Effect of Medicare Dialysis Payment Reform on Use of Erythropoiesis Stimulating Agents

Objective: In 2011, the Centers for Medicare and Medicaid Services (CMS) replaced fee-for-service reimbursement for erythropoiesis stimulating agents (ESAs) with a fixed-sum bundled payment for all dialysis-related care and pay-for-performance incentives to discourage maintaining patients' hematocrits above 36 percent. We examined the impact of the new payment policy on the use of ESAs.

Data Sources: CMS's Renal Information Management System.

Study Design: Regression discontinuity design assessing the use of ESAs by hematocrit level before and after the implementation of the payment policy change.

Data Extraction: Secondary data from 424,163 patients receiving hemodialysis treatment between January 2009 and June 2011.

Principal Findings: The introduction of bundled payments with pay-for-performance initiatives was associated with an immediate and substantial decline in the use of ESAs among patients with hematocrit >36 percent and little change in the use of ESAs among patients with hematocrit ≤36 percent. In the first two quarters of 2011, the use of ESAs during dialysis fell by about 7-9 percentage points among patients with hematocrit levels >36 percent. No statistically significant differences in ESA use were observed at the thresholds of 30 or 33 percent.

Conclusions: CMS's payment reform for dialysis care reduced the use of ESAs in patients who may not benefit from these agents.