Download 2010 Atlas of End-Stage Renal Disease in the United States

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costs of end-stage
renal disease
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levels, the ESRD component does not contain
Part D costs, as the USRDS has not yet received
the 2008 Part D data. Excluding Part D from general Medicare expenditures, the ESRD program consumes 6.6 percent of the budget, a figure
consistent since 2004.
Within its overall ESRD expenditures, Medicare HMO costs rose 26.8
percent in 2008, to $2.7 billion. This annual increase has been consistent
since 2003, when the new Medicare hierarchical payment model, with
disease burden risk adjusters, was implemented for Medicare Advantage
(HMOs). The degree of growth in overall expenditures, however, has not
been seen since 2004. These changes are concurrent with a 3.1 percent
increase in the prevalent Medicare ESRD population in 2008, to 453,443;
the non-Medicare population grew 7.5 percent, to 94,539. Per person per
year ESRD expenditures rose 7.3 percent — the largest increase since 1992.
These changes will require careful consideration, as the new bundled
payment system — to be implemented in 2011 — is based on the fee-forservice utilization of past years. Growth in total Medicare expenditures
includes 16.4 percent for total inpatient fees, 3.6 percent for outpatient
fees, 9.1 percent for physician/supplier fees, 15.4 percent for skilled
nursing, 5.5 percent for home health services, and 26.7 percent for hospice services.
Recent attention to therapies with erythropoiesis stimulating agents
(ESAs) has raised awareness of their costs to the healthcare system. After rising each year since 1992 (including growth of 11–19 percent in
2002–2004) to reach nearly $2 billion, Medicare ESA costs were stable
in 2004–2007, and in 2008 declined to a pre-2004 level of $1.8 billion.
The First Average Sale Price payment for injectables was introduced in
2004 to control the cost shifting of margins, as investigations showed that
many providers had very profitable discount agreements, accounting for
>JNONJA@I?NO<B@M@I<G?DN@<N@
introduction
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Expenditures (dollars, in billions)
significant margins paid under the Medicare system. The composite rate
payment was thus rebased, and the margins generated for injectables were
addressed by allowing providers to receive only 6 percent above the sale
price, monitored under quarterly reporting to CMS. There have been other
changes in ESA payment policies as well, including limited billing when
hemoglobin levels are greater than 13 g/dl for three months. These alterations, along with regular changes in package insert warnings regarding
ESA safety, have led to reductions in both ESA dosing and hemoglobin
levels. As shown below, use of other intravenous drugs continued to increase in 2008 — 12 percent for IV vitamin D, 4.8 percent for IV iron, and
13.2 percent for other injectables.
This year we have added new figures illustrating racial differences in
expenditure patterns, and looking at costs by modality in matched hemodialysis and peritoneal dialysis populations. These analyTotal Medicare spending
ses explore how racial differences in service utilization in
1ii for injectables
the outpatient dialysis setting may be an important con3
sideration in the new bundled payment system, and how
Other injectables
variations in expenditure structures for hemodialysis and
IV iron
IV vitamin D hormone
peritoneal dialysis may impact the way in which providESAs
ers adapt to this new system.
2
The last two spreads of the chapter provide information on use of the Part D Medicare prescription drug
benefit in the ESRD population, addressing the most fre1
quent claims for medications, rank order by cost, and
differences in use between the dialysis and transplant
populations. Part D analyses are new this year, and we
will provide greater detail in the 2011 ADR.
0
p!DBPM@QCCN?ECDMP?L?JWRGA?JKCRFMBQPeriod preva92
94
96
98
lent dialysis patients.
00
02
04
06
08
K<B@
Costs of the Medicare
& ESRD programs
500
8
Total Medicare*
400
6
* * *
300
4
200
2
100
ESRD
0
0
91
94
97 00
03
Estimated point
prevalent ESRD patients
3 ii
Number of patients (in thousands)
2 ii
Bars: ESRD’s % of Medicare program
Medicare costs rose nearly 11
percent in 2008 — up from a 7 percent
rise the previous year — to $454 billion.
ESRD costs rose 13.2 percent, to $26.8
billion, and accounted for 5.9 percent of
the Medicare budget. (*Starting in 2006,
total Medicare costs include Part D;
ESRD data here, however, do not include
Part D, making ESRD’s portion of Medicare costs appear lower than in prior
years. Available Part D data is examined
at the end of this chapter.) p!DBPM@
Lines: Expenditures ($, in billions)
hTTotal
600
400
Medicare
300
200
100
06
QCCN?ECDMP?L?JWRGA?JKCRFMBQ
Annual percent change
in Medicare ESRD spending
Percent change from previous year
16
12
Total spending
Costs per
patient year
8
4
0
-4
92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08
Total expenditures ($, in billions)
25
20
Transplant
Peritoneal dialysis
Hemodialysis
15
10
5
0
91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08
The estimated number of point prevalent Medicare ESRD paiTh
PNM?N
<IIP<G
?<O<
M@KJMO
QJGPH@
ORJ
esrd
K<B@
tients (Figure 11.3) rose 3.1 percent between 2007 and 2008, to
more than 453,000, while the non-Medicare population rose
7.5 percent, to 94,539.
