Plan for Kidney Drugs Spurs Division

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Plan for Kidney Drugs Spurs Division

By KEVIN SACK
New York Times
Published: December 14, 2009

A Congressional proposal to help pay for drugs needed by transplant recipients to prevent rejection of donated kidneys has run into opposition from dialysis providers, drug companies and the National Kidney Foundation.

Senator Richard J. Durbin backs a plan to pay for expanded coverage for transplant drugs by setting a flat fee for dialysis.

The groups have emphasized that they support extending Medicare coverage for the drugs. But they oppose the method Congress has identified to pay for expanded coverage, saying it would help transplant recipients at the expense of dialysis patients by effectively reducing government reimbursements for dialysis.

The proposal, put forward by leading Democrats, would extend Medicare coverage of immunosuppressant drugs beyond the current limit of 36 months after a kidney transplant. To pay for that extra coverage, a change would be made in the formula used to reimburse dialysis treatment.

The proposal has created a rift between those in the business of providing dialysis and those in the business of performing transplants. The discord is being felt on Capitol Hill, and supporters of the measure fear it may make it easy for Congress to kill the provision altogether in the late stages of negotiation.

On Saturday, a coalition of drug makers, dialysis providers and nephrologists known as Kidney Care Partners informed senators in a letter that “the kidney care community strongly objects” to the payment method.

But the American Society of Transplantation actively supports the provision and fears that opposition from the kidney groups may arrest its momentum.

Although Medicare is primarily an insurance program for older Americans and the disabled, it has since 1973 covered those with end-stage renal disease, regardless of their age or condition.

The federal program now pays for most costs associated with dialysis and transplantation. But for patients younger than 65, coverage of the anti-rejection dugs — which can run from $1,000 to $3,000 a month — ends after three years. If patients cannot afford the medications, they may lose their donated kidneys and have to return to dialysis while awaiting another transplant.

The policy is widely regarded as pound-foolish. Medicare spends an average of $17,000 a year on kidney transplant recipients, most of it for the anti-rejection drugs, compared with $71,000 a year on dialysis patients and $106,000 for a transplant.

“It’s like buying someone a new car and giving them only enough gas to drive around the block a few times,” said Dr. David J. Cohen, medical director of the kidney transplant program at Columbia University Medical Center.

The health care bill that passed the House last month includes a provision that would provide Medicare coverage for immunosuppressant drugs for all beneficiaries for life, starting in 2012.

To pay for the expanded coverage, House Democrats embraced a proposal that would set a flat fee for dialysis treatments and related medications that some providers say would not cover costs. The Congressional Budget Office has calculated that the package would save the government $100 million over the next 10 years.

The Senate majority leader, Harry Reid of Nevada, did not address immunosuppressant drugs in the bill now being debated on the Senate floor. But the second-ranking Democrat in the Senate, Richard J. Durbin of Illinois, last week submitted an amendment that replicates the House language, giving the provision a badly needed lift.

Senate Democratic aides said there was little chance the amendment itself would receive an up or down vote. But they said Mr. Durbin hoped to have it included in a package of loose-end amendments, supported by Mr. Reid, to be presented for a single vote at the end of the debate.

Dialysis providers argue that the bundled-payment mechanism may force some clinics to close. “We believe that the amendment as proposed, while helping one group of patients, would potentially put another very vulnerable group of patients at risk,” said the letter from Kidney Care Partners, which was signed by its chairman, Kent J. Thiry, the chief executive of DaVita, a large commercial dialysis provider.

The group instead proposed to pay for expanded drug coverage by delaying when Medicare would start covering kidney patients who also have private insurance.

The National Kidney Foundation, the largest advocacy group for renal patients, signed on to the letter because it shares the group’s concerns about bundling of payments. But Ellie Schlam, the foundation’s spokeswoman, said its support for extending coverage for anti-rejection drugs would ultimately outweigh its opposition to bundling.

Shortly after the House legislation passed, 40 Democrats in that chamber wrote to Speaker Nancy Pelosi to express concern about the bundling payment method. Many are members of the black or Hispanic caucus, and the letter cited kidney disease’s disproportionate impact on members of minorities.

Three-fourths of the signers had also accepted recent campaign contributions from dialysis providers and drug makers. That included 26 who had received donations in the last three years from Amgen, a California company that makes Sensipar, one of the drugs that would be in the new reimbursement bundle.

http://www.nytimes.com/2009/12/15/health/policy/15kidney.html?_r=2&scp=1&sq=american%20society%20of%20transplantation&st=cse