Extending Medicare coverage for immunosuppressive drugs through the life of a kidney transplant could reduce the costs of a patient’s care by $3163 while improving their quality of life, according to research presented at Kidney Week 2019.
Using a Markov model and data on posttransplant outcomes from US patients with Medicare and private insurance coverage, Matthew Kadatz, MD, a clinical assistant professor in the Division of Nephrology at the University of British Columbia in Vancouver, and his colleagues analyzed the cost effectiveness of extending Medicare coverage for the life of a kidney transplant. Currently, Medicare only covers immunosuppressive drugs for 36 months after a kidney transplant, which can result in recipients losing access to coverage.
Even when the team reduced the expected transplant survival benefit associated with immunosuppressive drug coverage by 50% of what is seen in privately insured patients, extending coverage remained cost effective at a cost of about $77,613 per quality adjusted life years, according to the research.
“Extension of the Medicare immunosuppression drug coverage will likely be, if not cost savings, a cost-effective strategy, and that’s important for healthcare policy and decision-makers to understand,” Kadatz said.
The study is the latest to show that extending Medicare coverage for posttransplant immunosuppressive drugs would likely be cost saving.
“It’s a really important addition to a growing body of evidence that current Medicare policies for [immunosuppression coverage] don’t make sense regardless of whether you look from a financial or patient perspective,” said nephrologist Allyson Hart, MD, MS, assistant professor of medicine at the University of Minnesota in Minneapolis. A recent study by Hart and colleagues found very high rates of kidney allograft loss among patients who lose Medicare coverage for immunosuppressive drugs either before or after three years posttransplant.
Hart noted a few limitations of the analysis presented at Kidney Week. First, comparing outcomes to patients on private insurance might not be ideal because Medicare patients may differ in many ways from patients covered by private insurance. Another limitation is that many patients lose access to immunosuppressive medications even with Medicare coverage, possibly because they can’t afford co-pays. This could reduce the benefits estimated by the model. Her study, for example, found “an astronomical rate” of allograft loss even among patients less than three years after transplant, who should have access to Medicare coverage.
“We need more information about which patients are losing Medicare coverage for immunosuppressive drugs early and late and why,” she said. “Unless we get a better idea of the additional burdens of co-pays we won’t see as much benefit as we expect.”
Kadatz acknowledged that there are disadvantages to using data on privately insured patients’ outcomes because of the socioeconomic and other differences between them and those covered by Medicare. But he noted that he and his colleagues adjusted for as many of those possible differences as they could. In Canada, where patients are guaranteed coverage through public insurance regardless of socioeconomic status, transplant graft rates are equivalent among different socioeconomic groups, he noted.
The team also did a threshold analysis that found extending immunosuppression coverage was cost effective even if there was only a 5.5% reduction in the risk of transplant failure at a cost-effectiveness threshold of $100,000 per quality adjusted life year, which is the typical threshold in the US. Kadatz suspects that the analysis may have even underestimated the potential cost savings of extending coverage. For example, he noted that some kidney transplant patients stay on disability in order to ensure continued coverage for immunosuppression, but if Medicare coverage were extended, they may be able to rejoin the workforce.
Over the past decade, there have been repeated failed attempts in Congress to pass legislation that would extend Medicare coverage for posttransplant immunosuppression, Kadatz noted. He explained that budgetary concerns have been a barrier.
“This really provides support to help get these legislators past the budgetary considerations,” he said.
Hart agreed that it is essential to change public policy to ensure patients can access immunosuppressive medications and prevent graft loss. “My hope is with analyses like these we can show this is a case in medicine where patient outcomes and financial incentives are lining up,” she said. “We have to have courage to spend money upfront [anticipating savings down the road].”
“Economic Evaluation of Lifelong Medicare Immunosuppressive Drug Coverage for Kidney Transplant Recipients” Oral Abstract 128.