In 2008, the one-year change in total Medicare spending
on ESRD rose to 9.8 percent, up from 3.6 percent the previous year. Costs per person per year rose 7.3 percent, up from
1.4 percent in 2007. By type of service, 37 percent of Medicare’s ESRD dollars were spent on inpatient services in 2008,
36 percent on outpatient care, and 20.5 percent on physician/
supplier costs. Total Medicare expenditures by modality also
94
97
00
03
06
25
Hospice
Home health
Skilled nursing
Physician/supplier
Outpatient
Inpatient
20
15
10
5
0
91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08
Total Medicare ESRD expenditures
per person per year, by modality
7 ii
PPPY expenditures ($, in thousands)
Total Medicare ESRD
expenditures, by modality
6 ii
0
91
Total Medicare dollars spent
on ESRD, by type of service
5 ii
Total expenditures ($, in billions)
4 ii
Non-Medicare
500
80
Hemodialysis
60
Peritoneal dialysis
40
20
Transplant
0
91
93
95
97
99
01
03
05
07
rose at a greater rate in 2008 than in the previous year. Hemodialysis costs increased 9.3 percent (compared to 3.8 percent
in 2007), to $19.4 billion. After a very slight decrease in 2007,
costs for peritoneal dialysis rose 8.3 percent in 2008, to $1.04
billion, while those for transplant rose 10.2 percent, to $2.08
billion — 9.2 percent of total ESRD expenditures. Per person
per year costs rose 5.5 percent for hemodialysis and 7.0–7.1
percent for peritoneal dialysis and transplant, to $77,506,
$57,639, and $26,668, respectively. p!DBPM@N†QCCN?EC
DMP?L?JWRGA?JKCRFMBQDecember 31 point prevalent ESRD patients (11.3); period prevalent ESRD patients (11.6–7).
>JNONJA@I?NO<B@M@I<G?DN@<N@
overall costs of end-stage renal disease
@SK@I?DOPM@N?PMDIBOC@OM<INDODJIOJ@NM?
Overall PPPM costs during
the transition to ESRD, 2007
Medicare
(age 67+)
MarketScan
(age <65)
20
10
0
-6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Months pre- & post-initiation
10ii
PPPM expenditures ($, in thousands)
PPPM expenditures ($, in thousands)
PPPM expenditures ($, in thousands)
40
30
2.0
1.5
25
Medicare
(age 67+)
20
MarketScan
(age <65)
15
10
5
0
-6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Months pre- & post-initiation
Per person per month inpatient hospitalization expenditures during
the transition to ESRD: vascular access & cardiovascular, 2007
Vascular access hospitalization
Medicare
(age 67+)
MarketScan
(age <65)
8
Cardiovascular hospitalization
6
1.0
4
0.5
2
0.0
PPPM inpatient costs during
the transition to ESRD, 2007
9ii
0
-6 -5 -4 -3 -2 -1 1 2 3 4 5 6
-6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Months pre- & post-initiation
hEEstimated Medicare costs for organ
acquisition have grown nearly 102 percent since 2000, reaching $648 million in 2008. Transplant costs have
increased at a rate of 123 percent, to
$786 million. Between 2007 and 2008,
however, costs for organ acquisition fell
2.2 percent, while transplant costs rose
nearly 18 percent. p!DBPM@QCCN?EC
DMP?L?JWRGA?JKCRFMBQOrgan acquisition costs computed from CMS hospital
reports (CMS form 2552-96). Transplant
costs estimated from the 5 percent Medicare sample; include inpatient costs only.
Costs to Medicare associated with
organ acquisition & transplant
11ii
Expenditures (dollars, in millions)
8ii
800
600
Transplant costs
400
Organ acquisition costs
200
0
96
98
00
02
04
06
08
gTTotal per person per month (PPPM)
costs during the transition to ESRD rise
sharply after the initiation of therapy.
For Medicare patients starting therapy in 2007, costs rose from $6,811 in
the month before initiation to nearly
$15,000 in the month following. In the
younger MarketScan population the
increase was five-fold, from $6,288 to
$31,904. The pattern is similar for inpatient costs during the transition, with
a six-fold rise in costs for MarketScan
patients. After initiation, overall PPPM
costs remain nearly twice as high for
MarketScan patients compared to their
Medicare counterparts; inpatient costs,
in contrast, are nearly equal.
Among patients beginning therapy in 2007, inpatient costs for vascular access in the month after initiation were $1,389 and $1,963 for
Medicare and MarketScan patients, respectively, while costs for cardiovascular hospitalizations reached $3,309 and
$7,070 — twice as high for MarketScan
patients as for those with Medicare
coverage. p!DBPM@N†QCCN?ECDMP
?L?JWRGA?JKCRFMBQ Incident Medicare
(age 67 & older) & MarketScan (younger
than 65) ESRD patients, 2007.
