Chronic Kidney Disease and Medicare

BACKGROUND: Since 1972, Medicare has covered the cost of end-stage renal disease (ESRD). Consequently, Medicare pays a large proportion of ESRD's costs. However, before implementation of Medicare Part D, employer health plans paid most ESRD-associated prescription costs. The ESRD population faces significant hurdles when using the new Part D benefit. To understand those challenges, a basic understanding of Part D is needed. SUMMARY: Medicare Part D has unique implications for chronic kidney disease (CKD) populations (dialysis, kidney transplant, and CKD patients not on dialysis). Approximately 405,000 ESRD patients were eligible for Part D coverage in 2006. Drug coverage is available for many drugs via Medicare Part B or Part D; however, the Medicare Part B and Part D medication coverage divide is confusing to most clinicians, including pharmacists. Many ESRD patients fall into the dual-eligible category they are covered by both Medicare and Medicaid. These patients now receive their medications through Part D and must enroll in a prescription drug plan (PDP). However, many PDP plans may not have the drugs that were covered in state-sponsored Medicaid programs. Dialysis-specific issues also abound because of the high-cost, high-use medications needed to treat the numerous comorbid conditions (diabetes, hypertension, anemia, bone and mineral metabolism disorders, and cardiovascular disorders) that flourish in the ESRD population. CONCLUSIONS: Managed care demonstration projects are underway to better understand if enrolling these patients into managed care plans with disease management models (i.e., special needs plans) can provide quality care in an effective and efficient manner. Screening patients at high risk for kidney disease, identifying patients with early kidney disease, preventing progression to ESRD, and effectively managing comorbid conditions may reduce long-term medical costs and maintain work productivity. Health care providers need to make an active effort to help CKD patients select kidney-friendly formularies. Medicare requires medication therapy management (MTM) services for certain beneficiaries (called targeted beneficiaries) enrolled in PDP plans to improve medication optimization. Approximately 80% of the typical ESRD population has more than 2 targeted comorbidities. Thus, many ESRD patients should be targeted for MTM services, a task that represents an opportunity for pharmacists.