The Cost of Making Medical Decisions Political

One of my long-time patients was in for a clinic visit recently, a routine check that seems almost unnecessary.  He has a history of kidney failure and heart disease, but has done well since his kidney transplant more than 8 years ago.  He sees a cardiologist who manages his heart disease, a nephrologist who makes sure his transplanted kidney is working well, and a variety of other specialists at a university medical center nearby who manage other more minor conditions.  Yet he continues to see me, his family doctor, every few months despite the fact that there is rarely anything medical I need to do for him.  The main function I serve, despite years of medical training, is to make sure he keeps his Medicaid insurance by double checking forms he is sent in the mail (his English is imperfect), filling out Medicaid eligibility forms, and scrambling to find sources for his anti-rejection medications when the system fails him and his insurance is cut off despite all of our work.  Despite the fact that dialysis would cost the system more than three times the cost of the medications to keep his transplant healthy, Medicare only paid for his medications for the first 36 months after the transplant.  After that, he was on his own, and without the help of safety net clinics like ours, he would join thousands of transplant patients who are at risk of losing priceless transplanted organs because of a law that makes no economic or logical sense.
In a recent perspective piece in the New England Journal of Medicine, John Gill and Marcello Tonelli detail the costs of this misguided policy as well as advocating for a solution, H.B. 2969, which would remove the arbitrary time limit for coverage of these critical medications.*  Overall, their estimate is that by not covering anti-rejection drugs, Medicare wastes about $200 million each year in unnecessary dialysis costs and repeat transplants.  Medicare won’t cover anti-rejection drugs after 3 years, but when the transplanted kidney inevitably fails for lack of these drugs, it will cover a return to dialysis and a second transplant.  The impact of this policy falls disproportionately on the poor and on minority populations, who are more likely to be uninsured once their 3 years of coverage is finished.  It means not only wasted money, but also a higher mortality rate among these patients, worsening health disparities, and the waste of irreplaceable transplants that should have been lifesaving.  If we are to cut costs and make our health care system both more equitable and sustainable, we cannot afford this kind of waste, both of money and of lives.
*As Gill and Tonelli state,  “H.R. 2969 represents a key opportunity to correct an irrational, needlessly wasteful policy that has harmed many U.S. patients.”  Penny Wise, Pound Foolish? Coverage Limits on Immunosuppression after Kidney Transplantation.  John S. Gill, M.D., and Marcello Tonelli, M.D., N Engl J Med 2012; 366:586-589, February 16, 2012.