K<B@
the 2008 distribution of costs by payor
was nearly identical to that in 2000,
with 61 percent attributed to Medicare
paid claims and 22 percent to nonMedicare costs. PPPY costs for Zemplar in 2008 were $1,954, considerably
higher than costs for the other main
types of IV vitamin D. IV iron costs were
$792 PPPY for Ferrlecit, $719 for Venofer,
and $198 for INFeD. p!DBPM@N†
QCCN?ECDMP?L?JWRGA?JKCRFMBQPeriod
prevalent dialysis patients.
hPPer person per month costs for eryth-
PNM?N
<IIP<G
?<O<
M@KJMO
QJGPH@
ORJ
esrd
K<B@
ropoiesis stimulating agents (ESAs) and
IV iron, and costs for IV vitamin D, both
show a distinct geographic pattern, and
are highest along the Gulf Coast and
the Eastern Seaboard and lowest in the
western half of the country. Costs average $581 and $149, respectively, in the
upper quintile p!DBPM@QCCN?EC
DMP?L?JWRGA?JKCRFMBQPeriod prevalent
dialysis patients, 2008; unadjusted.
15
MarketScan (<65)
Inpatient/outpatient: Medicare
Dialysis
Transplant within year
Functioning transplant
12
9
6
3
0
2.0
Physician/supplier
1.5
1.0
0.5
0.0
91
93
95
97
99
01
03
05
ESRD spending,
by payor
13ii
40
20
10
92 94 96 98 00 02 04 06 08
15ii
93
95
97
99
01
03
05
2.0
IV vitamin D
0.8
IV iron
1.5
0.6
1.0
0.4
0.5
0.2
0.0
Hectorol Calcijex
Zemplar
0.0
Venofer INFeD
Ferrlecit
Unadjusted PPPM costs (dollars)
for injectables, by HSA, 2008
ESAs/IV iron
IV vitamin D
380
581
427
489
541
564
07
PPPY costs for
injectables, 2008
14ii
0
91
Non-Medicare
Medicare HMO
Medicare patient
obligation
Medicare paid
30
07
PPPY expenditures ($, in thousands)
While ESRD spending continues to rise,
hW
Per person per month inpatient/outpatient & physician/supplier
net costs for Medicare & MarketScan (EGHP) patients with ESRD
12 ii
PPPM expenditures (dollars, in thousands)
tient/outpatient costs for MarketScan
patients with a transplant during 2008
reached $12,815 — 66 percent more than
the $7,733 incurred by their Medicare
counterparts, and 12.3 percent greater
than in 2007, compared to a 2.6 percent
growth in Medicare costs. At $2,530,
2008 costs for MarketScan patients
with a functioning graft were the same
as in 2007, but 2.8 times higher than the
$899 reported for Medicare patients.
Physician/supplier costs for those
with a transplant in 2008 were also
higher — 25 percent — for MarketScan
patients. Costs for those on dialysis or
with a functioning transplant, in contrast, were 30 and 70 percent higher in
the Medicare population. p!DBPM@
QCCN?ECDMP?L?JWRGA?JKCRFMBQMedicare: period prevalent ESRD patients;
MarketScan: period prevalent ESRD patients age 64 & younger.
Expenditures ($, in billions)
hPPPPM ESRD costs vary by insurer. Inpa-
79
149
92
107
116
132
>JNONJA@I?NO<B@M@I<G?DN@<N@
costs overall & for injectables & vascular access
jTTotal per person per year (PPPY) physi-
cian/supplier costs for vascular access
declined for all access types in 2008,
from 0.7 percent for catheters to 7.6
percent for arteriovenous (AV) grafts.
Costs related to AV fistulas continue to
fall from their peak in 2006, reaching
$79 PPPY in 2008. The sharp drop in
PPPY graft costs seen since 1991 is attributable to the number of graft insertions being performed. p!DBPM@
QCCN?ECDMP?L?JWRGA?JKCRFMBQPeriod
prevalent hemodialysis patients.
Total PPPY physician/supplier
costs for vascular access
16 ii
PPPY vascular access costs,
by physician specialty
17ii
300
100
PPPY expenditures (in dollars)
PPPY expenditures (in dollars)
Graft
200
Catheter
100
Fistula
gPPer person per year costs for vascular
All
80
Anesthesiology
Nephrology
Other
60
Surgery
40
Radiology
20
0
0
91 93 95 97 99 01 03 05 07
91 93 95 97 99 01 03 05 07
access services performed by surgeons
have fallen 39 percent since 1995, to
$29.4 in 2008. Costs for services performed by nephrologists, in contrast,
continue to increase, and at nearly $22
in 2008, are 11 times greater than in
2000. Anesthesiologist costs rose 18
percent in 2008, reaching $8.33. p!DB
PM@QCCN?ECDMP?L?JWRGA?JKCRFMBQ
Period prevalent hemodialysis patients.
PPPY access event costs,
by access type
PPPY expenditures ($, in thousands)
10
Graft
8
6
Catheter
4
AV fistula
2
PD catheter
0
99
01
03
05
PPPY total expenditures,
by access type
19ii
PPPY expenditures ($, in thousands)
18 ii
07
20ii
Unadj. PPPY costs ($) for vascular access
infectious hospitalizations, by HSA, 2008
100
Catheter
Graft
80
60
40
All
Fistula
PD catheter
20
587
0
99
01
03
05
1,976
07
800
iPPer person per year costs for vascular iPPer
person per year total costs are
access events are highest for patients greatest for patients with a catheter or
with an AV graft or a catheter, reaching AV graft, at $90,110 and $79,337 in 2008.
