Medicare's failure to provide lifelong coverage for immunosuppressive therapy after kidney transplant is bad for patients and for the system's finances, two researchers argued.
The policy forces many patients to give up anti-rejection drugs, leading to graft failure and a return to dialysis, according to John S. Gill, MD, of the University of British Columbia in Vancouver, and Marcello Tonelli, MD, of the University of Alberta in Edmonton.
The immunosuppressive drugs needed by every renal transplant recipient have an annual price tag of $15,000 to $20,000, yet dialysis after graft failure can cost $75,000, they wrote online in the New England Journal of Medicine.
Moreover, one-quarter of patients who return to dialysis after failure of their transplants die within two years.
"Failing to pay for ongoing immunosuppression ensures that Medicare's initial investment in kidney transplantation is squandered, that patients die prematurely, and that U.S. taxpayers pay for a more expensive but inferior therapy after some transplants fail unnecessarily," Gill and Tonelli asserted.
Currently, Medicare pays for immunosuppressive treatment for three years after transplantation except for patients 65 and older or who are unable to work because of disabilities.
This stands in stark contrast to policies in other countries such as Canada and Great Britain, where lifelong coverage is guaranteed -- and where five-year survival rates are 80% and 78%, respectively, compared with 69% in the U.S.
The notion that lifelong treatment should not be government funded arose from the expectation that transplantation would result in patients remaining employed and being eligible for private insurance, "optimism [that] is not borne out by the current reality," the authors observed.
Almost 20 years ago Medicare extended the payment for this treatment from one to three years, which began to reduce the demographic disparities in outcomes following renal transplantation.
Yet in a survey two years ago, 70% of kidney transplant programs in the U.S. reported that patients were experiencing serious difficulties in paying for their medications, and 68% had graft failures and deaths when patients stopped treatment because of cost.
With lifelong coverage, Medicare would save about $200 million each year, according to Gill and Tonelli, and the effects would be most dramatic among groups with few economic resources.
The disparity in outcomes affects both living and deceased donor grafts. In both types of transplant, graft loss after three years is significantly more common among patients relying on Medicare for insurance compared with those who have lifelong private insurance coverage (P<0.001).
Gill and Tonelli indicated that congressional passage of the Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act of 2011 would fix the problem. The bill "represents a key opportunity to correct an irrational, needlessly wasteful policy that has harmed many U.S. patients," they wrote.
Gill reported receiving grants, acting as a consultant, and being on speakers' bureaus for Novartis, Roche, Astrellas, BMS, and Genzyme. Tonelli reported grants from Abbott and the Alberta Heritage Foundation for Medical Research.