The views here are those of the author and not necessarily those of The Hope or its sponsor Kibow® Biotech.

Written By: James Myers

CURRENT STATE OF THE LAW

The current law is governed by Title XVIII of the Social Security Act To Provide for Extended Months of Medicare Coverage of Immunosuppressive Drugs for Kidney Transplant Patients (H12297).[i]  Medicare Part B covers these medications under very limited conditions.[ii]  What Medicare Part B does not pay for is covered by Medicare Part D.[iii]  The catch is if you’re entitled to Medicare because of your ESRD, your Medicare coverage ends after 36 months.[iv] Medicare will pay for your transplant drugs with no time if you were already entitled to Medicare because of age or disability before  you were ESRD or you became Medicare eligible because of your age or disability after getting a transplant that was paid for by Medicare or private insurance that paid primarily to your Medicare Part A (Hospital Insurance) coverage in a Medicare-certified establishment.[v]

In plain English, unless you are Medicare-aged (65) or Medicare-disabled (something besides ESRD), the coverage for these critical medications stop 36 months after your kidney transplant![vi]

THE RUB

The problem is regardless of your Medicare status, a kidney transplant recipient has no choice, but to take immunosuppressant drugs for the life of their kidney transplant.  The risk is your body rejecting your transplanted kidney, resulting in dialysis or death.[vii] When Medicare ends payments after 36 months for people who are too young or not disabled before they are declared ESRD, many kidney transplant recipients struggle to find affordable coverage.  Some people are denied, while others refuse to seek a transplant for this reason.  They simply cannot afford a transplant after the 36-month period ends.[viii] If a transplant recipient loses the kidney, they will have to go back on the waiting list for a kidney transplant and/or go back on dialysis.[ix]

THE COST ISSUE

There is a cost issue involved with the failure of a kidney after the 36 months expires.  At a hearing of the House Energy and Commerce Committee, NKF Board Member, Dr. Matthew Cooper spelled out this issue:

“As a transplant surgeon for nearly 20 years, I have witnessed firsthand the impact of this shortsighted policy…Patients struggle to pay for the immunosuppressive drugs needed to maintain the health of their transplant when their Medicare coverage ends, especially lower income patients who lack group health insurance or do not qualify for Medicaid or other assistance.  These financial pressures might force a patient into rationing their immunosuppressive drugs or foregoing them altogether, either of which almost absolutely results in graft failure.[x]”He further discussed that the cost of dialysis to Medicare per patient/per year is about $86,000.  Medicare covers 100% of these costs for the dialysis life of the patient.  Each transplant averages about $110,000.  At the same time, Immunosuppressive drug costs just cost $2,300 per patient/per year, that is not covered by Medicare after 36 months for the people who do not qualify for coverage. He estimated that if Medicare would provide immunosuppressive drug treatment for life, an estimated $300 million would be saved in the first 10 years.[xi]

He told the Committee that H.R. 5534 will reduce graft loss, reduce the demand for another transplant, enable more patients to seek a first transplant, and protect the taxpayers from inefficient and wasteful expense.  “As a taxpayer, it is doubly frustrating that Medicare will pay for dialysis and for the first and second transplant but will not pay for the medications needed to maintain and preserve the first transplant.[xii]

Members of the Committee commented on the absurdity of the current policy during the hearing.  Promises were made to move the bill quickly. Subcommittee Chair and Co-Sponsor of the bill, Anna Eshoo commented, “This bill will move.  It just makes sense.”[xiii] 

CONCLUSION

According to the NKF, nearly 95,000 people are on the waiting list for a kidney.[xiv]  In 2017, nearly 3600 people died that were on that list without receiving a kidney transplant.[xv] The struggle to afford immunosuppression medications for kidney transplant recipients is unnecessary.  The cost to continue Medicare coverage for all kidney transplant patients for the life of their kidney transplant will actually save money. The elimination of the 36-month rule will save lives, kidneys and money. It will encourage people to donate as opposed to discouraging kidney donation.

 Dr. Gill said it best: “The policy is irrational, since Medicare has already paid for the kidney transplant and will pay to treat the patient with dialysis-despite its markedly higher cost-when the transplanted kidney fails…Our research has shown the United States stands alone…All other wealthy nations recognize the benefits of immunosuppressive medications  and cover their costs for patients with functioning kidney transplants.[xvi]

It is impossible to justify continued inaction: The problem and its solution are both straightforward.  The machinery required to fund, prescribe and delivery immunosuppressive medications is in place.  All that is needed is the political will to pass legislation and allow U.S. patients to benefit.”[xvii]

As Kidney Advocates, we have been fighting to pass some version of this bill since 2011.[xviii]  Now is THE time!

