Association Between Changes in CMS Reimbursement Policy and Drug Labels for Erythrocyte-Stimulating Agents With Outcomes for Older Patients Undergoing Hemodialysis Covered by Fee-for-Service Medicare

JAMA Intern Med. 2016 Dec 1;176(12):1818-1825. doi: 10.1001/jamainternmed.2016.6520.


Importance: In 2011, the US Centers for Medicare & Medicaid Services (CMS) changed its reimbursement policy for hemodialysis to a bundled comprehensive payment system that included the cost of erythrocyte-stimulating agents (ESAs). Also in 2011, the US Food and Drug Administration revised the drug label for ESAs, recommending more conservative dosing in patients with chronic kidney disease. In response to concerns that these measures could have adverse effects on patient care and outcomes, the CMS and the FDA initiated a collaboration to assess the effect.

Objective: To assess the effects of the changes in reimbursement policy and the ESA drug label on patients who underwent incident hemodialysis.

Design, setting, and participants: For this retrospective cohort study, patients 66 years or older who had undergone incident hemodialysis, and were enrolled in Medicare parts A, B, or D for at least 12 months prior to hemodialysis initiation between January 1, 2008, and December 31, 2013, were recruited from hemodialysis centers across the United States. Patients were divided into 2 cohorts based on their date of hemodialysis initiation and followed: January 1, 2008, to December 31, 2009, for the prepolicy cohort and July 1, 2011, to June 30, 2013, for the postpolicy cohort, with the exclusion of January 1, 2010, to June 30, 2011, as a transition period.

Interventions: Changes in CMS reimbursement policy for dialysis and the FDA label for ESAs.

Main outcomes and measures: Major adverse cardiovascular events (MACEs), including acute myocardial infarction (AMI), stroke, and all-cause mortality; hospitalized congestive heart failure (H-CHF); venous thromboembolism; and red blood cell transfusions. Secondary outcomes included evaluating effects on black and other patient subgroups.

Results: Baseline characteristics of the 69 718 incident hemodialysis patients were similar between cohorts. Compared with the prepolicy period, the risk of MACE, death, H-CHF, and venous thromboembolism were similar in the postpolicy period, and the risk of stroke decreased (hazard ratio [HR], 0.77; 95% CI, 0.64-0.93; P = .01); the use of ESAs also decreased, and the rate of blood transfusions increased (HR, 1.09; 95% CI, 1.07-1.12; P < .001). In the post-postpolicy period, black patients had a significant reduction in risk of MACE (HR, 0.82; 95% CI, 0.73-0.92; P < .001) and all-cause mortality (HR, 0.82; 95% CI, 0.73-0.93; P = .002).

Conclusions and relevance: After the bundling policy and ESA labeling changes in 2011, the risks of MACE and death for patients 66 years or older and covered by fee-for-service Medicare who had undergone incident hemodialysis did not change; the risk of stroke was reduced, and the rate of blood transfusions modestly increased. Black patients had substantial reductions in the risks of MACE and death.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Black People / statistics & numerical data
  • Blood Transfusion / statistics & numerical data
  • Centers for Medicare and Medicaid Services, U.S. / economics
  • Centers for Medicare and Medicaid Services, U.S. / organization & administration*
  • Cohort Studies
  • Drug Labeling*
  • Fee-for-Service Plans
  • Female
  • Health Care Reform
  • Hematinics / administration & dosage*
  • Hematinics / economics
  • Humans
  • Kidney Failure, Chronic / mortality
  • Kidney Failure, Chronic / therapy*
  • Male
  • Myocardial Infarction / epidemiology
  • Reimbursement Mechanisms / economics
  • Reimbursement Mechanisms / organization & administration*
  • Reimbursement, Incentive / economics
  • Renal Dialysis*
  • Retrospective Studies
  • Stroke / epidemiology
  • United States / epidemiology
  • White People / statistics & numerical data


  • Hematinics