Health Care Beat
8/22/2010
New CMS physician fee schedule can have big impact on home dialysis patients
Rebecca Zumoff
A recent proposed rule that covers Medicare payments to physicians under Part B could require nephrologists to visit with home dialysis patients every month to meet reimbursement requirements.
Bill Peckham brought this to our attention in his blog Dialysis from the Sharp End of the Needle. He explains why this might restrict some of the freedoms that led people to home dialysis in the fist place.
CMS will be taking comments on the proposed rule here until Aug. 24.
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8/15/2010
JASN study highlights inconsistencies in government-funded coverage of kidney treatments
Editorial argues for enrollment extension of ESRD program to include advancing CKD care
By Rebecca Zumoff
Kidney disease patients insured by some federally sponsored national health care organizations are more likely to get an arteriovenous fistula than patients with other types of insurance, including Medicare according to a study in an upcoming issue of the Journal of the American Society of Nephrology.
The study showed that patients with Departments of Veterans Affairs (DVA) and Department of Defense (DoD) insurance were 40% more likely to initiate dialysis with an AVF compared with patients with other types of insurance. In the group, 27.2% of patients with DVA/DoD insurance initiated hemodialysis with an AVF, compared with 18.5% of patients reporting employer-group insurance, 16.7% of patients with other insurance, 15.6% of patients with Medicare, 13% of patients with Medicaid, and 8.2% of patients who reported no insurance. The analysis also revealed that patients who initiated hemodialysis at a DoD facility were twice as likely to use an AVF. Placing an AVF before dialysis initiation eliminates the cost and risk associated with prolonged catheter-based dialysis, but the authors also noted that the proportion of patients who initiate hemodialysis with an AVF, even among those in the special insurance groups, is still too low.
In an accompanying editorial, Steve Schwab, MD, and Kennard Brown, PhD, University of Tennessee Health Science Center, ask the question: How did we get to this situation, and can we fix this problem?
"We arrived here on the basis of groundbreaking public policy first passed into law in 1972 as an amendment to the Social Security Act that afforded dialysis care to many Americans when they reached a stage of renal failure requiring replacement therapy," the authors write. "This public policy did not provide preventive care, but rather, like catastrophic insurance, it insured for the catastrophe itself."
The policy, the authors argue, is immature. "We now have a public policy that treats a catastrophic illness such as renal failure but does not act to prevent or ameliorate that catastrophe earlier."
Medicare does not pay for a patient to be treated by a nephrologist and a vascular surgeon before the determination of dialysis dependence, the authors write. The Department of Defense and the Veterans Administration, and many commercial insurance programs, do pay for the predialysis care because of "incentives to reduce the costs of catastrophic illness by ameliorating complications and prevention of CKD progression, including early referral as a matter of financial policy."
The solution, they say, is to "mature a preexisting public policy by extending enrollment for advancing CKD," and it is "business-simple but politically difficult." We are in a political climate where people want to cut services, not provide more, the authors note. It makes medical and financial sense, they argue.
I agree that providing preventative care can save money in the long run. But it is important to remember that the AVF numbers from private insurers and federal health care organization are still very low, even though they are under incentive to cut costs.
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8/1/2010
The winners and losers on the business side of the bundle
By Thomas Keating
Now that the final rule for the bundled payment covering dialysis services is complete, investment analysts identified winners and losers this past week in the renal care industry.
As soon as the Centers for Medicare & Medicaid Services released the initial proposal this past September, companies were on their toes. But a lot of their fears assuaged last Monday when the final rule on the bundled prospective payment system for routine outpatient dialysis services was released---with stock prices reflecting that sentiment as well.
"There do seem to be favorable elements for industry within the rule," said Jefferies & Co. analyst Arthur Henderson, because the fee paid to dialysis centers led by Fresenius Medical Care AG and DaVita Inc will decline only 2% to $250 to $260 per treatment and because of the delay in including the oral drugs, he said.
