End-Stage Renal Disease: Characteristics of Kidney Transplant	 
Recipients, Frequency of Transplant Failures, and Cost to	 
Medicare (28-SEP-07, GAO-07-1117).				 
                                                                 
For individuals with end-stage renal disease (ESRD), the	 
permanent loss of kidney function, Medicare covers kidney	 
transplants and 36 months of follow-up care. Kidney transplant	 
recipients must take costly medications to avoid transplant	 
failure. Unless a transplant recipient is eligible for Medicare  
other than on the basis of ESRD, Medicare coverage, including	 
that for medications, ends 36 months posttransplant. Pediatric	 
transplant recipients, including those who were under 18 when	 
transplanted but are now adults (transitional recipients), may be
more likely than their adult counterparts to lose access to	 
medications once Medicare coverage ends because they may lack	 
access to other health insurance coverage. GAO was asked to	 
examine (1) the percentage of transplant failures and subsequent 
outcomes--retransplant, dialysis, or death--among pediatric,	 
transitional, and adult kidney transplant recipients and (2) how 
the cost to Medicare for a beneficiary with a functioning	 
transplant compares with the cost for a beneficiary with a	 
transplant failure. To do this, GAO analyzed 1997 through 2004	 
data from the United States Renal Data System (USRDS) and	 
interviewed officials from pediatric transplant centers. The	 
Centers for Medicare & Medicaid Services--the agency that	 
administers Medicare--commented that it is concerned about	 
beneficiary outcomes and has an education program to help them.  
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-1117					        
    ACCNO:   A76807						        
  TITLE:     End-Stage Renal Disease: Characteristics of Kidney       
Transplant Recipients, Frequency of Transplant Failures, and Cost
to Medicare							 
     DATE:   09/28/2007 
  SUBJECT:   Adolescent health					 
	     Comparative analysis				 
	     Cost analysis					 
	     Dialysis						 
	     Drugs						 
	     Health care costs					 
	     Health insurance					 
	     Health statistics					 
	     Medicaid						 
	     Medical economic analysis				 
	     Medically uninsured				 
	     Medicare						 
	     Transplantation of organs, tissues, etc.		 
	     Urologic diseases					 
	     State Children's Health Insurance			 
	     Program						 
                                                                 

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GAO-07-1117

   

     * [1]Results in Brief
     * [2]Background

          * [3]Medicare Coverage for Individuals with ESRD
          * [4]Posttransplant Immunosuppressive Therapy

     * [5]Transplant Recipients in All Age Groups Had Similar Demograp

          * [6]Pediatric, Transitional, and Adult Transplant Recipients Wer
          * [7]A Smaller Percentage of Pediatric and Transitional Recipient

     * [8]A Higher Percentage of Transitional Recipients Experienced T

          * [9]A Higher Percentage of Transitional Recipients Experienced T
          * [10]A Higher Percentage of Transitional Recipients Received Dial

     * [11]A Higher Percentage of Recipients with Both Medicare and Med
     * [12]Beneficiaries with Functioning Transplants Were Substantiall
     * [13]Concluding Observations
     * [14]Agency Comments
     * [15]Appendix I: Comments from the Centers for Medicare & Medicai
     * [16]Appendix II: GAO Contact and Staff Acknowledgments

          * [17]GAO Contact
          * [18]Acknowledgments

               * [19]Order by Mail or Phone

     * [20]PDF6-Ordering Information.pdf

          * [21]Order by Mail or Phone

Report to Congressional Requesters

United States Government Accountability Office

GAO

September 2007

END-STAGE RENAL DISEASE

Characteristics of Kidney Transplant Recipients, Frequency of Transplant
Failures, and Cost to Medicare

GAO-07-1117

Contents

Letter 1

Results in Brief 7
Background 8
Transplant Recipients in All Age Groups Had Similar Demographic
Characteristics, but Fewer Pediatric and Transitional Recipients Had
Medicare Coverage 12
A Higher Percentage of Transitional Recipients Experienced Transplant
Failure and Received Dialysis 15
A Higher Percentage of Recipients with Both Medicare and Medicaid Coverage
Experienced Transplant Failure and Received Dialysis 20
Beneficiaries with Functioning Transplants Were Substantially Less Costly
to Medicare Than Those with Transplant Failures 23
Concluding Observations 23
Agency Comments 24
Appendix I Comments from the Centers for Medicare & Medicaid Services 25
Appendix II GAO Contact and Staff Acknowledgments 27

Tables

Table 1: Distribution of Pediatric, Transitional, and Adult Kidney
Transplant Recipients by Sex 12
Table 2: Distribution of Pediatric, Transitional, and Adult Kidney
Transplant Recipients by Race 13
Table 3: Distribution of Pediatric, Transitional, and Adult Kidney
Transplant Recipients by Median Annual County-Level Household Income 14
Table 4: Distribution of Pediatric, Transitional, and Adult Kidney
Transplant Recipients by Insurance Coverage 15
Table 5: Median Annual Medicare Cost per Beneficiary with a Functioning
Transplant and after a Transplant Failure, by Age Group 23

Figures

Figure 1: Percentage of Kidney Transplant Recipients Whose Transplants
Failed, by Age Group and Number of Years Posttransplant 16
Figure 2: Percentage of Kidney Transplant Recipients Who Received Dialysis
after Transplant Failure, by Age Group and Number of Years Posttransplant
18
Figure 3: Percentage of Kidney Transplant Recipients Who Received
Retransplants after Transplant Failure, by Age Group and Number of Years
Posttransplant 19
Figure 4: Percentage of Kidney Transplant Recipients Who Died after
Transplant Failure, by Age Group and Number of Years Posttransplant 20
Figure 5: Percentage of Kidney Transplant Recipients Whose Transplants
Failed, by Type of Health Insurance Coverage and Number of Years
Posttransplant 21
Figure 6: Percentage of Kidney Transplant Recipients Who Received Dialysis
after Transplant Failure, by Type of Health Insurance Coverage and Number
of Years Posttransplant 22

Abbreviations

ARF Area Resource File
CMS Centers for Medicare & Medicaid Services
ESRD end-stage renal disease
HHS Department of Health and Human Services
NIH National Institutes of Health
SCHIP State Children's Health Insurance Program
USRDS United States Renal Data System

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United States Government Accountability Office
Washington, DC 20548

