Senator Grassley released a letter he wrote to CMS on 5/16 concerning the use of ESAs (mostly Epogen manufactured by Amgen) to treat anemia in dialysis patients. I'm tempted to go through the letter line by line but here is the meat:

"According to the GAO, bundling all ESRD drugs and services under a single rate would encourage more prudent use of ESAs. The Medicare Payment Advisory Commission (MedPAC) also recommends that payment be bundled to control costs and promote quality care. In addition, MedPAC has recommended implementation of a quality incentive payment policy for providers of outpatient dialysis services.

An overuse or inefficient use of ESAs is not only a financial concern to the Committee, but also a major patient safety concern. I am troubled by the findings in recent clinical studies of increased risks of death, blood clots, strokes, heart attacks, and tumor growths when ESAs are given in higher than recommended doses."

I think bundling medication reimbursement (basically those ESAs but other meds too and possibly other items) with dialysis reimbursement would be a mistake. I address why it is not a major patient safety concern here. After the fold I address the bundling strategy.

Bundling is a bad idea. If the goal is to save money through using less EPO than we should go to subq directly rather than indirectly via bundling. Subq means injecting directly into the muscle as opposed to injecting directly into the blood lines used to access the blood during hemodialysis. Studies consistently show that equivalent hematocrits can be achieved with 20% less medication if it is administered subq. Patients don't like it because it requires an additional needle stick. But if the government needs everyone to make a bit of sacrifice (though I don't recall hearing that message from the administration) then I think it is reasonable to ask dialysis patients accept the discomfort of an avoidable shot.

What I think is critical is keeping the savings in the ESRD program. Senator Grassley does mention the need for "implementation of a quality incentive payment policy for providers" which sounds a lot like HR1193/S635. A 20% ESA reduction from subq administration would create a $360 million a year pay go credit - that would pay for 1193 and last year's 5321 without extending the private payer period. A good idea. This would be a fair use of the savings that are built on patients having to accept a third needle stick each treatment.

It seems manifest that bundling would turn medications into costs to be controlled - along with 4x4s, band-aids and staff time - and corporations know nothing if not how to control costs. I am sure any renal professional could come up with policies that would lower costs (i.e. use less medication) in a bundled environment where medications are a pure expense. I am not sure that those cost control measures would advance patient care. And, I am not sure that bundling would in fact save money. It depends on the details of the bundling scheme and what is done about outliers.

I agree with a friend of mine who said reimbursement policy can either create incentives for giving too many drugs or not enough; it's not possible to create reimbursement incentives for giving the appropriate doses.

This is what single payer looks like. I don't mind but it should be understood that if medical dosing decisions have to be made through reimbursement rules then Congress will have to become experts on every medical condition covered and be open to taking the time to understand the issues. Since about November of last year the political discussion around ESAs has seemed rushed and poorly researched. Bundling looks to me like the US ESRD rule setters (CMS; Congress)are just throwing up their hands and telling the providers to figure it out. I think we can do better.