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Author Topic: Please support lifetime Medicare Coverage for transplant drugs  (Read 6313 times)
noahvale
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« on: April 06, 2013, 08:56:07 PM »

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« Last Edit: September 18, 2015, 04:37:19 PM by noahvale » Logged
Bill Peckham
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« Reply #1 on: April 06, 2013, 11:37:42 PM »

So if this Bill is signed into law ... in 2014 a person with a liver transplant and without Employer Group Health Insurance or access to Medicare due to age or disability will buy insurance through the health insurance exchanges so that all their post transplant needs are covered - coverage for physician visits, hospitalizations, diagnostic testing - including their transplant meds for whatever the cost of their coverage and subsidized to some degree for those who earn less than 400% of the federal poverty level. Those with a liver transplant won't be affected by this law, their post transplant care will be covered by the insurance through the health insurance exchanges.

As compared to a person in 2014 with a kidney transplant and without Employer Group Health Insurance or access to Medicare due to age or disability and 36 months post transplant, will buy insurance through the health insurance exchanges so that most of their post transplant needs are covered - coverage for physician visits, hospitalizations, diagnostic testing - but for their transplant meds they'll need to pay $400 more a year so that they can get 80%  coverage through Medicare for the immunosuppressant meds. That's a good idea? A $400 tax on kidney transplant patients?

If anyone takes the time to read through the advocacy literature for these misguided Bills, note there is no mention of the fact that as of 2014 the Affordable Care Act (aka Obamacare) requires everyone to have health insurance and for those with a chronic condition, for instance living with a transplant, they will have the opportunity to be insured and under the ACA all health insurance policies will have coverage for certain essential health benefits. How could the CKD Transplant community continue to press forward with this legacy policy without considering the impact of Obamacare? Some day the CKD Transplant community will make great fodder for a study of group think.

Personally I will continue to advocate against S 323 and H.R. 1325.
« Last Edit: April 06, 2013, 11:41:38 PM by Bill Peckham » Logged

http://www.billpeckham.com  "Dialysis from the sharp end of the needle" tracking  industry news and trends - in advocacy, reimbursement, politics and the provision of dialysis
Incenter Hemodialysis: 1990 - 2001
Home Hemodialysis: 2001 - Present
NxStage System One Cycler 2007 - Present
        * 4 to 6 days a week 30 Liters (using PureFlow) @ ~250 Qb ~ 8 hour per treatment FF~28
Rerun
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« Reply #2 on: April 07, 2013, 06:43:02 AM »

I have to agree with Bill?  OMG something is wrong with me or him!   ???

I just feel we (ESRD) have taken away from Old People (whom Medicare is for) and I feel blessed yet guilty.  I think if you get a transplant and you are over 65 then YES by all means your drugs should be paid for by Medicare.

But, sorry folks.... I feel that if Medicare pays for dialysis, all ages. ... what a blessing and for drugs for 3 years that is a blessing.  Other than that if you can't get a JOB with benefits then some other agency can help you like the National Kidney Foundation.  OR Maybe these drug companies could be forced to make these anti-rejection drugs affordable.  We always JUMP to who is going to pay for these drugs instead of Why are these drugs so damn expensive.  Don't give me the R&D crap excuse either.

Other transplants don't get to use Medicare for pre transplant survival or drugs for life.  We need to just be thankful for what we have before they take a good look at what we take and put a stop to it.
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Bill Peckham
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« Reply #3 on: April 07, 2013, 12:02:23 PM »

I have to agree with Bill?  OMG something is wrong with me or him!   ???



lol
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http://www.billpeckham.com  "Dialysis from the sharp end of the needle" tracking  industry news and trends - in advocacy, reimbursement, politics and the provision of dialysis
Incenter Hemodialysis: 1990 - 2001
Home Hemodialysis: 2001 - Present
NxStage System One Cycler 2007 - Present
        * 4 to 6 days a week 30 Liters (using PureFlow) @ ~250 Qb ~ 8 hour per treatment FF~28
noahvale
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« Reply #4 on: April 07, 2013, 02:44:39 PM »

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Rerun
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« Reply #5 on: April 07, 2013, 02:49:42 PM »

Of course the NKF would lobby for this bill.  They don't want to pay for drugs for us.  Heck YES let Medicare pay for it.