September 28, 2007

The Honorable Max Baucus
Chairman
The Honorable Charles E. Grassley
Ranking Member
Committee on Finance
United States SenateThe Honorable Max
Baucus Chairman The Honorable Charles E. Grassley Ranking Member Committee
on Finance United States Senate

The Honorable Christopher J. Dodd
Chairman
Subcommittee on Children and Families
Committee on Health, Education, Labor, and Pensions
United States Senate 

Regardless of age, most individuals with end-stage renal disease (ESRD),
the permanent loss of kidney function, are covered under Medicare.^1
Individuals with ERSD must either receive kidney transplants or undergo
regular dialysis treatments,^2 which remove excess fluids and wastes from
the blood, in order to survive. Medicare covers kidney transplants and 36
months of follow-up care, and for individuals who do not receive kidney
transplants, Medicare covers regular dialysis treatments.^3123 In the long
term, dialysis is associated with a lower quality of life and higher
mortality rates than kidney transplants and is considered a less desirable
treatment option. Regardless of age, most individuals with end-stage renal
disease (ESRD), the permanent loss of kidney function, are covered under
Medicare. Individuals with ERSD must either receive kidney transplants or
undergo regular dialysis treatments, which remove excess fluids and wastes
from the blood, in order to survive. Medicare covers kidney transplants
and 36 months of follow-up care, and for individuals who do not receive
kidney transplants, Medicare covers regular dialysis treatments. In the
long term, dialysis is associated with a lower quality of life and higher
mortality rates than kidney transplants and is considered a less desirable
treatment option.

^1Generally, individuals with ESRD are eligible for benefits under
Medicare if they (1) are entitled to monthly insurance benefits under
Title II of the Social Security Act (or an annuity under the Railroad
Retirement Act of 1974), (2) meet certain work requirements under the
Social Security or Railroad Retirement programs, or (3) are the spouse or
dependent child of a person who meets at least one of the first two
requirements. 42 U.S.C. S 426-1 (2000). In addition to Medicare,
individuals with ESRD may also be covered by other public or private
health insurance, including Medicaid.

^2Individuals with ESRD typically receive dialysis treatments three times
per week.

^3For the first 30 months of an individual's Medicare coverage, Medicare
is the secondary payer for individuals with employer-sponsored group
health insurance coverage.

Kidney transplant recipients must take immunosuppressive medications^4 for
the life of the transplant to avoid transplant failure, and the cost of
these medications is substantial--ranging from $5,000 to $13,000 annually.
Transplant recipients who stop taking immunosuppressive medications
(referred to as medication noncompliance) and experience transplant
failure must, absent a retransplant, receive regular dialysis treatments
in order to survive.^5 Transplant failures may be particularly problematic
for pediatric recipients^6 because long-term dialysis can lead to
developmental problems, such as inhibited growth, as well as poor academic
performance and delayed social development.

Unless a transplant recipient is eligible for Medicare^7 other than
because of ESRD, coverage of immunosuppressive medications, along with
follow-up care, ends 36 months posttransplant. Pediatric transplant
recipients may be more likely than their adult counterparts to lose access
to immunosuppressive medications once Medicare coverage for ESRD ends
because they may lack access to other health insurance coverage. Access to
health insurance may be particularly problematic for those individuals who
are 18 or older but were under 18 at the time of their transplants--for
the purposes of this report, we refer to these individuals as transitional
recipients. While some pediatric recipients may be covered by their
parents' health insurance, family insurance coverage often does not extend
to children over 18 unless they are full-time students. While a lack of
health insurance is one reason transplant recipients may stop taking their
medication, studies have reported that there are numerous other reasons
for medication noncompliance, including avoidance of adverse side effects
associated with immunosuppressive medications and difficulty following
complex treatment regimens.

In light of these concerns, you asked us to describe certain aspects of
kidney transplant recipients, determine the extent to which they
experience transplant failure and subsequent outcomes, and calculate the
cost associated with their treatment. In this report, we (1) compare
certain demographic characteristics and types of health insurance coverage
of pediatric, transitional, and adult kidney transplant recipients; (2)
examine the percentage of transplant failures and subsequent
outcomes--retransplant, dialysis, or death--among pediatric, transitional,
and adult kidney transplant recipients; (3) determine how the percentage
of transplant failures and subsequent outcomes of kidney transplant
recipients compare by type of health insurance coverage; and (4) examine
how the cost to Medicare for a beneficiary with a functioning transplant
compares with the cost for a beneficiary with a transplant failure.

^4Immunosuppressive medications diminish an individual's natural immune
response to the presence of foreign objects so that the body does not
reject the newly transplanted kidney.

^5Medicare covers the cost of a retransplant and regular dialysis
treatments if kidney transplant recipients experience a transplant
failure.

^6For the purposes of this report, we define pediatric transplant
recipients as those younger than 18 years old as of December 31, 2004.

^7In general, Medicare coverage is available to individuals who are 65
years or older or are disabled and who qualify for benefits under the
Social Security Act or Railroad Retirement Act. 42 U.S.C. S 426 (2000).

To determine the characteristics of pediatric, transitional, and adult
kidney transplant recipients,^8 we used 2004 data--the latest data
available--on recipient age, sex, race, and type of health insurance
coverage^9 from the United States Renal Data System (USRDS). The USRDS is
a national data system maintained by the Department of Health and Human
Services' (HHS) National Institutes of Health (NIH) that contains data on
individuals with ESRD collected from many sources, including HHS's Centers
for Medicare & Medicaid Services (CMS), the agency that administers
Medicare, and the United Network for Organ Sharing. We used USRDS to
define three age groups: pediatric recipients are those who were younger
than 18 years old as of December 31, 2004, transitional recipients are
those who were younger than 18 years old at the time of their transplants
and at least 18 years old as of December 31, 2004, and adult recipients
are those who were at least 18 years old at the time of their transplants.
We used USRDS data to compare the distribution of sex, race, and income
levels among pediatric, transitional, and adult recipients who had a
functioning transplant as of December 31, 2004. There were 3,675 pediatric
recipients, 4,608 transitional recipients, and 110,762 adult recipients in
the USRDS data who met this criterion. We also compared the demographic
characteristics of the three age groups to those found in the general U.S.
population, using data from the 2000 U.S. Census. To estimate the income
levels for recipients in each of our three age groups, we matched
recipients' zip codes and federal information processing standards codes
using the 2002 median household income for the county^10 of their
residence as published in the 2005 Area Resource File (ARF), the latest
data available.^11 The USRDS maintains health insurance information under
three categories: Medicare but not Medicaid, Medicare and Medicaid, and
Other. The Other category is defined as those who do not have Medicare
coverage but are covered by private health insurance, Medicaid, or other
governmental health insurance or are uninsured or whose health insurance
status is unknown. Our analysis is based on recipients who had a
functioning kidney-only transplant as of December 31, 2004.^12

^8We did not have information on the health status of the transplant
recipients beyond the fact that they had ESRD.

