Extended Medicare Coverage
Extended Medicare Coverage
Some call it the ultimate catch-22. Although a successful kidney transplant can mean freedom from dialysis and improved health, Medicare abruptly halts coverage of immunosuppressive drugs 36 months posttransplantation except for those recipients who are disabled or over the age of 65 years. As a result, the healthier you become following a kidney transplant, the more likely you are to disqualify for Medicare.
According to Troy Zimmerman, Government Relations Director with the National Kidney Foundation (NKF), federal legislation is needed to expand Medicare coverage for transplant patients. Two pieces of legislation currently pending in Congress will do just that. The Comprehensive Immunosuppressive Drug Coverage for Transplant Patients Act of 2005 (S. 173), introduced in early May by Senator Mike DeWine (R-Ohio), would amend Title XVIII (Medicare) of the Social Security Act to remove time limitations on the coverage of immunosuppressive drugs for individuals who have received organ transplants. Current law provides coverage for such drugs only for certain time periods (36 months) after the transplant procedure.
A companion bill, H.R. 2051, was introduced by Rep. Dave Camp (R-Michigan-4) and is very similar in scope. Both bills extend Medicare secondary payer requirements for end-stage renal disease beneficiaries. Both bills also amend the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code to set forth requirements for group health plans to provide coverage of immunosuppressive drugs.
The most persuasive policy argument in support of the legislation is that it will result in a cost savings to Medicare and extend graft viability to patients who otherwise may not have the financial resources to pay for immunosuppressive drugs. The hope is that continued graft function will result in fewer patients suffering graft failure and a return to dialysis or retransplantation, both of which are more costly treatment options for Medicare.
According to Mark Schnitzler, PhD, Associate Professor of Internal Medicine at St. Louis University (St. Louis, Missouri), economic studies indicate a significant cost savings for kidney transplantation with an estimated savings beginning 2.3 years posttransplantation. In data presented at the American Transplant Congress 2005 and more recently to members of Congress, Schnitzler showed that Medicare spends around $14,000 per patient per year to maintain a functioning kidney graft. However, if the kidney fails, Schnitzler estimates that the cost to Medicare to resume treatment and sustain the patient on dialysis is about $134,930.
Kidney graft failure is an economic drain on Medicare, according to estimates by the Congressional Budget Office. This drain exceeds the cost of expanding coverage for expensive immunosuppressive drugs that would keep patients healthy with a functioning graft. In further research by Dr. Schnitzler and Robert S. Woodward, PhD, McKerley Professor of Health Economics at the University of New Hampshire (Durham), if only 2% of kidney failures were prevented, the increased Medicare coverage proposed in the legislation would pay for itself.
According to Zimmerman, there were more than 120,000 patients living with a functioning kidney transplant in 2003 and nearly 3 times that number on dialysis. The two bills have limited sponsorship at this point, but Zimmerman and other leaders in the renal transplant community are committed to addressing the remaining gaps in Medicare coverage and ending the 36-month limitation. They remain hopeful that further support will be forthcoming in 2006.
Some call it the ultimate catch-22. Although a successful kidney transplant can mean freedom from dialysis and improved health, Medicare abruptly halts coverage of immunosuppressive drugs 36 months posttransplantation except for those recipients who are disabled or over the age of 65 years. As a result, the healthier you become following a kidney transplant, the more likely you are to disqualify for Medicare.
According to Troy Zimmerman, Government Relations Director with the National Kidney Foundation (NKF), federal legislation is needed to expand Medicare coverage for transplant patients. Two pieces of legislation currently pending in Congress will do just that. The Comprehensive Immunosuppressive Drug Coverage for Transplant Patients Act of 2005 (S. 173), introduced in early May by Senator Mike DeWine (R-Ohio), would amend Title XVIII (Medicare) of the Social Security Act to remove time limitations on the coverage of immunosuppressive drugs for individuals who have received organ transplants. Current law provides coverage for such drugs only for certain time periods (36 months) after the transplant procedure.
A companion bill, H.R. 2051, was introduced by Rep. Dave Camp (R-Michigan-4) and is very similar in scope. Both bills extend Medicare secondary payer requirements for end-stage renal disease beneficiaries. Both bills also amend the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code to set forth requirements for group health plans to provide coverage of immunosuppressive drugs.
The most persuasive policy argument in support of the legislation is that it will result in a cost savings to Medicare and extend graft viability to patients who otherwise may not have the financial resources to pay for immunosuppressive drugs. The hope is that continued graft function will result in fewer patients suffering graft failure and a return to dialysis or retransplantation, both of which are more costly treatment options for Medicare.
According to Mark Schnitzler, PhD, Associate Professor of Internal Medicine at St. Louis University (St. Louis, Missouri), economic studies indicate a significant cost savings for kidney transplantation with an estimated savings beginning 2.3 years posttransplantation. In data presented at the American Transplant Congress 2005 and more recently to members of Congress, Schnitzler showed that Medicare spends around $14,000 per patient per year to maintain a functioning kidney graft. However, if the kidney fails, Schnitzler estimates that the cost to Medicare to resume treatment and sustain the patient on dialysis is about $134,930.
Kidney graft failure is an economic drain on Medicare, according to estimates by the Congressional Budget Office. This drain exceeds the cost of expanding coverage for expensive immunosuppressive drugs that would keep patients healthy with a functioning graft. In further research by Dr. Schnitzler and Robert S. Woodward, PhD, McKerley Professor of Health Economics at the University of New Hampshire (Durham), if only 2% of kidney failures were prevented, the increased Medicare coverage proposed in the legislation would pay for itself.
According to Zimmerman, there were more than 120,000 patients living with a functioning kidney transplant in 2003 and nearly 3 times that number on dialysis. The two bills have limited sponsorship at this point, but Zimmerman and other leaders in the renal transplant community are committed to addressing the remaining gaps in Medicare coverage and ending the 36-month limitation. They remain hopeful that further support will be forthcoming in 2006.
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