$8,683 and $6,402 in 2008. Costs for Costs for patients with an AV fistula are
patients with an AV fistula, in contrast, 28 and 18 percent lower, respectively,
were $3,480 — 60 percent lower than at $64,701. After a growth in 2007 of
those for AV graft patients. Costs rose 3.3 percent for catheter patients and
7–17 percent for hemodialysis patients, 1.0–1.7 percent for those with a fistula
but fell nearly 32 percent for those with or graft, costs in 2008 rose 12.8 and
a peritoneal dialysis catheter. p!DBPM@ 8.2–8.6 percent. p!DBPM@QCCN?EC
QCCN?ECDMP?L?JWRGA?JKCRFMBQ DMP?L?JWRGA?JKCRFMBQDialysis patients
Dialysis patients (Medicare); ESRD CPM (Medicare); ESRD CPM data.
data.
1,039
1,254
1,599
Unadjusted per person per year costs
U
for hospitalizations due to vascular access infection show no clear geographic
pattern across the United States. Costs
range from an average of $587 in the
lowest quintile to $1,976 in the upper
quintile. p!DBPM@QCCN?ECDMP
?L?JWRGA?JKCRFMBQPeriod prevalent hemodialysis patients, 2008; unadjusted.
K<B@
Total per person per year
outpatient expenditures, by race
21ii
hTTotal per person per year (PPPY) outpatient expenditures in the prevalent
dialysis population do not vary widely
by race. In 2008, for example, costs
were $29,063 for white patients, $30,821
for African Americans, and $28,132 for
those of other races. p!DBPM@QCC
N?ECDMP?L?JWRGA?JKCRFMBQPeriod
prevalent dialysis patients.
20
10
0
91
93
95
97
99
01
03
05
07
PPPY expenditures ($, in 1,000s)
1.5
1.0
0.5
Per person per year expenditures
for ESAs, by race
23ii
2.0
White
African American
Other
All
0.0
8
6
4
0
91 93 95 97 99 01 03 05 07
3
2
Per person per year expenditures
for IV iron, by race
25ii
PPPY expenditures ($, in 1,000s)
Per person per year expenditures
for IV vitamin D, by race
24ii
White
Af Am
Other
All
1
0
1.5
1.0
Per person per year expenditures
for IV antibiotics, by race
26ii
0.0
91 93 95 97 99 01 03 05 07
400
40
30
20
10
Per person per year expenditures
for other injectables, by race
27ii
60
50
White
Af Am
Other
All
0
White
Af Am
Other
All
0.5
91 93 95 97 99 01 03 05 07
White
Af Am
Other
All
2
91 93 95 97 99 01 03 05 07
A?JKCRFMBQPeriod prevalent dialysis
patients.
30
PPPY expenditures ($)
QJGPH@
ORJ
esrd
K<B@
p!DBPM@N†QCCN?ECDMP?L?JWRG
White
African American
Other
All
Per person per year expenditures
for laboratory tests, by race
22ii
PPPY expenditures ($)
PNM?N
<IIP<G
?<O<
M@KJMO
40
JPOK<OD@IO>JNONAJMG<=JM<OJMTO@NONÒDIE@>O<=G@N
PPPY expenditures ($, in 1,000s)
person per year (PPPY) costs for laboratory tests are nearly equal for white
and African American patients, at
$1,737 and $1,707, respectively, in 2008.
Costs for IV iron are also similar, at
$714 and $752. Expenditures for erythropoiesis stimulating agents (ESAs) and
IV vitamin D, in contrast, differ more
by race. In 2008, African American dialysis patients incurred $6,277 PPPY for
ESAs, 15 percent higher than the $5,465
incurred by white patients. And IV
vitamin D costs reached $1,824 PPPY for
African Americans, 78 percent greater
than the $1,024 reported for whites.
Per person per year IV antibiotic
costs in 2008 were $14.43 for white
patients and $12.89 for African Americans; costs for patients of other races
were $10.40 per patient per year. And
costs for other injectables in 2008 were
$194 overall and $222 and $166, respectively, in whites and African Americans.
The wide variations seen in PPPY
costs for IV antibiotics and other injectables over time may in part be attributable to changes in payment rules
and pricing limits instituted by CMS.
PPPY expenditures ($, in 1,000s)
hIInn the prevalent dialysis population, per
PPPY expenditures ($, in 1,000s)
300
White
Af Am
Other
All
200
100
0
91 93 95 97 99 01 03 05 07
>JNONJA@I?NO<B@M@I<G?DN@<N@
racial differences in costs
91 93 95 97 99 01 03 05 07
Total per person per year inpatient
hospitalization expenditures, by race
28ii
PPPY expenditures ($, in1,000s)
30
gIIn
2008, total per person per year
(PPPY) costs for inpatient hospitalizations differed little between white and
African American patients, at $27,446
and $27,282, respectively. Hospitalization costs among patients of other races,
however, were 15–16 percent lower, at
$23,083. p!DBPM@QCCN?ECDMP?L?
JWRGA?JKCRFMBQPeriod prevalent dialysis
patients.