^9For the purposes of this objective, for each recipient, we determined
the type of health insurance coverage as of December 31, 2004, and as of
the recipient's transplant date.

To examine the percentage of transplant failures and subsequent outcomes
among pediatric, transitional, and adult kidney transplant recipients, we
used data through December 31, 2004, from the USRDS on individuals who
received kidney-only transplants from 1997 through 2000.^13 There were
1,218 pediatric recipients, 2,148 transitional recipients, and 49,940
adult recipients who met this criterion. We analyzed data separately for
pediatric, transitional, and adult recipients. We determined the frequency
of transplant failures among each of the three age groups at 1 year, 3
years, 5 years, and 7 years after the transplant using the date of failure
reported in the USRDS, and we grouped the frequencies by age group and
these follow-up periods.^14 For recipients whose transplants failed, we
determined the percentage who died,^15 received retransplants, or received
dialysis during the follow-up periods, by age group. These outcome groups
are not mutually exclusive; for example, if an individual received both
dialysis and a subsequent retransplant, the individual is counted in both
groups. A recipient who died after a transplant failure could have
received dialysis or a retransplant between date of failure and date of
death. Those recipients who had dates of failure but no subsequent
treatment information or dates of death were excluded from our analysis.
We included only transplant recipients in the 50 states and the District
of Columbia.

^10Median annual household income estimates are county-level averages and
are not calculated from actual annual household incomes of transplant
recipients. Data on individual recipients' household income levels are not
available.

^11The ARF is a database containing information on every county in the
United States. It is maintained by Quality Resource Systems, Inc., which
is under contract with the National Center for Health Workforce Analysis
within HHS's Health Resources and Services Administration.

^12We excluded those who received kidney-pancreas transplants. According
to data from the Organ Procurement and Transplant Network, kidney-pancreas
transplants represent less than 5.7 percent of all kidney transplants
performed since 1988.

^13We included individuals who received initial kidney transplants as well
as those who received retransplants from 1997 through 2000. We did not
have information on the health status of the transplant recipients beyond
the fact that they had ESRD.

^14For those who received transplants in 1997, we report at 1 year, 3
years, 5 years, and 7 years after the transplant. For those who received
transplants in 1998 and 1999, we report at 1 year, 3 years, and 5 years
after the transplant. For those who received transplants in 2000, we
report at 1 year and 3 years after the transplant.

^15These recipients could have died for causes other than transplant
failure because USRDS also categorizes death with a functioning transplant
as a transplant failure.

To compare the percentage of transplant failures and subsequent outcomes
of kidney transplant recipients by type of health insurance coverage, we
used data through December 31, 2004, from the USRDS on individuals who
received kidney-only transplants from 1997 through 2000.^16 The USRDS
maintains health insurance information under three categories: Medicare
but not Medicaid, Medicare and Medicaid, and Other. There were 33,702
recipients with Medicare but not Medicaid, 12,139 recipients with Medicare
and Medicaid, and 7,465 recipients in the Other category who met this
criterion. Using the same three categories, we determined the frequency of
transplant failures by type of health insurance coverage at 1 year, 3
years, 5 years, and 7 years after the transplant and we grouped the
frequencies by the follow-up periods.^17 For recipients whose transplants
failed, we determined the percentage who died,^18 received retransplants,
or received dialysis during the follow-up periods. As described above,
these outcome groups are not mutually exclusive.

To examine how the cost to Medicare for a beneficiary with a functioning
transplant compares with the cost for a beneficiary with a transplant
failure, we used data through December 31, 2004, from the USRDS on
individuals who received kidney-only transplants from 1997 through 2000
and for whom Medicare reported costs.^19 There were 669 pediatric
beneficiaries, 1,264 transitional beneficiaries, and 33,557 adult
beneficiaries who met this criterion. For beneficiaries with functioning
transplants, we summed the Medicare costs from their posttransplant
hospital discharge dates through December 31, 2004. For beneficiaries
whose transplants failed and who subsequently died, we summed the Medicare
costs from their transplant failure dates through the dates of death and
annualized any portion incurred during a period that was less than a full
year. For beneficiaries whose transplants failed but who did not die, we
summed the Medicare costs from their transplant failure dates through
December 31, 2004.^20 For beneficiaries with functioning transplants and
for those whose transplants failed, we calculated the median annual cost
per beneficiary in each age group. For each of the four objectives, we
included only transplant recipients in the 50 states and the District of
Columbia. We reviewed relevant documentation and spoke with knowledgeable
officials to determine the reliability of the USRDS and ARF. Based on
this, we found the USRDS and ARF suitable for our purposes.

^16We included individuals who received initial kidney transplants as well
as those who received retransplants from 1997 through 2000. We did not
have information on the health status of the transplant recipients beyond
the fact that they had ESRD.

^17For those who received transplants in 1997, we report at 1 year, 3
years, 5 years, and 7 years after the transplant. For those who received
transplants in 1998 and 1999, we report at 1 year, 3 years, and 5 years
after the transplant. For those who received transplants in 2000, we
report at 1 year and 3 years after the transplant.

^18These recipients could have died from causes other than transplant
failure because USRDS also categorizes death with a functioning transplant
as a transplant failure.

We conducted a literature search of reported studies related to ESRD and
pediatric, transitional, and adult kidney transplant recipients and
conducted interviews with officials from CMS; the Health Resources and
Services Administration, a federal agency focused on access to health care
services; and NIH, the primary federal agency that conducts and supports
medical research and maintains the USRDS. We also interviewed
representatives of the National Kidney Foundation, the Forum of ESRD
Networks, and the American Society of Pediatric Nephrology. Of the 251
pediatric transplant centers in the United States, we interviewed
representatives from 6 centers that treat a high number of pediatric
recipients. Those 6 centers accounted for about 10 percent of the 13,560
pediatric kidney transplants performed since 1988.^21 We performed our
work from October 2006 through August 2007 in accordance with generally
accepted government auditing standards.

