CareDx, Inc. (CDNA) Earnings Call Transcript & Summary

Good morning, and good afternoon, everybody. Thank you for joining our webinar today on the financial aspects of kidney transplant. My name is Scott Sable. I'm the Senior Director of Patient Education at CareDx. And I'm so excited to be presenting this topic to you. It's a really important topic. We know from talking to patients like yourselves and care givers like yourselves that navigating the finance act of any type of health care treatment is really challenging. It's really hard to get information on insurance and cost and coverage, and it's a complex environment to navigate. And this is all at the same time when you're dealing with a significant health challenge for yourself or a loved one. So we brought together two experts on this topic today to share their perspective and a load of information to help you navigate this process to the greatest extent possible. So before we get started, a quick disclaimer, while the participating medical professionals are licensed qualified to practice medicine, you should always seek the advice of your physician or medical team with any questions you may have regarding your specific medical condition. The information shared today is not intended or implied to be a substitute for professional medical advice from a healthcare provider. So before we get into the content, one, doesn't everyone think a quick second to hop in the chat and test it out and share where you're dialing in from today. See, Texas, Minnesota, another Texas, Pennsylvania, Washington, New York, Michigan, Ohio, North Carolina, Indiana. Wow, it's going really fast. Looks like you guys have the hang of it. Definitely feel free to use the chat throughout the presentation with any questions that you might have. So before I pass on to our panelists, I'm trying to share a little bit about CareDx and who we are as a company. We are the transplant company. Our vision is to be the leading partner for transplant patients and the transplant ecosystem. What that means is we touch transplant patients both from soup to nuts from pre-transplant where we have software that helps dialysis patients connect to the waitlist at different transplant centers as well as we have tests that help match donor organs with potential recipients. During the transplant process, we have a number of software and a soft service solutions that help transplant patients manage their workflows and patients. And then post transplant, we have blood tests that help monitor transplanted organs, kidneys, hearts and lungs, for risk of some type of issue happening to allow physicians and clinicians to hopefully make adjustments to care and extend the life of organs as long as possible. We also have a patient app. It's called AlloCare. It allows you -- if you are a CareDx patient to access your results directly through the app as soon as they're available, it also is a general health app to allow you to manage medications, track blood sugar, record blood pressure, track steps, track fluid intake. There's a host of articles and resources, and there's also a forum to connect with other pre-transplant or post-transplant patients to discuss issues that are -- you're dealing with in your life to ask expert -- ask questions of our experts and is it just general wealth of information for kidney patients. So with that, I'm going to pass it on to our experts because that's really who you guys are here to see. Rochelle on to you. Thank you for joining.

Hi, everyone. I'm really happy to be here as well. Again, my name is Rochelle Blum. I'm a licensed clinical social worker at Johns Hopkins Hospital. Just to give you a little bit of background, I've been primarily working in the hospital setting for most of my career as a social worker and I started working in the area of transplant probably almost 20 years ago and initially, I worked with families in hospital settings when unfortunately, they were going to be losing a loved one. And I was the person that would find out if they would be comfortable consenting to donation to try to help somebody through the gift of life. And often, we could help multiple people from one donor's organs. So that was when I worked for -- it was an organ procurement agency when I did that. And then eventually, I decided to come back to Hopkins and work with the recipient side of things. I kind of came full circle and I work with kidney transplant recipients now. And so my role includes doing the evaluations to see if somebody is a candidate or can be a candidate for a kidney transplant, but I also work with people after the surgery. And I follow them in the community to provide support and resources. So my goal today is really to hopefully shed a little more light on the transplant process, the importance of finances when it comes to transplant. Why does this matter in terms of getting a transplant and taking care of the transplant and hopefully give you some tools and some resources to make that process a little bit easier. So again, thank you for having me, and I'm going to let Mike do his introduction now.

