Possible Effects of the New Medicare Reimbursement Policy on African Americans with ESRD

The Centers for Medicare & Medicaid services (CMS) proposes to change the method of reimbursement for outpatient hemodialysis such that a fixed payment bundle will cover both outpatient dialysis therapy and injectable medications. The proposal does not include an adjustment for race, although this is up for debate. We aimed to determine if African Americans, compared with whites, continue to initiate dialysis with lower hemoglobin concentrations and require higher doses of erythropoiesis stimulating agents (ESA) to achieve similar hemoglobin concentrations, as they have historically. We constructed a cohort of 12,002 ESA-naive patients older than 67 yr who initiated hemodialysis between January 1, 2006 and October 31, 2006, had Medicare as their primary payer for 2 yr preinitiation, and received erythropoietin (EPO) during the first 2 mo postinitiation. At dialysis initiation, African Americans had lower hemoglobin values than whites (9.9 +/- 1.7 versus 10.3 +/- 1.6 g/dl, P < 0.001). On average, after adjusting for multiple variables (but not initial hemoglobin concentration), African Americans required 11.0% more EPO than whites (P < 0.001). With initial hemoglobin included in the model, this difference was attenuated to 6.8% more EPO than whites (P < 0.001). In conclusion, if CMS implements its proposed reimbursement scheme, facilities may have a financial disincentive to treat African Americans, potentially resulting in reduced access to outpatient dialysis therapy.