Medicare End-Stage Renal Disease Program Research Articles

Trends in Cost Attributable to Kidney Transplantation Evaluation and Waiting List Management in the United States, 2012-2017

While recent policy reforms aim to improve access to kidney transplantation for patients with end-stage kidney disease, the cost implications of kidney waiting list expansion are not well understood. The Organ Acquisition Cost Center (OACC) is the mechanism by which Medicare reimburses kidney transplantation programs, at cost, for costs attributable to kidney transplantation evaluation and waiting list management, but these costs have not been well described to date. To describe temporal trends in mean OACC costs per kidney transplantation and to identify factors most associated with cost. This economic evaluation included all kidney transplantation waiting list candidates and recipients in the United States from 2012 to 2017. A population-based study of cost center reports was conducted using data from all Center of Medicare & Medicaid-certified transplantation hospitals. Data analysis was conducted from June to August 2021. Year, local price index, transplantation and waiting list volume of transplantation program, and comorbidity burden. Mean OACC costs per kidney transplantation. In 1335 hospital-years from 2012 through 2017, Medicare's share of OACC costs increased from $0.95 billion in 2012 to $1.32 billion in 2017 (3.7% of total Medicare End-Stage Renal Disease program expenditure). Median (IQR) OACC costs per transplantation increased from $81 000 ($66 000 to $103 000) in 2012 to $100 000 ($82 000 to $125 000) in 2017. Kidney organ procurement costs contributed to 36% of mean OACC costs per transplantation throughout the study period. During the study period, transplantation hospitals experienced increases in kidney waiting list volume, kidney waiting list active volume, kidney transplantation volume, and comorbidity burden. For a median-sized transplantation program, mean OACC costs per transplantation decreased with more transplants (-$3500 [95% CI, -$4300 to -$2700] per 10 transplants; P < .001) and increased with year ($4400 [95% CI, $3500 to $5300] per year; P < .001), local price index ($1900 [95% CI, $200 to $3700] per 10-point increase; P = .03), patients listed active on the waiting list ($3100 [95% CI, $1700 to $4600] per 100 patients; P < .001), and patients on the waiting list with high comorbidities ($1500 [9% CI, $600 to $2500] per 1% increase in proportion of waitlisted patients with the highest comorbidity score; P = .002). In this study, OACC costs increased at 4% per year from 2012 to 2017 and were not solely attributable to the cost of organ procurement. Expanding the waiting list will likely contribute to further increases in the mean OACC costs per transplantation and substantially increase Medicare liability.

A historical perspective of how public policy shaped dialysis care delivery in the United States.

Broadly defined public policy has been said to be whatever "governments choose to do or not to do" As applied to healthcare, public policy can be traced back to the 4000-year-old Code of Hammurabi. As it applies to dialysis care its history is barely 50years old since national coverage for end-stage renal disease (ESRD) was legislated as Public Law 92-603 in 1972. As with most healthcare policy changes, it was a result of medical progress which had changed renal function replacement by dialysis from its rudimentary beginnings during the Second World War into an experimental acute life-saving procedure in the 1950s and to an established life-sustaining treatment for the otherwise fatal disease of uremia in the 1960s that was limited by its costs. Since 1973, the Medicare ESRD Program has saved the lives of thousands of individuals, a compassionate achievement that has come at increasing costs which have exceeded all estimates and evaded containment. Apart from cost containment, policy changes in dialysis care have been directed at improving its safety and adequacy. Some of the results of these changes are evident as one compares the outcomes and complications of dialysis encountered in the 1970s to those in the present; others, particularly those related to vascular access and hospitalization rates have improved modestly. This article recounts the historical background in which national coverage for dialysis care was developed, legislated and has evolved over the past 50years.

Palliation Versus Dialysis for End-Stage Renal Disease in the Oldest Old: What are the Considerations?

As the US population continues to age, new cases of end-stage renal disease (ESRD) in individuals, aged 85 years or older (the oldest old), are increasing. Many patients who begin hemodialysis despite questionable benefit may struggle with high symptom burden and rapid functional decline. This article reviews the history regarding the funding and development of the Medicare ESRD program, reviews current approaches to the oldest old with ESRD, and considers strategies to improve the management approach of this vulnerable population.

The Envy of Scholars: Applying the Lessons of the Framingham Heart Study to the Prevention of Chronic Kidney Disease.