Well, thank you very much, Rochelle. I really appreciate you being here with us today, and American Kidney Fund is very glad to be partnering with CareDx on today's webinar. Mike Spigler, I'm the Vice President of Patient Support and Education for the American Kidney Fund. And in my role, I oversee most of our programmatic activities we do outside of things like government affairs and advocacy. So not just our education programs, our health equity work, our research and also our financial assistance programs, which would be the real key part of what we're doing today. I've been here 9 years in this role, but was here in the early 2000s as well for an additional 5 years and to see how far the industry in the nephrology field has come in the innovations that are being developed, including those that CareDx have put into the space, it's just really, really impressive to me. Rochelle is going to give you the real kind of big scoop on everything today, but I wanted to give you a little bit of an overview on the American Kidney Fund if you're not familiar with us. We've been around since 1971 and we fight on all fronts for kidney patients on behalf of all 37 million Americans that have kidney disease. And we do that in a variety of ways. Obviously, we have lots of awareness programs that we do, our educational programs, and we also do a lots of advocacy and public policy both federal and state level, including work around the living donor Protection X, and if you're interested in that on our website, we certainly would invite you to visit there. We have a whole report card on how each state is doing in that regard. And we're able to do that because we have over 30,000 advocates that are helping us do that work at the local state and federal level. On the prevention side of things, we have had a long-standing program in trying to make those that are at risk for kidney disease aware that -- make people aware of the interventions like medications and diet and exercise and things like that, that can help people hopefully prevent disease or at least slow it. But for those that aren't able to do that and many people aren't for a variety of reasons, including rare kidney diseases, we are there to help with them should they need that help. And so we have a variety of public education programs that we have. We have a Kidney Action week, which is a virtual program that we do for patients in March this year starts on March 18 in 2024. We have a program on home dialysis. But really, anything that you could possibly need or one information on is available on the AKF website, which is kidneyfund.org. For any professionals that might be in the audience, we also have a large range of courses both for allied health care professionals and physicians on a variety of topics. And I would certainly -- those are all free, all of our programs are free that are available as well. On the research side of things, probably our biggest impact there, we have a program called the clinical scientists and nephrology program. It's been around for more than 30 years now, and that really tries to help keep young promising nephrologists in the field of research where we still need to help. And we certainly feel like some of the work that we've put into that has paid off in some of the innovations down the line that we're starting to see now. And then just the last piece before I turn it to Rochelle, obviously, our financial assistance programs, which I'm going to spend my entire presentation talking about, so I'll wait for that for now, but it is a large impactful program that has really been with us at the start of AKF's history. So I will turn this over to Rochelle.

