By Bill Peckham
Via email I've been asked, what/who in my view, killed the immunosuppressant drug extension? Fate.
My historical narrative of the immunosuppressant drug extension begins in 2009 with the 111th Congress (though I think I first heard of the issue in 2001). In March the Senate introduced S. 565: the Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act of 2009 and the House introduced twin legislation H.R. 1458. The bills attract bipartisan support; at this point the goal is to get these bills incorporated into the various pieces of healthcare legislation that are working their way through committee.
This happens in July when the House health insurance reform bill HR3200, includes language that would extend immunosuppressant drug coverage. In September the Senate Finance Committee passes a bill that does not include immunosuppressant drug extension. Note that this happens in September, and despite unanimous support from all corners of the CKD advocacy community.
Meanwhile, while Congress works on healthcare reform, CMS is working to implement legislation that was passed in 2008. Medicare Improvements for Patients and Providers Act of 2008 requires CMS to expand the dialysis payment bundle but leaves it to CMS exactly how and on September 15th CMS released their proposed rule. DSEN tracks all public comments on the proposed rule and offers comments at a CMS town hall meeting in October. The most commented on issue is CMS's proposal to include "binders in the bundle", the overwhelming majority of comments express concern with that one element of the proposal. My official comments on the proposed PPS include my objections to including binders.
In November the House combines their various healthcare reform bills into HR 3962 which in addition to extending immunosuppressant drug coverage mandates the inclusion of binders in the dialysis payment bundle as a pay for. This is the first time that these two issue get linked but there is very little comment on this provision in the advocacy community. The thinking is that when the House and Senate healthcare reform bills get merged in committee the binder language will be stripped out.
The goal is to have immunosuppressant coverage in the final bill; to get there you need only to have it in the House or the Senate version, the language is in the House bill so things are looking good. In December the Senate passes their version of healthcare reform without immunosuppressant drug coverage. The Senate bill does have a provision directing the GAO to study including binders in the bundle.
Here is where my narrative and the narrative presented by Dr. Cohen diverge. It's here that the NKF/KCP is said to have killed the immunosuppressant drug provision by objecting to the binder language in the House bill. I disagree. The Senate never linked the issues and I think looking ahead there is every reason to believe that in the conference that is expected to happen, the conference that is required to merge the House and Senate bills together, Senator Durbin, an immunosuppressant coverage supporter, will be in the room. By not including immunosuppressant drug coverage in the Senate Managers amendment, Durbin avoids having to come up with any pay fors. In conference the projected cost of immunosuppressant drug coverage will amount to a rounding error when considered against the total cost of the final healthcare reform bill.
That was the expectation I expressed in December when Congress breaked for the Christmas recess. I didn't read any commentary at the time from the transplant community saying that hope was lost or calling on anyone to support the House's specific language. Things were looking good that Christmas. Then Scott Brown won the Massachusetts Senate race. No one saw that coming. Fate had intervened.
By flipping the Senate seat from Democrat to Republican, the Massachusetts election made it impossible for the Senate to bring a post conference bill to a vote. The only way for healthcare reform to proceed was for the House to vote for the Senate bill, which as it happened did not have the immunosuppressant drug provision. How could this result be the fault of KCP lobbying?
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