I wonder is Medicare has a lobbyist?

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Bill Peckham
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« Reply #6 on: April 07, 2013, 05:07:05 PM »

So if this Bill is signed into law ... in 2014 a person with a liver transplant and without Employer Group Health Insurance or access to Medicare due to age or disability will buy insurance through the health insurance exchanges so that all their post transplant needs are covered - coverage for physician visits, hospitalizations, diagnostic testing - including their transplant meds for whatever the cost of their coverage and subsidized to some degree for those who earn less than 400% of the federal poverty level. Those with a liver transplant won't be affected by this law, their post transplant care will be covered by the insurance through the health insurance exchanges.

As compared to a person in 2014 with a kidney transplant and without Employer Group Health Insurance or access to Medicare due to age or disability and 36 months post transplant, will buy insurance through the health insurance exchanges so that most of their post transplant needs are covered - coverage for physician visits, hospitalizations, diagnostic testing - but for their transplant meds they'll need to pay $400 more a year so that they can get 80%  coverage through Medicare for the immunosuppressant meds. That's a good idea? A $400 tax on kidney transplant patients?

If anyone takes the time to read through the advocacy literature for these misguided Bills, note there is no mention of the fact that as of 2014 the Affordable Care Act (aka Obamacare) requires everyone to have health insurance and for those with a chronic condition, for instance living with a transplant, they will have the opportunity to be insured and under the ACA all health insurance policies will have coverage for certain essential health benefits. How could the CKD Transplant community continue to press forward with this legacy policy without considering the impact of Obamacare? Some day the CKD Transplant community will make great fodder for a study of group think.

Personally I will continue to advocate against S 323 and H.R. 1325.

I am not a medical economist, so I can't really analyze whether or not a transplant patient will pay an extra $400 per year or not under the affordable care act.  I don't think anyone, at this point, can say how the act will be implemented and who will have access to which types of insurance (exchange or Medicare/aid expansion) and how much they will cost at this time.  In particular, states like Georgia, that are not expanding Medicaid, make predictions even more difficult.

I also think the financial argument is a false argument --  a percentage of patients who lose their Medicare after 3 years into transplant find a way to get their drugs, whether out of pocket, through assistance programs, etc -- but it is true that many patients lose their transplants after losing Medicare and go back on dialysis.  Whether the government saves or loses money by covering immunosupressants for life, it is just wrong to stop drug and other medical coverage at three years.

I know that professional organizations like the Kidney Foundation and AST are strongly supporting these bills, and that they have access to political and financial expertise in analyzing the pros and cons.



The world in 2014 is not unknowable, if instead of busying themselves with this effort the transplant advocates spent their time familiarizing themselves with the implications of Obamacare they would be doing the people they are advocating for a real service.

Without even considering the details, the fact that the advocates for this coverage don't ever mention the Affordable Care Act or even allude to the sea change in insurance coverage that happens after 2014 should raise concerns. One must notice the dog that doesn't bark - the information that is missing is what should concern people thinking of supporting these Bills. How serious can their analysis be if they don't even mention that they've considered how their legislation would fit into a post ACA world?
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http://www.billpeckham.com  "Dialysis from the sharp end of the needle" tracking  industry news and trends - in advocacy, reimbursement, politics and the provision of dialysis
Incenter Hemodialysis: 1990 - 2001
Home Hemodialysis: 2001 - Present
NxStage System One Cycler 2007 - Present
        * 4 to 6 days a week 30 Liters (using PureFlow) @ ~250 Qb ~ 8 hour per treatment FF~28
noahvale
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« Reply #7 on: April 10, 2013, 11:47:35 AM »

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Bill Peckham
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« Reply #8 on: April 10, 2013, 07:39:35 PM »



The world in 2014 is not unknowable, if instead of busying themselves with this effort the transplant advocates spent their time familiarizing themselves with the implications of Obamacare they would be doing the people they are advocating for a real service.

