Since the Medicare payment bundle for dialysis patient services came into effect in January 2011, providers have looked for ways to reduce treatment costs. Items like lab tests and certain drug therapies that were previously separately billable are now wrapped up into one Medicare payment.

Nephrologists are responsible for the dialysis prescription and care plan for each of their patients, but they are also aware of economic pressures impacting dialysis clinic operations––particularly if they are involved in a joint venture with the provider. It is worthwhile to look at how Medicare’s bundled payment system may be influencing physician practices.

Overall bundling impressions

BioTrends Research Group surveys at least 200 U.S. nephrologists each quarter through the TreatmentTrends: Nephrology report series. The survey covers various nephrology topics, including the dialysis bundle.1 A rating scale of 1-5 (5 being extremely positive about the topic) is used.

In Q1 2011, surveyed nephrologists were negative towards bundling, providing a mean rating of 2.5. Overall, 49% providing a negative rating (1-2 out of 5). In  Q4 2013 however, nephrologists turned in a mean rating of 3.0 on their views about the bundle, with only 28% (compared to 49% in Q1 2011) having a negative view. That represented a significant change in attitude over the two-year period. The positive ratings could mean the dialysis bundle has already changed the way nephrologists treat patients today and that physicians are getting more accustomed to the payment rules. But, regardless of the more positive ratings, perceived pressures do exist from dialysis chain management to ultimately reduce patient costs.

Are economic pressures impacting practice?

In addition to asking about overall general bundling impressions, BioTrends has been tracking nephrologist perceptions of pressures felt from their dialysis unit across many different areas of dialysis patient management. The following question is asked quarterly for at least 10 different statements: How much pressure have you felt from your dialysis unit regarding the following? They are asked to use a scale of 1-10 where a score of 1 is “no pressure at all” to a 10, which is “extremely high pressure.” We believe this is a good measure to help understand how the dialysis bundle may impact (or has impacted) dialysis patient management.

The questions asked include:

  • Pressure to use Calcijex vs. Zemplar or Hectorol*
  • Pressure to use Sensipar earlier to reduce active Vitamin D (AVD)*
  • Pressure to use more subcutaneous (SC) vs. intravenous (IV) erythropoietin stimulating agent (ESA) dosing*
  • Pressure to use oral vs. IV active Vitamin D (AVD)*
  • Pressure to use lower doses of AVD*
  • Pressure to use lower doses of ESAs
  • Pressure to use more home dialysis (home hemodialysis and peritoneal dialysis) vs. in-center HD*
  • Pressure to identify sources of ESA hyporesponsiveness*
  • Pressure to provide more time and attention to the CMS 2728-ESRD form*
  • Pressure to use more iron at the expense of ESAs
  • Pressure to have more stringent Hb targets resulting in less EPO use
  • Pressure to restrict measurement of nonessential labs

The pressures noted with an asterisk (*) above have all significantly increased between Q4 2011 (n=303) and Q4 2013 (n=301). Here is a closer look at physician perceptions of a selection of statement pressures from dialysis units. Results are presented in Figure 1.

Pressure to use more subcutaneous vs. intravenous ESA dosing
Nephrologists surveyed in Q4 2013 indicated a greater pressure to use more SC vs. IV ESA dosing compared with two years ago. Initially, surveyed nephrologists felt less pressure towards using more SC dosing (mean rating of 5.1, with only 24% feeling high pressure [8-10]). Compare this with Q4 2013 survey results, which indicate a mean rating of 6.0, with 33% feeling greater pressure. That is a significant finding for both the mean rating and percentage of nephrologists who indicated a high pressure rating.

A second BioTrends study, via a survey administered online, finds that this pressure is a reality. For the last several years, nephrologists were asked to submit information from dialysis patient charts. In 2010, just over 10% (n=833 patients) of ESA-treated hemodialysis patients were on SC dosing compared with over 30% (n=654 patients) in 2013.2

The TreatmentTrends: Nephrology report series also indicates that use of Amgen’s Aranesp and Janssen’s Procrit in the dialysis setting has recently increased. These products are typically dosed subcutaneously; therefore, this shift may explain one reason why SC dosing is increasing. Note that Aranesp offers a more convenient dosing regimen than Epogen and this may be contributing to uptake of the product. In addition, BioTrends has noticed average monthly dose declines of Aranesp in our ChartTrends studies and the use of Aranesp may be a cost-saving measure. Interestingly, this study also indicates that subcutaneous administration is least common among patients dialyzing in large dialysis organizations (LDOs) and most common in medium/small dialysis organizations (MDOs/SDOs) and non-chain independents.

