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In connection with the fact that my wife may soon be at the stage of kidney disease where a transplant or dialysis is recommended, we've recently been researching the cost of and advantages/disadvantages of dialysis vs. transplantation.  It won't affect us, because my wife is already a Medicare beneficiary based on being over 65, rather than solely because having end-stage renal disease, but this research has revealed an utterly INSANE aspect of our current health care system that affects everybody who reaches end stage renal disease when they're younger.

First, on the merits of dialysis vs. transplantation.  There is no question that for the great majority of people, transplanation and permanent treatment with anti-rejection drugs is vastly preferable to dialysis, both from the standpoint of the person's health, and the effects on their lifestyle.  If you get a transplant from somebody with whom you're reasonably compatible immunologically, it's a matter of taking several pills per day -- very expensive pills, but pills.  You can hold a regular job, take normal vacations, and otherwise live a normal life.  If you're on dialysis, on the other hand, you spend major parts of 3 days per week connected to a dialysis machine.  And while there are potential side effects to anti-rejection drugs, they tend to be much less serious than those of dialysis.

What's more, transplantation is vastly cheaper than dialysis.  I'm sure these figures have gone up, since they're from a 2009 article, but there is no indication that the relative comparison has changed.

As of 2009, a transplant cost approximately $109,000, and anti-rejection drugs cost $17,000 per year.  By contrast, dialysis cost 173,507 per year.  So even in the year of the transplant, it's cheaper than dialysis, and in the succeeding years, it is vastly cheaper.

Medicare benefits pay for dialysis, and also for transplantation and the anti-rejection drugs.  But here is the truly INSANE thing:  While Medicare will pay for dialysis for as long as the patient lives, it will only pay for anti-rejection drugs for 3 years.  When the Medicare benefit for end-stage renal disease was first enacted, anti-rejection drugs were only covered for one year, because there was hope that after an initial period, the patient would permanently accept the new organ.  The one year period was extended to three years, but the companies that comprise the dialysis industry (including those such as Amgen that provide drugs that dialysis patients must take) have lobbied vigorously in opposition to annual bills sponsored by Dick Durbin and others to provide permanent coverage for anti-rejection drugs, and to pay for it by taking funding from dialysis -- even though if more people could have transplants and avoid rejecting them, there would be much less need for the more expensive dialysis.

The Ventura County Star ran an excellent four-part series of articles on kidney transplantation that you can read here.

You can read Senator Durbin's bill, S. 1454, here.  The companion bill in the House, H.R. 2969, sponsored by Republican Representative (and physician) Michael Burgess can be seen here.  One would think that with a Democratic lead sponsor in the Senate and a Republican lead sponsor in the House, and with having the benefit of both saving money and improving the quality of patients' lives, this would be passed easily.  But instead, it has been bottled up in relevant House and Senate committees without hearings .

The only explanation I can fathom is that we have the best government that money can buy, and if it puts money into the pockets of the right corporations, and from them into the campaign coffers of the right politicians, the welfare of the public (both kidney patients and taxpayers) be damned.

Originally posted to leevank on Tue Mar 27, 2012 at 10:26 AM PDT.

Also republished by Community Spotlight.


Does it make sense to cover dialysis for life while only covering anti-rejection drugs for 3 years?

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Comment Preferences

  •  Thank you for putting this info out there. (16+ / 0-)

    Things like this are so stupid that once people find out about it, it will be fixed correctly.  There is really no way to justify not changing this system.  The key is to make sure that people are aware of it.  Well done.

  •  Not quite that simple. (9+ / 0-)

    Your analysis is greatly distorted. You understate the cost of transplantation by quite a lot. Most folks pay lots more for the anti-rejection drugs than you state, sometimes by many orders of magnitude. A sizeable fraction of transplant recipients unfortunately see their graft fail, meaning they end up back on dialysis. Or, they get another transplant, which vastly increases the net cost.

