600,000 of American citizens suffer from ESRD and kidney failure.  This leaves you with 3 choices:  (1) dialysis; (2) a kidney transplant or (3) death.  Kidney transplant recipients must take immunosuppressive drugs for the life of their transplant, or they risk losing their new organ.  Medicare pays for the transplant and immunosuppressive drugs for 36 months post transplant, but coverage of these critical medications stops unless the beneficiary is Medicare-aged(65) or Medicare-disabled.  The Medicare End Stage Renal Disease (ESRD) program pays for dialysis or transplantation for over 600,000 kidney disease patients every year, regardless of age, and has saved millions of lives in the four decades since its enactment.  After a transplant, recipients must take immunosuppressive drugs every day for the life of the transplant; failure to do so significantly increases the risk of organ rejection.  Kidney recipients, who qualify for Medicare based on their ESRD, rather than on age or other disability, lose Medicare coverage 36 months after the transplant.  However, if they remain on dialysis, they have lifetime Medicare eligibility.  Transplant recipients often have difficulty finding other coverage for their immunosuppressive drugs after Medicare coverage ends.


Medicare spends an average of $86,316 per year for an individual who is on dialysis and $124,643 during the first year of a kidney transplant.  However, after the year of transplant, the cost is much lower at $24,612 for an individual with a functioning kidney transplant.  If the transplant fails, the patient returns to dialysis or receives another transplant, each covered again by Medicare.


Extending immunosuppressive coverage beyond the 36-month post-transplant limit would improve outcomes and enable more kidney patients who lack adequate insurance to consider transplantation.  Most transplant recipients also have a higher quality of life, and are more likely to return to work than dialysis patients.


Currently, there is a bill pending, S. 323, “The Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act of 2013,” would extend Medicare Part B coverage for kidney transplant recipients for the purpose of immunosuppressive drugs only.  All other Medicare coverage would end 36 months after the transplant. Beneficiaries would be responsible for the appropriate portion of the Part B premium, as well as applicable deductible and coinsurance requirements. For patients who have another form of health insurance, Medicare would be the secondary payer.  The bill also requires that group health plans currently providing coverage of immunosuppressive drugs for kidney transplant recipients maintain this coverage.  There is a corresponding bill in the House, H.R. 1428: Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act of 2013.  The Senate version of the bill has been passed out of committee.


Last week, I read a blog I found to be disturbing.  Coupled with that, I received a note from one of my friends.  The note and the blog indicated that people who were unable to age/disability qualify for Medicare were refusing transplants due to the high costs of the anti-rejection medications.  According to Cameron Field and Kidney Buzz,  of the 275,000 people are on dialysis in the United States, only 93,000 individuals choose to be listed on the US Kidney Transplant Waiting List. Two thirds of dialysis patients are not listed, while only one third had chosen to list.  Does the prospect of Medicare coverage for only 36 months and then the average monthly cost of approximately $2100/month cause people to decline the transplant option?  Of course, there may be others reasons to decline; it requires a surgery, the risk of infection, the risk of rejection even if you take the meds, the necessary follow up, and pain, but sources are now saying that it may be possible that up to 34% of dialysis patients are declining transplants due to the cost of anti-rejection meds. 


The Dialysis Patient Citizens conducted a survey last year on this issue.  29% said they had other medical conditions. 26% said they were too old. 7% said they were overweight. 6% said their doctors didn’t recommend it.  5% said they were satisfied with dialysis. However, 6% cited financial reasons generally, 4% said they couldn’t afford the surgery, and 2.5% said they couldn’t afford the medications. 17% cited personal reasons. Who knows how many in that 17% didn’t want to disclose financial hardship. So according to the DPC’s data, it between 13% and 30% that aren’t on the list due to financial reasons.


In addition of the 13,000 transplants performed last year and 6,000 of those were from living donors. There are also significant financial barriers to donors, like the wages they lose while in the hospital and travel to the transplant center. Some states will provide reimbursement in the form of tax deductions for these costs. The federal government also provides some grants, but the program is woefully underfunded.  The DPC estimates that cost to reimburse someone’s lost wages is about $6k for one surgery.  When you look at in in terms of Medicare paying for the transplant surgery ($100,000) and for the cost of anti-rejection drugs ($24,000/yr), travel and lost wages costs are minimal. 


If 30% of the people taking dialysis refuse to be listed due to the costs of transplant autoimmune medications, then we are talking about approximately 100,000 people.  Your life expectancy on dialysis on average is said to be 3-5 years.  Your life expectancy for a transplant, from a living donor functions, on average, 12 to 20 years, while a deceased donor kidney is somewhat less, 8 to 12 years. If you receive a kidney transplant before you are required to begin dialysis then you will live 10 to 15 years longer than if you stayed on dialysis, on average. So, even though a kidney transplant involves major surgery and requires some risk, in comparison it offers you a longer life. Most patients who have been on dialysis before their transplant report having more energy, less restricted diet, and less complications with a kidney transplant than if they had stayed on dialysis. 


Is this 13%-30% reluctance of dialysis patients to obtain a kidney transplant a substantial argument in favor of lifetime protection for anti-rejection meds?  Maybe it should be.




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