Pressure to use Sensipar earlier to reduce AVD
Nephrologists surveyed in Q4 2013 indicated they were under greater pressure to use Amgen’s Sensipar earlier to reduce active Vitamin D compared with two years ago. Initially, surveyed nephrologists felt low pressure to use Sensipar (mean rating of 5.0). Only 20% felt a high pressure to use the drug (8-10 on the scale). Compare this with Q4 2013 survey results, which indicate a mean rating of 5.9, and 30% feeling high pressure to use Sensipar––a notable increase during the two-year period.

figure 1

Surveyed nephrologists generally agreed with this pressure, and made changes. In Q4 2013, over 42% of physicians agreed that increased use of Sensipar in dialysis in place of AVD can significantly offset dialysis center costs under bundling. Only 13% of physicians disagreed with this statement (n=301). Physicians tend to be divided on their reasons for initiating Sensipar but the primary reasons tend to also be cost-saving measures. When physicians are asked to allocate 100 points in our TreatmentTrends study, giving more points to the greatest reason to use Sensipar, physicians allocate the most points to the following three reasons:

  • to lower parathyroid hormone (PTH) when vitamin D cannot be used
  • to lower calcium, phosphorus, and PTH
  • to lower PTH instead of increasing vitamin D

The last two reasons for initiation could be considered cost-saving measures.

Pressure to use more home dialysis (home HD and PD) vs. in-center HD
Surveyed nephrologists indicate a greater pressure to use more home dialysis (home HD and PD) vs. in-center HD compared with two years ago. Initially, surveyed nephrologists felt less pressure to use more home dialysis (home HD and PD) vs. in-center HD with a mean rating of 5.7 and only 28% feeling a high pressure (8-10 on the rating scale). Compare this with Q4 2013 survey results, which indicate a mean rating of 6.4, and 37% feeling greater pressure to use more home therapy.

We are seeing greater use of other non-traditional modalities in our tracking studies, most notably PD being followed by home HD. Many organizations in the nephrology community are working towards providing patients with greater access to these modalities. One example of this is that on Nov. 22, 2013, the Centers for Medicare and Medicaid Services finalized a 50% increase to the home dialysis training add-on payment adjustment that is made for both PD and home HD training treatments.4 In addition, data from the United States Renal Data System indicates that the cost per patient per year is lower when using PD compared with in-center hemodialysis. According to the 2013 Annual Data Report, the total Medicare ESRD expenditure per person per year on PD was $16,312 lower than HD in 2011.4 So, we are not surprised by this high pressure physicians are recalling if dialysis chains can reduce costs by greater use of alternative modalities.

Oral drugs in the dialysis bundle

Future legislation may also impact patient management. When Congress passed the American Taxpayer Relief Act of 2012, language included in the law delayed by two years the implementation of adding oral-only ESRD related drugs, including phosphate binders and Sensipar, to the bundled ESRD PPS. The new date is January 1, 2016.

Regardless of the delay, physicians do seem to be preparing for this change, although awareness of it has decreased. For example, in Q4 2013, 53% of respondents were aware of the future inclusion of oral-only medications in the bundle compared with 81% in Q4 2012. Of the surveyed nephrologists in Q4 2013 who were aware of oral drugs being added to the bundle, 46% were aware of enrolling patients in clinic’s pharmacy programs and 45% were aware of examining and cutting costs.


The dialysis bundle, and associated cost pressures, may have fundamentally changed the way nephrologists treat dialysis patients today. The perception of bundling by physicians is certain to change as bundling progresses and oral-only drugs are added to the dialysis bundle in 2016.



1. BioTrends Research Group TreatmentTrends: Nephrology (U.S.) report series.

2. BioTrends Research Group ChartTrends: Renal anemia in dialysis (U.S.), May 2013.

3. CMS press release. CMS finalizes policy and payment rate changes for End-Stage Renal Disease facilities in 2014. Issued November 22, 2013.

4. U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md., 2013. Figure 11.7.