Calcimimetic Use in Dialysis-Dependent Medicare Fee-for-Service Beneficiaries and Implications for Bundled Payment

Abstract

BackgroundPatients who are dialysis dependent and have secondary hyperparathyroidism (SHPT) may require calcimimetics to reduce parathyroid hormone levels to treatment goals. Medicare currently uses the Transitional Drug Add-on Payment Adjustment (TDAPA) designation under the ESKD Prospective Payment System (“bundled payment”) to pay for calcimimetics (the first products eligible for the adjustment); this payment designation for calcimimetics is expected to conclude after 2020. This study explores variability in calcimimetic use across key patient characteristics and its potential effect on policy options for incorporating calcimimetics permanently into the bundle.MethodsThis descriptive analysis used the 100% sample of Medicare FFS Part B (outpatient) 2018 claims to describe national-, regional-, and patient-level variation (including race, dual eligibility, and dialysis vintage) in calcimimetic use among beneficiaries who are dialysis dependent.ResultsA total of 373,874 beneficiaries were analyzed, 28% had ≥90 days of calcimimetic use during 2018. At the national level, the proportion of patients on dialysis using calcimimetics was roughly 80% higher in Black versus non-Black patients on dialysis, 30% higher in patients on dialysis who were dual eligible versus non–dual eligible, and three times higher in patients with a dialysis vintage ≥3 years versus <3 years (all results unadjusted). Calcimimetic use was similar across census regions, however, substantial variation in calcimimetic use was observed at the facility level. Medicare spending for calcimimetic therapies as a proportion of total Medicare dialysis spending was >10% in approximately 20% of dialysis facilities.ConclusionsAlthough less than a third of beneficiaries use calcimimetics, certain patient-level characteristics are associated with higher rates of maintenance calcimimetic use. Due to the financial pressure many dialysis facilities face, how calcimimetics are incorporated into the bundle may have a direct effect on facility reimbursement for, and patient access to, therapy. Careful consideration will be required to ensure patients who are vulnerable and require treatment for SHPT do not face barriers to appropriate care.

Calcimimetic use in US hemodialysis facilities in first 2 years after the launch of etelcalcetide: A descriptive analysis of real‐world clinical practice and outcomes

“…These proportions are higher than the percent of Black patients in the overall US dialysis population but consistent with other recent studies of calcimimetic use. [12][13][14] Black patients are at higher risk of SHPT 15,16 and are therefore more likely to be prescribed calcimimetics.…”

“…13 And while Medicare added about 4% to the average per-case payment to cover the costs of calcimimetics, 24 spending for calcimimetics exceeded 10% of total costs in approximately 20% of facilities in 2018. 13 Given this gap between the Medicare addition to the PPS and calcimimetic cost, there is a potential for a poor transition which could have ramifications for patient health. 25 Close monitoring of outcomes postbundling will be needed.…”

“…Spoendlin et al, 2018, 7 reported that active vitamin D sterol use declined by 7% in 2011 immediately after the introduction of the end‐stage renal disease prospective payment system (PPS). Whereas in recent years only about one third of patients were prescribed calcimimetics, 24 certain subpopulations of patients had much higher use 13 . And while Medicare added about 4% to the average per‐case payment to cover the costs of calcimimetics, 24 spending for calcimimetics exceeded 10% of total costs in approximately 20% of facilities in 2018 13 .…”

“…Whereas in recent years only about one third of patients were prescribed calcimimetics, 24 certain subpopulations of patients had much higher use 13 . And while Medicare added about 4% to the average per‐case payment to cover the costs of calcimimetics, 24 spending for calcimimetics exceeded 10% of total costs in approximately 20% of facilities in 2018 13 . Given this gap between the Medicare addition to the PPS and calcimimetic cost, there is a potential for a poor transition which could have ramifications for patient health 25 .…”