During the past 50 years, a dramatic reduction in the mortality rate associated with cardiovascular disease has occurred in the US and other countries. Statistical modeling has revealed that approximately half of this reduction is the result of risk factor mitigation. The successful identification of such risk factors was pioneered and has continued with the Framingham Heart Study, which began in 1949 as a project of the US National Heart Institute (now part of the National Heart, Lung, and Blood Institute). Decreases in total cholesterol, blood pressure, smoking, and physical inactivity account for 24%, 20%, 12%, and 5% reductions in the mortality rate, respectively. Nephrology was designated as a recognized medical professional specialty a few years later. Hemodialysis was first performed in 1943. The US Medicare End-Stage Renal Disease (ESRD) Program was established in 1972. The number of patients in the program increased from 5,000 in the first year to more than 500,000 in recent years. Only recently have efforts for risk factor identification, early diagnosis, and prevention of chronic kidney disease (CKD) been undertaken. By applying the approach of the Framingham Heart Study to address CKD risk factors, we hope to mirror the success of cardiology; we aim to prevent progression to ESRD and to avoid the cardiovascular complications associated with CKD. In this paper, we present conceptual examples of risk factor modification for CKD, in the setting of this historical framework.

System Dynamics Modeling Can be Leveraged to Predict Critical Care Pathways and Costs for End Stage Renal Disease: US Population to 2020.

Background: End Stage Renal Disease (ESRD) accounts for 9% of Medicare spending, with the beneficiaries suffering from ESRD costing 7-9 times more than the average. This population is expected to continue to grow as a portion of Medicare beneficiaries. To provide clinicians and administrators with a greater understanding of the combined costs associated with the multiple critical care pathways for End Stage Renal Disease we have developed a model to predict ESRD populations through 2020. Methods: A system dynamics model was designed to project the prevalence and total costs of ESRD treatment for the United States through 2020. Incidence, transplant and mortality rates were modeled for 35 age and primary diagnosis subgroups coursing through different ESRD critical care pathways. Using a web interface that allows users to alter certain combinations of parameters, several demonstration analysis were run to predict the impact of three policy interventions on the future of ESRD care Results: The model was successfully calibrated against the output of United States Renal Data System's (USRDS) prior predictions and tested by comparing the output to historical data. Our model predicts that the ESRD patient population will continue to rise, with total prevalence increasing to 829,000 by 2020. This would be a 30% increase from the reported 2010 prevalence. Conclusions: Findings suggest that clinical care and policy changes can be leveraged to more effectively and efficiently manage the inevitable growth of ESRD patient populations. Patients can be shifted to more effective treatments, while planning integrating systems thinking can save Medicare's ESRD program billions over the next decade.

Cancer Incidence Among US Medicare ESRD Patients Receiving Hemodialysis, 1996-2009

Patients with end-stage renal disease (ESRD) receiving dialysis have been reported to have increased risk of cancer. However, contemporary cancer burden estimates in this population are sparse and do not account for the high competing risk of death characteristic of dialysis patients. Retrospective cohort study. US adult patients enrolled in Medicare's ESRD program who received in-center hemodialysis. Demographic/clinical characteristics. For overall and site-specific cancers identified using claims-based definitions, we calculated annual incidence rates (1996-2009). We estimated 5-year cumulative incidence since dialysis therapy initiation using competing-risk methods. We observed a constant rate of incident cancers for all sites combined, from 3,923 to 3,860 cases per 100,000 person-years (annual percentage change, 0.1; 95% CI,-0.4 to 0.6). Rates for some common site-specific cancers increased (ie, kidney/renal pelvis) and decreased (ie, colon/rectum, lung/bronchus, pancreas, and other sites). Of 482,510 incident hemodialysis patients, cancer was diagnosed in 37,128 within 5 years after dialysis therapy initiation. The 5-year cumulative incidence of any cancer was 9.48% (95% CI, 9.39%-9.57%) and was higher for certain subgroups: older age, males, nonwhites, non-Hispanics, nondiabetes primary ESRD cause, recent dialysis therapy initiation, and history of transplantation evaluation. Among blacks and whites, we observed 35,767 cases compared with 25,194 expected cases if the study population had experienced rates observed in the US general population (standardized incidence ratio [SIR], 1.42; 95% CI, 1.41-1.43). Risk was most elevated for cancers of the kidney/renal pelvis (SIR, 4.03; 95% CI, 3.88-4.19) and bladder (SIR, 1.57; 95% CI, 1.51-1.64). Claims-based cancer definitions have not been validated in the ESRD population. Information for cancer risk factors was not available in our data source. These results suggest a high burden of cancer in the dialysis population compared to the US general population, with varying patterns of cancer incidence in subgroups.