Oral drugs will not be included in the bundle until after 2014, following additional study. Also, there are fewer case mix adjusters. CMS declined to use a patient's sex or race/ethnicity to adjust payment.
Because of this, providers will be able to bill Medicare for Amgen Inc.'s Sensipar and Genzyme Corp.'s Renagel and Renvela until 2014.
"Genzyme is encouraged by CMS' final decision, as we believe it will put the needs of the patients first by providing the time needed to collect data to document the current standard of care, enabling assessment in the future of any unintended negative consequences that the new bundled payment system may have on the management and outcomes of dialysis patients," Dan Regan, senior vice president and general manager of the company's renal business, said in a statement.
Amgen's stock rose 84 cents, or 1.6%, to $54.51 last Monday while its shares have declined 3.6 percent this year. Genzyme gained 13 cents to $67.51, and has increased 38% this year. Fresenius Medical Care rose 4.9% in Frankfurt trading to 43.15 euros. DaVita fell 34 cents, less than 1%, to $60.52.
But it wasn't all good news for those in the industry. The new rules may cut sales of Faraheme, an intravenous iron-boosting drug from AMAG Pharmaceuticals Inc., as the centers opt instead for cheaper products, said Yaron Werber, an analyst for Citi Investment Research in New York. "Why would centers use an expensive intravenous iron product instead of a fairly comparable and much cheaper IV iron formulations?" Werber said.
But Leerink Swann analyst Joseph Schwartz contended that the bundling weakness for AMAG's shares was "overdone," arguing that Feraheme already is much less of a dialysis story, with expectations that it would "make greater inroads in nondialysis settings.
"Despite angst on the Street regarding the impact on all companies in the nephrology space, we believe AMAG is relatively well positioned," Schwartz said.
While Feraheme is a premium-priced IV iron supplement, it is nonetheless cheaper than ESAs, with Wall Street already having minimal expectations for use in dialysis.
"We believe AMAG is well prepared and has concentrated marketing efforts appropriately," as evidenced by 60% of Feraheme sales already being in nondialysis, Schwartz said.
Another loser from the bundle will be sales of Amgen's intravenous Epogen. Sales of the world's top-selling anemia drug are likely to fall under the new rules. Epogen sales may decline 38% from last year's $2.6 billion as the regulations are phased in over the next three years, said Michael Yee, an analyst with RBC Capital Markets in San Francisco. Anemia drugs "were a profit center, now they'll be an expense," Yee said. "Now there will be some incentive to use the minimal amount."
Concern about this system grew stronger when some clinical trials revealed that overuse of Epogen might harm patients, increasing their risk of heart attacks and strokes.
"When drugs remain outside the payment bundle, financial issues can influence both facility and patient behavior, as the over-utilization of EPO to the detriment of patient care in the past has demonstrated,'' Medicare said in its ruling Monday.
Of course, the new system could have the opposite effect. Epogen will go from being a potential profit source for dialysis clinics to an expense that detracts from profit. So now there will be an incentive to under-use the drug, perhaps subjecting dialysis patients to more anemia and fatigue.
Analysts have been expecting the final rules since Medicare first proposed the changes last year, and they have by and large already factored in a reduction in sales of Epogen of as much as 40%.
In a note to clients Monday afternoon, however, Jim Birchenough, an analyst at Barclays Capital, said such estimates might be too high and that the transition to giving patients separate injections will occur gradually.
7/18/2010
Study finds facility and patient characteristics associated with home dialysis
By Rebecca Zumoff
A new study in the Clinical Journal of the American Society of Nephrology finds that factors such as clinic size, location, and chain association affect the use of home dialysis.
Despite the mounting evidence of the medical and financial success of home dialysis, the percentage of patients receiving home dialysis has decreased over the last decade.
