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House bill looks to extend Medicare coverage of immunosuppressive drugs for kidney transplant patien

By Soumya Karlamangla, The Oregonian

on August 07, 2013 at 6:00 AM, updated August 07, 2013 at 6:04 AM

For a transplant patient, medicines that suppress the immune system are the only thing stopping the body from rejecting the foreign organ.Though Medicare covers dialysis, and the cost of a kidney transplant, it stops paying for anti-rejection drugs needed to sustain the transplant after three years. This puts patients at risk of losing their life-saving transplant.

A bill in the U.S. House aims to extend coverage in perpetuity, and abolish a policy that many see as wasteful.

“Oddly, it’s federal policy, not the disease itself that’s the gravest threat to these patients,” said Rep. Mike Burgess, R-Texas, the bill’s sponsor, at a committee hearing in June. “Instead of insuring the investment, the government would rather patients lose their graft, lose their kidney, return to dialysis, and get back in line for another transplant, taking another organ out of circulation for someone else.”

Starting in January, the Affordable Care Act requires insurance companies to offer insurance to everyone, regardless of pre-existing conditions such as kidney disease. Although everyone is required to buy insurance, costs and plans of prescription drug coverage will vary by state and still risks a gap in coverage. Medicare coverage would ensure patients will get their medicines, said Lisa Morrison, a financial coordinator at Legacy Good Samaritan Hospital.

“We know for sure that some people will not pursue transplants because they’re afraid of reaching a point where they can’t afford maintaining a transplant,” Morrison said.

Thousands of people die each year waiting for a kidney. There were more than 16,000 kidney transplants in the United States last year, about 190 in Oregon.

When policy makers set Medicare’s 36-month immuno-suppressive drug coverage cap more than a decade ago, they reasoned patients three years out would have jobs with health coverage, or would be able to afford coverage on their own.

Transplants greatly improve patients’ quality of life, freeing them from hours-long dialysis three times a week. But as transplants become more common, more people risk losing their transplants without the Medicare safety net.

There’s no way to know exactly how many patients lose their transplants each year because of financial reasons, but many people won’t even be considered for a new organ if it they won’t be able to afford the immuno-suppressives on their own.

“No way to cover your medicines means no transplant,” said William Bennett, medical director of kidney transplantation at Legacy Transplant Services.

Bennett said he thinks fixing the policy should a no-brainer. A kidney transplant costs $125,000, and immuno-suppressives cost about $15,000 a year. But dialysis costs around $70,000 a year, making the transplant the wiser long-term investment.

Medicare already pays more than $6 billion in for kidney transplants every year. And the average lifespan of someone on dialysis is only five years, while a transplanted organ lasts 11 to14 years.

If the House bill were to pass, approximately 10 more years of immuno-suppressive costs would be $150,000 per patient per transplant, still cost effective. The bill faces tough odds in the House, with the many votes for repeal of the Affordable Care Act the House has pushed this year. A provision that would have extended coverage almost passed as part of the Affordable Care Act, but was cut in the 11th hour.

“It’s been totally frustrating,” Bennett said.

When a patient’s transplant fails, he or she can either go back on dialysis or get in line for another organ. A match is more difficult the second time around because the patient becomes harder to match with each transplant, according to Dan Salomon, president of the American Transplant Society.

“By the time they hit the third transplant, it can be near impossible,” he said.

–Soumya Karlamangla

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