Healthcare Reform: Implications for Renal Dietitians

Over the last 40 years, the financing and programmatic changes in the Medicare end-stage renal disease (ESRD) program have affected the renal dietitian's practice and the care of the patients we serve. The Affordable Care Act (ACA) will affect the ESRD program and funding for primary and specialty care (including medical nutrition therapy) for our patients before with chronic kidney disease Stage 1 to 4. One of the underpinnings of the ACA is the Institute for Healthcare Improvement Triple Aim Initiative http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/MeasuresResults.aspx, which aims to •Improve the health of the population served, •Improve the experience of the individual, and •Provide affordability as measured by the total cost of care.

Early Trends From the Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS)

Launched in January 2011, the prospective payment system (PPS) for the US Medicare End-Stage Renal Disease Program bundled payment for services previously reimbursed independently. Small dialysis organizations may be particularly susceptible to the financial implications of the PPS. The ongoing Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS) was designed to describe trends in care and outcomes over the period of PPS implementation. This report details early results between October 2010 and June 2011. Prospective observational cohort study of patients from a sample of 51 small dialysis organizations. 1,873 adult hemodialysis and peritoneal dialysis patients. Secular trends in processes of care, anemia, metabolic bone disease management, and red blood cell transfusions. Facility-level data are collected quarterly. Patient characteristics were collected at enrollment and scheduled intervals thereafter. Clinical outcomes are collected on an ongoing basis. Over time, no significant changes were observed in patient to staff ratios. There was a temporal trend toward greater use of peritoneal dialysis (from 2.4% to 3.6%; P = 0.09). Use of cinacalcet, phosphate binders, and oral vitamin D increased; intravenous (IV) vitamin D use decreased (P for trend for all <0.001). Parathyroid hormone levels increased (from 273 to 324 pg/dL; P < 0.001). Erythropoiesis-stimulating agent doses decreased (P < 0.001 for IV epoetin alfa and IV darbepoetin alfa), particularly high doses. Mean hemoglobin levels decreased (P < 0.001), the percentage of patients with hemoglobin levels <10 g/dL increased (from 12.7% to 16.8%), and transfusion rates increased (from 14.3 to 19.6/100 person-years; P = 0.1). Changes in anemia management were more pronounced for African American patients. Limited data were available for the prebundle period. Secular trends may be subject to the ecologic fallacy and are not causal in nature. In the period after PPS implementation, IV vitamin D use decreased, use of oral therapies for metabolic bone disease increased, erythropoiesis-stimulating agent use and hemoglobin levels decreased, and transfusion rates increased numerically.

Preface

George Schreiner, one of a group of first-generation nephrologists who developed hemodialysis for the treatment of acute renal failure during the 1940s and '50s, passed away recently and in this issue we include his obituary written by Eli Friedman. George was one of the giants of those early days, who went on to contribute to the development of nephrology over the years. With Paul Doolan and Paul Teschan (both still alive), he was part of the group that established the dialysis unit at Walter Reed Hospital. After and as a result of his experience in the battlefield in Korea in 1951, he went on to establish one of the earliest programs for the treatment of acute renal failure with the artificial kidney in the U.S. at Georgetown. This led him to develop the famous Georgetown University nephrology department that trained hundreds of nephrologists from the U.S. and elsewhere. He was one of the early members of the American Society of Artificial Internal Organs and was editor of the society's Proceedings for many years, taking pride in having these published in less than three months after the annual meeting. However, perhaps his most important achievement from the point of view of patients was that he was a very important factor in getting the U.S. Congress to legislate the Medicare End-Stage Renal Disease Program. Also in the last few months another one of the well-known pioneers in the field of dialysis–Dimitrious Oreopoulos–died. He was a renowned figure in Canadian nephrology for his work on peritoneal dialysis and his role in instigating the use of plastic bags of peritoneal dialysate that led to a rapid increase in the use of continuous ambulatory peritoneal dialysis (CAPD) worldwide. During his years working at the Toronto Western Hospital he devoted himself to improving the care of dialysis patients and to the education of nephrology fellows from Canada and many other countries. He was one of the first to realize the increasing importance of geriatric nephrology and because of his concern for patients he established the Humane Medicine Journal as a medium for writing about ethical issues in patient care. There are only few of that first generation of dialyzing nephrologists from the 1940s and early 50s still alive and in the United States the oldest, well in his 90s, is Irving Kroop, who participated in the very first dialyses in New York using a rotating drum dialyzer from Dr. Kolff and who wrote an article for this journal a couple of years ago. Others are Paul Doolan and Paul Teschan, whom I mentioned in connection with Dr. Schreiner. Brian McCracken who, with Frank Parsons, started the dialysis unit in Leeds, England, in 1956 is still alive as is Gabriel Richet in France. I would be interested to know of others. An important part of the mission of the International Society for Hemodialysis is continuing medical education on hemodialysis for practicing nephrologists, renal fellows, practicing nephrologists, nephrology nurse practioners and dialysis nurses, patient-care technicians and others involved in the care of patients. As you will see in the advertisement in this journal, in September the ISHD is starting a new educational venture called “Hemodialysis University” and its first program is to be held in Chicago in September of this year. Check the advertisement for more information and go to http://www.ishd.net to access the online registration form for the event. Also note that that from August 3 to 5, the Fifth Congress of the International Society for Hemodialysis will be held at the Grand Hotel in Taipei, Taiwan—see advertisement in this issue and visit the website at http://www.ishd2012.org. Finally, to learn more about the ISHD and to find how to join the society, log on to http://www.ishd.net

