Medicare policy on antirejection drugs imperils kidney transplants

For people with failing kidneys — and there are thousands of them in the United States — a kidney transplant offers a new lease on life. But like every other type of transplant, its success depends on taking drugs for life to suppress the immune system. Otherwise, the body begins rejecting the transplanted organ.

That’s basic medical science. So it makes no sense that Medicare covers these drugs for just 36 months for the majority of people who receive new kidneys. Because of this, many patients find themselves back where they started in a risky and frightening place: on dialysis and in need of a new kidney that for many will never come.

Chronic kidney disease (CKD) is the ninth leading cause of death in the United States, claiming more lives than breast cancer or prostate cancer. More than 37 million Americans are living with CKD today. Individuals with irreversible kidney failure, known as end-stage renal disease, have only two choices to survive: undergo regular and frequent dialysis or be fortunate enough to receive a kidney transplant.

Since 1973, Medicare has covered the care for individuals with irreversible kidney failure, or end-stage renal disease. Dialysis does mechanically what the kidneys do naturally: removes waste products and excess fluid from the body. Most people undergo dialysis at a hospital or dialysis center, usually three times a week for about four hours each time. Medicare spends $86,300 a year per patient on dialysis, and there is no time limit on this coverage.

Kidney transplantation is a medical success story. It can dramatically improve the recipient’s quality and length of life. But not everyone who needs a donated organ receives one. There are currently more than 103,000 individuals on the kidney transplant waiting list, while just 23,000 kidney transplants were performed in 2019.

The upfront cost of a kidney transplant is about $110,000. Afterward, coverage of immunotherapy under Medicare Part B is approximately $2,300 per year. The savings to the government of providing immunosuppressive medications are clear.

As Medicare law currently stands, patients’ lives are at risk, donor kidneys are being neglected, and taxpayer money is being squandered. It’s time for change. That’s why I’m testifying before Congress Wednesday in support of lifetime Medicare coverage of immunosuppressive medications for kidney transplant recipients.

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 their transplants when their Medicare coverage ends, especially lower-income patients who lack group health insurance or who do not qualify for Medicaid or other assistance. These financial pressures force some patient into rationing their immunosuppressive drugs or forgoing them altogether, either of which generally results in the failure of the transplanted kidney.

I can recall several patients who had to choose between paying their mortgage or utility bills and paying for their transplant-saving medication. Many of my colleagues report that they encounter patients in similar situations. A 2012 New England Journal of Medicine article reported that nearly 70% of kidney transplant programs reported either a death or transplant loss due to patients’ inability to pay for their antirejection medications.

The 36-month limitation on coverage also has a detrimental effect on living kidney donations. Patients are reluctant to ask a friend or family member to be a living donor if they fear they will be unable to afford their antirejection medications long term. As an advocate for increasing kidney donation, I have trouble asking living donors or donor families to give the most amazing “gift of life” knowing that Medicare will cut off necessary immunosuppressive coverage after three years.

In May of 2019, the Department of Health and Human Services conducted an analysis that indicated potentially significant cost savings from extending immunosuppressive coverage for kidney transplant patients by averting future dialysis and re-transplantation. The Centers for Medicare and Medicare’s Office of the Actuary concluded that extending coverage could save Medicare up to $300 million over ten years.

In December 2019, Reps. Ron Kind (D-Wis.) and Michael Burgess (D-Texas) introduced the Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act (H.R. 5534). This legislation would extend Medicare coverage of immunosuppressive medications for kidney transplant recipients for life.

By providing this coverage of last resort, Congress can help reduce the likelihood of the failure of transplanted kidneys, minimize the need for repeat transplants, enable more patients to pursue transplants, and save taxpayers money on the potential cost of re-transplantation. Most importantly, this measure also honors the gift of kidney donation for those who gave selflessly so others may have a second chance at life.

The current 36-month coverage policy for immunosuppressive drugs is not medically, economically, or ethically justified. Congress must fix it.

Matthew Cooper, M.D., is the director of kidney and pancreas transplantation at Medstar Georgetown Transplant Institute, professor of surgery at Georgetown University School of Medicine, and a board member of the National Kidney Foundation. He reports receiving consulting and research fees from several companies that manufacture immunosuppressive drugs. More information about H.R. 5534 is available at Honor the Gift, a patient-centered campaign for extending Medicare coverage of kidney transplant antirejection medications sponsored by CareDx, a precision medicine company focused on improving transplant outcomes.