Economic forces influence care decisions and outcomes for patients with end-stage kidney disease (ESKD) who require outpatient hemodialysis (HD), according to a study of Centers for Medicare & Medicaid Services (CMS) reimbursements.
Co-authored by Ryan McDevitt, PhD, a Duke Fuqua School of Business microeconomist, the study compares reimbursements for bundled and fee-for-service (FFS) payment models and the effects of those models on prescriptions for erythropoietin (EPO), used to stimulate red blood cell production and help prevent transfusions in patients with anemia.
Trends identified by the analysis offer a microcosm of the intersection of economic forces and health care decisions, says John P. Middleton, MD, a Duke nephrologist.
“We work daily with patients with ESKD, many of whom eventually require dialysis and seek that service at outpatient HD clinics reimbursed by CMS,” says Middleton, who has served as a board member for a dialysis provider and on steering committees of major, multicenter trials studying chronic kidney disease.
“The intersection of these forces is both good and bad,” Middleton explains. “But I have learned that you can do good for patients within this model. Sometimes it’s frustrating when policies come down that more strongly reflect corporate priorities than medical priorities. In those instances, we can and do campaign for exceptions for our patients.”
Analysis of economic trends in hemodialysis
McDevitt shared his research with Duke nephrologists as the initial step in a potential collaboration. The analysis offers insights into trends in an HD industry in which two companies—DaVita and Fresenius Medical Care—dominate the largely consolidated operations, owning two-thirds of all clinics. The industry receives $36 billion annually in reimbursement for HD in outpatient clinics—$92,000 per patient per year, approximately 1% of the federal budget.
Following an initial, 30-month period of coverage by private insurance, outpatient dialysis is reimbursed entirely by CMS and patient co-pays, McDevitt says. The database of patient outcomes and Medicare reimbursements has become “a treasure trove for researchers,” he adds.
McDevitt’s analysis demonstrated that EPO doses declined 49% following a 2011 reform in which Medicare reimbursements shifted from the FFS model to a bundled approach. The study concluded that the changes resulted in EPO being deployed more effectively to patients with the greatest need, though the decline varied across chain and independent outpatient clinics.
These changes reduced overall Medicare spending on HD by about 0.4% after growing at approximately 2% annually; the study highlighted several confounding factors, including the fact that patients living at higher elevations experienced less significant changes in the use of EPO.
Another key factor, Middleton says, is the new warnings about EPO use presented in 2011, highlighting increased risks associated with EPO-induced cardiovascular or thromboembolic events, stroke or the risk of tumor regression of recurrence. The FDA issued a “black-box” warning associated with EPO in summer 2011, although McDevitt and co-authors show that this warning did not cause the large change in EPO doses around that time.
