Medicare Coverage for Life in Kidney Recipients May Save Money

By Rob Goodier

December 11, 2019

NEW YORK (Reuters Health) - Medicare may save money by taking on lifetime payments for immunosuppressant drugs after kidney transplantation, rather than the current policy that stops coverage at three years, a new cost-effectiveness analysis suggests.

By avoiding the loss of a transplant, lifelong Medicare drug coverage could save the system $3077 and 0.37 additional quality adjusted life years (QALYs) per patient, the analysis found.

"(Even when) the improvement in transplant survival associated with extending immunosuppressive coverage was reduced to 50% of that observed in privately insured patients, the strategy of extending drug coverage had an incremental cost:utility ratio of $51,694 per QALY gained," researchers reported November 7 at the American Society of Nephrology's annual meeting in Washington, DC, and online in the Journal of the American Society of Nephrology.

"In a threshold analysis," they continued, "the extension of immunosuppression coverage was cost-effective at a willingness-to-pay threshold of $100,000, $50,000, and $0 per QALY if it results in a decrease in risk of transplant failure of 5.5%, 7.8%, and 13.3%, respectively."

"It's time for practitioners to talk to their healthcare and policy decision makers about pushing through policy change in the U.S. to make life-long immunosuppression coverage freely available," coauthor Dr. Matthew Kadatz, transplant nephrologist at the University of British Columbia, in Vancouver, told Reuters Health by email.

End-stage kidney disease patients are eligible for Medicare regardless of their age. That special coverage ends three years after transplantation, however. Immunosuppressant drugs are needed throughout the life of the transplant to prevent rejection. When Medicare coverage ends, patients who cannot afford immunosuppressants may stop taking them, risking graft loss - at which point they are again eligible for Medicare coverage. Medicare could potentially pay for multiple transplantations in these cases.

Keeping patients on dialysis may be even more expensive than transplantation. Dialysis costs are nearly triple those of a transplant, according to the study. In 2016, Medicare paid an average of $34,780 for a kidney transplant, while it paid $90,971 for a year of dialysis.

This new analysis takes into account the recent availability of generic immunosuppressants. The costs of two commonly used drugs, tacrolimus and mycophenolate, for example, were $10,000 per patient per year in 2008 and dropped by half to $5000 in 2013, the study notes.

"The generic equivalents really changed the market by creating competition between the drug companies, which has substantially lowered the price of mycophenolate and tacrolimus," Dr. Kadatz said.

Dr. Kadatz and colleagues employed a Markov model to test the cost and effectiveness of extending Medicare coverage. The model considered several scenarios, including conservative estimates of the benefit to extended coverage. If extended coverage were only to reduce the difference in transplant survival between Medicare and private insurance patients by 36%, it would remain cost-effective, the research suggests.

The study supports other evidence of the efficacy of extended immunosuppressant coverage. Earlier this year, the U.S. Department of Health and Human Services estimated that Medicare would begin to save money on the fifth year of covering a patient's immunosuppressant drugs.

"It is cost-effective to continue to cover immunosuppressant drugs. Because it preserves the transplant. Imagine that," Dr. Pascale Lane, a nephrologist at the University of Oklahoma, in Oklahoma City, who was not involved in the study, said by phone.

SOURCE: Journal of the American Society of Nephrology, online November 8, 2019.