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. 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. However,  after 36 months, a transplant recipient can become eligible for Medicare  again after a transplant failure and subsequently receive a retransplant or  dialysis. However, once individuals turn 19, they may lose access to their parents’  private insurance coverage as well as coverage under SCHIP and  Medicaid. Recipients who do not take their immunosuppressive medications  according to the prescribed regimens are more likely to have their  transplanted kidneys fail. 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. 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. 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). 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). 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.
Why GAO Did This Study

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.

What GAO Found

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. 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.