Ethical Principles and Processes Guiding Dialysis Decision-Making

When the US Congress created the End-Stage Renal Disease (ESRD) Program in 1972, it gave physicians the responsibility of determining which patients were "appropriate" for dialysis. Congress provided no guidance on who should be selected or how. Only five years later, Dr. Belding Scribner, the father of chronic dialysis, noted that there was a need for a "deselection committee" because virtually all criteria for dialysis patient selection had been slackened, if not abandoned. In 1991, the Institute of Medicine Committee to Study the Medicare ESRD Program recommended the development of a clinical practice guideline because they noted there were "an increasing number of [dialysis] patients with limited survival possibilities and relatively poor quality of life." In 2000, the Renal Physicians Association and the American Society of Nephrology heeded the Institute of Medicine committee's recommendation and published Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis. In 2010, prompted by a substantial body of new research evidence, the Renal Physicians Association published a second edition of this clinical practice guideline. This article describes the application of the ethical principles of respect for patient autonomy, beneficence, nonmaleficence, justice, and professional integrity, and the ethical process of shared decision-making in making decisions about starting, withholding, continuing, and stopping dialysis with patients and families. It urges examination of medical indications and identifies appropriate limits to shared decision-making when the burdens of dialysis can be predicted to substantially outweigh the benefits.

The D&amp;T report

The D&amp;T report

Some thoughts on the future of home hemodialysis

Some thoughts on the future of home hemodialysis

Potential Impact of Nutritional Intervention on End-Stage Renal Disease Hospitalization, Death, and Treatment Costs

Our objective was to estimate the effect of an improvement in nutrition, represented by albumin concentrations, on hospitalization, mortality, and Medicare end-stage renal disease (ESRD) program cost. Based on published trials, the impact of an improvement in serum albumin of +0.2 g/dL from a hypothetical nutritional program for severely malnourished patients with albumin < or = 3.5 g/dL (base case) was estimated by reassigning patients to higher albumin categories, along with outcome risks associated with the new albumin category. Data from Fresenius Medical Care North America (Waltham, MA) were utilized in regression models to determine the association between albumin and change in albumin concentration with outcomes. Albumin < or = 3.5 g/dL was associated with a > 2-fold increase in death and hospitalization risk, compared to > or = 4 g/dL (P < .001) in this population. An increase in albumin concentration was associated with a lower risk of death and hospitalization, whereas a declining albumin concentration led to worse outcomes. Projections for the United States dialysis population from the base case showed approximately 1400 lives saved, approximately 6000 hospitalizations averted, and approximately $36 million in Medicare cost savings resulting from a reduction of approximately 20,000 hospital days. A sensitivity analysis, varying the albumin response to +0.1 and +0.3 g/dL combined with varying albumin responder rates to 25% and 75% of patients, revealed robust results. Nutritional interventions that increase serum albumin by > or = 0.2 g/dL (e.g., via oral nutritional supplements) may lead to considerable improvements in mortality, hospitalization, and treatment costs.

