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Early loss of immunosuppressive drug coverage linked to graft failure
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Patients with a kidney transplant who lose immunosuppressive drug coverage through Medicare before and after the scheduled 3 year end to eligibility show a much higher rate of graft failure than those who have continued coverage, a new study shows.
“These findings provide critical new information to help evaluate the effect of Medicare coverage on transplant recipient outcomes and costs, and have important implications for consideration of future policy,” wrote Allyson Hart, MD, from the Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, and colleagues.
While Medicare patients over 65 have lifetime coverage for kidney transplant immunosuppressive medications, the benefit ends 3 years posttransplant for patients aged younger than 65 years and not disabled. Sometimes, however, the benefit can end early due to non-payment of Medicare premiums or other reasons.
“Patients may remain on Medicare after 3 years due to disability benefits, but then subsequently lose their Medicare access through loss of disability status or inability to pay premiums, or they may transition to private insurance options,” Hart told Healio/Nephrology. Patients can also lose their disability status due to a lapse in paperwork, voluntarily ending the benefit due to a return to work or deemed medically capable of working but still not able to work or find work, Hart said.
“Previous analyses have found that risk of graft failure is higher for transplant recipients with Medicare at the time of transplant than for recipients with private insurance, and that the higher risk of graft failure is even more pronounced after 3 years posttransplant,” the investigators wrote. “Those data raise concerns that the scheduled loss of Medicare coverage at 3 years for patients aged younger than 65 years or not disabled results in loss of access to immunosuppressive medications, causing unnecessary graft failure.”
The researchers sought to determine the association between timing of Medicare loss, immunosuppressive medication fills and kidney allograft loss. Using data from the Scientific Registry of Transplant Recipients (SRTR), United States Renal Data System, and the Symphony pharmacy fill database, they reviewed 78,861 transplant patients younger than 65 years and assessed the timing of Medicare loss posttransplant. They created three cohorts with insurance loss: early (less than 3 years), ontime (at 3 years), or late (past 3 years).
The researchers used a medication possession ratio (MPR) to measure immunosuppressant use, and allograft loss was assessed using SRTR data.
They wrote that MPR “was lower for recipients with early or late Medicare loss compared with no coverage loss for all immunosuppressive medication types.”
Further, those who lost Medicare on time or late were more likely to be younger, white, have a higher median zip code income and less dialysis time. African Americans had a higher risk for losing Medicare early compared with white people (HR = 1.4; 95% CI, 1.3-1.6). Patients aged 18 to 34 years at transplant also had a higher risk vs. those aged 35 to 49 years (HR = 1.2; 95% CI, 1-1.4).
When recipients matched by age and donor risk who lost Medicare coverage were compared to recipients who had not lost coverage, the hazard of allograft loss was 990% to 1,630% higher after early Medicare loss, and 140% to 740% higher after late Medicare loss, with no difference in the hazard for on‐time Medicare loss, the researchers reported.
“These findings provide critical new information to help evaluate the effect of Medicare coverage on transplant recipient outcomes and costs, and have important implications for consideration of future policy,” Hart and colleagues wrote. “Allograft outcomes improved significantly following the extension of Medicare coverage from 1 to 3 years posttransplant between 1993 and 1995, suggesting that extension of Medicare coverage helped in maintaining access to critical immunosuppressive medications. In 2000, the Beneficiary Improvement and Protection Act extended Medicare coverage to patients who qualified for disability. This policy provided Medicare access to some transplant recipients who could not obtain or afford private insurance. ... More contemporary analyses have demonstrated that the cost of immunosuppressive medications remains a significant burden on patients, and that costrelated nonadherence is a significant source of both graft loss and patient death.”
The researchers concluded, “we found that kidney transplant recipients receiving Medicare who lost coverage before or after the current 3year policy time point filled immunosuppressive medications at a significantly lower rate and had a higher risk of allograft failure, while those who lost coverage on time were not. This finding has substantial policy implications, suggesting that closer examination of the risks of Medicare loss, as well as medical coverage safety nets and access to immunosuppressive medications, beyond simply extending Medicare eligibility for transplant recipients, is critical.” – by Mark E. Neumann
Disclosures: Hart reports no relevant financial disclosures. Please see the full study for all other researchers’ relevant financial disclosures.
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