Oaky, So I know that the majority of people who are attending the presentation today either have kidney disease or you know somebody that's had kidney disease. So it's not probably surprising for many of you that kidney disease can be expensive to manage. There are a lot of costs that come along with this. And really, that can be applied to many chronic health issues, not just kidney disease, not just transplant. And some of the ways that we see financial constraints with kidney disease would be, if you're on dialysis, you may not be able to work anymore or you might not be able to work full time anymore. You might have fatigue after your treatment. And we know that often, if you apply for disability and you get approved, it's not the same as having a salary. You may be on a special renal diet and we know that it's not inexpensive to buy groceries these days, especially healthy things. There are monthly medication costs the cost of transportation to go back and forth for your treatments and your labs. And the more treatments you have, the more co-pays you have. And so those things add up. And then you're last sometimes with a lot of medical bills and medical debt. And that's a hard reality for many people. Next slide, please. So what is the impact of these financial stressors. Understandably, it's easy to get overwhelmed. You might feel depressed or anxious, and if you have any underlying mental health issues, that can just exacerbate those. I know that, especially in particular, during the COVID pandemic, a lot of my patients felt extremely isolated. They had to be careful about their health that they were on dialysis. Many of them couldn't go to work anymore if they were working. If they had a transplant, they had to be careful because the anti-rejection medicines made them very much at risk for getting sick. And so it was sort of this vicious cycle where maybe they weren't able to work as a result of the pandemic and then that increased isolation and depression. You might turn to unhealthy coping strategies that are destructive like alcohol or smoking to cope with all of that. We might see people having to make tough decisions like if you have the choice between filling your medications or putting food on the table for your family, you're probably going to choose to put food on the table. And I can't blame people for that. Roles and relationships can change. In families, in marriages, your spouse might have to pick up a second job if you're not able to work anymore. They might have to pick up more things around the house, more children care activities. And that can bring all kinds of emotions. Your spouse -- or that, that caregiver might feel resentful they might feel exhausted. The person who's sick might feel guilty or like they're a burden to their family. And all of those emotions are normal and you should not judge yourselves or others you're feeling that way. But the important thing is that you don't have to suffer with those feelings. It's imperative that you reach out, whether it's to a trusted family member or a friend, the social worker at the dialysis center or the transplant center, a clergy, a pastor or Rabbi, or a counselor. Next slide, please. So how is kidney disease get treated in terms of insurance. So you might hear a lot about Medicare. Medicare is a federal program through social security. And if you have Medicare, it doesn't matter what state you live in, the coverage should be the same. But Medicare covers end-stage renal disease. So you do typically have to be on dialysis to be eligible for Medicare. And it also covers the transplant, and we can thank President -- former President Nixon, because he had something to do with voting that into law that Medicare would cover those things. Medicaid or Medical Assistance. That's a state insurance program. And most states have Medicaid, but maybe the eligibility requirements might vary a little bit, but often it is based on income and it's pretty strict income criteria, but Medicaid can cover treatment for kidney disease. Private insurance or an employer plan should cover treatment. In a few states particularly on the East Coast, have a renal program that is very similar to health insurance. I know Maryland, where I live, has the kidney disease program, and it will pick up things related to the kidneys. Pennsylvania has a similar program, and I believe New Jersey and Delaware do as well. So a lot of that is based on income criteria if you qualify. In Maryland, though, everybody can qualify if they're on dialysis or they've had a transplant, but they may have a premium dependent on their income. And the other thing is with the Renal Programs, coverage is limited to the state that you live in with that particular program. Next slide, please. Okay. So why consider a kidney transplant as opposed to staying on dialysis or going on dialysis. And that might seem like there should be an obvious answer to that. But I do see plenty of people who are afraid to get a transplant. They're afraid of going through this significant surgery and all the lifestyle changes that can happen. But we know that transplant really is the best treatment we have available. It's not a cure because you're always going to be taking some medicine and be followed by a physician, but it's very close to a cure. It's associated with a longer life and a better quality of life. You're not on dialysis. You're not on a strict renal diet anymore. It's actually more affordable for our health care system in the long run because dialysis, over time, can take a toll and there can be more health complications as a result. But it's not the right option for everybody, so it's important to talk with your doctor and find out if it's right for you. Next slide, please. So what is the role of Medicare when it comes to a kidney transplant? So