20
White
African American
Other
All
10
0
91
95
97
99
01
03
05
07
gPPPPY costs for cardiovascular hospital-
Per person per year expenditures for cardiovascular
& heart failure/fluid overload hospitalizations, by race
29ii
PPPY expenditures ($, in1,000s)
93
8
All cardiovascular
Heart failure & fluid overload
3
6
2
4
White
African American
Other
All
2
1
0
0
91 93 95 97 99 01 03 05 07
91 93 95 97 99 01 03 05 07
DIA@>ODJPNCJNKDO<GDU<ODJI>JNONK@MK@MNJIK@MT@<M
PPPY expenditures ($, in 1,000s)
8
6
4
PPPY hospitalization expenditures for
vascular access infections, by race
31ii
PPPY expenditures ($, in 1,000s)
PPPY hospitalization expenditures
for all infections, by race
30ii
White
Af Am
Other
All
2
0
2.0
1.5
1.0
0.5
0.0
91 93 95 97 99 01 03 05 07
91 93 95 97 99 01 03 05 07
PPPY expenditures ($, in 1,000s)
PPPY hospitalization expenditures
for bacteremia/septicemia, by race
2.5
2.0
1.5
PPPY hospitalization expenditures for
pneumococcal pneumonia, by race
33ii
1,000
White
African American
Other
All
1.0
0.5
0.0
PPPY expenditures ($)
32ii
White
Af Am
Other
All
800
600
400
200
White
African American
Other
All
izations have converged over time for
white and African American dialysis
patients, reaching $7,534 and $7,375 in
2008. Hospitalization costs for heart
failure and fluid overload in 2008 were
$1,860 overall and $1,877 and $1,903,
respectively, in whites and African
Americans. p!DBPM@QCCN?ECDMP
?L?JWRGA?JKCRFMBQPeriod prevalent dialysis patients.
Overall PPPY hospitalization costs for
gO
infections have remained similar over
time among white and African American dialysis patients, reaching $7,165
and $7,185 in 2008. Costs for hospitalizations related to bacteremia/septicemia stabilized in the later 1990s before beginning a steady increase; they
have, however, also remained similar
by race, reaching $2,328 for white patients and $2,178 for African Americans in 2008. PPPY expenditures for
vascular access infections, in contrast,
have remained higher among African
American patients, in 2008 reaching
$1,813 — 42 percent greater than the
$1,279 incurred by their white counterparts. Costs for hospitalizations related
to pneumonia show a different pattern
by race; in 2008 they were 30 percent
higher among white patients, at $904
compared to $698. p!DBPM@N†
QCCN?ECDMP?L?JWRGA?JKCRFMBQPeriod
prevalent dialysis patients.
0
91 93 95 97 99 01 03 05 07
91 93 95 97 99 01 03 05 07
K<B@
Total PPPY outpatient expenditures,
by dialysis modality & race, 2008
34ii
hIInn 2008, per person per year (PPPY) outpatient dialysis expenditures were 6.0 percent higher in African Americans
than in whites, at $30,821 and $29,063, respectively. When
comparing costs by modality in unmatched dialysis populations, those for hemodialysis were 26 percent higher than
those for peritoneal dialysis. This difference was sustained
among hemodialysis patients matched to peritoneal patients,
at 25 percent for whites and 28 percent for African Americans. p!DBPM@QCCN?ECDMP?L?JWRGA?JKCRFMBQPeriod
prevalent dialysis patients, 2008.
QJGPH@
ORJ
esrd
K<B@
40
30
20
10
White
African American
0
All dialysis
All HD
All PD
HD matched to PD
JPOK<OD@IO>JNONAJMG<=JM<OJMTO@NONÒDIE@>O<=G@N
1.5
1.0
0.0
All dialysis All HD All PD HD matched
to PD
PPPY expenditures for IV vitamin D,
by dialysis modality & race, 2008
37ii
PPPY expenditures ($, in 1,000s)
White
African American
1.5
1.0
White
African American
0.0
All dialysis All HD All PD HD matched
to PD
PPPY expenditures for IV antibiotics,
by dialysis modality & race, 2008
39ii
2
White
African American
0
All dialysis All HD All PD HD matched
to PD
PPPY expenditures for IV iron,
by dialysis modality & race, 2008
800
600
400
200
White
African American
0
All dialysis All HD All PD HD matched
to PD
PPPY expenditures for other injectables,
by dialysis modality & race, 2008
40ii
20
300
15
10
5
4
1,000
2.0
6
38ii
2.5
0.5
8
PPPY expenditures (in dollars)
PPPY expenditures ($, in 1,000s)
2.0
0.5
PPPY expenditures for ESAs, by
dialysis modality & race, 2008
36ii
PPPY expenditures ($, in 1,000s)
PPPY expenditures for laboratory
tests, by dialysis modality & race, 2008
35ii
White
African American
0
PPPY expenditures ($)
PNM?N
<IIP<G
?<O<
M@KJMO
laboratory tests were greater in both
matched (hemodialysis to peritoneal
dialysis) and unmatched hemodialysis
populations than for patients on peritoneal dialysis. The difference, however,
varies by race. In unmatched populations, costs for hemodialysis patients
compared to peritoneal patients are 9.5
percent greater for whites, and 8.9 percent greater for African Americans. In
matched dialysis populations, costs are
6.3 and 10.2 percent greater, respectively.