To help shine a light on clinic and patient characteristics that are associated with high use of home dialysis, researchers at Baxter Healthcare Corporation analyzed data from 4,653 dialysis clinics that made up 92% of the facilities in the 2007 ESRD annual network reports
About the clinics
According to results from the study:
Ms. Zumoff is Web Content Manager for NephrOnline and is based in Chicago.
A new study in the Clinical Journal of the American Society of Nephrology finds that factors such as clinic size, location, and chain association affect the use of home dialysis.
Despite the mounting evidence of the medical and financial success of home dialysis, the percentage of patients receiving home dialysis has decreased over the last decade.
To help shine a light on clinic and patient characteristics that are associated with high use of home dialysis, researchers at Baxter Healthcare Corporation analyzed data from 4,653 dialysis clinics that made up 92% of the facilities in the 2007 ESRD annual network reports
About the clinics
According to results from the study:
- The average amount of dialysis patients on home dialysis in all clinics was 7%.
- Approximately 80% of facilities were owned or managed by a chain and 82% were for-profit.
- Late shifts were available in 23% of independent clinics compared with 18.7% of chains.
- Twenty-eight percent of not-for-profit clinics compared with 17.6% of for-profit clinics had a late shift.
- The average number of years since a facility had received Medicare certification was 12.6 years.
- Thirty-one percent of the total dialysis population was between 18 and 54 years old and 20% of this dialysis population was employed.
- On average 15.9% of the dialysis population was black.
- On average, there are approximately 1.2 facilities per zip code, but no more than 7 dialysis facilities in a single zip code.
- Larger dialysis facility size.
- More years of facility certification.
- Higher population of working patients.
- High percentage of patients between the ages of 18 to 54 years old.
- Owned by a chain organization. (There was no association between profit status and the use of home dialysis.)
- Rural location. The study authors speculate that this may indicate there are insufficient patients, resources, or infrastructure to support and sustain a home dialysis program in some rural areas.
- Located in a geographically larger zip code area, or high-population-density.
- The presence of a late shift (the average facility with a late shift had a 4.4% lower. The authors question whether facilities with a late shift are motivated to preferentially fill available in-center chairs.
- Higher black population (each absolute 1% increase in the black population within a zip code was associated with an absolute 0.03% decline in the percent of patients on home dialysis).
Ms. Zumoff is Web Content Manager for NephrOnline and is based in Chicago.
7/12/2010
Despite the controversy, Obama made a smart move with Donald Berwick
Rebecca Zumoff
On July 11 on ABC News' "This Week," Senior White House Advisor David Axelrod said that President Obama's recess appointment of Donald Berwick, MD as the administrator of the Centers for Medicare & Medicaid Services was too important to wait for a Congressional hearing.
"This is too important. This position is too important. In the midst of implementing health reform, it is too important to allow that kind of game-playing to go on," he said.
CMS has been without an administrator for too long. Anyone involved in health care knows the important role the agency plays in our health care system. The agency is working on implementing new payment policies, like the ESRD bundle, and needs strong leadership to ensure it gets done efficiently.
Prior to Obama's decision to bypass a hearing, some Republican Senators, like Pat Roberts of Kansas, shared their plans to stall the Berwick nomination and use it as a political platform to argue about health care reform and the mythical death panels. It looked like Congress was preparing for a fight that would place Medicare beneficiaries in the middle.
"Once again, the Obama administration is going behind closed doors out of fear the American people will learn that Dr. Berwick plans to use rationing as a cost-cutting tool to achieve the billions of dollars in cuts to Medicare called for in the health care reform bill," Roberts told The Boston Globe.
But Berwick has already explained his view on rationing: the decision is not whether or not we will ration care--the decision is whether we will ration with our eyes open, Berwick said.
The argument that Berwick is going to destroy our health care system with rationing is nothing more than a political game. Rationing is a buzz word we are supposed to be afraid of, but obviously it already exists in our health care system; preexisting conditions and rescission are little more than euphemisms for health care rationing. CMS has been rationing care long before Berwick was nominated for the job to head the agency.