    Moreover, your numbers for dialysis are also misleading. That's about the going retail cost for hemodialysis. But the widely available peritoneal dialysis is much, much cheaper. Not denying it comes with its own limitations, but it's a lot cheaper per month.

    Finally, as your diary implies, the insane cost of hemodialysis is artificially supported by the Medicare mandate to cover it. This massive taxpayer subsidy permits vendors to keep costs absurdly high, because they have no pressure to reduce them. Similar care is provided in Europe at far lower cost, with equivalent or better outcomes.

    •  Dialysis payment is capped (11+ / 0-)

      Not wide-open, so the costs can't be driven up by vendors, because the rates paid are pre-set by Medicare. When I worked at a consulting firm in the early 90s, the rate for dialysis treatments had not changed in over a decade, and according to the most recent CMS (Centers for Medicare and Medicaid Services) rule for 2012, payments will increase only by 2.1% between 2011 and 2012, much less than the inflation rate of health care (which was 3.38% in February of 2012).

      The real issue here is that dialysis and transplantation treatment policies were never set in a comprehensive way. When Medicare first started covering dialysis in the early 70s, transplantation was rare and risky; now it's not only common, but the preferred method of treatment. Dialysis was also not that efficient or effective 40 years ago, so three years of anti-rejection drugs was probably equal to the effective lifetime of dialysis a couple decades back (as one nephrologist quipped to me "kidney failure will kill you in two weeks, dialysis takes about 5-10 years").

      It's just another example of needing a global strategy to deal with health care coverage, not the piecemeal and patchwork system we've had for too long (and which will only continue even under the Obama plan).

      A government that denies gay men the right to bridal registry is a facist state - Margaret Cho

      by CPT Doom on Tue Mar 27, 2012 at 02:46:47 PM PDT

      [ Parent ]

      •  True for Medicare (8+ / 0-)

        However, if you have end stage renal disease before age 65 you are covered by commercial insurance for the first 30 months before Medicare becomes primary. In the bad old days, pre PPACA, you would be subject to a cap on benefits, but most of the time that could be streched to get you to Medicare. PPACA removed the caps, which would be a good thing except that Dialysis is increasingly dominated by two for-profit companies, Fresenius and Davita. The average daily charge for these two outfits: over $4500 per day or roughly 20 times the Medicare allowable and nearly triple what these same companies charged before the limits were removed for commercial insurers. It seems insurers are not the only bad guys.

      •  Excellent post, except I would amend one (3+ / 0-)
        Recommended by:
        leevank, Wee Mama, Sue B

        statement.  There is no piecemeal and patchwork system, because we don't really have a system.  And the only reason we don't have a system is that a relatively few people are getting horribly rich and don't like the thought of not being rich.

    •  I know someone who has had four. (3+ / 0-)

      Her first was when she was a small child. It happens.

      I know someone who has had one 30 years. I know someone else whose graft didn't even last 2 days. Some never work. It is what it is.

      I will take however long I get and call it good - well, mostly.

      Organ donors save lives! A donor's kidney gave me my life back on 02/18/11; he lives on in me. Please talk with your family about your wish to donate.

      Why are war casualty counts "American troops" and "others" but never "human beings"?

      by Kitsap River on Wed Mar 28, 2012 at 01:19:02 AM PDT

      [ Parent ]

    •  Well, we are lucky! (2+ / 0-)
      Recommended by:
      BusyinCA, One Pissed Off Liberal

      We've got good health insurance, and my wife became Medicare eligible based on age rather than end-stage renal disease, so Medicare will cover the anti-rejection drugs permanently.  But that raises another question, which is why somebody who is lucky enough to be in their late 60's when they get end-stage renal disease gets anti-rejection drugs paid for forever, but somebody who is unlucky enough to reach the same stage a couple of decades earlier has them cut off after three years.  The entire system is simply INSANE, and it wouldn't exist were it not for the financial incentives of the companies that provide dialysis services, manufacture the dialysis machines, and make the drugs that dialysis patients have to take (such as to prevent anemia.