^19We included individuals who received initial kidney transplants as well
as those who received retransplants from 1997 through 2000. We did not
have information on the health status of the transplant recipients beyond
the fact that they had ESRD.

^20If USRDS did not report Medicare cost data on a beneficiary through
December 31, 2004, we summed cost data from hospital discharge date
following the transplant to the latest date with available cost data.

^21We interviewed representatives from transplant centers in California,
Texas, Pennsylvania, Illinois, and Florida.

Results in Brief

Pediatric, transitional, and adult transplant recipients were similar with
respect to demographic characteristics such as sex, race, and income level
but differed in their types of health insurance coverage. As of December
31, 2004, recipients in all three age groups were predominately male,
white, and lived in counties with a median annual household income of
$25,000 to less than $50,000. Unlike the demographic characteristics,
recipients' type of health insurance coverage varied by age group. While
more than two-thirds of adult recipients had health insurance coverage
under Medicare, just over one-third of pediatric recipients and less than
half of transitional recipients were covered under Medicare. At the time
of their transplants, the percentage of recipients covered by Medicare was
higher for all age groups, although the percentages of pediatric (67
percent) and transitional (81 percent) recipients with Medicare coverage
were still lower than adult recipients (87 percent). It is not known why
these differences in Medicare coverage existed, given that most
individuals who have ESRD are eligible for Medicare coverage.

After the first year posttransplant, a higher percentage of transitional
recipients experienced a transplant failure and subsequently received
dialysis compared with their pediatric and adult counterparts. For
example, by 5 years posttransplant, the percentage of transitional
recipients who experienced a transplant failure (33 percent) was about
twice as high as pediatric recipients (16 percent) and somewhat higher
than adult recipients (28 percent). The largest increase in transplant
failures for each age group occurred during the first 3 years
posttransplant--before the termination of Medicare coverage on the basis
of ESRD--and the increase was substantially higher for transitional
recipients (133 percent) than for pediatric (83 percent) and adult (100
percent) recipients. Compared to adult and pediatric recipients, a higher
percentage of transitional recipients received dialysis after experiencing
a transplant failure. A higher percentage of pediatric recipients received
retransplants after the first year posttransplant, compared with adult and
transitional recipients, and a higher percentage of adult recipients died
after experiencing a transplant failure.

Recipients who had both Medicare and Medicaid coverage experienced a
higher percentage of transplant failures than those who had Medicare but
not Medicaid coverage or were in the Other category. For example, by 7
years posttransplant, the percentage of recipients covered by both
Medicare and Medicaid who experienced a transplant failure (56 percent)
was more than three times as high as the percentage of recipients in the
Other category (16 percent). In addition, after experiencing a transplant
failure, a higher percentage of recipients who had both Medicare and
Medicaid coverage received dialysis when compared with recipients who had
Medicare but not Medicaid coverage or were in the Other category.
Throughout the 7 years of posttransplant follow-up, the percentage of
recipients covered by both Medicare and Medicaid who received dialysis was
substantially higher than the percentage for recipients in the Other
category.

Medicare beneficiaries with functioning transplants cost substantially
less per year to treat than those beneficiaries who experienced transplant
failures. Specifically, we found that the median annual Medicare cost for
a beneficiary whose transplant failed ($50,938) was 500 percent more than
the median annual Medicare cost for a beneficiary with a functioning
transplant ($8,550).

The substantial cost of treating transplant recipients who experience
transplant failures underscores the importance of maintaining functioning
kidney transplants. While there are many reasons that could account for
transplant failures during the first 3 years posttransplant--including
medication noncompliance--the large percentage increase in transplant
failures from 1 year to 3 years posttransplant for transitional recipients
cannot be attributed to an inability to access immunosuppressive
medications due to a lack of Medicare coverage.

In commenting on a draft of this report, CMS stated that it appreciated
our interest in kidney transplant patients and in the cost of care
provided to those receiving transplants or dialysis. CMS stated that it
was concerned about the quality of care and the outcomes experienced by
Medicare beneficiaries, including the higher rate of transplant failure
among transitional patients. CMS also pointed out that it engages in
numerous educational and outreach efforts targeted to beneficiaries,
providers, and national organizations that represent renal patients.

Background

ESRD occurs when an individual's kidneys have regressed to less than 10
percent of normal baseline function. Without functioning kidneys, excess
wastes and fluids in the body rise to dangerous levels, and certain
hormones are no longer produced. Individuals with ESRD must undergo either
regular dialysis treatments or receive kidney transplants to survive. As
of the end of 2004, of the approximately 480,000 adults with ESRD (those
at least 18 years old), just over one-fourth (about 130,000) had
functioning kidney transplants and two-thirds (about 330,000) were
receiving dialysis treatments.^22 In addition, of the almost 5,700
pediatric individuals with ESRD (those younger than 18 years old),
approximately two-thirds (about 3,800) had functioning transplants and
less than one-third (about 1,700) were receiving dialysis treatments.^23

A kidney transplant is the preferred method of treatment for individuals
with ESRD because it increases an individual's quality of life and
decreases long-term mortality rates compared with lifetime dialysis
treatments. Studies have reported that pediatric ESRD patients tend to
perform better developmentally with transplants than on dialysis. For
example, one study reported improvement in neurological development in
infants aged 6-11 months following transplantation.^24 Another study
showed that transplantation increased the rate at which pediatric ESRD
patients improved on measures of intelligence and mathematical skills.^25

Medicare Coverage for Individuals with ESRD

Medicare covers over 80 percent of all individuals with ESRD. For these
individuals, Medicare covers the cost of lifetime dialysis treatments, or
for individuals who receive kidney transplants, the cost of the
transplants and 3 years of follow-up care--including immunosuppressive
medications needed to sustain the transplants. Medicare also covers
hospital inpatient services and outpatient services, such as physician
visits and laboratory tests, as well as medical evaluations provided to
living donors and recipients in anticipation of transplants. In addition
to Medicare, individuals with ESRD may be covered by other public or
private health insurance, such as Medicaid or an employer-sponsored health
plan. For individuals who are eligible for Medicare on the basis of ESRD,
Medicare is the secondary payer if the individuals have employer-sponsored
group health insurance coverage during the first 30 months of Medicare
coverage. After the first 30 months, Medicare becomes the primary payer
for these beneficiaries until they are no longer entitled to Medicare. For
an individual who is eligible for Medicare solely because of ESRD and who
has a kidney transplant, Medicare coverage ends on the last day of the
36th month after the individual receives the transplant unless the
individual is entitled to Medicare other than because of ESRD.^26 However,
after 36 months, a transplant recipient can become eligible for Medicare
again after a transplant failure and subsequently receive a retransplant
or dialysis.

