Study: Bundling Could Cut Dialysis Access to Blacks

WASHINGTON— A change in Medicare reimbursement policy could make it more difficult for African Americans with kidney disease to access dialysis services, according to a study published online April 23 in the Journal of the American Society of Nephrology.

Last summer, President Bush signed into law the Medicare Improvements for Patients and Providers Act. Under the new policy, the Centers for Medicare & Medicaid Services will “bundle” dialysis and injectable medications, which were previously reimbursed separately, into a single payment to dialysis units.

"The change in payment policy may disadvantage a substantial group of dialysis patients," comments Areef Ishani, MD, who is an assistant professor of medicine in the Renal Disease and Hypertension division at the University of Minnesota.

The researchers said African-American dialysis patients have more problems with anemia (low hemoglobin) than white patients and thus may require more treatment with costly erythropoiesis-stimulating agents (ESAs) to raise hemoglobin levels. Medicare spent more than $2 billion on ESAs, such as Amgen’s Epogen, in 2005.

After analyzing 12,000 patients starting dialysis during 2006, the researchers confirmed that African Americans had lower initial hemoglobin levels when starting hemodialysis compared to white patients. Also, the average required dose of ESAs over the first two months on dialysis was 11 percent higher in African-American patients.

The study is limited in that it included only patients who were over age 67 at the start of dialysis and had Medicare as their primary insurance source. Also, it only looked at ESA use during the first two months on dialysis.

Since dialysis centers will no longer be reimbursed for the higher ESA doses, the researchers said they are concerned that the new policy could create a "financial disincentive" to accept African Americans.

"The CMS has suggested that the new reimbursement scheme will adjust for a variety of factors," according to Ishani. "If race is not included as a payment adjuster, African-American patients could be disadvantaged by this policy change."