Without even considering the details, the fact that the advocates for this coverage don't ever mention the Affordable Care Act or even allude to the sea change in insurance coverage that happens after 2014 should raise concerns. One must notice the dog that doesn't bark - the information that is missing is what should concern people thinking of supporting these Bills. How serious can their analysis be if they don't even mention that they've considered how their legislation would fit into a post ACA world?

ACA does not stipulate immuno drug coverage as an "Essential Health Benefit."  Therefore, insurers and state Medicaid programs (participating or not) are left to determine if it will be included as a benefit.

Although states can add new protections of many varieties, many do not seem to be going in this direction. In fact, they are doing the opposite, limiting coverage to the minimum required by the law (Georgia is one of them).  According to the American Society of Transplant Surgeons, advocates are reporting that very few of the new state benchmark plans would provide immuno drug coverage.  As such, this legislation remains necessary to guarantee kidney transplant recipients receive coverage beyond the current 3 year limit.

Don't know if you were aware,  this legislation only serves as a last resort.  If a beneficiary has additional coverage, like a plan through an exchange that includes drug coverage, the bill does not apply.

I think it is prudent and pragmatic for the transplant/renal community to support this Medicare legislation. It will guarantee coverage no matter what the final fallout of ACA.  This has all to do with what is best for patient care, not a legacy policy.

On a political note, unlike the ACA, this bill has bipartisan sponsorship and support.


So no explanation as to why in their advocacy materials they don't even mention the ACA or the requirement to carry insurance starting in 2014.

Ok lets assume this is true: the plans offered through the exchanges will not cover immunosuppressant meds or at least the plans offered in some states will not include immunosuppressant drug coverage. Now assume you are running the policy shop at the  American Society of Transplant Surgeons. What policy solution would you suggest so that people with a transplant - kidney, yes but also heart, lung, liver - could continue to live after 2014? I mean, if you believed that after 2014 people living with a heart transplant were going to face certain death because they live in a state where the insurance available to them does not cover their immunosuppressant meds, what policy would you propose? That kidney transplant patients need lifetime access to Medicare so they can maintain their immunosuppressant drug coverage? Sorry heart transplant guy you don't cost Medicare any money if you lose your graft, you're not our problem ... that's the public policy solution favored by the American Society of Transplant Surgeons? That is truly remarkable.

No. That's ridiculous. The Affordable Care Act established that that Essential Health Benefits be equal in scope to benefits offered by a “typical employer plan.” In the proposed rule published 11/26/12 (PDF), Medicare provides some  flexibility on this base benchmark plan, including allowing the exchanges to set the benchmark as:
  • the largest plan by enrollment in the state’s small group market
  • any of the largest three state employee health benefit plans
  • any of the largest three national Federal Employees Health Benefits Program
  • the largest insured commercial HMO in the state.
So which of these plans in Georgia does not cover immunosuppressant meds? (my guess: they all do).

As far as this new coverage being a last resort that would be novel. Right now every health insurance plan requires that you avail yourself of any public insurance option before they pay a claim. If you are eligible for for a Medicare benefit then a private insurer won't cover the service. Where is the language in the Bill saying that this coverage is only a last resort? Because unless some law is passed saying that, it isn't going to happen. Without language to the contrary insurers in all states will require people with kidney transplants to avail themselves of this coverage in order to have their immunosuppressant meds covered. aka a $400 kidney transplant tax.

On a political note unlike these bills the ACA is the law of the land. It would be smart of the CKD advocacy community to consider what policies to promote based on the actual law of the land.
« Last Edit: April 10, 2013, 07:44:26 PM by Bill Peckham » Logged

http://www.billpeckham.com  "Dialysis from the sharp end of the needle" tracking  industry news and trends - in advocacy, reimbursement, politics and the provision of dialysis
Incenter Hemodialysis: 1990 - 2001
Home Hemodialysis: 2001 - Present
NxStage System One Cycler 2007 - Present
        * 4 to 6 days a week 30 Liters (using PureFlow) @ ~250 Qb ~ 8 hour per treatment FF~28
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