 1985 kidney transplant waiting lists have
increased from 5, 072 to 9, 781, from 9. 
7 percent of the dialysis
population to 11. 5 percent.

But there are two maj or factors that serve to constrain patient
ini tiati ve in  option. 
seeking out the transplantation  One is
that those .
wi th unsuccessful transplants typically return to the 
dialysis facility and share their frustrations with the other 
patients, while those with successful transplants are seldom if 
in. 
ever seen aga 

More significant perhaps is the other factor - the dependence and

deference that generally characterize the patients I relationship 
wi th their nephrologists. From the onset of their kidney
failure 
, which often causes considerable disorientation and 
anxiety, patients usually become accustomed to following the 
direction and advice of their nephrologists on matters concerning 
their treatment.  As noted 
earlier, it appears that most nephrologists are quite
conscientious in considering the best treatment plan for their

patients and that many are becoming increasingly inclined to

recommend transplantation. On the 

ations  basis of medical consider

, however, some still seem to have major reservations about
transplantation and are likely to take a very conservative

approach in determining its appropriateness for their 

patients.
Instead of the previously cited 20-25 percent of the dialysis

patients being prime candidates for 
transplantation, they may

regard 5 to 10 percent as a more appropriate 
level.

Notwi thstanding that there is room for disagreement on the basis 
of medical considerations
, many individuals
of transplant  , including a numer
surgeons, feel that other considerations often loom
behind a nephrologist' 
s lack of enthusiasm for transplantation.
In particular, they refer to financial 

considerations. By

referring a patient for transplantation
take the chance of losing income In a ne,w etrh efya cnioltiet,y  nterpyhirnogl otgoi
sts

get established
, a proprietary one owned by nephrologists

having a difficult time maintaining its  , or one

factor  caseload, this financial

, some feel, may be particularly important. 
Nephrologists are quick to deny such 

them do express concern that patients awshsoe rrteicoenisv.e  Bau ttr amnasnpyl aonft

often become "captured" by the transplant surgeons -- that 
is,

they don't refer the patients back to the nephrologists for post-
transplant care concerning their renal disease. 
respond that they are best suited to manage the drSuugr greeognism etne nfdo rt o
the patients and to identify early signs of impending graft
failure. 
Given that a dialysis facility is required in Medicare regula

tions to develop patient long-term care plans that designate

suitable treatment modalities for patients and that involve

transplant surgeons in the process

facili ty,  , one might well ask how a

for whatever reasons, could deny its patients full and
fair access to transplantation. The answer 

of this requirement has been spotty and ofteni s that the oversight

ineffectual,

particularly, it 
appears, during the past year or 
two.

The responsibility for oversight 1s that of the state survey

agencies and the ESRD network 
review dialysis facil i ties  organizations. The State agencies

as part of the Medicare survey and
certification process to assure that they are in accord with

Medicare conditions of 
participation. The 
network organizations

are responsible under Medicare regulations for fostering the

quality and appropriateness of patient 
care, including "the use

of those treatment settings most compatible with the successful

rehabil itation of the patient.

The State survey teams, first of all, review ESRD facilities

about every other year. 
From HCFA' s Medicare/Medicaid Automated

Certification System (MMCS), we 
years  found that over the past 2
, 183 or 12 percent of the 1503 dialysis facilities reviewed  were found to be deficient in meeting the Medicare standard

concerning a patient long-term care program. 
(This standard and
another concerning patient care plans together constitute a

condi tion. "  We have not determined the exact nature of the

deficiencies found across the country. 
But for one State having
a significant number of these deficiencies
, we learned that most

involved a failure to have a written long-term care program in

the patient' s file. 
This data and our review suggest that some States give a good

deal of attention to whether or not proper procedures are

followed in determining a patient' 
s treatment modality. 
But in
24 States no facilities at all were found to be deficient with

respect to the above noted standard and in 14 others only 2 or

less were identified as deficient. In 
one heavily populated
urban area, where referral for transplantation has been a

significant problem
, the State survey team cited only two

facil i ties 
, during the past 2 years, for being in violation of 
the standard.

Further 
, even where deficiencies are identified and corrective 
action subsequently taken, it does not necessarily have a notable
effect on the rate of referral, since the thrust of the State 
review is on process elements rather than outcomes. Illustrative
is the experience in one State where the State survey team awhile 
back raised concerns about how transplant surgeons were not 
adequately involved in preparing patient care programs. 
to an arrangement whereby the dialysis facilities would reTghuilsa rlleyd 
send medical records to a transplant 
surgeon, who would review
them and then send them back to the facility with his comments
about the sui tabili ty of a transplant. In 
assessing that
process 
, the surgeon told us how he seldom heard back concerning

any of the cases he reviewed.

