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Am J Kidney Dis. 2019 Jan 3. pii: S0272-6386(18)31124-7. doi: 10.1053/j.ajkd.2018.11.007. [Epub ahead of print]

Calcimimetics and Bundled Reimbursement.

Author information

1
Division of Nephrology and Hypertension, Department of Medicine, University of Southern California, Los Angeles, CA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA; Kidney Research Center, University of Southern California/University Kidney Research Organization, Los Angeles, CA. Electronic address: eugeneli@usc.edu.
2
Division of Nephrology and Hypertension, Department of Medicine, University of Washington, Seattle, WA; Northwest Kidney Centers, Seattle, WA.

Abstract

Since 2011, the Centers for Medicare & Medicaid Services has provided reimbursement for renal dialysis services furnished to Medicare beneficiaries through a bundled payment system known as the Prospective Payment System. Medications that have no injectable equivalent, known as "oral-only medications," are currently excluded from the bundle and are paid separately through Medicare Part D. Thus, before the development of etelcalcetide, the first injectable calcimimetic, calcimimetics were reimbursed outside the bundle. Etelcalcetide's introduction and approval for use in Medicare triggered a transition payment for a minimum of 2 years that will eventually result in the incorporation of calcimimetics into the dialysis bundle. Consequently, providers may face incentives to reduce calcimimetic use when the transition period has expired. The complexity of bone-mineral management in conjunction with the paucity of evidence-based recommendations in this area makes it difficult to predict the impact of this transition. Because these medications are expensive, a poor transition could have financial ramifications for dialysis organizations and potentially patient health. To ensure that patients are not adversely affected, it is critical that Medicare incorporate these medications into the bundle carefully, with close monitoring of outcomes.

KEYWORDS:

Etelcalcetide; Prospective Payment System (PPS); bone-mineral metabolism; bundle; calcimimetic; dialysis clinic; drug costs; end-stage renal disease (ESRD); health care incentive; hemodialysis; medical parathyroidectomy; parathyroid hormone (PTH); payment; reimbursement rate; transition

PMID:
30611600
DOI:
10.1053/j.ajkd.2018.11.007

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