^22The remaining approximately 20,000 adults with ESRD were lost to
follow-up.

^23The remaining approximately 200 pediatric individuals with ESRD were
lost to follow-up.

^24M.S. Polinsky et al., "Neurologic Development of Children with Severe
Chronic Renal Failure from Infancy," Pediatric Nephrology, vol. 1 (1987),
157-165 (citing endnote 6).

^25R.S. Fennell III et al., "Effects of Kidney Transplantation on
Cognitive Performance in a Pediatric Population," Pediatrics, vol. 74
(1984), 273-278.

Following termination of Medicare coverage, individuals who are unable to
pay for immunosuppressive medications and other transplant-related
follow-up care must rely on other public or private health insurance or
charity care. Pediatric recipients have several potential sources of
coverage when their Medicare coverage ends: private health
insurance--generally, a parent's employer-sponsored coverage;^27
Medicaid;^28 the State Children's Health Insurance Program (SCHIP);^29 and
charity care. However, once individuals turn 19, they may lose access to
their parents' private insurance coverage as well as coverage under SCHIP
and Medicaid.

Posttransplant Immunosuppressive Therapy

Individuals who receive kidney transplants require immunosuppressive
therapy--usually a combination of at least two different immunosuppressive
medications--as well as regular laboratory tests to monitor and maintain
their transplants. Although the frequency of laboratory tests decreases
over time, the need for immunosuppressive medications continues for the
life of the transplant.

Recipients who do not take their immunosuppressive medications according
to the prescribed regimens are more likely to have their transplanted
kidneys fail. Studies have shown that not only does medication
noncompliance cause 13 to 35 percent of transplants to fail, one of the
studies indicated that it also causes recipients to die at rates fourfold
greater than compliant recipients.^30 One recent study showed that about
23 percent of recipients with failed transplants who returned to dialysis
died within 2 years.^31

^26For beneficiaries with ESRD who are also eligible for Medicare due to
age or disability, Medicare covers the immunosuppressive medications for
the life of the individual.

^27Some private health insurance plans provide coverage for dependants
until age 23 if the dependant is a full-time student.

^28Medicaid provides health care coverage to eligible low-income people
and is jointly financed by the federal government and the states.

^29SCHIP provides health care coverage to uninsured children in families
whose incomes exceed the eligibility requirements of Medicaid. SCHIP has a
capped allotment to states. States have some flexibility in how they
design their programs.

Several studies have reported that there are a number of reasons why some
transplant recipients do not comply with their medication regimens. More
specifically, one study reported that adverse side effects of the
medications,^32 difficulty following complex treatment regimens that
involve several drugs and varying schedules of dosing, and an inability to
pay for medications due to a lack of health insurance coverage, among
other reasons, can contribute to medication noncompliance.^33 Other
studies have reported that medication noncompliance can be unpredictable,
often without an identifiable reason.^34

Studies have also shown that adolescent recipients are especially prone to
medication noncompliance or partial compliance. For example, one study
showed that for individuals aged 12 to 19 years, dissatisfaction with body
image and the physical side effects of medications have been linked to
poor compliance with prescribed transplant medication regimens.^35 Another
study found that 57 percent of participating recipients under 20 years old
were not compliant with their medication regimens, compared with only 15
percent of participants over 40 years old.^36

^30E. F. Yen et al., "Cost-Effectiveness of Extending Medicare Coverage of
Immunosuppressive Medications to the Life of a Kidney Transplant,"
American Journal of Transplantation, vol. 4 (2004): 1703-1708 (citing
endnotes 4-7 (reported from 1989, 1990, 1992, and 1999)), and S.D. Geest
et al., "Incidence, Determinants, and Consequences of Subclinical
Noncompliance with Immunosuppressive Therapy in Renal Transplant
Recipients," Transplantation, vol. 59, no. 3 (1995): 340-347 (citing
endnotes 18-19 (1992)).

^31Yen et al., "Cost-Effectiveness of Extending Medicare Coverage of
Immunosuppressive Medications to the Life of a Kidney Transplant."

^32Immunosuppressive medications can increase patients' risk of developing
infections and can cause weight gain, cataracts, diabetes, high blood
pressure, bone disease, and damage to the liver and kidney.

^33M. A. Chisholm, "Issues of Adherence to Immunosuppressant Therapy After
Solid-Organ Transplantation," Drugs, vol. 62, no. 4 (2002): 567-575.

^34See, for example, R. T. Schweizer et al., "Noncompliance in Organ
Transplant Recipients," Transplantation, vol. 49, no. 2 (1990): 374-377,
and Chisholm, "Issues of Adherence to Immunosuppressant Therapy After
Solid-Organ Transplantation."

^35M. E. Ferris et al., "Trends in Treatment and Outcomes of Survival of
Adolescents Initiating End-Stage Renal Disease Care in the United States
of America," Pediatric Nephrology, vol. 21 (2006): 1020-1026 (citing
endnote 16).

Transplant Recipients in All Age Groups Had Similar Demographic Characteristics,
but Fewer Pediatric and Transitional Recipients Had Medicare Coverage

Pediatric, transitional, and adult kidney transplant recipients were
similar with respect to sex, race, and income level. As of December 31,
2004, all three age groups were predominately male, white, and lived in
counties with a median annual household income of $25,000 to less than
$50,000. However, the three groups differed in terms of their types of
health insurance coverage, with a smaller percentage of pediatric and
transitional recipients covered by Medicare compared to their adult
counterparts.

Pediatric, Transitional, and Adult Transplant Recipients Were Similar with
Respect to Sex, Race, and Income Level

Based on our analyses of USRDS and ARF data, we found that pediatric,
transitional, and adult recipients were similar with respect to sex, race,
and income level, as of December 31, 2004. All three age groups were
predominantly male, and the proportion of males in each age group was
higher than that found in the general U.S. population--49 percent (see
table 1). Approximately 59 percent of individuals with ESRD are male.

Table 1: Distribution of Pediatric, Transitional, and Adult Kidney
Transplant Recipients by Sex

                 Percentage of Percentage of transitional Percentage of adult 
Sex    pediatric recipients                 recipients          recipients 
Male                     62                         57                  59 
Female                   39                         43                  41 

Source: GAO analysis of USRDS data.