Follow this link to request your Congressman to sponsor H.R. 5534, exercising our political will for the Immunosuppression Bill to pass:  https://advocacy.kidney.org/action-view/?sl=immunosuppressive-drug-alert

If this topic was interesting to you, read James other article “Why The Living Donor Act Is Important”


Sponsored By: Kibow® Biotech

From The Author James Myers

To learn more about James follow this link

My name is James Myers. I live in Hammond, Indiana. I graduated from Valparaiso University Law School and I have 2 MBA’s in Business and Healthcare Administration. Polycystic Kidney Disease runs in my family. I’ve lost 5 members of my family to PKD, including my Father. I have PKD. I was fortunate. Because of my family’s history, I was diagnosed at the age of 25, and was able to put off dialysis until the age of 58. I was on dialysis for 4 years and was transplanted on April 27th, 2016. I named my new kidney Woody. Woodrow is a family name, so I did this to honor my father and my grandfather.

My advocate nickname is Uncle Jim. If you have a kidney question or issue you need help with, please do not hesitate to contact me at kidneystories@hotmail.com. I thank the NKF for all the opportunities they have given to me.

ENDNOTES

[i] Title XVIII of the Social Security Act To Provide for Extended Months of Medicare Coverage of Immunosuppressive Drugs for Kidney Transplant Patients (H12297).

[ii] Prescription Drugs (Outpatient)  https:// www.medicare.gov/coverage/prescription-drugs-outpatient (2019) (Transplant/Immunosuppressive Drugs)(Only if Medicare Paid for the Transplant).

[iii] Id. 

[iv] Id.

[v] Id.

[vi] Id. , Congressional Hearing Held on the Comprehensive Immunosuppressive Drug Coverage for the Coverage for the Kidney Transplant Patients Act of 2019, https://www.google.com/amp/s/nkfadvocacy.blog/2020/01/09/congressiional-hearing-held-on-the-comprehensive-immunosuppressive-drug-coverage-for-kidney-transplant-patients-act-of-2019-h-r-5534/amp/ (January 9, 2020); Dr Cooper’s Testimony, https://nkf.egnyte.com/dl/pfc8TtWWCj (January 8, 2020); NKF’s Statement for the Record, https://nkf.egnyte.com/dl/Nf0D50B9Mk (January 8, 2020); Hearing Congressional Hearing National Kidney Foundation’s Dr. Matthew Cooper to Testify Before Congress, Congress Must Pass H.R. 5534 to extend immunosuppressive drug coverage, https://www.kidney.org/news/national-kidney-foundation-dr-matthew-cooper-to-testify-congress (Jan 8, 2020); NKF Applauds New Immunosuppressive Drug Coverage Legislation to Help Save Transplant Patients From Organ Rejection, https://www.kidney.org/news/nkf-applauds-new-immunosuppressive-drug-coverage-legislation-to-help-save-transplant-patients (January 6, 2020);

See Also: “Hear Bobbie’s Story on Why Transplant Patients Need Drug Coverage Now”, https:// youtu.be/37xSeUICFOc (2019); Immunosuppressants, https://www.kidney.org/atoz/content/immuno (2014); Medicare Policy on Antirejection Drugs Imperils Kidney Transplants, https://www.statnews.com/2020/01/08/medicare-policy-antirejection-drugs-imperils-kidney-transplants (January 8, 2020); NKF Leave Behind Infographic, Extending Medicare Coverage for Immunosuppressive Medication, 08-41-7476_BBJ (2019).

See Generally:  H.R. 5534-Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act of 2019, https://www.congress.gov/bill/116th-congress/house-bill/5534/all-action?overview=closed&KWICView=false (2019-2020)

[vii] Id., Life After Transplant-Rejection prevention and healthy tips, https://www.kidneyfund.org/kidney-disease/kidney-failure/treatment-of-kidney-failure/kidney-transplant/life-after-transplant/ (2020) ([without antirejection medication] “Your immune system, which protects your body from germs and harmful cells, recognizes your new kidney as a foreign tissue, and may try to reject it.”); Cleveland Clinic, Kidney Transplant Rejection, https:// my.clevelandclinic.org/health/articles/21134-kidney-transplant-rejection(May 20, 2019) Tushla, Lara, When A Transplant Fails, https://www.kidney.org/transplantation/transaction/TC/summer09/TCsm09_TransplantFails (2009). 

See Also:  Tonelli, Marcello & Gill, John, Our Medicare Policy for Kidney Transplants Is Totally Irrational, www.washingtonpost.com%2Fopinions%2Four-medicare-policy-for-kidney-transplants-is-totally-irrational%2F2017%2F12%2F06%Fecda8828-d9ec-11e7-b859-fb0995360725_story.html&psig=AOvVaw2rkc7sr3UsANE1nio-IrRM&ust=1559162459862631 (2019)(“We estimate that in the past five years, 7700 patients have needlessly lost their kidney transplants, 900 patients have prematurely died and Medicare has squandered nearly $1 billion in health-care costs that could have been averted if only immunosuppressive medications had been secured.”)

