End-Stage Renal Disease: Characteristics of Kidney Transplant Recipients, Frequency of Transplant Failures, and Cost to Medicare
Published: 2007-09-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: Regardless of age, most individuals with end-stage renal disease (ESRD),  Regardless of age, most individuals with end-stage renal disease (ESRD),  the permanent loss of kidney function, are covered under Medicare.  the permanent loss of kidney function, are covered under Medicare. which remove excess fluids and wastes from  regular dialysis treatments, In the long term,  transplants, Medicare covers regular dialysis treatments.
Generally, 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.  § 426-1 (2000). In addition to Medicare, individuals with ESRD may also be covered by  other public or private health insurance, including Medicaid.
Individuals with ESRD typically receive dialysis treatments three times per week.
For 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  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. Transplant failures may be particularly problematic for  pediatric recipients 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 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.
To determine the characteristics of pediatric, transitional, and adult  kidney transplant recipients, we used 2004 data—the latest data  available—on recipient age, sex, race, and type of health insurance  coverage 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  of their residence as published in the 2005 Area Resource File (ARF), the  latest data available. 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.
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.  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. For recipients whose transplants  failed, we determined the percentage who died, 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.
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.  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. For recipients whose  transplants failed, we determined the percentage who died, 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. 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. 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.
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. We performed our  work from October 2006 through August 2007 in accordance with  generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: 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. 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.
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. Another study  showed that transplantation increased the rate at which pediatric ESRD  patients improved on measures of intelligence and mathematical skills.
subsections: section_title: Medicare Coverage for Individuals with ESRD
paragraphs: 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. However,  after 36 months, a transplant recipient can become eligible for Medicare  again after a transplant failure and subsequently receive a retransplant or  dialysis.
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; Medicaid; the State  Children’s Health Insurance Program (SCHIP); 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.
section_title: Posttransplant Immunosuppressive Therapy
paragraphs: 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. One recent study showed that  about 23 percent of recipients with failed transplants who returned to  dialysis died within 2 years.
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, 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. Other  studies have reported that medication noncompliance can be  unpredictable, often without an identifiable reason.
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.  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.
section_title: Transplant Recipients in All Age Groups Had Similar Demographic Characteristics, but Fewer Pediatric and Transitional Recipients Had Medicare Coverage
paragraphs: 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.
subsections: section_title: Pediatric, Transitional, and Adult Transplant Recipients Were Similar with Respect to Sex, Race, and Income Level
paragraphs: 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.
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.
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.
section_title: A Smaller Percentage of Pediatric and Transitional Recipients Had Medicare Coverage
paragraphs: 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.
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.
section_title: A Higher Percentage of Transitional Recipients Experienced Transplant Failure and Received Dialysis
paragraphs: 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.
subsections: section_title: A Higher Percentage of Transitional Recipients Experienced Transplant Failure Compared with Pediatric and Adult Recipients
paragraphs: 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.
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.
section_title: A Higher Percentage of Transitional Recipients Received Dialysis Compared with Pediatric and Adult Recipients
paragraphs: 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). 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.
section_title: A Higher Percentage of Recipients with Both Medicare and Medicaid Coverage Experienced Transplant Failure and Received Dialysis
paragraphs: 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.
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.
section_title: Beneficiaries with Functioning Transplants Were Substantially Less Costly to Medicare Than Those with Transplant Failures
paragraphs: 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.
section_title: Concluding Observations
paragraphs: 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.
section_title: Agency Comments
paragraphs: 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.
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section_title: Appendix I: Comments from the Centers for Medicare & Medicaid Services
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: 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.