As a rule 
, it appears that transplant surgeons are not regularly
invol ved in reviewing patient long term care programs.
And when 
they are involved, it tends to be in a distant and rather
passive way as noted above. 
Rarely, it seems, do the nephrolo
gist, transplant surgeon, and other professionals meet with the

dialysis patient, as a 
team, to discuss treatment options. 
One
factor that may tend to discourage such practice is that trans
plant surgeons are not allowed to bill Medicare for consultation 
rvices for dialysis patients considering a 
transplant. Such
services are regarded as part of the nephrologist'
capitation payment.  s monthly
Any payment to the surgeons must be made
directly by the nephrologists.

Network organizations
, as noted, also have a role in overseeing

dialysis facilities. Over 
the years, many of them, have devoted

considerable attention to the adequacy of dialysis facility 
practice in alerting patients to transplant opportunities.
Through surveys 
, medical record reviews of individual facilities  patient education, and other initiatives

, they have been instru

mental in improving referral rates for transplantation 

(as well
as home dialysis). In 
many cases 
, peer review and pressure seem
to have had some effect 
 changing the practice of those with

unusually low rates.  in 
In cases where they haven'
t, the network

it. 
organizations haven't been able to do much about 

During the past 2 
years, as a result of bUdgetary cutbacks

pnetworrk oerganpizatiaons arppeear tod haye. be come less active and, the
effecti ve in this area. 
In a number of cases
, the financial
restrictions have led to reductions 
 the scope of studies 
undertaken, medical records reviewedin 
, and informational material

THE IMPLICATIONS

The most important implication associated with the finding that

many dialysis patients who are sui 
are  table transplant candidates

, in fact, not being considered for a transplant is

course , quite clear.  , of

It means that they are being deprived of an

opportunity to improve the quality of their 

life. A national
study conducted recently by the Batelle Human Affairs Research

Centers and funded by HHS found that

" transplant recipients

consistently reported a higher objective and subjective quality

of life than patients undergoing any form of dialysis.

Preclud
ing this opportunity to a dialysis patient is an unethical and

lirirsets.po nsible practice
, regardless of the length of a waiting

This is reason enough for attempting to eliminate the
practice. 
Nevertheless 
, in the current environment where demand for cadaver 
kidneys exceeds the supply, where close to 10,

000 individuals are

reported to be awaiting a transplant
, one may argue that a

significant increase in referrals would yield little net
benefit. 
In fact, one may even argue that it would only serve to
raise expectations and add to the laboratory and other costs 
incurred by those on a transplant waiting list. 
We find such a position to be short-sighted and detrimental 
because it overlooks a number of important 
considerations.
Four 
are of particular note. 
Non-sensi tized dial vsis patients are likelY to receive
a transplant auickly  lists,
Despite the long waiting 
patients with a low level of preformed antibodies are

usually able to have a kidney transplant wi 

thin a few

months of the time they are placed on a waiting list.
This is because highly sensitized patients
, those who

are most difficult to match with a donor kidney, have 
become an increasingly prominent part of the transplant
wai ting lists. As of June 1986, 40 percent of 8, 
610  recipients on the national waiting list of the 
United 
Network for Organ Sharing had a Panel Reactive 
Antibody
(PRA) level of 60 percent or more. 
This means that
ktheiy dwenre eliykelsy  tot rehjeactt 
  became availabalet.  least 6 of every 10 donor

Thus many non-sensitized patients who are not on the

waiting lists could receive a transplant much sooner

than the waiting list statistics might lead one to

expect. 
Moreover, many immunologists and surgeons

believe that they would be likely to keep the trans
planted kidney longer and have fewer
' complications than
would those who are highly sensitized. 
Increased waitina lists would reduce the likelihood of 
cadaver kidneys beina discarded or Drovided to foreian
nationals 
In accord with recommendations in our first 
report, HCFA is taking steps to assure that kidneys are 
not offered to foreign nationals unless it has been
determined that no sui 
found. In  table U. s. recipients can be
many localities and transplant centers,
increased waiting lists would add measurably to the

likelihood of suitable U. 
s. recipients being found.

The same applies to increasing the possibility of a

kidney being used. 
As waiting lists 
increase, the jOb

of finding a suitable recipient tends to be expedited

and simplified. More 
specifically, the organ procure

ment agency is more likely to find a suitable candidate

in the same vicinity of the donor hospital, thereby

saving travel time and reducing the complexity and

uncertainty associated with sending kidneys a long

distance. This
, in turn, reduces the risk of wastage.