A lot of people in this country rely on Medicare. Most dialysis patients depend on it. And we all pay for it. It's in everyone's best interest to make it the best it can be.
6/27/2010
Lancet editorial calls for a new strategy to curbing type 2 diabetes
By Rebecca Zumoff
A new editorial in The Lancet says "the fact that type 2 diabetes, a largely preventable disorder, has reached epidemic proportion is a public health humiliation. Diabetes need not be an inevitable consequence of urbanization or social inequity, nor should future generations be condemned to perpetuate diabetogenic lifestyles.
"The fact that type 2 diabetes, a largely preventable disorder, has reached epidemic proportion is a public health humiliation," says an editorial in the recent issue of The Lancet.
The editorial begins a special issue on diabetes made to coincide with the 70th Scientific Sessions meeting of the American Diabetes Association. The various articles and studies in the issue represent the medical progress made in understanding and lowering blood glucose, the editorial notes. "But there is a glaring absence: no research on lifestyle interventions to prevent or reverse diabetes. In this respect, medicine might be winning the battle of glucose control, but is losing the war against diabetes."
According to The Lancet, 90% of people with diabetes have type 2 diabetes. And although the disease was once perceived as disproportionately affecting the affluent, it is now the poor who are actually hit hardest. Since 2000, the number of people with diabetes has more than doubled to 285 million.
For solutions to work, they must involve schools and urban planners, The Lancet writes. The barriers to diabetes prevention are great. Physical activity must become a part of daily existence. Neighborhoods that have long suffered urban decay need to be built back up.
A few studies have shown that diabetes is more prevalent and less treated in U.S. neighborhoods that residents don’t perceive as safe. These neighborhoods tend to have less access to safe areas for kids to exercise and play. In addition, the White House estimates that 23.5 million Americans currently live in what is known as a 'food desert,' which is an area in urban cities and rural areas that lack reasonable, affordable access to grocery stores with fresh produce and other healthy foods.
According to The Lancet, to combat the diabetes epidemic, "a strong, integrated, and imaginative response is required, in which the limits of drug treatment and the opportunities of civil society are recognized."
As industrialization sweeps through Asia and Africa, creating opportunities for physical activity within the built environment has become the greatest---and most urgent---challenge, The Lancet writes. Without these opportunities, growing nations will become hotbeds for diabetes. "Urban recreation must be readily accessible, affordable, and include safe areas for youngsters, whose requirement for exercise is greater than that of adults," The Lancet writes.
"To lessen the burden of diabetes requires a substantial change in diet and routine, such as that advocated by Michelle Obama's Let's Move campaign," The Lancet writes.
The First Lady's campaign aims to solve the childhood obesity epidemic within a generation by focusing on increasing physical activity and promoting healthier choices among young people. She has also set a goal to completely eliminate food deserts in America in the next seven years.
"Diabetes need not be an inevitable consequence of urbanization or social inequity, nor should future generations be condemned to perpetuate diabetogenic lifestyles," The Lancet writes.
A new editorial in The Lancet says "the fact that type 2 diabetes, a largely preventable disorder, has reached epidemic proportion is a public health humiliation. Diabetes need not be an inevitable consequence of urbanization or social inequity, nor should future generations be condemned to perpetuate diabetogenic lifestyles.
"The fact that type 2 diabetes, a largely preventable disorder, has reached epidemic proportion is a public health humiliation," says an editorial in the recent issue of The Lancet.
The editorial begins a special issue on diabetes made to coincide with the 70th Scientific Sessions meeting of the American Diabetes Association. The various articles and studies in the issue represent the medical progress made in understanding and lowering blood glucose, the editorial notes. "But there is a glaring absence: no research on lifestyle interventions to prevent or reverse diabetes. In this respect, medicine might be winning the battle of glucose control, but is losing the war against diabetes."
