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

Abstract

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. CMS's Renal Information Management System. Regression discontinuity design assessing the use of ESAs by hematocrit level before and after the implementation of the payment policy change. Secondary data from 424,163 patients receiving hemodialysis treatment between January 2009 and June 2011. 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. CMS's payment reform for dialysis care reduced the use of ESAs in patients who may not benefit from these agents.