if you get a kidney transplant, you are eligible to have Medicare for 3 years. Now after 3 years, it would typically stop unless you're disabled for other reasons or if you're turning retirement age, 65. Medicare Part A is free, and that's what covers people in the hospital, our tax dollars pay into that. Medicare Part B is the portion of Medicare that covers outpatient services. Doctor visits, labs. And if you have Medicare, when you get a transplant, it also helps to cover the antirejection medications. There are a couple of limitations, though, to Part B. One is that it only pays 80% of anything outpatient. So then if you don't have another form of coverage to pick up the remaining 20%, you're going to have some bills. There's also a premium for Part B. This year, it's $164 for most people monthly, and it goes up a little bit every year. Then there's also Medicare Part D, and that's the prescription plan that Medicare offers, and there's different plans available and they have a premium as well, some kind of a smaller premium. Now there are assistance programs for these premiums. You can apply through your local social services office to see if you might qualify for some help with the Part B premiums and/or the Part D premiums. And some insurances, so if you're working, let's say, or you have private insurance, they will actually require people to enroll in Medicare after a transplant. So it's a good idea to check with the insurance company and ask them if they do require that. Now if you have employer insurance, and you want to enroll in Part A but maybe not Part B, maybe you have good insurance and you don't want that extra premium, you're not penalized if you decide not to get Part B right away. You can just get Part A if you have employer insurance. Next slide, please. The bottom line is if you have questions, certainly, you can talk to the transplant social worker. But it's also a good idea maybe to take those questions directly to Social Security or Medicare. And there's also a program, it's nationwide and it's called the SHIP program, SHIP. It stands for State Health Insurance Assistance Program. And it's made up of volunteers who were trained in all areas of Medicare to assist. And there's no fee for this. And like I said, most states have the SHIP program, most counties have their own SHIP office too. Next slide, please. So if you want to be considered for a transplant, you have to go through an evaluation at that transplant center. That's actually required by, UNOS, the United Network For Organ Sharing. And so that means you'll be meeting with a doctor, a social worker, a nurse. And the clinic visits can take -- they can take the better part of an afternoon or a morning. You're evaluated from a medical standpoint, but also a psychosocial standpoint. And by psychosocial, meaning the social worker is going to ask questions to sort of gain an understanding of who you are as a person, what your understanding is of your health issues, how you're adjusting to all of this, what your work history is and if you have any financial concerns, do you have any mental health issues. And by the way, just because somebody might have a history of psychiatric illness or substance use, doesn't mean they're going to be denied for a transplant but we want people to do well afterwards. So if we know about it, we could talk to you about it, find out if you're in treatment, how is that going? If not, do we need to look at maybe getting you hooked up with some treatment. And insurance plans will typically cover the workup, the evaluation and the surgery. Again, it's to their interest to do that. It's more affordable for insurances in the long run, than paying for so much to stay on dialysis. And then we meet weekly as a transplant team to discuss everybody who would like to get listed and see if they're a candidate. Next slide. So why are finances so important when it comes to a transplant. Why do we bring this up during the evaluation for a transplant? I understand finances are private, and it's uncomfortable to talk about it. But it is important for the transplant team to get a sense of, if there are any financial concerns. We want you to do well bottom line afterwards and to be successful in maintaining that transplant. Next slide. Thank you. You can see that without insurance, transplants can be very expensive. The average out-of-pocket cost for the first year after a transplant is close to $400,000. Now that includes the workup, the surgery and the follow-up care. The anti-rejection medicines alone can be over $2,000 a month. Appointments can be over $400 per appointment. So having health insurance is critical measure extremely wealthy. But otherwise, you need coverage. And even with health insurance, it can get costly. Next slide, please. I like this cartoon I know it's in black and white, so it's kind of hard to make it out. But I think it kind of captures the essence of what we're talking about. Basically, you see this position and he's at the bedside of a patient in the hospital, and he's asking him to rate his pain 0 to 10. But for this slide, he's saying, what is your pain caused by out-of-pocket expenses. And that's very real. Next slide, please. Okay, So what are the direct costs associated with the transplant? You're coming back and forth to the transplant center after the surgery frequently. There's multiple appointments, multiple labs that you'll be doing, particularly in the first 1 to 2 months. So that adds up and that equals more co-pays. I believe pediatric patients, so children who had a transplant have to get even more frequent labs. So we know that adds up. You may have deductibles that you have to meet, monthly premiums for your insurance. And again, if you have Medicare only, then we would consider someone to be underinsured