Major declines in epoetin dosing after prospective payment system based on dialysis facility organizational status

Am J Nephrol. 2014;40(6):554-60. doi: 10.1159/000370334. Epub 2015 Jan 10.


Background: Epoetin therapy used to treat anemia among ESRD patients has cost Medicare ∼$40 billion. Since January 2011, epoetin has been reimbursed via a new bundled prospective payment system (PPS). Our aim was to determine changes in epoetin dosing and hematocrit levels in response to PPS by different types of dialysis providers.

Methods: Data from the USRDS were used to identify 187,591 and 206,163 Medicare-eligible ESRD patients receiving hemodialysis during January 2010 (pre-PPS) and December 2011 (post-PPS). Standardized weekly mean epoetin dose administered pre- and post-PPS and adjustment in dose (titration) based on previous hematocrit level in each facility was disaggregated by profit status, chain membership and size.

Results: Major declines in epoetin use, dosing and achieved hematocrit levels were observed after PPS. Among the three largest dialysis chains, the decline in standardized epoetin dose was 29% at Fresenius, 47% at DaVita, and 52% at DCI. The standardized weekly epoetin dose among profit and nonprofit facilities declined by 38 and 42%, respectively. Changes in titration patterns suggest that a new hematocrit target of 30-33% was in place after PPS, replacing the erstwhile 33-36% hematocrit target used before PPS.

Conclusion: Historically, important differences in anemia management were evident by dialysis organizational status. However, the confluence of financial incentives bundling epoetin payments and mounting scientific evidence linking higher hematocrit targets and higher epoetin doses to adverse outcomes have culminated in lower access to epoetin and lower doses across all dialysis providers in the first year after PPS.

MeSH terms

  • Ambulatory Care Facilities / organization & administration*
  • Anemia / drug therapy*
  • Anemia / etiology
  • Drug Therapy / economics
  • Drug Therapy / trends
  • Epoetin Alfa
  • Erythropoietin / administration & dosage*
  • Erythropoietin / economics
  • Hematinics / administration & dosage*
  • Hematinics / economics
  • Hematocrit
  • Humans
  • Kidney Failure, Chronic / complications
  • Kidney Failure, Chronic / therapy
  • Medicare / economics
  • Ownership / organization & administration
  • Prospective Payment System* / economics
  • Recombinant Proteins / administration & dosage
  • Recombinant Proteins / economics
  • Renal Dialysis / adverse effects
  • Renal Dialysis / economics*
  • United States


  • Hematinics
  • Recombinant Proteins
  • Erythropoietin
  • Epoetin Alfa