This point was well illustrated in an article written 
by G.M. Williams 
, et al, that was published in the 
February 1985 issue of 
 TransDlantation Proceedings

Entitled "Renal Transplant Wastage: 

Problem  An International

" the article focuses on 575 kidneys that were
excised by members of the United Network for Organ
Sharing 
(UNOS) during an 1S month period and that were 
either discarded or sent 
overseas. It showed that 393

(68 percent) of these kidneys "failed to be trans
planted in the United States because of our inability 
to identify non-sensitized recipients" (p. 1594). 
More
effective systems for sharing kidneys could help reduce 
such losses. 
So, too, could increased waiting lists

that would facilitate timely placements of donor

kidneys.  The supply of cadaver kidneys may increase siqnifi

cantl y in the near future 
This certainly is not a

sure thing. 
But given the considerable untapped

potential of the donor pool and the extensive support 
being shown for the establishment of hospital "
routine 
inquiry" procedures 
, it is quite probable. 
Such
procedures would ensure that the next-of-kin of

suitable donors are alerted to opportunities for

donating organs and tissues. 
The Task Force on Organ Transplantation, wi 
thin its 
April 1986 final report, strongly endorsed " 
routine
inquiry" and recommended that the Joint Commission on
the Accreditation of Hospitals 
(JCAH) incorporate
it as a standard and that HCFA include it as a Medicare 
condition of participation for 
hospitals. The 
considering the adoption of a standard of this kJiCnAdH  ainsd 
Congress is considering legislation that would tie 

routine inquiry" with the Medicare and Medicaid

programs. 
More notable is that at least 25 States already have

passed legislation requiring hospitals to establish

routine inquiry" procedures. 
The great maj ori ty

the States passing such legislation have done so in

1986. In 
those and still other States considering

similar legislation, there is considerable optimism

that it will increase the level of organ and tissue

donations. 
Mindful of these developments and the problems he has

experienced in receiving referrals from dialysis

facilities in his area
predicted:  , one transplant surgeon

"We'll have a surplus of kidneys sooner
than we'll have appropriate sized referral lists.

Low referral rates can add to Medicare costs

This is
most obviously the case if Medicare recipients are

deprived of kidneys because they were discarded or

given to foreign nationals, 
or, as speculated above, if

the supply of kidneys were to increase substantially

(without a concomitant jump in referrals). 

cases the Medicare program could be denied thIen  ospupcohr
 

tuni ty of cost savings, 
since, over time, the cost of

dialysis exceeds that of transplantation. 
There are also other, more subtle ways in which costs 
can be affected. 
One, as noted in the following 
comment by the director of a tissue typing 
laboratory, 
concerns the frequency of collecting serum 
those on transplant waiting lists:  samples. for  ! :
"Dialysis facilities and transplant centers 
are in competition. They 
another.  don't like one
They don't cooperate. If there
were better cooperation, we wouldn't need a

serum sample every two weeks. 
We'd get one

only after a blood transfusion.

RECOMMENDATIONS 
In the United Kingdom
, kidney dialysis now tends to be regarded

as a sustaining device, pending a kidney transplant. 

those admitted to the dialysis program are admitted witNhe atrhley
 all

understanding that they are candidates for a 
transplant.

In the United States
, where dialysis is a near universal entitle

ment regardless of medical condition or age

tion concerning transplantation would not be, a parallel presump

desirable. Yet

given the significant advances in transplant outcomes and the

fact that transplantation is more cost effective than dialysis

an increased emphasis on transplantation would be quite

desirable. 
The " routine inquiry" initiatives that were mentioned earlier

reflect an important move in this 
direction. As we 
can provide a significant impetus to the supply of candoatveedr,
 they

organs. At 
the same time, for the reasons we have addressed, the
demand side should also be addressed. 
when Congress extended program coverage Tfhriosm  w1a2s  tdoo n3e6  imno n1t9h7s8
,

following transplantation. Now
, with transplant outcomes much

better than those in 1978 and with thousands of medically

sui table dialysis patients not on transplant waiting lists
once again time to devote some policy attention to the  , it is

matter. 
In this regard, we urge that HCFA ensure full and effective

enforcement of the Medicare condition of coverage requiring that

dialysis facilities maintain patient long-term programs and

patient care plans. 
In addition to requiring an up-to-date,

wri tten 
assessment geared to the particular needs of a patient 
this condition requires that a transplant surgeon as well as the
physician-director 
(nephrologist) of a dialysis facility and
other professionals participate in making that 

assessment. 
HCFA' s recent regulatory changes concerning the structure and 
roles of the ESRD network organizations could help with the 
enforcement of this important 
condition. They 
have the potential
of generating more efficient network organizations that are more 
sharply focused on their statutory requirements concerning the 
and appropriateness of care. 
quali ty  Below we offer five recommendations. Each is 

directed to HCFA

and each can help the network organizations perform their 
oversight responsibilities more 
effectively. The 
first two
directly concern network organization acti vi ties; 
the next three 
an indirect way, but are no less important. 
do so  in 
HCFA should reauire that network orqaniza

tions Drepare and disseminate, annuallY, a

report that indicates, bv dialysis facility, 
the DroDortion of Datients on a transDlant

waitinq list

Such a report should also provide information on the total number

of patients of each facility; on certain characteristics

whether or not the facility is part of  , such as

a transplant center;

and/or the proportion of patients on a transplant waiting list in

the network area as a whole. 
Moreover, it should be distributed
widely to ESRD professionals
other interested parties.	 , patients, State survey teams