because, again, they're going to be responsible for that 20%, that Part B does not cover for outpatient things. And part covers some things in the hospital, too, but again, only at 80%. Next slide, please. Okay, So there are indirect costs associated with transplant. These are the things that people don't always consider when they're planning for a transplant. The recovery after a transplant, usually people have to take off from their jobs for a couple of months, unless they have an ability maybe to work from home. So if you don't have paid time off that can throw a dent into things financially or maybe your caregiver doesn't get paid time off. Maybe you get short-term disability, but we know short-term disability is usually 60% of your income. So you have to kind of factor that in. Traveling back and forth to the transplant center, that's gas money. We know that's not cheap these days. Parking fees at the garage. Not every hospital has those fees, but I know Hopkins unfortunately does. Lodging. So if you're having an out-of-state transplant, you have to factor in cost of -- maybe flights and hotels. And again, this gets added to any existing financial stresses you might already be dealing with. Next slide, please. So how can people prepare for a transplant? There absolutely are things we can do to be in a better position financially for this. I always encourage people to contact the finance office at their transplant center. They can give you a good idea of maybe what your out-of-pocket responsibility will be for the surgery. Talk to your insurance company, many insurance companies have a case manager that has a specialty in transplant. They might be able to help guide you with some of this. And some insurances will actually cover or reimburse for things like travel, lodging, many don't, but some will. Get to know the social worker at your transplant center. They can talk to you about available resources in the area, whether it's talking to maybe guest services. There might be some grants available, I know the hospital here at Hopkins, we have a financial assistance application that people can apply to get some help with bills and such. And I also encourage people to talk to other folks who have been through this before, other transplant recipients. And there are a number of support groups in the transplant community. They can give you guidance in a way that sometimes the transplant team can't. So that can be very helpful. And the last thing that I really do encourage my patients and families to consider is something called Medical Fundraising. There are organizations that will partner with patients and their families and friends to put on a fundraising event. And it might just be a virtual fundraiser or a social media campaign. But I've had some families raise hundreds to thousands of dollars from working with one of these organizations. Now I know a lot of people might feel a little bit leery about this. It's one more thing that they might have to take on when they already feel sick. They're dealing with appointments, dialysis. But it doesn't have to be the patient that reaches out to these programs. Somebody else can do that on their behalf. People feel private about their health issues. It's understandable. So that could also be maybe a reason for some hesitancy. And I've got some patients say to me, I don't want to take charity. I don't want to take a handout. A lot of these programs have people who will talk to you that have actually done fundraising for themselves or a loved one, so they can talk to you about what that experience was like. And I kind of look at this as it's an investment for the future because it's not just the immediate surgery that you have to think about planning for, but there may be times down the road where complications come up and you have to come back and forth to the center again. Next slide, please. So, is fundraising something that you might want to consider? It can help with covering household expenses like mortgage or utilities. It can help cover co-pays and insurance premiums, travel expenses, like, again, flights, gas mileage, hotels. It can also help with a donors expenses. So if you have a living donor and maybe they're traveling here from the opposite side of the country, it can help with that or lost wages. It's tax deductible for any donations made and what you earn, what you raise is not taxed by the IRS and it should not hurt your benefits. So if you're getting disability or Medicaid, it shouldn't impact that. And it may be safer than going through programs like GoFundMe, things can go wrong with GoFundMe, things can fall through the cracks. And with these organizations, people know that they know where their money is going to, that it's going to a safe, reputable program. You do usually need to have a community to do fundraising, but you can think outside the box. So if you don't have a large community of friends, colleagues, church members, maybe you have a relative that does or maybe there's a local radio station that you could pitch this to. So the first step is to reach out to some of these programs and hear what they have to say. Next slide, please. And so basically, I'll kind of just put together a list of some of these financial resources that I touched on in the slides. Again, there are limited grants available. The American Kidney Fund is a program that, obviously, they can help people with health insurance premiums. I know they have other grants available to help with, certain expenses like gas or a small grant to help with lodging, utilities, things like that. Again, the state renal programs that we discussed can be very helpful. So I'm not going to go through all of these, but I believe we are going to provide these two people attending the conference today. And I will turn this over to Mike.