Costs for erythropoiesis stimulating
agents (ESAs) are higher for hemodialysis than for peritoneal dialysis, and
greater in African Americans than in
whites. When comparing costs in unmatched hemodialysis and peritoneal
populations, those for hemodialysis are
81.1 and 47.0 percent greater in whites
and African Americans, respectively; in
matched hemodialysis and peritoneal
populations, hemodialysis costs are 76.0
and 48.8 percent higher.
Intravenous iron costs in matched
dialysis populations are six times higher
for hemodialysis patients than for peritoneal dialysis patients in both white
and African Americans. Antibiotic costs
for whites and African Americans in
matched dialysis populations are 24 and
12 percent higher, respectively, for hemodialysis patients compared to those
on peritoneal dialysis. p!DBPM@N†
QCCN?ECDMP?L?JWRGA?JKCRFMBQPeriod
prevalent dialysis patients, 2008.
PPPY expenditures ($)
hIInn 2008, per person per year costs for
PPPY expenditures ($, in 1,000s)
200
100
White
African American
0
All dialysis All HD All PD HD matched
to PD
All dialysis All HD All PD HD matched
to PD
>JNONJA@I?NO<B@M@I<G?DN@<N@
costs in matched & unmatched dialysis populations
Total per person per year inpatient expenditures,
by dialysis modality & race, 2008
41ii
PPPY expenditures ($, in 1,000s)
40
30
gPPer person per year (PPPY) inpatient dialysis expenditures
White
African American
20
10
0
All dialysis
All PD
HD matched to PD
gPPPPY costs for cardiovascular and heart
Per person per year expenditures for cardiovascular & heart failure/
fluid overload hospitalizations, by dialysis modality & race, 2008
42ii
PPPY expenditures ($, in 1,000s)
All HD
are similar in whites and African Americans, at $27,446 and
$27,382, respectively. Costs for unmatched hemodialysis
populations are greater than for those on peritoneal dialysis — 24 percent higher for whites, and 8 percent for African
Americans. In matched dialysis populations, costs for whites
on hemodialysis are 3 percent greater than costs for those on
peritoneal dialysis, but are 7 percent lower in African Americans. p!DBPM@QCCN?ECDMP?L?JWRGA?JKCRFMBQPeriod
prevalent dialysis patients, 2008.
All cardiovascular
8
Heart failure & fluid overload
2.0
6
1.5
4
1.0
2
0.5
White
African American
0
0.0
All dialysis
All HD
All PD
All dialysis
HD matched
to PD
All HD
All PD HD matched
to PD
DIA@>ODJPNCJNKDO<GDU<ODJI>JNONK@MK@MNJIK@MT@<M
PPPY hosp. expenditures for all infections,
by dialysis modality & race, 2008
8
6
4
White
African American
0
All dialysis All HD
45ii
PPPY expenditures ($, in 1,000s)
PPPY expenditures ($, in 1,000s)
PPPY expenditures ($, in 1,000s)
10
2
All PD HD matched
to PD
PPPY hosp. expenditures for bacteremia/
sepsis, by dialysis modality & race, 2008
2.5
2.0
1.5
1.0
0.5
White
African American
0.0
All dialysis All HD
All PD HD matched
to PD
PPPY hosp. expenditures for pneumonia,
by dialysis modality & race, 2008
46ii
1,000
2.5
2.0
1.5
1.0
0.5
PPPY hosp. expenditures for vasc. access
infections, by dialysis modality & race, 08
44ii
White
African American
PPPY expenditures ($)
43ii
800
600
400
200
White
African American
failure/fluid overload hospitalizations
in unmatched and matched dialysis
patients are greater for hemodialysis
patients than for peritoneal patients.
When compared to those of peritoneal
dialysis patients, cardiovascular costs
for matched hemodialysis patients are
8 and 11 percent greater, respectively, for
whites and African Americans. !DBPM@
QCCN?ECDMP?L?JWRGA?JKCRFMBQ
Period prevalent dialysis patients, 2008.
gIInn both unmatched and matched dialy-
sis populations, 2008 hospital costs for
all infections are less for hemodialysis
than for peritoneal dialysis. In the unmatched populations, hemodialysis
costs are 8 percent lower for whites and
27 percent lower for African Americans,
while in the matched populations, costs
are 24 percent lower for whites and 41
percent lower for African Americans.
Hospitalization costs for bacteremia/septicemia in both unmatched
and matched populations, in contrast,
are greater for hemodialysis than for
peritoneal dialysis. In the unmatched
populations, hemodialysis costs are 73
percent greater for whites and 98 percent greater for African Americans.
Differences in the matched dialysis
populations are not as extreme, yet
costs for hemodialysis patients remain
28–29 percent higher. p!DBPM@N†
QCCN?ECDMP?L?JWRGA?JKCRFMBQPeriod
prevalent dialysis patients, 2008.
0
0.0
All dialysis All HD
All PD HD matched
to PD
All dialysis All HD
All PD HD matched
to PD
K<B@
Part D expenditures
for Medicare & ESRD
Lines: Expenditures ($, in billions)
60
a ii
4
Total Part D Medicare
45
3
30
2
15
1
Total Part D ESRD
0
Bars: ESRD‘s % of Medicare
47ii
0
2006
2007
iTTotal Part D Medicare expenditures
reached $51.3 billion in 2007, and ESRD
patients accounted for $1.3 billion — 2.4
percent — of these costs.
