New Medicare policy may pose risks to black kidney patients

A change in Medicare reimbursement policy could make it more difficult for African Americans with kidney disease to access dialysis services, suggests a study in an upcoming issue of the Journal of the American Society of Nephrology (JASN). "The change in payment policy may disadvantage a substantial group of dialysis patients," comments Areef Ishani, MD (University of Minnesota).

Under the new policy, the Centers for Medicare & Medicaid Services (CMS) will make a single payment to dialysis units to cover both dialysis and injectable medications, which were previously reimbursed separately. 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.

On analysis of 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 eleven percent higher in African American patients.

Since dialysis centers will no longer be reimbursed for the higher ESA doses, the researchers 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 Dr. Ishani. "If race is not included as a payment adjuster, African American patients could be disadvantaged by this policy change."

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.

Dr. Ishani consults for the Chronic Disease Research Group. Haifeng Guo; Thomas Arneson, MD; Lih-Wen Mau, PhD; Suying Li, PhD; and Stephan Dunning are employed by the Chronic Disease Research Group. David Gilbertson, PhD and Allan Collins, MD have received consulting fees from Amgen.

The study will appear online at http://jasn.asnjournals.org/ on April 23, 2009, doi 10.1681/ASN.2008080853.

Founded in 1966, the American Society of Nephrology (ASN) is the world's largest professional society devoted to the study of kidney disease. Comprised of 11,000 physicians and scientists, ASN continues to promote expert patient care, to advance medical research, and to educate the renal community. ASN also informs policymakers about issues of importance to kidney doctors and their patients. ASN funds research, and through its world-renowned meetings and first-class publications, disseminates information and educational tools that empower physicians.