      We're also lucky in that my wife has a twin sister who has healthy kidneys, and is willing to be a living donor if they're immunologically compatible.  (They're not identical twins, so they aren't necessarily compatible, but siblings of any kind are are a lot more likely to be compatible, and we at least know already that they're both O-.)  I really feel for people who don't have our good fortune.

      Bin Laden is dead. GM and Chrysler are alive.

      by leevank on Tue Mar 27, 2012 at 06:27:18 PM PDT

      [ Parent ]

  •  Just one of the many "benefits" of for-profit (16+ / 0-)

    health care. What I find even crazier is that we as a society refuse to see how bad this whole idea is.

    Let me just say this once and for all, If you're in medicine simply to make money, do everybody a favor and get out. Real estate and finance are quite lucrative and there is far less chance you will kill people.

    Health care, education, and justice are three fields that are essential to a society's functionality and therefore, should not depend on a member of that society's ability to pay.

    "Those who can make you believe absurdities can make you commit atrocities." - Voltaire

    by Greyhound on Tue Mar 27, 2012 at 11:06:28 AM PDT

  •  new research (6+ / 0-)
    The method, published this month in the journal Science Translational Medicine, suggested that through the manipulation of donor stem cells, the recipient's immune system might be tricked into accepting the new organ as a natural part of the body, thereby eventually eliminating the need for immunosuppressant drugs.
    •  There are also lots of advances in making new (5+ / 0-)

      organs from the person's own cells going on, although mainly with 'simple' organs so far, but the 3-dimensional biological 'printers' are only going to keep getting more amazing as time goes on.  Iirc, they've already made things like sections of esophagi, and were working on bladders and hearts lately.   With 'self' transplants, you also shouldn't need rejection drugs.

      •  No rejection drugs (3+ / 0-)

        and the only wait is for growing the cells and time on the 'printer', not for a compatible donor. These things are possibly the most amazing advance in medicine I've heard of since antibiotics.

        Unfortunately, they're not yet ready for mass production. I sincerely hope they get there in my lifetime. As a trans guy, I'm at the bottom of the priority list after all the disease/trauma patients, so out of sheer self-interest, I want to fund this research until there's a damned 3-D organ printer in every kitchen.

        But we still need to do something to help the people suffering from kidney failure right now. And part of the problem with the Medicare 3-year cap on anti-rejection drugs is that transplants generally won't be done unless the patient shows they have provisions to cover the cost of the drugs for lower-income seniors are often not even able to get transplants.

        "Let’s just move on, treat everybody with firmness, fairness, dignity, compassion and respect. Let’s be Marines." - Sgt. Maj Michael Barrett on DADT repeal

        by kyril on Tue Mar 27, 2012 at 06:21:33 PM PDT

        [ Parent ]

      •  It won't be long and you will be able to get (1+ / 0-)
        Recommended by:
        Dr Erich Bloodaxe RN

        an implantable 'scaffold' and an injection to jump start it, that will grow you a new kidney or other organ.

        It's science, man.

        I just hope I can live long enough, and be able to afford it.

    •  That's fascinating (0+ / 0-)

      It'll probably be a number of years before it's available for clinical use (if it ever is), but it's one potential benefit for transplant patients.

      Bin Laden is dead. GM and Chrysler are alive.

      by leevank on Tue Mar 27, 2012 at 06:29:03 PM PDT

      [ Parent ]

  •  If she is over 65 she can get a Part D plan (3+ / 0-)
    Recommended by:
    elfling, glorificus, kyril
    If you have Medicare because you’re 65 or older, your Medicare coverage including coverage for anti-rejection drugs will not end. If you have Medicare coverage because you have another disabling condition besides kidney failure, your Medicare coverage, including your coverage for antirejection drugs, will last as long as you’re considered disabled.