Thank you, Rochelle. Thank you very much. So let me -- Rochelle talked a little bit about some of our programs. So let me just do a little bit of a deeper dive on the financial assistance programs. And I know a lot of you are taking us up on this already, but please continue to send in your questions in the chat. And in the Q&A, we'll definitely have time for some of those here in just a little bit. Well, one of the programs that Rochelle mentioned is our partner that helps with health insurance premiums, and that's called our Health Insurance Premium Program or if you've been around this and heard of it before we made her just called HIPP. It is -- we have an advisory opinion from the federal government that allows us to do this program to help with dialysis patients. But once your transplant at AKF also continues that assistance, for a time after that transplant takes place as well. We can help with any kind of health insurance premiums, so that Medicare Part B as an example, Medigap plan. And usually, that's kind of the main combination that we help patients with as a Medicare Part B premium and a Medigap premium, but also commercial insurance. So COBRA, employee group health plans, and there's even a few states where there is a small premium for Medicaid, we can help with that, too. We can help with up the two different insurance types. Like I mentioned, Medicare Part B and Medigap being the most common one that we see with our patients. And this is a very large program. We helped 62,000 dialysis and transplant patients last year maintained their health insurance. And I think the thing that AKF, and certainly I am most proud of is that about 125 patients right now this year per month are getting kidney transplants because of the assistance that we're providing them or I should say, in large part because the assistance that we're providing them. And that's no small number. I mean, that accounts for this year on pace for about 7.5%, almost 8% of all the kidney transplants, in the United States are patients that have come through our Health Insurance Premium Program. We also have a safety net program, which Rochelle also touched on a little bit. This is a small program. it's really meant for emergency when you just -- your at wits end, and you don't know how you're going to fill the gas tank. You don't know how you're going to pay for this unexpected medication co-pay. It is a once per year $200 grant. In D.C., Maryland and Virginia that we have a slightly bigger one, we can offer $250, thanks to some additional foundation -- private foundation support that we have there. But in 2022, we helped over 10,000 patients get assistance through these programs and get a safety net grant. It really hits anything even tangentially related to your care. So our biggest use case by far is transportation, gas, a small car repair, tires, things like that. But we also help with things like I mentioned, medication co-pays, medical supplies, anything really treatment-related expenses, like nutritional supplements that you may need as an example, are all available we give it in cash, not any of those particular things, but then you can use that money to pay for whatever it is that you need. Eligibility to this program. I'm sure that's something you're very curious about. You must live and receive treatment in the United States or its territories, and we have patients from Maine to the Northern Mariana Islands. So there is not a territory or state that we are not assisting patients in. For the health insurance premium program, in particular, you do have to come to us already having that insurance secured. So what AKF does not do is help you pick insurance, recommend insurance. We just assist you with whatever you've already chosen, whatever you're already trying to pay for it yourself. We do recommend as with anyone, I mean, you heard Rochelle talking about some of the intricacies that are there with paying for this. Talk to your dialysis social worker, talk to your transplant social worker, whether or not for our program or anything, really try to find out exactly what the best option is for you because there's so many different options out there that you may qualify for. And as far as financial visibility goes, there are a few ways that you can apply for this, but I'll just talk about some of them from a financial standpoint. We have a pretty generous program. We -- you can have a household income, and this includes how many people in your house up to 500% of the federal poverty level. We ask you not have more than $30,000 in liquid assets in the bank, and it sounds like a lot of money, but we have encountered some patients where they need some money in the bank to assist some of the transplant costs, and we certainly didn't want to do anything where we were restricting that ability to have that money on hand. So that's why that's quite generous there. And in addition, kind of a second way in, is if you're already receiving things like food stamp assistance or SNAP assistance, housing assistance, fuel assistance, things that have even stricter guidance than us, if you provide us information showing that you're already in those programs, you're automatically in. So we don't do any of the financial tests after that. Another program I wanna talk about depending on where you are in the country, you may be more likely to have this program turned on than others is our disaster relief program. This is a program that really started around -- I think it was shortly after Katrina was one of our first ones that we did, Hurricane Katrina, but we have done it several times. The biggest one this year, as you can probably guess, was the Maui wildfires. We've given out a little over $47,000 to patients just there. But these are for large-scale natural disasters. So this is not -- there was a fire in my home or something like that. These are natural disasters. And we can provide onetime grants of up to $250, but that can go up and down depending on the scope and the disaster. As I mentioned, in Maui, we had $1,000 grants, we were just giving out for that program. So it really is meant to be a lots of different reasons. You can use it for. If you had to evacuate, there's a hurricane coming, and you needed a night hotel to avoid the eye of the storm coming through. We can help with that. Temporary Housing, replaced items food, nutritional supplements, clothing, things like that, or any other treatment-related costs you may have if you have to leave your typical center to go somewhere else. All of our programs -- so none of this is paper-based. It is all done digitally through our system called Our Grants Management System, and you can see the website there, it's gms.kidneyfunds.org. You, as a patient can start the process or your health care professional can start the process for you. We do require health care professional just to confirm that you are a kidney patient, obviously, as part of that process. So that is part of that. But everything is done online through our Grants Management System. And we've actually even just added a virtual assistant as well. So if you get to the page and you just want information about how to register can even walk you through that as one of our latest additions that we've added. And this program is only in one state. So we certainly hope to expand this moving forward, and it launches -- I can't believe it's in just two weeks, this program will be launching. This is for patients in Massachusetts. David Atkins Living Donor Assistance Program. David Atkins is a person who was a living donor, donated their kidney to their friend. And we have this program now in place. We can help up, $2,500 assistance for out-of-pocket costs that a living donor may experience for plane tickets to be tested and child care expenses, things like that. that has to take place inside of a Massachusetts hospital. It is open to any living kidney donor all the way back from earlier this year. So we've been telling people, if you were living kidney donor, there are opportunities anytime this year to talk to your Massachusetts Social Worker and they can help you there. And we do hope to expand this moving forward with the generosity of the donors that we've been working with on this. But right now, it's just in Massachusetts. And if you like more information on that, it's kidneyfund.or/living donor. And then I'll wrap, and we have plenty of time for questions, but just a couple of things. If you want more information on our resources, our financial systems resources, you can go to kidneyfund.org. And we also have a new -- as of this year, what we're calling our community resource finder. So if you are in a place and you're like, well, Mike and Rochelle, none of you talked about the things that I'm having problems paying for if you go to this link, you can actually put in your ZIP code, you can put in what you need help with and lots of resources with links and direct ways how to get there, pop up. So if can you help with housing or other things that we didn't talk about today, there's options there. And with that, I turn it back to you, Scott.

