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ESRD payment bundle linked to reductions in vitamin D prescriptions
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Changes made in the Medicare payment methodology for dialysis care in 2011 that bundled prescription drugs and treatment payment resulted in both a drop in initiation and in the dosage of vitamin D, according to a recently published study.
Medicare introduced the Prospective Payment System for covering the costs of treating patients with end-stage renal disease to “curb overuse of separately billable injectable drugs,” wrote Julia Spoendlin, PhD, MPH, and colleagues from the Brigham and Women’s Hospital and Harvard Medical School in Boston. “After epoetin, intravenous (IV) vitamin D analogues are the biggest drug cost drivers in hemodialysis (HD) patients, but the association between PPS introduction and vitamin D therapy has been scarcely investigated.”
The researchers looked at vitamin D prescriptions among adults on hemodialysis (n=359,600 at the start of study) represented in the U.S. Renal Data System between 2008 and 2013. Researchers used models to adjust for seasonal variation of drug use and plotted the experience of vitamin D users after PPS implementation. They used predicted probabilities in the absence of PPS, extrapolated from pre-PPS trends, to compare the impact of PPS implementation. Researchers also performed subgroup analyses by product type (IV analogues or less expensive alternatives, such as calcitriol or oral vitamin D analogues), and noted the dialysis provider profit status.
The results of the review showed that in 2008, 88.9% of patients in the group were receiving vitamin D therapy. That dropped to 84.6% in the patient sample in 2013.
“PPS implementation was associated with a 7% reduction in the average dose and starting dose of IV vitamin D analogues and a 10% reduction in the rate of vitamin D therapy initiation,” the authors wrote. They also observed a shift from paricalcitol (69.4% in 2008 to 45% in 2013) to doxercalciferol (26.2% in 2008 to 54.7% in 2013).
“Use of phosphate binders was constant between 77.3% (in 2008) and 76.4% (in 2013), whereby sevelamer carbonate largely replaced sevelamer hydrochloride over time,” they wrote. Overall, IV vitamin D analogues accounted for 99% of the total use and this trend was unchanged during the study period, the researchers wrote.
Disclosures: Spoendlin reports support by an independent research grant by the Swiss National Science Foundation to conduct this project (P2BSP3-165324). The other authors reported no relevant financial disclosures.
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Jay B. Wish, MD
None of the findings in the Spoendlin and colleagues study are surprising, given that the intent of the bundled payment system for dialysis was to reduce the overuse of profitable intravenous drugs such as erythropoietin, iron and vitamin D analogues in ESRD patients. It is well known that the PPS reduced erythropoietin use by around 40%, and a report from the U.S. Government Accounting Office in 2012 revealed that IV vitamin D utilization (in dollars) among dialysis patients decreased by around 15% between mid-2010 (before bundling) and late-2011 (after bundling). This decrease in utilization can be due to fewer patients receiving vitamin D, lower vitamin D doses per patient and lower costs of vitamin D. All these factors appear to be operative based on the data reported by Spoendlin and her colleagues. The shift from paricalcitol to doxercalciferol probably represents a cost-saving strategy. Since the therapeutic dose of paricalcitol is higher than that of doxercalciferol, it is not clear whether the decrease in vitamin D dose reported by the authors also reflects this shift between agents. There does not appear to be a progressive vitamin D-sparing effect of cinacalcet over time, since the use of cinacalcet was relatively stable over the time period examined.
Whether other non-PPS factors contributed to the decrease in vitamin D utilization is not clear. CMS’s Quality Incentive Program began to include a measure for hypercalcemia in performance year 2014, and it is possible that providers began to prepare for this in 2013 or earlier by using less vitamin D. This may also explain why there was not a greater shift to calcitriol since it is less expensive than paricalcitol and doxercalciferol but may be associated with a higher incidence of hypercalcemia.
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