    Find out the anti-rejection drugs your wife's transplant center will want to use and then go to:

  •  For people under 65 who are married (4+ / 0-)
    Recommended by:
    ladybug53, glorificus, kyril, jan4insight

    the possibility of getting on a spouse's employer plan exists.

    Of course for SingleVoter, there is no spouse and no spousal plan.

  •  That may explain why kidney dialysis centers (5+ / 0-)
    Recommended by:
    ladybug53, leevank, glorificus, kck, kyril

    have become such a high profit margin investment over the past few decades.

    The other problem with transplantation is that the wait list time is long -- the median is three years.    

  •  My son had a kidney transplant (mine). (14+ / 0-)

    He had been on dialysis for a couple years prior to the transplant.  The improvement in his health was amazing. It has been five years and he is still doing fine, except for the continuing worry about keeping his meds covered.  

    He has not been able to get a job that provides health insurance and of course having had kidney failure is a rather red flag of a preexisting condition.  He has received good support from the counselors at Medicare.  I am hoping that Obamacares will survive so that he can, too.

    “when Democrats don’t vote, Democrats don’t win.” Alan Grayson

    by ahumbleopinion on Tue Mar 27, 2012 at 03:16:22 PM PDT

  •  Yup. This was diaried a while back, when an (6+ / 0-)

    undocumented worker in California was denied a transplant from his own wife because while medicare was covering his ongoing dialysis, the guy wouldn't be able to pay for the anti-rejection meds after a transplant, because they wouldn't be covered, even though it was going to save gov't something like $150k a year.

    Sheer stupidity, but nobody has gotten around to updating the medicare regs to cover rejection drugs in order to save money longterm.

  •  We don't have a health care system nt (6+ / 0-)

    The radical Republican party is the party of oppression, fear, loathing and above all more money and power for the people who robbed us.

    by a2nite on Tue Mar 27, 2012 at 05:34:51 PM PDT

  •  Informative diary (3+ / 0-)
    Recommended by:
    leevank, BusyinCA, happymisanthropy

    Thanks for writing this.

    Mr. Boehner, where are the jobs?

    by Tx LIberal on Tue Mar 27, 2012 at 07:01:26 PM PDT

  •  Medicare and disability insanity (3+ / 0-)
    Recommended by:
    BusyinCA, leevank, kkmd

    The hodgepodge (tip of the hat to cocinero) in our disability program and Medicare entitlement is truly dizzying. End-stage Renal Disease patients get one set of breaks. People with ALS ("Lou Gehrig's Disease") have another. People who meet the strict criteria for statutory blindness have other extra benefits. People with other conditions, equally serious, even life-threatening, get no special breaks. For example, ALS is awful, but is it worse than Huntington's Chorea? Blindness imposes extra burdens, but are they more than those experienced by someone who is paralyzed?

    The answer, of course, is a universal system of single-payer health care, providing everyone with what they need. A lifetime (36 years, retired January 31 2012) in the disability program convinced me that the only solution is a single-payer plan.

    No one in this world has ever lost money by underestimating the intelligence of the great masses of the plain people. H. L. Mencken

    by jim0121 on Tue Mar 27, 2012 at 08:33:58 PM PDT

    •  You're certainly right about the answer! (1+ / 0-)
      Recommended by:

      I've said before that if I had my druthers, although it wouldn't be perfect, I would HAPPILY be willing to take the Canadian statute, rewrite it by substituting "state" for "province," and the titles of the approriate U.S. officials for those of the Canadian officials and enact it pretty much "as is."

      This wouldn't be "one size fits all," since the Canadian system allows plenty of variation between the provinces, so long as everybody gets a single payer system that covers pretty much all necessary services (with the details varying among the provinces).  But the FACT is that I've never met anybody who lives in Canada who would trade their system for ours.