, and 
The report would provide comparative data that could be of

considerable value. 	
Most important, perhaps
, is that it would

serve as a form of peer pressure on those facilities with 
referral rates below the average and with no plausible explana
tion accounting for them. 
Through a proposed regulatory revision requiring the creation and

maintenance of a transplant waiting list by each 

facility, HCFA

is taking an important step in the above noted 
direction.
However, to achieve sufficient 
impact, we still feel it is
important to assure that the proportion of dialysis patients on 
each list is clear and that this information is widely
disseminated. 
HCFA should ensure that intensive oversiqht 
to dial ysis 
is qi ven  facilities having
transplant referral rates aDDreciablY below
the network averaqe. 
In Darticular, the
network orqanizations should be reauired to 
conduct thorouqh medical records reviews of 
( I	
such facilities and be authorized to Dre
scribe 60rrective action Dlans 
For the laggard dialysis 
facilities, a greater sense of urgency

and seriousness must be 
that.  conveyed. The above steps would provide

There are, of course, some facilities that will have lower

referral rates for justifiable reasons -- most notably because of

the age and/or medical condition of their patients. 
Network
organizations should have flexibility in determining such

facili ties 
and what if any special attention should be given to  them. 
For those with unjustifiably low referral 
the network organizations should address the problreamt ebso,t hh oiwne
ver

terms of individual cases and the systemic factors that led to

the problem. It 
is with respect to the latter that corrective

action plans should be directed. 
In cases where more information appears to be 

needed, HCFA could

ask the State survey agency to investigate the reasons for a low

percentage of transplants. The network 

organizations, however,

should remain involved and have primary responsibility for

identifying and directing corrective actions. 
HCFA should ensure that State survey aaencies

conduct a thorouah and more outcome-oriented

review of the Medicare condition of coveraae

concernina Datient lona-term Droarams and

patient care Dlans

Through a State agency bulletin, HCFA should alert the States to 
the fact that many dialysis patients are not adequately informed 
about transplantation opportunities and should urge the survey 
teams to give more scrutiny to this issue. In 
should ask that the survey teams determine if trpaanrstpilcaunlta rs,u rigteons 
have been involved in developing the 
programs , as is called for in the regpuatlaietinotns's .l ong-term care
it would be helpful to amend the interpretive guiIdne ltihinse sr eigsasrude,d

to State survey teams so that they call for verifying the

participation of transplant 
surgeons. Even 
more helpful would be

to redesign the survey instrument for ESRD facilities so that it

is more outcome oriented. 
This was done recently for skilled

nursing facilities and intermediate care 

facilities. The case

for a similar change involving ESRD facilities is no less
compelling.

The network organizations could facilitate the State 

agencies'
oversight in this area by providing them with data on the trans

plant referral rates of dialysis facilities. 

Similarly, the

State agencies could help the network organizations by passing on

to them any problems they identify concerning a facility'

efforts in developing patient long-term programs and patient care

pl ans . 
HCFA should require that as a condition of

reimbursement for routine dial 
facility must have for each patvsisi, ent a written 
lonq-term DrOqram and a written Datient care 
plan siqned bY the Datient, a neDhroloqist,
and a transDlant suraeon 
Except for the signature 
requirement, this is the same require

the condition of Medicare coverage. 
ment set forth 
 in  The
rationale for making it 
a condition of payment is that the level
 of importance attached to the practice is raised. 
requiring signatures is that the participation of thTeh ep aptoiienntt so f
and the physicians is more readily documented and 
audited. 
HCFA should work with the Public Health 
Service to encouraae the American Society of
TransDlant Suraeons 
fASTS) to Drovide some
quidance on which dialysis Datients are

medicall y suitable candidates for a kidney

transDlant 
Al though 
we recognize that no hard and fast criteria concerning
medically sui table 
transplant candidates could or should be
developed 
, some general statement addressing this matter by an
authoritative body such as ASTS 
would be of considerable value.
For network organizations, State survey teams and 

others, it

would provide a useful frame of reference 
 determining the
overall adequacy of a dialysis facility' s ein fforts to alert
patients to transplant opportunities. 
If these recommendations were to be carried 

would have a considerable effect in improvingo utth,e  waec cfeesesl  otfh
ey

dialysis patients to kidney 
transplantation. They would extend

the opportunity for a transplant to many who are now denied that

opportuni ty. And they would contribute to cost savings in the

Medicare program.

