Effect of Medicare dialysis payment reform on use of erythropoiesis stimulating agents

Health Serv Res. 2015 Jun;50(3):790-808. doi: 10.1111/1475-6773.12252. Epub 2014 Oct 30.


Objective: In 2011, the Centers for Medicare and Medicaid Services (CMS) replaced fee-for-service reimbursement for erythropoiesis stimulating agents (ESAs) with a fixed-sum bundled payment for all dialysis-related care and pay-for-performance incentives to discourage maintaining patients' hematocrits above 36 percent. We examined the impact of the new payment policy on the use of ESAs.

Data sources: CMS's Renal Information Management System.

Study design: Regression discontinuity design assessing the use of ESAs by hematocrit level before and after the implementation of the payment policy change.

Data extraction: Secondary data from 424,163 patients receiving hemodialysis treatment between January 2009 and June 2011.

Principal findings: The introduction of bundled payments with pay-for-performance initiatives was associated with an immediate and substantial decline in the use of ESAs among patients with hematocrit >36 percent and little change in the use of ESAs among patients with hematocrit ≤36 percent. In the first two quarters of 2011, the use of ESAs during dialysis fell by about 7-9 percentage points among patients with hematocrit levels >36 percent. No statistically significant differences in ESA use were observed at the thresholds of 30 or 33 percent.

Conclusions: CMS's payment reform for dialysis care reduced the use of ESAs in patients who may not benefit from these agents.

Keywords: Medicare; Renal dialysis; bundled payments; incentive.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Aged, 80 and over
  • Centers for Medicare and Medicaid Services, U.S. / economics
  • Centers for Medicare and Medicaid Services, U.S. / organization & administration*
  • Female
  • Hematinics / administration & dosage
  • Hematinics / economics*
  • Hematocrit
  • Humans
  • Kidney Failure, Chronic / therapy*
  • Male
  • Middle Aged
  • Reimbursement Mechanisms / economics
  • Reimbursement Mechanisms / organization & administration*
  • Reimbursement, Incentive / economics
  • Renal Dialysis / methods*
  • United States


  • Hematinics