Not all drugs are covered through
Part D. Notable exclusions include
all over-the-counter medications (e.g.
calcium carbonate), benzodiazepines,
weight gain drugs, and vitamins and
minerals (e.g. kidney-specific multivitamins, cholecalciferol, ergocalciferol, and phosphorus supplements).
Prenatal vitamins and oral vitamin D
hormones (calcitriol, paricalcitol, doxercalciferol) are covered, but not all
plans cover all available products. In
2007, sevelamer HCl, cinacalcet, lanthanum carbonate, and calcium acetate — drugs used in bone and mineral
disorder management — were in the
top ten drugs in terms of total cost, accounting for $363 million. p!DBPM@
º/<=G@<QCCN?ECDMP?L?JWRGA?JKCRF
PNM?N
<IIP<G
?<O<
M@KJMO
QJGPH@
ORJ
esrd
K<B@
MBQ11.47 & 11.a: Includes Part D claims
for all ESRD patients beginning at the latest of first ESRD service date or January
1, 2006, & continuing until the earliest of
death or December 31, 2007, regardless of
payor status. 11.47: Part D ESRD costs are
estimated net pay: sum of plan covered
payments & low income subsidy payment
amounts; out-of-pocket expenditures not
included. 11.a: Costs are estimated Medicare payment, defined as the sum of the
plan covered payment amount & low income subsidy amount.
Top 25 Part D prescription drugs used in
the ESRD population, by frequency & cost
2006
By frequency
Generic name
Metoprolol Tartrate
Insulin
Sevelamer HCl
Amlodipine
Hydrocodone-Acetaminophen
Calcium Acetate
Clonidine
Atorvastatin
Lisinopril
Furosemide
Cinacalcet
Levothyroxine
Warfarin
Clopidogrel
Prednisone
Nifedipine
Simvastatin
Carvedilol
Gabapentin
Lansoprazole
Atenolol
Pantoprazole
Isosorbide Mononitrate
Metoclopramide
Omeprazole
2007
By frequency
Generic name
Metoprolol Tartrate
Insulin
Sevelamer HCl
Amlodipine
Hydrocodone-Acetaminophen
Calcium Acetate
Clonidine
Lisinopril
Cinacalcet
Atorvastatin
Furosemide
Levothyroxine
Clopidogrel
Warfarin
Simvastatin
Prednisone
Nifedipine
Carvedilol
Omeprazole
Gabapentin
Pantoprazole
Isosorbide Mononitrate
Atenolol
Metoclopramide
Oxycodone w/acetaminophen
# claims
By net cost
Generic name
# claims
Total cost ($)
538,565
528,691
446,534
424,122
381,611
351,889
315,574
300,376
278,048
263,152
238,698
236,277
226,760
225,002
188,463
185,058
175,261
170,504
156,101
154,979
152,510
148,952
147,837
144,568
128,576
Sevelamer HCl
Cinacalcet
Insulin
Tacrolimus
Lanthanum Carbonate
Atorvastatin
Amlodipine
Valganciclovir
Clopidogrel
Mycophenolate Mofetil
Lansoprazole
Simvastatin
Calcium Acetate
Esomeprazole
Carvedilol
Pantoprazole
Nifedipine
Epoetin Alfa
Pioglitazone
Zolpidem
Clonidine
Sirolimus
Metoprolol Tartrate
Darbepoetin Alfa
Rosiglitazone
446,534
238,698
528,691
51,164
79,645
300,376
424,122
22,914
225,002
50,706
152,510
175,261
351,889
125,307
170,504
147,837
185,058
16,918
67,168
116,447
315,574
13,273
538,565
6,864
60,823
148,463,756
107,817,904
38,271,241
28,336,957
26,762,482
26,288,719
25,378,175
25,043,053
24,978,242
23,763,827
21,390,461
19,353,865
18,222,496
17,316,000
16,118,833
15,640,412
11,961,391
11,940,809
9,929,041
9,595,214
9,506,350
9,180,170
9,010,820
7,590,442
7,448,098
# claims
By net cost
Generic name
# claims
Total cost ($)
631,190
605,596
516,007
476,294
439,082
373,248
347,939
333,693
323,316
314,753
302,046
270,961
254,925
254,447
250,305
214,617
212,365
211,599
207,584
179,530
179,044
158,716
151,447
150,152
147,983
Sevelamer HCl
Cinacalcet
Insulin
Lanthanum Carbonate
Valganciclovir
Clopidogrel
Atorvastatin
Calcium Acetate
Amlodipine
Esomeprazole
Pantoprazole
Tacrolimus
Lansoprazole
Carvedilol
Mycophenolate Mofetil
Nifedipine
Pioglitazone
Epoetin Alfa
Clonidine
Metoprolol Tartrate
Valsartan
Zolpidem
Thalidomide
Omeprazole
Oxycodone
516,007
323,316
605,596
89,424
25,868
254,925
314,753
373,248
476,294
146,103
179,044
38,447
135,045
211,599
38,258
212,365
78,766
15,255
347,939
631,190
130,962
147,044
2,044
207,584
58,140
202,988,459
159,785,972
50,203,191
33,799,276
29,828,651
29,111,569
29,073,949
26,877,931
22,289,564
21,493,616
20,411,323
20,286,364
20,128,865
17,818,948
17,702,287
13,354,837
12,196,263
11,151,873
10,811,935
10,097,908
9,191,406
8,387,172
8,074,349
