vey may improve understanding of the impact of coverage on both patient compliance and other social and economic activities such as employment.


Good evidence supports patients’ continued need for immunosuppressive therapy and the increased risk of graft loss if they cannot follow the prescribed drug regimen. Given this evidence and the existing Medicare policy of supporting organ transplants, the rationale for eliminating the current time limits for coverage of immunosuppressive drugs for all solid organ transplant recipients is strong. Although people who lose coverage often find ways to obtain sufficient drugs to maintain immunosuppression, experience and limited evidence suggest that some grafts—and some lives—are eventually lost for lack of coverage. The estimated five-year net cost to Medicare of eliminating the three-year limit on coverage would be approximately $778 million if extended coverage were limited to those eligible by virtue of age or disability, and $1.06 billion if the time limit was also removed for those who have been Medicare-eligible only by reason of an ESRD diagnosis.

In addition to the economic and possible clinical consequences of time-limited drug coverage for transplant recipients, the committee notes that current policy has societal implications. Organs are a scarce resource for which demand far outstrips supply. Every graft failure that results in retransplantation is a special burden on this limited supply. Beyond those immediately affected, the larger society of citizens has a strong interest in the successful maintenance of grafts to protect their potential access or that of their loved ones.

From a societal perspective, elimination of the time limit on coverage of immunosuppressive drugs for transplant patients presents some delicate ethical and policy considerations. On the one hand, recipients of organ transplants who are eligible for Medicare by reason of age, disability, or ESRD already have a drug benefit that few other classes of beneficiaries have, and ESRD-qualified Medicare beneficiaries are generally treated as a special group. On the other hand, termination of the drug benefit at the end of three years may result in more graft loss, more expenses for treatment of graft rejection and possible return to dialysis, and added demands for scarce organs for retransplantation. The committee returns to this issue in Chapter 6.

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