The Centers for Medicare & Medicaid Services’ (CMS) proposed fixed payment bundle system could have an unintended consequence—reduced access to dialysis for African Americans, suggests a study in the July Journal of the American Society of Nephrology.
Racial differences in hemoglobin levels and requirements for erythropoietin-stimulating agents (ESAs) could provide a financial disincentive for dialysis centers to accept African American patients under the coming bundled payment policy, according to Areef Ishani, MD, of the University of Minnesota. “The concern is that when you go into a fixed-bundle payment, where everyone gets paid the same irrespective of race and the influence of race on injectable medications, it could turn out to disadvantage African Americans,” said Ishani.
The concerns arise from the recent proposal to alter CMS reimbursement for outpatient hemodialysis. The proposal calls for a “fixed payment bundle” covering both outpatient dialysis and injectable medications. According to the proposal, dialysis facilities “would no longer have an incentive to provide more ESRD drugs than clinically necessary” and clinicians would have “more flexibility in decision making because incentives to prescribe a particular drug or treatment are reduced.” (The complete proposal can be downloaded at http://www.gao.gov/new.items/d0777.pdf.)
However, Ishani and colleagues saw cause for concern regarding the policy’s potential impact on African-American patients. They noted that African Americans historically start dialysis at lower hemoglobin levels that white patients and are less likely to receive ESA therapy before initiating dialysis.
Using Medicare data, they identified about 12,000 patients starting hemodialysis during 2006. “We were looking primarily at people with the same insurance source—they all had Medicare,” said Ishani. “None had been treated with an ESA in the two years prior.” All received EPO during their first two months on dialysis. (A small number of patients who received darbepoietin alfa were excluded from the analysis.)
“We looked at initial hemoglobin, and yes, African Americans did come into the program with lower hemoglobins compared to whites,” said Ishani. The baseline hemoglobin level in African American patients was 9.9 g/dL, compared to 10.3 mg/dL in white patients. After adjustment for sex and other variables, the racial difference was about 0.35 mg/dL.
African-American patients also had higher initial EPO requirements. “We looked specifically at EPO during the first two months, and it turned out that African Americans used about 10 to 11 percent more, compared to whites.” When baseline hemoglobin level was taken into account, the racial difference in EPO narrowed to about 7 percent.