According to The Lancet, 90% of people with diabetes have type 2 diabetes. And although the disease was once perceived as disproportionately affecting the affluent, it is now the poor who are actually hit hardest. Since 2000, the number of people with diabetes has more than doubled to 285 million.
For solutions to work, they must involve schools and urban planners, The Lancet writes. The barriers to diabetes prevention are great. Physical activity must become a part of daily existence. Neighborhoods that have long suffered urban decay need to be built back up.
A few studies have shown that diabetes is more prevalent and less treated in U.S. neighborhoods that residents don’t perceive as safe. These neighborhoods tend to have less access to safe areas for kids to exercise and play. In addition, the White House estimates that 23.5 million Americans currently live in what is known as a 'food desert,' which is an area in urban cities and rural areas that lack reasonable, affordable access to grocery stores with fresh produce and other healthy foods.
According to The Lancet, to combat the diabetes epidemic, "a strong, integrated, and imaginative response is required, in which the limits of drug treatment and the opportunities of civil society are recognized."
As industrialization sweeps through Asia and Africa, creating opportunities for physical activity within the built environment has become the greatest---and most urgent---challenge, The Lancet writes. Without these opportunities, growing nations will become hotbeds for diabetes. "Urban recreation must be readily accessible, affordable, and include safe areas for youngsters, whose requirement for exercise is greater than that of adults," The Lancet writes.
"To lessen the burden of diabetes requires a substantial change in diet and routine, such as that advocated by Michelle Obama's Let's Move campaign," The Lancet writes.
The First Lady's campaign aims to solve the childhood obesity epidemic within a generation by focusing on increasing physical activity and promoting healthier choices among young people. She has also set a goal to completely eliminate food deserts in America in the next seven years.
"Diabetes need not be an inevitable consequence of urbanization or social inequity, nor should future generations be condemned to perpetuate diabetogenic lifestyles," The Lancet writes.
6/20/2010
People of all races miss out on kidney care in predominantly black communities
Regardless of race, fewer people see a kidney specialist before starting dialysis if they live in predominantly black communities, reports a study appearing in an upcoming issue of the Journal of the American Society of Nephrology.
According to the researchers, a large proportion of black patients starting dialysis live in predominantly black residential areas. Suma Prakash, MD, FRCPC, University of Toronto, and her colleagues investigated whether patient location has an effect on access to and quality of kidney-related care before starting dialysis, independent of individual patient's.
The researchers retrospectively studied 92,000 white and black adults who started dialysis in the United States between June 1, 2005 and October 5, 2006. They found that a residential area's racial composition had a significant effect on a patient's access to a kidney specialist before starting dialysis, regardless of the patient's race.
Researchers found that as the percentage of blacks in residential areas increased, the likelihood of not receiving pre-dialysis kidney care from a specialist increased: 29.5% of patients living in zip codes with <5% black residents did not see a kidney specialist compared with 40.7% of those living in zip codes with >50% black residents. However, if a patient received care from a specialist before starting dialysis, the quality of this care was no different in predominantly black areas compared with other residential areas.
Prakash said that the findings might be explained by several factors, such as the availability of pre-dialysis patient education or the accessibility of primary care doctors and kidney specialists. Prakash noted that the findings might be explained by several factors, such as the availability of pre-dialysis patient education or the accessibility of primary care doctors and kidney specialists. Addressing these findings might lead to improved access to kidney care in predominantly black residential areas.
6/6/2010
Study finds most dialysis patients not prepared for emergency evacuation
By Rebecca Zumoff
A survey of North Carolina kidney dialysis patients by researchers at the University of North Carolina at Chapel Hill School of Medicine found that most have not taken the emergency preparedness measures that would enable them to survive a disaster that disrupts power and water services. North Carolina ranks fourth among the states in hurricane landfalls, behind Florida, Texas and Louisiana. Mark Foster, lead author of the study and a UNC medical student, presented the results June 3 at the annual meeting of the Society for Academic Emergency Medicine in Phoenix.