Note: Our analysis is based on kidney transplant recipients who had
functioning transplants as of December 31, 2004. The percentages may not
total 100 because of rounding.

All three age groups were also predominantly white, and the percentage
distribution of other races among the three groups was similar (see table
2). Although a higher percentage of transitional recipients were white and
a lower percentage were black compared with pediatric and adult
recipients, the differences were not substantial. In addition, the
distribution of racial groups among pediatric, transitional, and adult
transplant recipients was similar to that found in the general U.S.
population.

^36Schweizer et al., "Noncompliance in Organ Transplant Recipients."

Table 2: Distribution of Pediatric, Transitional, and Adult Kidney
Transplant Recipients by Race

                   Percentage of                                              
                       pediatric  Percentage of transitional    Percentage of 
Race               recipients                  recipients adult recipients 
White                      77                          82               74 
Black                      16                          12               19 
Asian                       3                           3                5 
Native American             1                           1                1 
Other                       2                           1                1 
Not available               1                           0                0 

Source: GAO analysis of USRDS data.

Note: Our analysis is based on kidney transplant recipients who had
functioning transplants as of December 31, 2004. The percentages may not
total 100 because of rounding.

Pediatric, transitional, and adult transplant recipients were similar in
terms of their household income level (see table 3). Seventy-five percent
of recipients in each age group resided in counties with a median annual
household income of $25,000 to less than $50,000, which is almost three
times the percentage for the general U.S. population (27 percent). When
compared to the general U.S. population, a very small percentage of
recipients in each of the three age groups resided in counties with the
lowest and highest median annual household incomes--less than $25,000 or
$75,000 or more, respectively. About 27 percent of the U.S. population
resided in counties with a median annual household income of less than
$25,000 and about 28 percent resided in counties with a median annual
household income of $75,000 or more.

Table 3: Distribution of Pediatric, Transitional, and Adult Kidney
Transplant Recipients by Median Annual County-Level Household Income

                                    Percentage of Percentage of Percentage of 
Median annual county-level           pediatric  transitional         adult 
household income                    recipients    recipients    recipients 
Less than $10,000                            0             0             0 
$10,000 to less than $25,000                 2             2             1 
$25,000 to less than $50,000                75            75            75 
$50,000 to less than $75,000                18            20            21 
$75,000 or more                              1             1             1 
Not available                                5             3             1 

Source: GAO analysis of USRDS data and the 2005 ARF of 2002 median annual
county-level household income.

Note: Our analysis is based on kidney transplant recipients who had
functioning transplants as of December 31, 2004. The percentages may not
total 100 because of rounding.

A Smaller Percentage of Pediatric and Transitional Recipients Had Medicare
Coverage

While pediatric, transitional, and adult transplant recipients were
similar in terms of sex, race, and income, they were less similar in terms
of their health insurance coverage. As of December 31, 2004, while more
than two-thirds of adult recipients had coverage under Medicare, just over
one-third of pediatric recipients and slightly less than half of
transitional recipients were covered under Medicare (see table 4).
Although each group had about the same percentage of recipients with both
Medicare and Medicaid coverage, almost three times as many adult
recipients had Medicare but not Medicaid coverage compared with pediatric
recipients, and almost twice as many adult recipients had Medicare but not
Medicaid coverage compared with transitional recipients.

Table 4: Distribution of Pediatric, Transitional, and Adult Kidney
Transplant Recipients by Insurance Coverage

                    Percentage of                                             
Insurance            pediatric Percentage of transitional    Percentage of 
coverage            recipients                 recipients adult recipients 
Medicare but not                                                           
Medicaid                    20                         30               55 
Medicare and                                                               
Medicaid                    15                         17               15 
Other^a                     65                         53               30 

Source: GAO analysis of USRDS data.

Note: Our analysis is based on the latest reported health insurance
coverage by kidney transplant recipients who had functioning transplants
as of December 31, 2004.

aOther is defined as those who do not have Medicare coverage but are
covered by private health insurance, Medicaid, or other governmental
health insurance or are uninsured or whose health insurance status is
unknown.

Although still smaller than the percentage of adult recipients, based on
our analysis of USRDS data, a larger percentage of pediatric and
transitional recipients had Medicare coverage at the time of their
transplants-- 67 percent and 81 percent, respectively, compared to 87
percent. It is not known why these differences in Medicare coverage
existed, given that most individuals who have ESRD are eligible for
Medicare coverage.

A Higher Percentage of Transitional Recipients Experienced Transplant Failure
and Received Dialysis

Our analysis of data from the USRDS show that after the first year
posttransplant, a higher percentage of transitional recipients experienced
a transplant failure compared with their pediatric and adult counterparts.
In addition, the largest increase in transplant failure among the three
age groups occurred in the first 3 years posttransplant--before
termination of Medicare coverage--and the increase was substantially
higher for transitional recipients than for pediatric and adult
recipients. After experiencing a transplant failure, a higher percentage
of transitional recipients received dialysis, a higher percentage of
pediatric recipients received retransplants after the first year
posttransplant, and a higher percentage of adult recipients died.

A Higher Percentage of Transitional Recipients Experienced Transplant Failure
Compared with Pediatric and Adult Recipients

Based on our analysis of USRDS data, we found that after the first year
posttransplant, a higher percentage of transitional recipients experienced
a transplant failure when compared with their pediatric and adult
counterparts (see fig. 1). For example, we found that by 5 years
posttransplant, the percentage of transitional recipients who experienced
a transplant failure (33 percent) was about twice as high as the
percentage of pediatric recipients (16 percent) and somewhat higher than
adult recipients (28 percent). According to several representatives of
pediatric kidney transplant centers that we interviewed, adolescent kidney
transplant recipients--who generally populate our transitional age
group--are less likely than other age groups to comply with their
medication regimens, which, among other things, can lead to transplant
failure.

Figure 1: Percentage of Kidney Transplant Recipients Whose Transplants
Failed, by Age Group and Number of Years Posttransplant

Notes: Our analysis is based on individuals who received kidney
transplants from 1997 through 2000. The percentage of kidney transplant
failures is equal to the number of recipients whose transplants failed in
that time period divided by the total number who received transplants
during the same time period.