The savings 
, as suggested earlier, would be generated in a 
of ways. In  numer
the near term, the most significant would appear to
be those associated with a reduction in the number of discarded

kidneys. In this 
regard, we assume that implementation of the

above noted recommendations would be responsible for a reduction 
in the overall rate of discarded kidneys from an estimated 14 
percent at present to about 11 percent in 1988. 
substantial number of discarded kidneys are lost bGeicvaeuns et hoaft  aa 
failure to identify non-sensitized patients, as was indicated in 
the study cited earlier, this projection would appear to be quite
reasonable. 
Because of the increased number of Medicare 
recipients who would be able to receive a transplant in 

1988 , the Medicare program would benefit from cost saving1s9 8t7h aatnd

wi thin 5 years would amount to an estimated $18. 
3 million 
Appendix II).  (see APPENDIX I 
BACKGROUND AND METHODOLOGY

Over the past few years
, the subj ect of organ acquisition has

become an increasingly important and 
controversial one. 
paper reports 
, television news shows, radio talk shows
 News

sional hearings , and other sources have been raising ha,r dc oqnugerse
s

tions about the adequacy of current systems for obtaining and

distributing cadaver organs and tissues that will be used for

transplantation. 
Because of these questions and the Medicare program 

I s significant 
stake in the condition of the country 
I s 
systems  organ acquisition
, the Off ice of Inspector General has undertaken a broadly
based study of these 
systems. Its 
overriding pUrpose is to
promote a better understanding of them in terms of their effec
tiveness 
, efficiency and equity, and to identify policy direc
tions that might be taken to promote these 

ends. 
The study, which was initiated in January 1986

three maj or modes of inquiry:  , has involved

Reviews of literature and data bases

articles  , including journal

, books , governmental reports and statistical
compilations of public and private organizations.

Particular attention has been devoted to the review and

analysis of 1984-85 cost reports submitted by HHS

certified independent organ procurement agencies and by

Medicare certified transplant 

centers, and to the

review of documents and reports generated by the Organ 
Transplantation Task Force established by the National 
Organ Transplant Act of 
1984. 
Visi ts to 17 cities
, focusing on reviews of the organ

acquisition practices in those cities. 

These involved

discussions with transplant surgeons and
nephrologists  coordinators,
directors, fis,c aimlm unologists, procurement agency
analysts, ESRD network directors and
others associated with organ acquisition and transplan
tation. 
The cities visited were: 
San Francisco; Los

Angeles; Denver; Chicago; MinneapOlis; Memphis;

Nashville; Houston; Dallas 

Charlottesville; PhSain Alntaondio e
 lphia; NMieamiw York;

Richmond 
Boston; and Washington, 
D. C.

Telephone discussions and selected visits with various

individuals knowledgeable about organ acquisition

issues. 
practices and 
These included representatives
of organizations, such as the Southeastern Organ

Procurement Foundation, and the American Council on

Transplantation; many of the members of the task 

force;
academics; and various officials in the Department of
 Heal th and Human Services, most especially in the

Public Health Service and the Health Care Financing

Administration; and others. 
This report is the second of a series of reports that will

study. 
present the findings and recommendations of the  Forth
coming reports will address the costs of organ acquisition

and the effectiveness of organ procurement and distribution

systems 
, with particular attention to the extent and nature of 
both wi thin regions and across the country. 
organ sharing 

In each of these reports primary attention will be given to

kidney acquisition. This is because there has been much more 
experience and activity concerning renal than non-renal organs.
Congress has extended Medicare coverage on a near universal basis 
to those requiring dialysis and transplantation since 
1972. 
During that time more than 50, 000 kidney transplants have been
performed in the U. S. , the maj ori ty of which have involved the
use of cadaver kidneys. 
In the years ahead, however, transplantation of non-renal organs,
especially hearts and livers, will become especially prominent 
given the continued advances in technology and the fact that 
Medicare now covers liver transplants for Medicare eligible 
children with biliary atresia and will be covering heart trans
plants for Medicare eligible individuals meeting specified 
medical criteria. This prospect for accelerated growth is

suggested by the fact that the number of both heart and liver 
transplants doubled between 1984 and 
1985, and from 346 to 719 in
the case of hearts and from 308 to 602 with respect to livers. 
the 
In that period, the number of kidney transplants performed 

s. rose from 6, 968 to 7, 965.  in 
Thus, the problems encountered and lessons learned concerning 
kidney acquisition have broader relevance to organ acquisition
generally. 
There are some distinguishing characteristics between 
non-renal and renal acquisition (not the least of which is that
non-renal organs must be made available for transplantation much 
more quickly). But there are also important commonalities
, among
which is the fact that the same organizations typically handle 
renal acquisition. 
renal and non- Accordingly, the findings and
recommendations of this study, although focused on kidneys, have 
general. 
significance for organ acquisition  in  (,. 
APPENDIX II

