Blog entry by Arif Khwaja
Oscar Wilde wrote that " a cynic is someone who knows the price of everything but the value of nothing" ....... Over 100 years later the same might be said of Medicare's attitude to kidney transplantation. In a depressing critique of Medicare's funding of kidney transplantation in the United States, Gill and Tonelli ( see NEJM online first) point out the impact of a lack of a universal funding strategy on clinical outcomes in transplantation. The 10 year graft survival in the US of 43% contrasts with a graft survival of between 55-60% in Canada, Australia and the UK. Whilst these differences maybe due to a multitude of factors it's worth noting that in the US itself the likelihood of graft failure is much higher in the Medicare-insured group than those not insured by Medicare. The risk of graft failure rapidly increases after 3 years in the Medicare group. So what happens at 3 years? At present those insured with Medicare have their funding for immunosuppressants stopped after 3 years unless they are over 65 or deemed to have significant disability. Of course one can't prove that the cost of drugs accounts for the poorer outcomes amongst the Medicare group but the authors point to a survey of US transplant program's in which 68% of centres reported deaths or graft failures related to cost-related non-adherence.
Whilst the clinical reasons to support transplantation are overwhelming the economic reasons are just as robust. The cost of transplantation is initially estimated at $110,000 but this cost falls rapidly after the first year - making transplantation a much more cost effective therapy that dialysis which costs $75,000 per annum with the cumulative cost of dialysis much more than transplantation. However despite the fact that Medicare won't fund immunosuppressants after 3 years ( even though effective generics for Tacrolimus and MMF now widely available) they are able to fund lifelong dialysis. The economic modelling suggests that $200 million could be saved annually by providing universal coverage for lifetime immunosuppressive medication. An amendment to the the Social Security Act before the US Congress proposes to provide universal coverage for transplantation. A previous attempt to provide such coverage in 2009 failed. One can only hope that in the midst of a global economic crisis the policymakers can do their sums and come up with the right answer.
Penny Wise, Pound Foolish? Coverage Limits on Immunosuppression after Kidney Transplantation. John S. Gill, M.D., and Marcello Tonelli, M.D. February 1, 2012 (10.1056/NEJMp1114394) http://www.nejm.org/doi/full/10.1056/NEJMp1114394