[viii] Myers, James, Pre-Transplant Deposits, Can You Afford A Kidney Transplant? , https://kidneystoriesonblogger.blogspot.com/2019/10/pre-transpant-deposits-can-you-afford.html?m=1(October 14, 2019)

[ix] Congressional Hearing Held on the Comprehensive Immunosuppressive Drug Coverage for the Coverage for the Kidney Transplant Patients Act of 2019, https://www.google.com/amp/s/nkfadvocacy.blog/2020/01/09/congressiional-hearing-held-on-the-comprehensive-immunosuppressive-drug-coverage-for-kidney-transplant-patients-act-of-2019-h-r-5534/amp/ (January 9, 2020); Dr Cooper’s Testimony, https://nkf.egnyte.com/dl/pfc8TtWWCj (January 8, 2020); NKF’s Statement for the Record, https://nkf.egnyte.com/dl/Nf0D50B9Mk (January 8, 2020); Hearing Congressional Hearing National Kidney Foundation’s Dr. Matthew Cooper to Testify Before Congress, Congress Must Pass H.R. 5534 to extend immunosuppressive drug coverage, https://www.kidney.org/news/national-kidney-foundation-dr-matthew-cooper-to-testify-congress (Jan 8, 2020); NKF Applauds New Immunosuppressive Drug Coverage Legislation to Help Save Transplant Patients From Organ Rejection, https://www.kidney.org/news/nkf-applauds-new-immunosuppressive-drug-coverage-legislation-to-help-save-transplant-patients (January 6, 2020);

See Also: “Hear Bobbie’s Story on Why Transplant Patients Need Drug Coverage Now”, https:// youtu.be/37xSeUICFOc (2019); Immunosuppressants, https://www.kidney.org/atoz/content/immuno (2014); Medicare Policy on Antirejection Drugs Imperils Kidney Transplants, https://www.statnews.com/2020/01/08/medicare-policy-antirejection-drugs-imperils-kidney-transplants (January 8, 2020); NKF Leave Behind Infographic, Extending Medicare Coverage for Immunosuppressive Medication, 08-41-7476_BBJ (2019).

See Generally:  H.R. 5534-Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act of 2019, https://www.congress.gov/bill/116th-congress/house-bill/5534/all-action?overview=closed&KWICView=false (2019-2020); Life After Transplant-Rejection prevention and healthy tips, https://www.kidneyfund.org/kidney-disease/kidney-failure/treatment-of-kidney-failure/kidney-transplant/life-after-transplant/ (2020) ([without antirejection medication] “Your immune system, which protects your body from germs and harmful cells, recognizes your new kidney as a foreign tissue, and may try to reject it.”); Cleveland Clinic, Kidney Transplant Rejection, https:// my.clevelandclinic.org/health/articles/21134-kidney-transplant-rejection(May 20, 2019) Tushla, Lara, When A Transplant Fails, https://www.kidney.org/transplantation/transaction/TC/summer09/TCsm09_TransplantFails (2009). 

[x]  Congressional Hearing Held on the Comprehensive Immunosuppressive Drug Coverage for the Coverage for the Kidney Transplant Patients Act of 2019, https://www.google.com/amp/s/nkfadvocacy.blog/2020/01/09/congressiional-hearing-held-on-the-comprehensive-immunosuppressive-drug-coverage-for-kidney-transplant-patients-act-of-2019-h-r-5534/amp/ (January 9, 2020); Dr Cooper’s Testimony, https://nkf.egnyte.com/dl/pfc8TtWWCj (January 8, 2020); NKF’s Statement for the Record, https://nkf.egnyte.com/dl/Nf0D50B9Mk (January 8, 2020); Hearing Congressional Hearing National Kidney Foundation’s Dr. Matthew Cooper to Testify Before Congress, Congress Must Pass H.R. 5534 to extend immunosuppressive drug coverage, https://www.kidney.org/news/national-kidney-foundation-dr-matthew-cooper-to-testify-congress (Jan 8, 2020); NKF Applauds New Immunosuppressive Drug Coverage Legislation to Help Save Transplant Patients From Organ Rejection, https://www.kidney.org/news/nkf-applauds-new-immunosuppressive-drug-coverage-legislation-to-help-save-transplant-patients (January 6, 2020);

[xi] Id.

[xii] Id.

[xiii] Id., Congressional Hearing Held on the Comprehensive Immunosuppressive Drug Coverage for the Coverage for the Kidney Transplant Patients Act of 2019, https://www.google.com/amp/s/nkfadvocacy.blog/2020/01/09/congressiional-hearing-held-on-the-comprehensive-immunosuppressive-drug-coverage-for-kidney-transplant-patients-act-of-2019-h-r-5534/amp/ (January 9, 2020).

[xiv] NKF Leave Behind Infographic, Extending Medicare Coverage for Immunosuppressive Medication, 08-41-7476_BBJ (2019).

[xv] Id.

[xvi] Tonelli, Marcello & Gill, John, Our Medicare Policy for Kidney Transplants Is Totally Irrational, www.washingtonpost.com%2Fopinions%2Four-medicare-policy-for-kidney-transplants-is-totally-irrational%2F2017%2F12%2F06%Fecda8828-d9ec-11e7-b859-fb0995360725_story.html&psig=AOvVaw2rkc7sr3UsANE1nio-IrRM&ust=1559162459862631 (2019).

[xvii] Id.

[xviii] Id.

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