METHODOLOGY FOR MEDICARE

COST SAVINGS ESTIMATES

The methodology involves the following assumptions and calcula

tions: 
We base the estimate on the period between

October 1, 1987 and September 
30, 1988 and

. assume that during that period and the 
preceding periods of October 
1, 1986 
September 30, 1987 and October 1, 1985 
September 30, 1986 the rate of Medicare 
reimbursed cadaver kidney transplants would 
increase at the same rate that all cadaver 
transplants increased between CY 1984 and CY
1985: 
10 percent. Such a rate of increase 
would result in 5, 772 Medicare reimbursed 
cadaver transplants in FY 1986 (5,
percent increase), 6,  247 plus 10

349 in FY 1987 (5 772
plus 10 percent increase), and 6, 984 in FY
1988 (6 
349 plus 10 percent). 
We assume that the discard 
(wastage) rate for
percent. 
FY 1987 will be 14 
This is based on
estimates of individuals who have studied the 
depth and on data obtained from 
matter  in 
Aetna and from the HCFA Annual Facility
Survey. 
See page 10 of our forthcoming 
report entitled "Organ Acquisition 
Costs: An

Overview. " 
With a 14 percent wastage rate, organ

procurement agencies would have to procure

121 cadaver kidneys in FY 1988 to account 
for 6, 984 cadaver transplants. 
This involves
the wastage of 1, 
137 kidneys. If 
the wastage
rate were 11 percent, 893 kidneys would have
been wasted (11 percent of 8, 
121) instead of
137 (14 percent of 8, 121). 
This represents
an additional 244 transplants that could be
performed (1, 137 minus 
893) for a total of
228. 
Each transplant of a Medicare beneficiary

generates an estimated 5-
year cost savings of
$75, 000 (for an explanation of the method
ology used in deriving this $75, 
000 estimate,

see Appendix II of our August 1986 report

entitled "The Access of Foreign Nationals to

U. S. Cadaver Organs.  Thus , the estimated 5-year cost savings for
the 244 additional kidneys that

would be

provided to Medicare recipients
$18. 3 million  in FY 1988 is 
(244 x $75 000).  APPENDIX III

HCFA, ASH, AND ASPE COMMNTS ON THE 
DRAFT REPORT AND OIG RESPONSES 
We received comments on the draft report from the Administrator, 
Heal th Care Financing Administration (HCFA), the Assistant

Secretary for Health 
(ASH), and the Assistant Secretary for 
Plannitnyg paends :E valuation (ASPE). These comments were of four 
maj or  (1) general observations about the overall report 
(2) reactions to draft recommendations, (3) reactions to specific
findings, and (4) concerns about methodology. 
Below, we indicate 
the maj or comments offered in each of these areas and, where
appropr ia te, present our responses. 
GENERAL OBSERVATIONS

HCFA indicated that it generally concurred with the findings 
report. 
presented in the draft  Further, it noted that the 
Omnibus Budget Reconciliation Act (OBRA) of 1986 (P.L. 99-509)

includes several sections that address the subject matter con

tained in the report and suggested that the Office of Inspector

General 
(OIG) may wish to review these sections. They include:
Section 93l8--Hospital Protocols for Organ Procurement and

Standards for Procurement Agencies; Section 9335 (d) --Reorgan
ization of ESRD Network Areas and Organizations; Section 9335 (f)
--Responsibilities of Network Organizations; and Section 9335 (i)
--National ESRD Registry.

ASPE noted that the report "raises many valid issues regarding a

subj ect that is of great interest to the Department.  It ex
pressed support for the "general conclusion that the option of 
kidney transplantation must be offered to all eligible patients, 
but indicated concern about placing onerous reporting require
facilities. 
ments on treatment 
ASH' s comments focussed on the recommendation directly involving 
the Public Health Service and on the methodology of the inspection. 
I . 
REACTIONS TO DRAFT RECOMMNDATIONS 
HCFA should require that network organiza

tions prepare and disseminate, annually, a

report that indicates, by dialysis facility, 
the proportion of patients on a transplant

waiting list.  HCFA reacted as follows: 
"In the proposed End stage Renal Disease (ESRD) 
regulation revision, we will require the creation and

maintenance of a transplant waiting list by each

facili ty. 
This, plus the proposed expansion of organ 
procurement requirements via the creation of a new