The largest increase in the percentage of transitional recipients who
experienced a transplant failure occurred in the first 3 years
posttransplant, and this increase was substantially higher than the
increase for pediatric and adult recipients. Specifically, the percentage
of failures for transitional recipients increased by 133 percent between 1
and 3 years posttransplant, while the percentage increases for pediatric
and adult recipients were 83 and 100 percent, respectively.

After 3 years posttransplant, all three age groups showed a smaller
increase in transplant failures when compared with the period between 1
and 3 years posttransplant. Between 3 and 5 years posttransplant, the
percentage increase in transplant failures was 45 percent for pediatric,
57 percent for transitional, and 56 percent for adult recipients. The
percentage increase in failures remained lower during the 5 to 7 years
posttransplant period--63 percent, 33 percent, and 43 percent for
pediatric, transitional, and adult recipients, respectively. Failure to
see a large percentage increase of transplant failures in pediatric and
transitional recipients beyond 3 years posttransplant, when Medicare
coverage terminates for many recipients, may be explained by the practices
of transplant centers. Representatives from pediatric kidney transplant
centers with whom we spoke stated that once Medicare coverage ends, they
either help recipients to acquire other health insurance coverage or
provide them with free or reduced-cost immunosuppressive medications if
they lack health insurance coverage or otherwise cannot afford the
medications. They also stated that the percentage of recipients who
experience transplant failures because of an inability to pay for their
medications after Medicare coverage ends (3 years posttransplant) is low.

A Higher Percentage of Transitional Recipients Received Dialysis Compared with
Pediatric and Adult Recipients

Based on our analysis of USRDS data, we found that after experiencing
transplant failures, a higher percentage of transitional recipients
received dialysis, a higher percentage of pediatric recipients received
retransplants after the first year posttransplant, and a higher percentage
of adult recipients died (see figs. 2, 3, and 4).^37 By 7 years
posttransplant, the percentage of transitional recipients who received
dialysis after experiencing a transplant failure was nearly 30 percent
higher than that of pediatric recipients and nearly 60 percent higher than
that of adult recipients. In addition, at 7 years posttransplant, the
percentage of pediatric recipients who received retransplants after
experiencing a transplant failure was over 25 percent higher than that of
transitional recipients and more than twice the percentage of adults who
received retransplants. The percentage of adults who died following a
transplant failure was about twice as high as the percentage of pediatric
recipients and about three times as high as transitional recipients.

^37After experiencing a transplant failure, the outcome for an individual
can be dialysis, retransplant, or death.

Figure 2: Percentage of Kidney Transplant Recipients Who Received Dialysis
after Transplant Failure, by Age Group and Number of Years Posttransplant

Notes: Our analysis is based on individuals who received kidney
transplants from 1997 through 2000. The percentage of kidney transplant
recipients who received dialysis is equal to the number of transplant
recipients on dialysis in that time period divided by the total number of
recipients whose transplants failed during the same time period.

Figure 3: Percentage of Kidney Transplant Recipients Who Received
Retransplants after Transplant Failure, by Age Group and Number of Years
Posttransplant

Notes: Our analysis is based on individuals who received kidney
transplants from 1997 through 2000. The percentage of kidney transplant
recipients who received retransplants is equal to the number of transplant
recipients who received retransplants in that time period divided by the
total number of recipients whose transplants failed during the same time
period.

Figure 4: Percentage of Kidney Transplant Recipients Who Died after
Transplant Failure, by Age Group and Number of Years Posttransplant

Notes: Our analysis is based on individuals who received kidney
transplants from 1997 through 2000. The percentage of kidney transplant
recipients who died is equal to the number of recipients who died in that
time period divided by the total number of recipients whose transplants
failed during the same time period.

A Higher Percentage of Recipients with Both Medicare and Medicaid Coverage
Experienced Transplant Failure and Received Dialysis

Based on our analysis of USRDS data, we found that recipients who had both
Medicare and Medicaid coverage experienced a higher percentage of
transplant failures compared with those who had Medicare but not Medicaid
coverage or were in the Other category (see fig. 5). By 7 years
posttransplant, the percentage of recipients covered by both Medicare and
Medicaid who experienced a transplant failure was slightly higher (24
percent) than recipients covered by Medicare but not Medicaid and was more
than three times as high as the percentage of recipients in the Other
category.

Figure 5: Percentage of Kidney Transplant Recipients Whose Transplants
Failed, by Type of Health Insurance Coverage and Number of Years
Posttransplant

Notes: Our analysis is based on individuals who received kidney
transplants from 1997 through 2000. The percentage of kidney transplant
failures is equal to the number of recipients whose transplants failed in
that time period divided by the total number who received transplants
during the same time period.

aOther is defined as those who do not have Medicare coverage but are
covered by private health insurance, Medicaid, or other governmental
health insurance or are uninsured or whose health insurance status is
unknown.

After experiencing a transplant failure, a higher percentage of recipients
who had both Medicare and Medicaid coverage received dialysis when
compared with recipients who had Medicare but not Medicaid coverage or
were in the Other category (see fig. 6). For example, by 7 years
posttransplant, the percentage of recipients covered by both Medicare and
Medicaid who received dialysis after experiencing a transplant failure was
about 70 percent higher than recipients in the Other category. After the
first year posttransplant, the percentage of recipients covered by both
Medicare and Medicaid who received dialysis after a transplant failure was
substantially higher than the percentage for recipients in the Other
category.

Figure 6: Percentage of Kidney Transplant Recipients Who Received Dialysis
after Transplant Failure, by Type of Health Insurance Coverage and Number
of Years Posttransplant

Notes: Our analysis is based on those who received kidney transplants from
1997 through 2000. The percentage of kidney transplant recipients who
received dialysis is equal to the number of transplant recipients on
dialysis in that time period divided by the total number of recipients
whose transplants failed during the same time period.

aOther is defined as those who do not have Medicare coverage but are
covered by private health insurance, Medicaid, or other governmental
health insurance or are uninsured or whose health insurance status is
unknown.