Should the Medicare ESRD Program Pay for Daily Dialysis? An Ethical Analysis

End-stage renal disease (ESRD) is a growing problem in the United States and has now reached epidemic proportions. The mortality rate and other complications related to conventional dialysis remain unacceptably high necessitating improvements in dialytic therapies. One strategy has been to increase dialysis frequency through daily dialysis since the Hemodialysis study showed that clinical outcomes are not improved by simply increasing delivered dialysis dose per session. Most studies of daily dialysis are observational and limited by small sample size, variable dialysis techniques, high patient dropout, and lack of adequate control group. These studies have shown consistent improvements in blood pressure and solute clearance, but improvements in patient survival, anemia, and health-related quality of life are less clear. The costs of providing daily dialysis on a large scale are likely to be substantial. However, if there are significant improvements in the outcome measures outlined earlier as well as decreased hospitalization rates, daily dialysis may prove cost-effective or budget neutral from a global standpoint. A scientific basis is needed to justify a change in the Medicare ESRD Program to fund daily dialysis. Decisions regarding the allocation of limited medical resources such as the Medicare budget should consider ethically appropriate criteria including likelihood of benefit, urgency of need, change in quality of life, duration of benefit, patient selection, equitable distribution, and the amount of resources required. In examining the evidence base on daily dialysis according to these ethical criteria, we find that there are not yet sufficient grounds to recommend funding of daily dialysis by the Medicare ESRD Program. Randomized controlled trials comparing conventional hemodialysis to short daily and long nocturnal hemodialysis are much needed.

The Early History of Dialysis for Chronic Renal Failure in the United States: A View From Seattle

Forty-seven years have passed since the first patient started treatment for chronic renal failure by repeated hemodialysis (HD) at the University of Washington Hospital in Seattle in March 1960, and some 34 years have elapsed since the United States Congress passed legislation creating the Medicare End-Stage Renal Disease Program. Many nephrologists practicing today are unfamiliar with the history of the clinical and political developments that occurred during the 13 years between these 2 dates and that led to dialysis as we know it today in this country. This review briefly describes these events. Clinical developments following introduction of the Teflon shunt by Belding Scribner and Wayne Quinton included empirical observations leading to better understanding of HD and patient management, out-of-hospital dialysis by nurses, bioethical discussions of the problems of patient selection, home HD, improved dialysis technology, intermittent peritoneal dialysis, including automated equipment for home use and an effective peritoneal access catheter, the arteriovenous fistula for more reliable blood access, dialyzer reuse, the first for-profit dialysis units, understanding of many of the complications of treatment, the first considerations of dialysis adequacy, early development of other technologies, and more frequent HD. Political developments began less than 3 years after the first Seattle patient began dialysis, but it took another 10 years of intermittent activities before Congress acted on legislation to provide almost universal Medicare entitlement to patients with chronic kidney disease requiring dialysis or kidney transplantation.

Factors Influencing Route of Administration for Epoetin Treatment Among Hemodialysis Patients in the United States

Published clinical guidelines advocate subcutaneous (SC) administration for epoetin therapy, although this is practiced among only 7% of all hemodialysis patients. Despite this disparity, few studies have examined factors associated with route of epoetin administration in hemodialysis patients. Data from the Centers for Medicare & Medicaid Services End-Stage Renal Disease Clinical Performance Measures Project were used to identify 13,854 patients receiving hemodialysis in 3,069 dialysis facilities from October to December in 1999 and 2000. Unadjusted associations were examined by using t-test and chi-square test. Adjusted associations were estimated by using generalized estimating equations to control for clustering of patients within the same dialysis facility. In the United States, use of the SC route of epoetin administration varies widely across the country. After adjusting for patient sociodemographics and comorbidities, the greatest rates of SC therapy are found in the Midwest and West, in providers not affiliated with chains, and in hospital-based and not-for-profit freestanding units. Previous exposure to SC administration (as a predialysis or peritoneal dialysis patient) predicted subsequent SC use, for-profit and large chains were significantly less likely to use SC administration, and increased use of injectable drugs overall (to maximize income) was associated with less SC use. In addition to regional variation in SC use, study findings indicate that physician decision making for epoetin administration route is influenced primarily by type of ownership and financial incentives. Adherence to published clinical guidelines was not a consistent predictor of SC use. Given the similar effectiveness, but significantly decreased dose associated with SC epoetin, these findings suggest an enormous opportunity for cost savings for the Medicare program.