condi tion of coverage would appear, when coupled with 
existing criteria, to provide sufficient data to

prepare and disseminate an annual report, rather than

invol ve the networks. 
Development of a national 
average, rather than a network average of patients

referred, could be coupled with appropriate comments on

transplant situations and covered in the existing ESRD

annual report. 
In response, we add1e2d )a.  paragraph in the discussion following the
recommendation (p.  In it we note that in requiring a 
transplant waiting list for each facility, HCFA is taking an 
important step. However, we also note that we still feel that to 
assure sufficient impact, it is important (1) to require that 
each facility specify the proportion of its patients on a 
transplant waiting list and (2) to disseminate this information
widely. 
HCFA should ensure that intensive oversight

is given to dialysis facilities having

transplant referral rates appreciably below

the network average. 
In particular, the 
network organizations should be required to

conduct thorough medical records reviews of

such facilities and be authorized to (1)
prescribe corrective action plans and 
(2) 
recommend sanctions for facilities failing to

respond. 
follows: 
HCFA reacted as 
"Where transplant referral rates appear appreciably 
below the national average, we could have the state 
survey agency investigate the reason for such a low 
average. It appears inappropriate to adopt the concept 
tehtact .t he network consider such options as sanctions,
Any action with respect to the facilities 
participation, sanctions, or reimbursement should be 
restricted to HCFA. To do otherwise would place HCFA 
challenge,
in the position of having to defend, upon 
network determinations. 
In response, we deleted the provisions in the recommendation that 
called for ESRD network organizations to be authorized . 
respond. 
recommend sanctions for facilities failing to  While we  (p.

feel such authorization could be helpful at some point 
HCFA' s jUdgment that it is "inappropriate" at this  , we accept
time. 
We have also added a paragraph in the discussion following the
recommendation (p . 
13) that suggests that HCFA could ask the State
survey agency to investigate the reasons for a low percentage of 
referrals from a particular dialysis facility. 
indicate in that same paragraph, we still regard Hiotw eavse ra,p parso we
priate and important for network organizations to be given 
responsibili ty for 
identifying and directing corrective 

actions. 
HCFA should ensure that State survey agencies 
conduct a thorough and more outcome-
oriented
review of the Medicare condition of coverage 
concerning patient long-term programs and 
patient care plans. 
HCFA reacted as follows: 
"We concur with this recommendation and we are cur

rently pilot testing new survey requirements in one

State. We 
expect to implement the new survey require

ments in all States by October 
1987. 
Also 
, our proposed revision of the ESRD regulation will 
be directed toward outcomes via a requirement that 
transplantation and home dialysis assessments become a 
part of the patient' s medical record. 
HCFA should require that as a condition of

reimbursement for routine dialysis a facility

must have for each patient a written long-

term program and a written patient care plan

signed by the patient and the professional

team.

HCFA reacted as follows:

l .  "Subpart U, S405. 2l37 currently provides for a written
long-term program and a written patient care plan

involving the professional team and the patient. 

The 
change being suggested here is that it be 
 siqned by the 
patient and professional team 
While we do not object 
to this for audit pUrposes
required  , if a signature is to be

, we recommend it be restricted to the trans
plant surgeon
, nephrologist and patient rather than the
entire team.

We agreed with HCFA' 
s reaction and amended the recommendation

13) to restrict the signature requirement to a 
nephrologist, 
transplant surgeon and patient.  Pulic 
HCFA should work with the  Health 
Service to encourage the American Society of
Transplant Surgeons 
(ASTS) to provide some 
guidance on which dialysis patients are
medically suitable candidates for a kidney

transplant. 
HCFA , ASH, and ASPE concurred with this recommendation. 
HCFA, 
first of all, reacted as follows: 
"We concur with the recommendation that the ASTS 
provide some guidance regarding criteria for deter
mining medically sui table 
candidates for transplan
tation. We would recommend said contact be expanded to 
include an assessment concerning the reason why older 
kidneys are refused by American surgeons, yet
successfully transplanted by foreign surgeons. 
ASPE expressed its support with the following 
words: 
" . . . I strongly endorse your recommendation that the 
American Society of Transplant Surgeons be asked to 
provide guidance on which dialysis patients are
medically sui table 
candidates for kidney transplants.
This guidance could be developed in a form suitable for

medical professionals and in a pamphlet for patients.