Beneficiaries with Functioning Transplants Were Substantially Less Costly to
Medicare Than Those with Transplant Failures

Based on our analysis of USRDS data, we found that Medicare beneficiaries
with functioning transplants cost substantially less per year to treat
than those beneficiaries who experienced transplant failures.
Specifically, we found that overall, the median annual Medicare cost for a
beneficiary with a functioning transplant was $8,550, compared with a
median annual Medicare cost of $50,938 for a beneficiary after a
transplant failure--a difference of 500 percent. For pediatric
beneficiaries, the percentage difference was even higher--the median
annual Medicare cost after a transplant failure was 750 percent higher
than for a functioning transplant (see table 5). The differences for
transitional and adult beneficiaries were 550 percent and 500 percent,
respectively.^38

Table 5: Median Annual Medicare Cost per Beneficiary with a Functioning
Transplant and after a Transplant Failure, by Age Group

                          Median annual cost per       Median annual cost per 
                       beneficiary to maintain a beneficiary after transplant 
Age group              functioning transplant                      failure 
All                                    $8,550                      $50,938 
Pediatric                               4,916                       41,929 
Transitional                            6,714                       43,678 
Adult                                   8,708                       51,755 

Source: GAO analysis of USRDS data.

Note: Our analysis is based on those who received kidney transplants from
1997 through 2000.

Concluding Observations

The substantial cost of treating transplant recipients who experience
transplant failures underscores the importance of maintaining functioning
kidney transplants. While there are many reasons that could account for
transplant failures during the first 3 years posttransplant--including
medication noncompliance--the large percentage increase in transplant
failures from 1 year to 3 years posttransplant for transitional recipients
cannot be attributed to an inability to access immunosuppressive
medications due to a lack of Medicare coverage.

^38Although the percentage difference for pediatric and transitional
recipients was well above 500 percent, the overall percentage is virtually
the same as the adult percentage because adults account for 95 percent of
all recipients.

Agency Comments

In commenting on a draft of this report, CMS stated that it appreciated
our interest in kidney transplant patients and in the cost of care
provided to those receiving transplants or dialysis. CMS stated that it
was concerned about the quality of care and the outcomes experienced by
Medicare beneficiaries, including the higher rate of transplant failure
among transitional patients. CMS also stated that educating beneficiaries
with kidney failure is critical to improving beneficiaries' ability to
actively participate in and make informed decisions about their care. As a
result, the agency engages in numerous educational and outreach efforts
targeted to beneficiaries, providers, and national organizations that
represent renal patients. CMS's comments are reprinted in appendix I.

As agreed with your offices, unless you publicly announce the contents of
this report earlier, we plan no further distribution of it until 30 days
from the date of this letter. At that time, we will send copies of this
report to the Secretary of HHS and to other interested parties. In
addition, this report will be available at no charge on GAO's Web site at
http://www.gao.gov. We will also make copies available to others upon
request.

If you or your staff have any questions about this report, please call me
at (202) 512-7114 or [email protected]. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last page
of this report. GAO staff who made major contributions to this report are
listed in appendix II.

Laurie E. Ekstrand
Director, Health Care

Appendix I: Comments from the Centers for Medicare & Medicaid Services

Appendix II: GAO Contact and Staff Acknowledgments

GAO Contact

Laurie Ekstrand, (202) 512-7114 or [email protected]

Acknowledgments

In addition to the contact named above, Nancy Edwards, Assistant Director;
Kelly DeMots; Krister Friday; Joanna Hiatt; Xiaoyi Huang; Martha Kelly;
and Ba Lin made key contributions to this report.

(290566)

To view the full product, including the scope
and methodology, click on [22]GAO-07-1117 .

For more information, contact Laurie E. Ekstrand at (202) 512-7114 or
[email protected].

Highlights of [23]GAO-07-1117 , a report to congressional requesters

September 2007

END-STAGE RENAL DISEASE

Characteristics of Kidney Transplant Recipients, Frequency of Transplant
Failures, and Cost to Medicare

For individuals with end-stage renal disease (ESRD), the permanent loss of
kidney function, Medicare covers kidney transplants and 36 months of
follow-up care. Kidney transplant recipients must take costly medications
to avoid transplant failure. Unless a transplant recipient is eligible for
Medicare other than on the basis of ESRD, Medicare coverage, including
that for medications, ends 36 months posttransplant. Pediatric transplant
recipients, including those who were under 18 when transplanted but are
now adults (transitional recipients), may be more likely than their adult
counterparts to lose access to medications once Medicare coverage ends
because they may lack access to other health insurance coverage. GAO was
asked to examine (1) the percentage of transplant failures and subsequent
outcomes--retransplant, dialysis, or death--among pediatric, transitional,
and adult kidney transplant recipients and (2) how the cost to Medicare
for a beneficiary with a functioning transplant compares with the cost for
a beneficiary with a transplant failure. To do this, GAO analyzed 1997
through 2004 data from the United States Renal Data System (USRDS) and
interviewed officials from pediatric transplant centers.

The Centers for Medicare & Medicaid Services--the agency that administers
Medicare--commented that it is concerned about beneficiary outcomes and
has an education program to help them.

The percentage of kidney transplant recipients who experience a transplant
failure varies by age group as do the percentages who experience dialysis,
retransplant, or death. After the first year posttransplant, a higher
percentage of transitional recipients (those younger than 18 at the time
of their transplants and at least 18 as of December 31, 2004) experienced
a transplant failure and subsequently received dialysis compared with
their pediatric (those younger than 18 as of December 31, 2004) and adult
(those at least 18 at the time of their transplants) counterparts. By 5
years posttransplant, the percentage of transitional recipients who
experienced a transplant failure (33 percent) was about twice as high as
pediatric recipients (16 percent) and somewhat higher than adult
recipients (28 percent). The largest increase in transplant failures for
each age group occurred in the first 3 years posttransplant--before the
termination of Medicare coverage on the basis of ESRD--and the increase
was substantially higher for transitional recipients (133 percent) than
for pediatric (83 percent) and adult (100 percent) recipients.

Percentage of Kidney Transplant Recipients Whose Transplants Failed, by
Age Group and Number of Years Posttransplant, 1997-2004

Medicare beneficiaries with functioning transplants cost substantially
less per year to treat than those who experienced a transplant failure.
GAO found that the median annual Medicare cost for a beneficiary whose
transplant failed ($50,938) was 500 percent more than the median annual
Medicare cost for a beneficiary with a functioning transplant ($8,550).
This percentage difference was consistent across transplant recipient age
groups.

The substantial cost of treating transplant recipients who experience a
transplant failure underscores the importance of maintaining functioning
kidney transplants. While there are many reasons that could account for
transplant failures, the large percentage increase in transplant failures
from 1 year to 3 years posttransplant for transitional recipients cannot
be attributed to an inability to access medications due to a lack of
Medicare coverage.

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