By Bill Peckham
Medicare has made available a paper in its entirety by doctors Page and Woodward that appears in the winter 2008-2009 issue of Health Care Financing review. Cost of Lifetime Immunosuppression Coverage for Kidney Transplant Recipients (pdf link) builds on research done in 2004 by Yen et al. Cost-effectiveness of extending Medicare coverage of immunosuppressive medications to the life of a kidney transplant (pdf link).
As the Page, Woodward page states at the beginning Yen et al.:
Politically this makes the most sense. If you can make the case that aside from the positive societal value for lifetime immunosuppression coverage there is a cost savings to Medicare by making this coverage change then that would make it politically very easy to pass legislation granting lifetime immunosuppression coverage. And there is an easily understandable way that you could imagine Medicare saving money. Each year of immunosuppression coverage is cheaper than a year of dialysis, extending coverage would keep people off dialysis, Medicare saves money. That is a good elevator message.
However, Page & Woodward with what reads to be regret, shoot that idea down:
That's unambiguous. They did break out people in low economic demographics and show a potential savings in this group but under Medicare there isn't a way to introduce an economic need threshold, so they could only point back to the Yen et al. approach of including all societal cost/savings as the way forward. I think it does make sense to consider the entire societal cost of healthcare policy but I think Page & Woodward missed some potential Medicare savings.
Over the years of peer to peer online discussions I have "met" a lot of people and there is a group of people who self report that they are not seeking a transplant because of the three year immunosuppression coverage rule. I can't say how large this group is but my impression is that it is not insignificant. Often it is when a person would be accepting a living donation that they are most reluctant to put themselves into a position where they could not support the gift. My hypothesis would be that there is both a cohort who selects to not pursue a transplant and a cohort who selects to pursue a cadaveric transplant even though there is a potential for a living donor.
These two groups of patients should be investigated to determine their size and by extension the financial impact of switching them to transplant once lifetime immunosuppression coverage is available under Medicare.