As most of our readers know, Medicare is the government-sponsored health insurance program for the elderly and disabled. What many Americans may not realize, however, is that Medicare has, by law, for many years been unusually and selectively dedicated to the care and feeding of kidney function. This leads us to the question for today: when our elected leaders pass laws about the coverage of specific healthcare services, what logic (if any) dictates the services that will be provided? Is common sense involved? And most importantly, is healthcare policy formulated mostly in the brain, or mostly in the kidneys?
For those of you who may not be overly familiar with them, we should note that kidneys are certainly among the most amazing organs ever created. Their functions include regulating the amount of water and salt in the body, balancing the amounts and proportions of sodium and potassium in the bloodstream, maintaining an appropriate blood pressure, helping to manage the production of red blood cells and various other tasks of great utility, such as detoxifying and/or eliminating potential poisons. There is no question that anything we can do to mitigate the loss of kidney function is a useful social and medical endeavor.
Perhaps as a consequence of the kidney’s great importance in our lives, in 1972 Congress passed an amendment to the Medicare law that essentially made the federal government responsible for the cost of all care associated with end-stage renal disease (ESRD). Since that time this has included both kidney dialysis (a process whereby the blood is filtered by a machine that amounts to an “artificial kidney” when it comes to eliminating excess salt, water and toxins in the bloodstream), and covering the cost of transplanting real kidneys from human donors into ESRD patients. Medicare’s coverage is based upon Congress declaring that any American with ESRD would be declared to be “disabled” for Medicare purposes.
Of course all of this comes with a price. As a recent review article in the New England Journal of Medicine recently documented, this has been considerable:
“In 2008, there were more than 112,000 new patients with ESRD in all eligibility categories (elderly, disabled, and ESRD-only). There were approximately 548,000 U.S. patients with ESRD (about 382,000 of whom were undergoing dialysis) at the end of 2008, but many of them were not covered by Medicare, either because they had not yet fulfilled the initial waiting period or because they had received transplants and their coverage had ceased after 3 years. Medicare expenditures for ESRD in 2008 were $26.8 billion for Parts A and B. Non-Medicare expenditures for ESRD (covered by employer-sponsored group health plans or paid directly by patients) added another $12.7 billion, for total national expenditures of $39.5 billion. According to an analysis by the U.S. Renal Data System, ESRD beneficiaries represented 1.3% of all Medicare beneficiaries and used 7.9% of Medicare expenditures.”
So it was with great pleasure that we met a patient just this week who had directly benefited from this program. She is a middle-aged diabetic woman who had been on dialysis for several years before being able to find a compatible kidney donor. The good news was that she was doing very well with her new kidney and was both pleased and relieved to have been able to discontinue the ritual and inconvenience of dialysis. She felt better, looked better and felt that she could really enjoy life for the first time in years. The bad news was that she was worried. Very worried. In spite of her new kidney she has not yet been able to find work – or at least find work with health insurance. She was most worried about being able to keep using the drugs that were preventing rejection of her kidney. But wasn’t she still covered by Medicare we asked?
“I am for a few more months,” she replied, “but Medicare benefits automatically terminate three years after a successful transplant.” But won’t Medicare continue paying for her transplantation drugs and insulin even after that if she’s unable to find other insurance? After all, if her diabetes rages out of control and she’s unable to take her transplantation medications, she’ll lose her kidney.
“I know. That’s what I’m worried about.” She gave a grim, twisted little smile. “But at least if that happens I’ll qualify for Medicare again and we can start all over.”
In fact, she’s right about that. It’s written in black and white, right here in this document that describes Medicare benefits for those with ESRD:
“If you have Medicare only because of ESRD, your Medicare coverage will end:
• 12 months after you stop dialysis; or
• 36 months after you have a kidney transplant and no longer need dialysis.
Your Medicare coverage will continue if:
• You start dialysis or you get a kidney transplant within 12 months after the month
you stopped getting dialysis; or
• You start or resume dialysis or get another kidney transplant within 36 months after the month you have a kidney transplant.
Your Medicare coverage will resume if:
• Your ESRD Medicare ends and you resume dialysis or get another transplant for kidney failure. Your Medicare can start right away without any waiting period.”
Now here is something strange.
One common theme in the great commotion about healthcare in America today is the concept of “waste, fraud and abuse”. A second one – most common among intellectuals such as President Obama and former head of Medicare Dr. Donald Berwick – has to do with the need to institute and disseminate “best practices” in medicine. And a third has to do with not delivering more care, but “smarter care”. In light of all of these let’s consider the facts of this particular patient’s case.
A kidney transplant costs between $100,000 and $125,000.
A year of hemodialysis costs between $6,000 and $10,000 per month, or about $71,000 to $120,000 per year.
Put them together and you have the same amount of money that would place a taxpayer in the top 2% of annual income. This is so much money that the President routinely lumps households like this into the general category of “millionaires” for tax purposes.
A month of immunosuppressant medications to prevent rejection of a transplanted kidney costs between $1,000 to $3,000 per month, less than one-third the cost of hemodialysis.
But even now, several years after the passage of the Affordable Care (“Obamacare”) Act, the federal government’s own health insurance program will pay for the entire cost of years of dialysis and a kidney transplant to get patients like this one off of dialysis, and then completely squander those investments by discontinuing coverage of the immunosuppressant drugs after 36 months, regardless of whether this will cause the patient to lose the kidney and go back on dialysis.
Lord knows we hate to be critical, but this is just plain stupid – even for a government agency whose healthcare policies routinely seem to be, er, ill-considered. And clearly the patient we met this week is hardly an isolated case. The briefest of Web searches on the topic uncovered this 2009 New York Times article about a patient on her second Medicare-funded transplanted kidney. She lost the first one when she started stretching out her doses of immunosuppressant drugs due to cost considerations.
Perhaps what baffles us most about all of this is that so many people continue to place so much faith a single-payer healthcare system run by the federal government. On what basis can they possibly believe that it will be efficient and/or well-run? These are people who will appropriate and spend $17 billion to force physicians and hospitals to deploy expensive, inefficient and frequently despised and quite possibly even dangerous electronic medical record systems, but they can’t find the money to preserve organs they already paid to transplant once already? Can’t this whole kidney program be considered a rather pure and special form of wasting and abusing taxpayers’ dollars?
Under these circumstances it’s hard to say which is in shorter supply: kidneys or common sense.