Finally, ASH offered the following reaction and information: 
"We concur. PHS will work with HCFA to assist the

American Society of Transplant Surgeons to provide

guidance concerning kidney transplants for dialysis

patients. 
The National Institute of Diabetes and Digestive and

Kidney Diseases (NIDDK) already has an interagency

agreement with HCFA to facilitate the collection and

analysis of such data. To this end, NIDDK will

establish through a contract, an End Stage Renal

Disease 
(ESRD) data system that will compile data on 
all types of ESRD patients, including those undergoing 
hemodialysis, continuous ambulatory peritoneal dialy
sis, and transplantation. The 
system will contain
types of data which are currently not collected at all 
or are collected in only a limited way, including data
on the etiology of the underlying renal disease 
methods of patient treatment and associated patient
outcomes, and complications of treatment. 
The new ESRD data system will enable tracking of 

patients through multiple therapies and some comparison

of the effectiveness and complications of dialysis and

transplantation.  !!  ..
NIDDK expects to award the contract to establish the 
year. 
ESRD data system during this fiscal 
The system
should be operational in mid-fiscal year 1988. 
The
data collected and analyzed through this effort may 
prove useful to HCFA and other agencies and organiz
ations in addressing issues surrounding therapeutic 
alternatives in ESRD. In addition 
to the American 
Society of Transplant Surgeons, the following groups
will' 
be involved in the definition of tasks
, scope, and
workplans for the development and implementation of the
data system: 
American Society of Nephrology; American 
Society of Pediatric Nephrology; American Society of

Transplant Physicians; American Society of Artificial

Internal Organs; National Kidney Foundation; Renal

Physicians Association; National Association of

Patients on Dialysis and Transplantation; American

Diabetes Association; and Juvenile Diabetes Foundation

International. " 
REACTIONS TO SPECIFIC FINDINGS

ASH noted that the reasons we cited for the differential between
the proportion of sui 
table transplant candidates and the percent
actually awaiting a transplant were not complete (p. 3). 
I .	 Speci
l ,	 fically, ASH indicated that we did not mention that dialysis 
patients also elect not to undergo transplantation because they 
fear giving up their time slot for weekly dialysis or because 
they cannot pay for cyclosporine. 
OIG Response  Upon review, we decided that the concern

taiboount .g iving up a time slot is a pertinent considera
Accordingly, we noted it on page 3 of the final 
report. wi th respect to the concern about the costs of 
cyclosporine, we did get some comments about how cost

considerations might dleilsaty .t ransplantation for a

patient on a waiting 
However, we did not have
sufficient information to determine whether or not it 
was an important factor in determining whether or not a 
list. 
patient was listed on a transplant waiting 
ASH indicated that "while an 11 percent referral rate may be low

tnaott iaolnl .p atients on dialysis can be considered for transplan

For example, the patients may be too sick or have other 
medical problems that preclude them from being considered for

transplantation. " 
OIG Response  We recognize that not all dialysis

patients are transplantation candidates. Accordingly,
we note on page 2 of the draft and final reports that 
"transplant surgeons report that at least 20 to 25 
percent of the dialysis population is medically 
suitable for a kidney transplant.  . ,
CONCERNS ABOUT METHODOLOGY

the report 
bBoteh iHCFnA gan d AiSHn raaisde ecoqnceurnas taboeutl coync lussiounsp 	ported by documentation.  in 
OIG Response  As indicated in Appendix I, the report

is based on a careful review of available data sources

and on extensive discussions with individuals directly

involved with organ acquisition. It is not based on a

random sample of dialysis facilities or medical

professionals. 
Thus, while the findings are not statistically valid 
according to the precepts of experimental design, they 
are based on wide-ranging and thorough explorations in 
settings. 
a diversity of  Such explorations, although 
not allowing for certainty, do allow for reasoned 
insights and judgments. 
ASH noted that the methodology used to predict Medicare cost

savings has two flaws. First, it indicated that the report used

total  numer of transplants 
performed in 1985 to predict 
the 
savings, even though about 25 percent of all transplants are from
living related donors. 
Second, it added that kidney wastage 
rates have declined considerably in recent years, thereby 
numer of additional transplants
affecting our estimate on the 
that might be performed. 
In this context, ASH noted that "the 
Organ Transplantation Task Force found that in some areas of the 
country the wastage rates are as low as 5 percent. 
OIG Response  With respect to the first point, our 
l ,	 calculations have been based on the total numer of 
cadaver kidney transplants. They have not included
living related transplants. 
On the second point, in a 
forthcoming report on organ acquisition costs, we 
present data that shows that the kidney wastage rate 
has, indeed, dropped over the past few years but was 
1985. 
still at about 14 percent in  Moreover, and 
perhaps more importantly, we indicate that in some 
numer of 
places the  cadaver kidneys wasted is signif
icantly underreported. 
The cost savings data and methodology presented in this 
final report are somewhat revised to reflect more 
recent data and to focus on FY 1988 rather than FY 
1987. As a result, the savings estimate is increased
from $16. 9 million to $18. 3 million.  I ,