In the survey, 311 dialysis patients who receive treatment at six regional dialysis centers in central North Carolina answered questions about their demographics, general disaster preparedness, dialysis-specific preparations for "sheltering in place" at home, and preparations for a forced evacuation.
According to Foster, both the general disaster preparedness and dialysis-specific preparedness of most respondents was poor, regardless of their sex, race, age, income or level of education.
Dialysis-specific preparations
Despite annual disaster preparedness education provided by the dialysis facilities, only 57% of patients surveyed understood what they needed for a renal emergency diet. Forty-three percent knew of other dialysis centers where they could get treatment if their current center was out of service and 42% said they had sufficient medical records at home with treatment information that they could provide to a new center.
General disaster preparedness
With regard to general disaster preparedness, 58% said they had enough bottled water at home to last for three days while 54% said they had enough food and water for three days. Forty-eight percent said they had 75% of the items on a disaster preparedness checklist recommended by the Department of Homeland Security while 38% said they had both food and water for three days and 75% of the checklist items.
Only 31% said they had collected all of these items into a disaster preparation bag or kit, as this checklist recommends.
Are people not on dialysis prepared?
A new survey commissioned by the Florida Division of Emergency Management found that the majority of people living in Florida do not have sufficient water stored for a disaster. And despite education efforts, preparedness levels were very similar to those reported by residents in 2006.
"Too few people in the most dangerous areas realize they're at risk, and too many people in relatively safe locations think they're at greater risk than they are," Florida State University geography professor Jay Baker, an author of the study, told the Palm Beach Post.
According to the National Oceanic and Atmospheric Administration Climate Prediction Centerwww.cpc.noaa.gov/products/outlooks/hurricane.shtml (NOAA), this season has the potential to be very active this year.
"The conditions expected this year have historically produced some very active Atlantic hurricane seasons," NOAA said in its annual hurricane outlook. "The 2010 hurricane season could see activity comparable to a number of extremely active seasons since 1995. If the 2010 activity reaches the upper end of our predicted ranges, it will be one of the most active seasons on record."
In the past the renal community has worked together to respond to disaster. The Kidney Community Emergency Response Coalition and many dialysis providers and ESRD networks have worked hard to learn from previous disasters and to prepare clinics, staff, and patients for future problems. Some providers already have generators and temporary housing in place. Many clinics closely outside of disaster zones are ready for an influx of refugees.
But the survey suggests that perhaps the message is not often enough getting through to the patients.
5/23/2010
The Nashville Flood: how the dialysis community came together to respond
By Rebecca Zumoff
One word came up several times to describe the dialysis patients in flooded regions of middle Tennessee during my interviews with renal community members: resilient. No one was fully prepared for the magnitude of the destruction caused by Nashville's 100-year flood, but patients and health care providers did not let the flood waters keep them down.
With most clinics up and running with electricity and safe water, closed public transportation and flooded roads were the biggest obstacles to treatment that dialysis patients faced. But renal community members did have to offer help to some patients and clinic workers who have lost homes.
Theresa Davidson, CEO of the Tennessee Kidney Foundation, said she knew of a patient who had to cross a river to get to his clinic because of a bridge that had been destroyed in the storm.
"Nashville as a whole, and dialysis patients in particular have been very resilient about handling this storm," Davidson told NN&I. The Tennessee Kidney Foundation had a cab service set up for patients who were unable to find transportation to their clinics.
"We were actually really lucky in middle Tennessee," Dana Talley, regional vice president of Fresenius Medical Care North America who oversaw FMCNA's relief efforts for the flood, told NN&I. "We had emergency plans in place but we did not need them."
Fresenius, which has generators and temporary housing on reserve for disasters, had one clinic close for one treatment day because the facility lacked a power and water supply. Talley said Fresenius was most concerned about water integrity issues. Two pumps in the surrounding cities did go out, but backup systems were already in place.