Rochelle and Mike, thanks so much. Super comprehensive coverage of all that. We have about 15 minutes going to try and get through as many questions as possible from before the presentation as well as during, one that came in was around Medicare's coverage for post-transplant lab tests. A clarification on this. Medicare does pay for post-transplant lab tests for routine labs, they continue to pay for them for a -- some of the advanced molecular tools like CareDx's AlloSure test. They also will continue to pay for those as well. The recent changes that you may be referring to, they implemented some stricter clinical criteria for that coverage. But they will still pay for them as long as the clinical criteria are met. The next question that came in, I think this is probably for Rochelle. For kidney disease patients, is Medicare only available if you don't have private insurance.

Okay. I'm sorry, is what available if you don't have private insurance ?

Is Medicare only available if you don't have private insurance ?

So no. So Medicare is available to anybody who's had a kidney transplant, whether you have private insurance or not. Now, the way it works is the first 13 months of that 3-year window post transplant, Medicare is secondary to your private insurance or your employer insurance. And then after 30 months, it becomes primary Medicare becomes primary. But as long as, again, now if you're -- you have to be a citizen you have to be here legally and have had -- even if you're here legally, you have to have had a green card for 5 years to qualify for Medicare. And again, worked enough quarters in this country. But yes, everybody is eligible then for Medicare based on those things after the kidney transplant.

Awesome. And then a related question, could you speak to -- will Medigap interfere with medication coverage for Medicare?

No. So, and this gets a little tricky. With Medicare, there's two different ways that your transplant medications can get covered. If you have Medicare at the time of the surgery, Part B is going to pay that 80% for them. And if you have a Medigap plan, that will pick up what's left over. Otherwise, you would want to have a Part D plan, a prescription drug plan through Medicare to cover all of your other medicines, and if you didn't have Medicare at the time of the surgery, the anti-rejection medicines too. But having a supplement, a Medicare supplement is a plus because it's going to pick up what Medicare Part B doesn't cover. It's going to pick up the remaining 20%. So a supplement, if you can cover the cost is a great thing to have. It's just that -- especially if you're under the age of 65, supplements can be expensive. So a lot of people can't afford to have a Medicare supplement. That it's something to look into and the ship office that I mentioned before, could help you look into some different options for Medicare supplements. And I think there's a 90-day window frame maybe when you first sign up for Medicare that you have to look into a Medicare supplement when you're under the age of 65.

Awesome. And then one more related question, Rochelle. Are you required to get Medicare post-transplant if you already have employer-based insurance.

Great question. So some insurance policies will require that. So it's a good idea to check with the insurance company and ask them that question. Am I required to enroll? But again, let's say the answer is yes. You could potentially just get Part A, that's free. That will help pick up things that maybe your insurance doesn't cover in the hospital, It could pick anything left over up. But you don't have to get Part B if you have employer insurance. If you did get Part B, just know you'll have a premium, but Part B could pick up things that your employer insurance doesn't cover like co-pays for outpatient services, labs, doctor visits.

Awesome. I'm going to try and get Mike in the mix a little bit, in case he's feeling lonely, or it could be you as well, Rochelle, but how does the cost of the kidney transplant compared to other treatment options for kidney disease like dialysis?

Well, obviously, I mean, transplant in most cases, hopefully, once it happens, that's pretty much yet, right? The surgery happens the appointments afterwards happened obviously as well. But dialysis, you're talking about, depending on the type of dialysis you're doing, 3 to 6 a week with a lot more comorbidities that you're dealing with as far as anemia and other things that you probably wouldn't up dealing with and having more medications associated with it, more medication co-pays. And the other thing is, too, just from a living perspective, unfortunately, many patients on dialysis can't work, right? And when you get a transplant, the hope is you're able to start to get some of your life activities back and feel some sense of normalcy come back in. So that's an important part of it. So it's -- obviously, it's the cost itself to the medical system and the person, but also just like the living expenses. It's so much cheaper for everyone for transplant versus dialysis.

I mean, I think, Mike, you just summed it up. I mean, the idea here -- I know we're talking about transplant and can be expensive, especially in the beginning when you're going to the doctor frequently, you're taking so many medicines, which, by the way, the number of pills will go down over time after the transplant. But the whole goal here is to give you your quality of life back so that you can go back to work, spend more time with your family. And Mike is right, the longer you're on dialysis, the more of a toll it can take on the body and more comorbidities can come up, So.

One more for Mike. There are several questions about considering the extension of the HIPP program for post-transplant?

Sure. Well, in April 2019, we did extend it so that we cover the rest of whatever plan year you're in. And if -- we wanted to do that because we didn't want to want to be locked into a plan that might be too expensive that they couldn't pay that we were covering and then not get a transplant and not be able to do it anymore. So, we've extended it so that you have time for the next cycle to choose a different insurance, Medicare, or whatever it may be to get on that. So the key there is the rest of your plan year and if you were to transplant in the last 3 months of your plan year, let's say you have a January to December health insurance plan year and you transplant on October 15, we would pay for the transplant -- the premium for the entire next year, as well. We certainly would love to do it more, but we are charity at the end of the day, our resources are limited. We are doing as best we can to extend it even further, maybe at some point in the future. But I will be very honest and realistic. It's a very expensive program every year that we extended is in the millions of dollars. So we're doing the best that we can, and we certainly we'll try harder.