The direction of end-stage renal disease reimbursement in the United States.

In the 1960s, care of the end-stage renal disease (ESRD) patient changed. Either through transplantation or intermittent hemodialysis ESRD patients were able to live longer. The Gottschalk Committee issued the "Report of the Committee on Chronic Kidney Disease" to the Bureau of Budget. This report established that hemodialysis and kidney transplantation were the standard of care for the treatment of ESRD patients. Section 2991 of the Social Security Amendment of 1972 provided that patients with ESRD who qualified for Medicare were entitled to receive dialysis and/or transplantation nationwide. The first Medicare hearing held in 1975 regarding the Medicare ESRD program found that the cost of the program was much greater than had been predicted in 1972. Ever since 1975, accelerating cost has been a concern of the government. Quality of care for ESRD patients has been a major focus of the renal community and the Centers for Medicare and Medicaid Services (CMS) over the past 10 years. Consensus for entitlement has remained, but the staggering cost of the program as a whole has become a major problem that must be addressed. Since 1978, Congress and the CMS have passed laws and developed demonstration projects to improve quality of care and reduce costs in the Medicare ESRD program. Kt/V, urea reduction ratio (URR), and hemoglobin levels have all improved, but hospital admissions have remained unchanged and mortality rates have increased. Do the renal community and CMS need to rethink how they will improve the quality of care for ESRD patients and reduce costs in the Medicare ESRD program?

To have and have not: Health and health care disparities in chronic kidney disease

A 50-year-old African American man came to the emergency room complaining of substernal chest discomfort over the past 2 months, as well as anorexia, general malaise, and decreased urinary frequency over the past 2 weeks. The patient stated that his chest pain lasted 2 to 3 minutes; did not radiate to the neck, jaw, or shoulder; was precipitated by lifting heavy objects; and did not occur at rest. He admitted to mild shortness of breath when walking up the stairs at home. He noted that for 2 weeks, he had been feeling exhausted and had had poor appetite, weight loss, and less frequent urination than usual. The patient had last seen a physician 4 years ago at an urgent care facility for a pilonidal cyst abscess. Five years prior to that, he had been told by a primary care physician that he had hypertension. He was treated with an unknown medication and, after a follow-up visit, was told that his blood pressure was normal. He has no other known history of cardiovascular or renal disease. He takes no medications. He lost his job as a cook and the health insurance that the job provided; he now says that he is unable to continue seeing the physician. He completed high school, is married, and works as a taxi driver as well as at a local farmers market on weekends. His father had hypertension and died suddenly at age 55. His mother is 71 and has diabetes. He has one older brother who

The uneven distribution of kidney transplants: Getting at the root causes and improving care

The uneven distribution of kidney transplants: Getting at the root causes and improving care

Potential cost savings of erythropoietin administration in end-stage renal disease

Background In a Department of Veterans Affairs randomized controlled trial, a lower dose of recombinant human erythropoietin (epoetin) was shown to attain target hematocrit levels when administered subcutaneously compared with intravenously. Since epoetin is expensive, optimizing the therapeutic effect of epoetin using a strategy that includes subcutaneous administration could lead to substantial cost savings. Methods We used an economic cost projection model to estimate potential savings to the Medicare End-Stage Renal Disease Program that could occur during a transition from intravenous to subcutaneous administration of epoetin among hemodialysis patients. Data included clinical results from the Department of Veterans Affairs randomized controlled trial, the 1998 Centers for Medicare and Medicaid Services’ End-Stage Renal Disease Core Indicators Survey, and the 1997–1998 Medicare claims files. In sensitivity analyses, we varied the expected dose reductions (10% to 50%) and the proportion of patients (25% to 100%) who switched to subcutaneous administration. Results Medicare cost savings were estimated at $47 to $142 million annually as 25% to 75% of hemodialysis patients who received epoetin intravenously switched to subcutaneous administration while reducing the dose by 32%. A minimal reduction (10%) in epoetin dose would result in Medicare cost savings of an estimated $15 to $44 million annually. Conclusion Administering epoetin subcutaneously would provide substantial cost savings to Medicare. For the transition to occur, consensus among stakeholders is needed, especially among patients whose treatment satisfaction and health-related quality of life would be most affected.