Market Competition and Anemia Management in the United States Following Dialysis Payment Reform

Abstract

Background: Whether market competition influences health care provider responses to national reimbursement reforms is unknown. Objectives: We examined whether changes in anemia management after the expansion of Medicare’s dialysis payment bundle varied with market competition. Research Design: With data from the US dialysis registry, we used a difference-in-differences (DID) design to estimate the independent associations of market competition with changes in anemia management after dialysis reimbursement reform. Subjects: A total of 326,150 patients underwent in-center hemodialysis in 2009 and 2012, representing periods before and after reimbursement reform. Measures: Outcomes were erythropoiesis-stimulating agent (ESA) and intravenous iron dosage, the probability of hemoglobin <9 g/dL, hospitalizations, and mortality. We also examined serum ferritin concentration, an indicator of body iron stores. We used a dichotomous market competition index, with less competitive areas defined as effectively having <2 competing dialysis providers. Results: Compared with areas with more competition, patients in less competitive areas had slightly more pronounced declines in ESA dose (60% vs. 57%) following reimbursement reform (DID estimate: −3%; 95% CI, −5% to −1%) and less pronounced declines in intravenous iron dose (−14% vs. −19%; DID estimate: 5%; 95% CI, 1%–9%). The likelihoods of hemoglobin <9 g/dL, hospitalization, and mortality did not vary with market competition. Serum ferritin concentrations in 2012 were 4% (95% CI, 3%–6%) higher in less competitive areas. Conclusions: After the expansion of Medicare’s dialysis payment bundle, ESA use declined by more, and intravenous iron use declined by less in concentrated markets. More aggressive cost-reduction strategies may be implemented in less competitive markets.