Thanks, Mike. There was a question for me around the clinical criteria for post-transplant testing related to Medicare coverage. There isn't a single list of criteria. The criteria relate to the physician having for cause or a clinical reason for administering the test. So this could be a whole multitude of reasons, it could be monitoring response to rejection treatment. It could be issues with adherence to immunosuppressive medication. It could be clinical symptoms. The patient is not feeling well for whatever reason. It really comes down to the physician's judgment that they want more information around the health of your transplant. And as long as the physician feels like the test is important for making a clinical decision, and they're documenting that, then Medicare should cover the test management. The next question is for Rochelle. What are the potential costs associated with pre-transplant evaluations and tests?

That's a great question. So your insurance should take care of the pre-transplant workup as well as the donors workup. So let's say you have somebody that would like to donate a kidney to you. Your insurance will pay for their workup and the transplant surgery. Anything that might come up that needs further work up, sometimes insurer insurance, the recipients insurance might not cover. But the standard work up your insurance will pay for that on the recipient side and for a living donor. So you shouldn't have out-of-pocket expenses for the workup in general.

Thanks, Rochelle. And maybe related, I heard you mention living donor, but could you speak to the financial costs that a donor might need to consider?

Yes. So, a donor, for example, is going to have to take some time off also from work, maybe not quite as long for their recovery. Now they're not going to be on lifelong medications, the way kidney transplant patients are. They might be on pain meds for a short time. But if a donor is concerned about whether it's maybe traveling from another state to the transplant center or time off from a job lost wages. There are some donor grants available. But I would encourage that living donor bring that up when they meet with the donor team. They have to go through their own evaluation with the donor team, just like the recipient does. And they'll meet with a social worker, but they should bring those concerns up because there are a couple of grants. One of the grants I know they will want to look at the recipients income information because the idea is if a recipient is in a position financially to help with the donors expenses that they'd be able to do that. But there are some grants for that. But the medical side of things is covered by the recipients insurance, the surgery, maybe one follow-up visit, the work up, that kind of thing.

Thank you so and for maybe a couple more questions. Another one for Rochelle, are there variations that you see in transplant costs depending on the hospital or medical facility?

Now it would be tough for me to answer because I only work here at Hopkins. So I'm sure doctor visits, appointments might vary from hospital to hospital. I think, the best thing to do would be to know what your co-pays are through your insurance company. For example, when you see a specialist, what do you have to hey, what is your copay. And then you want to kind of calculate that for the number of visits that you'll be coming after the transplant. Usually, it's weekly visits the first month, maybe every other visits the second month and then it kind of goes down from there.

And then we'll close with Mike. There was a question about does AKF CT Net grants cover things like diabetes testing for strips?

Yes. Any medical supplies. And -- but again, we collect that information just to kind of know what it's being used for, so that we can seek other fine sports to do that. But really, once you have the assistance from us, you can use it for what you need to. But yes, in short, absolutely.

Awesome. Well...

By the way, sometimes drug companies offer assistance programs and the transplant center can help enroll you in those two. If you have high co-pays or no insurance. If something happens after the transplant you lose insurance. That's something else that they can help with.

Thanks, Rochelle. We probably could have kept going for another 30 minutes in the interest of time though, I want to let everyone drop at the hour. This has been amazing. Thanks so much to all the attendees. Your engagement has been phenomenal. This is always more fun if it's interactive and you guys are asking us questions. I also want to thank Mike and the AKF, we couldn't have done this without you guys. I really appreciate your support, your knowledge, your insights and you're resourcing to make this happen. And of course, Rochelle, thank you. You've just been a wealth of knowledge. It's been amazing to hear you. I've learned so much personally from listening to you. A couple of closing items, Kevin, if you can go forward the slide. You can follow CareDx on social media. We're on Facebook, Instagram, LinkedIn, as well as Twitter. So definitely follow us there. And then I'm going to put in the chat information on our post-transplant test security apps on AlloSure. We have a guide for talking to your doctor about these tests and there's a load of information about the test and how they work and et cetera. So thank you. Continue to look out for e-mails from us on additional webinars. These are always fun. And I wish everyone a really happy Thanksgiving and a great rest of your day. Take care.