      Bin Laden is dead. GM and Chrysler are alive.

      by leevank on Tue Mar 27, 2012 at 10:28:41 PM PDT

      [ Parent ]

  •  Not one comment specifically stating how the (1+ / 0-)
    Recommended by:

    healthcare law (or single payer, for that matter) would make this better. Just visions of unicorns in the field. I'm doubting that Kathleen will declare a "free organ transplant for everyone who needs one" policy. They can run numbers too.

    I've been on home peritoneal dialysis (PD) since last August. I chose it specifically to avoid hemodialysis. Lifestyle changes are minimal, I determine the schedule within required parameters, there are no travel costs, I rearranged my office so that I can sit and work while it's going on if I can't sleep, otherwise it occurs while I sleep. I start transplant eval on 1 May. Compared to other friends and acquaintances with various medical and emotional stresses, I'm one lucky guy.  

    •  Peritoneal dialysis isn't available for everybody (0+ / 0-)

      For people with polycystic kidney disease which has caused the kidneys to become very enlarged, it doesn't work well.  But for those who can use it, it seems to be a solution that's preferable to hemodialysis.

      Bin Laden is dead. GM and Chrysler are alive.

      by leevank on Wed Mar 28, 2012 at 04:59:32 AM PDT

      [ Parent ]

  •  Hi there, leevank. I'm one of the ones under 65. (4+ / 0-)

    I got my transplant a little over a year ago (more or less liveblogged here at Daily Kos by me and my husband), thanks to Medicare, and I'm now 52. I started dialysis a little over a month after my 48th birthday. I keep hoping that someday, Congress will gain the fortitude to pass the Medicare Part B extension for anti-rejection drugs; the program was billed (but spent certainly well less than) $188,000 for my transplant surgery, harvesting the organ and getting it to me (halfway across town), a blood transfusion, and eight days in the hospital with all that that entails and ought to get the most from its investment. But almost any kidney transplant is going to fail eventually, in part because some of the anti-rejection medications are toxic to the kidney; my transplant surgeon, whom I ran into the week before last at the hospital, hopes mine goes 30 years. It could happen; it's happened to others. I'm going to do the best I can to ensure that I keep this kidney going longterm, but there are things over which I have no actual control that can affect it, too, and those I can only work with the transplant program to monitor.

    As to valion's question, what about the ACA, well, as a 52 year old who is disabled by more than just my  now--mostly-unnecessary failed native kidneys, I hope I can hang onto my Medicare coverage when the time comes, but I do not know, so I cannot count on it. If I do get kicked off in two years, I hope the ACA is there to catch me. That legislation, if it survives the SCOTUS, will guarantee that an insurer has to sell me insurance, kidney transplant or no kidney transplant, degenerative spinal cord condition or not, diabetes or not. It will not only let me keep Bimaaji the kidney going strong for as long as possible, it will keep me alive.

    And to anyone on dialysis or who has a beloved on dialysis, or who is about to start dialysis, please check out my diary on Living Well with Home Dialysis. I go through all my dialysis experiences, and I think I tried about every form of dialysis there is except nocturnal in-center dialysis. My email's in my profile; email me with any questions, no matter how personal, and I'll answer them, because if you are a kidney patient or the beloved and caregiver for one, you deserve answers.

    BTW: you can have sex while dialyzing. You can dialyze in your car. You can have three dogs in the room while you dialyze. You do not have to give away any of your pets if you choose PD. You can travel when you're on dialysis; ask your clinic or home program's social worker about that. You can live a full and satisfying life and still dialyze. The only reason I did not go and dialyze on Antarctica (and wow, did I want to) is that we figured getting the dialysate down there was going to cost more than going to Antarctica, and we couldn't afford it.

    Organ donors save lives! A donor's kidney gave me my life back on 02/18/11; he lives on in me. Please talk with your family about your wish to donate.

    Why are war casualty counts "American troops" and "others" but never "human beings"?

    by Kitsap River on Wed Mar 28, 2012 at 01:17:28 AM PDT

  •  what health care system? (0+ / 0-)

    you have to get rid of this insurance obsession, somehow.

    Single Payer - now.

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