Fresenius, as well as other providers in the area, extended clinic hours to give patients more time for transportation. "We did not close the doors until everyone was dialyzed," Talley said. Of 1,200 Fresenius patients at 16 clinics in the area, only 22 missed a day of treatment. "Our patients were very resilient about making it to their clinics."
Ms. Zumoff is Web Content Manager for NephrOnline and is based in Chicago.
5/2/2010
A case for the race-mix adjuster in the ESRD bundled payment
By Rebecca Zumoff
Setting reimbursement rates based on race doesn't sit well with most people. But clinicians have known for a long time that many factors affect the way a patient responds to treatment, and to a disease itself.
In 2007 researchers from Albert Einstein College of Medicine/Montefiore Medical Center, released a study that showed how estrogen can slow kidney scarring in women with CKD.
Black ESRD patients have higher incidences of anemia, and a new study suggests that this is not entirely due to a decreased access to care. Black children with chronic kidney disease have more severe anemia than white children even when they receive the same treatment, according to a multicenter study led by Johns Hopkins Children's Center to be published in the May issue of the American Journal of Kidney Disease.
The study also found that black children did not respond as well to anemia treatment compared to white children.
Some in the renal community have expressed concern that the new bundled payment rate is too one-size-fits-all and will create incentives for clinics to provide higher quality care to white patients.
A new report by the Government Accountability Office on the ESRD bundled payment system recommends that CMS monitor access to and quality of care for certain beneficiary groups as soon as possible after implementation of the new system.
Rep. Pete Stark , D-Calif, Chair of the House Ways and Means Health Subcommittee, and Rep. John Lewis, D-Ga., Chair of the House Ways and Means Oversight Subcommittee, requested the report to assess whether there are unique factors that would affect continued access to care under the new payment system, particularly for vulnerable populations.
GAO analyzed 2007 data on Medicare ESRD expenditures and input from 73 nephrology clinicians and researchers. The GAO also reviewed reports and CMS's proposed rule on the payment system's design and interviewed CMS officials.
Monthly Medicare expenditures per beneficiary for injectable ESRD drugs in 2007 were above average for certain demographic groups, and blacks and people with Medicaid coverage were among the groups in which this difference was largest, according to the report.
But the majority of the 73 clinicians and researchers surveyed identified clinical factors, rather than demographic characteristics, as likely to result in above average doses of injectable ESRD drugs. Specifically, at least 50% of these experts identified 14 such factors, including chronic blood loss, low iron stores, and recent hospitalization, as likely to result in above average doses of ESAs. A majority of the clinicians and researchers surveyed indicated that demographic factors were not likely to result in above average doses of ESAs.
Medicare expenditures on injectable ESRD drugs in 2007 were $782 per African American beneficiary per month, about 13% more than the $693 spent for all Medicare beneficiaries on dialysis. The above average spending per African American beneficiary was due primarily to higher spending on ESAs and IV vitamin D. Monthly Medicare spending per African American beneficiary on ESAs was about 10% higher than the average across all beneficiaries on dialysis, and spending on IV vitamin D was about 38% higher than average.
Average monthly Medicare expenditures per beneficiary for other racial groups were below the average for all beneficiaries on dialysis in 2007. As a result, average monthly expenditures for African Americans were about 41 to 42% higher than spending for beneficiaries who classified themselves as American Indian/Alaskan Native or Asian or Pacific Islander and about 21% higher than for expenditures for White beneficiaries.
In a letter to the GAO, CMS administrators said they agree with the recommendation to monitor access to and quality of dialysis care immediately after the implementation of the new end-stage renal disease prospective payment system.
However, the GAO noted that the monitoring plans are preliminary, and the extent to which CMS intends to monitor quality for various groups of beneficiaries is unclear.
I hope CMS finds a way to monitor quality of care, because the last thing the renal community needs is more racial disparity.
Ms. Zumoff is Web Content Manager for NephrOnline and is based in Chicago.
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