Market Competition and Anemia Management in the United States Following Dialysis Payment Reform

Authors

Anshul Bhatnagar
Vishnupriyadevi Parvathareddy
Wolfgang C Winkelmayer
Glenn M Chertow
Kevin F Erickson

Publication Date

11-1-2023

Journal

Medical Care

DOI

10.1097/MLR.0000000000001924

PMID

37721983

PMCID

PMC10592119

PubMedCentral® Posted Date

11-1-2024

PubMedCentral® Full Text Version

Author MSS

Published Open-Access

yes

Keywords

Humans, United States, Renal Dialysis, Male, Female, Anemia, Hematinics, Middle Aged, Economic Competition, Aged, Medicare, Kidney Failure, Chronic, Ferritins, Iron, Hemoglobins, Reimbursement Mechanisms, Hemodialysis, ESRD Prospective Payment System, Market Competition, Anemia Management, Pay-for-Performance, United States Renal Data System, Health Outcomes

Abstract

BACKGROUND: Whether market competition influences health care provider responses to national reimbursement reforms is unknown.

OBJECTIVES: We examined whether changes in anemia management after the expansion of Medicare's dialysis payment bundle varied with market competition.

RESEARCH DESIGN: With data from the US dialysis registry, we used a difference-in-differences (DID) design to estimate the independent associations of market competition with changes in anemia management after dialysis reimbursement reform.

SUBJECTS: A total of 326,150 patients underwent in-center hemodialysis in 2009 and 2012, representing periods before and after reimbursement reform.

MEASURES: Outcomes were erythropoiesis-stimulating agent (ESA) and intravenous iron dosage, the probability of hemoglobin/dL, hospitalizations, and mortality. We also examined serum ferritin concentration, an indicator of body iron stores. We used a dichotomous market competition index, with less competitive areas defined as effectively havingproviders.

RESULTS: Compared with areas with more competition, patients in less competitive areas had slightly more pronounced declines in ESA dose (60% vs. 57%) following reimbursement reform (DID estimate: -3%; 95% CI, -5% to -1%) and less pronounced declines in intravenous iron dose (-14% vs. -19%; DID estimate: 5%; 95% CI, 1%-9%). The likelihoods of hemoglobin/dL, hospitalization, and mortality did not vary with market competition. Serum ferritin concentrations in 2012 were 4% (95% CI, 3%-6%) higher in less competitive areas.

CONCLUSIONS: After the expansion of Medicare's dialysis payment bundle, ESA use declined by more, and intravenous iron use declined by less in concentrated markets. More aggressive cost-reduction strategies may be implemented in less competitive markets.

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