7,944,808
7,035,802
>JNONJA@I?NO<B@M@I<G?DN@<N@
overview of medicare part d costs
PPPM net costs for Part D-enrolled dialysis
patients: cardiovascular medications, 2007
48ii
Age
20
15
15
10
10
PPPM expenditures (in dollars)
PPPM expenditures (in dollars)
20
PPPM net costs for Part D-enrolled tx
pts: cardiovascular medications, 2007
49ii
5
0
20-44
20
45-64
65-74
75+
Race
15
Age
5
0
20-44
20
10
5
5
0
Af Am
Other
PPPM net costs for Part D-enrolled
dialysis pts: lipid lowering agents, 2007
White
15
10
10
20-44
45-64
65-74
75+
Race
15
PPPM expenditures (in dollars)
PPPM expenditures (in dollars)
20
0
Age
5
0
20-44
20
45-64
65-74
75+
Race
15
10
10
5
5
0
Other
PPPM net costs for Part D-enrolled
transplant pts: lipid lowering agents, 2007
51ii
Age
5
Af Am
ACEIs/ARBs/renin inhibitors
Beta blockers
NDP-CCBs
DP-CCBs
15
20
75+
Race
ACEIs/ARBs/renin inhibitors
Beta blockers
NDP-CCBs
DP-CCBs
20
65-74
0
White
50ii
45-64
15
10
Although beta blockers are used in
gA
0
White
Af Am
Other
Absorption inhib.
Statins
Fibrates
All others
Bile acid sequestrants
White
Af Am
a higher percentage of patients (see
Chapter Five), Part D costs in 2007
were highest for dihydropyridine calcium-channel blockers (DP-CCBs). This
reflects the fact that amlodipine recently went off patent, and that metoprolol (the most frequently used ESRD
Part D drug in 2006–2007) has been
available as a generic since the 1990s.
Following patterns of use, cardiovascular drug costs are lowest in
white patients, and highest in African
Americans and patients of other races.
In the 2007 dialysis population, overall net Medicare Part D costs for the
four cardiovascular drug classes were
$31.30, $36.13 and $41.69 per person per
month for whites, African Americans,
and patients of other races, respectively,
compared to $26.37, $38.71 and $33.35
in the transplant population. p!DBPM@N
†QCCN?ECDMP?L?JWRGA?JKCRF
MBQPoint prevalent ESRD patients, enrolled in Part D all of 2007.
gFFollowing the patterns of medication
use illustrated in Chapter Five (Figures 5.31–32), Medicare Part D net costs
for statins far outweigh combined net
costs for fibrates, bile acid sequestrants,
cholesterol absorption inhibitors, and
other cholesterol-lowering medications.
Among white dialysis patients, for example, costs for statins reached $12.78
PPPM in 2007, compared to $4.24 for all
other lipid lowering agents. In the African American transplant population,
statin costs reached $17.04, compared to
$5.53 for other agents. Use of lipid lowering agents is considerably higher in
the transplant population than among
dialysis patients. p!DBPM@N†QCC
N?ECDMP?L?JWRGA?JKCRFMBQPoint
prevalent ESRD patients, enrolled in Part
D all of 2007. “Other” category includes
lipid-lowering combination drugs (e.g,
atorvastatin-ezetimbe).
Other
Absorption inhib.
Statins
Fibrates
All others
Bile acid sequestrants
K<B@
PPPM net costs for Part D-enrolled
dialysis patients: oral vitamin D, 2007
52ii
PNM?N
<IIP<G
?<O<
M@KJMO
QJGPH@
ORJ
esrd
K<B@
tively high in the dialysis population.
(Generic products were not available
for these phosphate binders in 2007.)
In 2007, PPPM net costs for sevelamer
ranged from $53.21 in dialysis patients
75 and older to $112.75 in those 20–44.
Costs were similar in whites and African Americans, at $83.60 and $86.98,
and reached $113.35 in patients of other
races. Although use of calcium acetate
is 2–4 times higher than that of lanthanum carbonate (see Chapter Five, Figure 5.35), overall PPPM costs for calcium
acetate are lower because of its lower
market price.
Net PPPM costs for phosphate repletion agents in transplant patients are
low, reflecting the low percentage of
transplant patients using these products through Medicare Part D (see
Figure 5.36 in Chapter Five). p!DBPM@N
†QCCN?ECDMP?L?JWRGA?JKCRFMBQ
Point prevalent ESRD patients, enrolled in
Part D all of 2007.
Age
4
3
2
2
PPPM expenditures (in dollars)
3
1
0
20-44
4
45-64
65-74
75+
Race
3
Age
1
0
20-44
4
2
1
1
0
Af Am
Other
White
Doxercalciferol
Paricalcitol
Calcitriol
120
75+
Af Am
Other
Doxercalciferol
Paricalcitol
Calcitriol
PPPM net costs for Part D-enrolled
dialysis pts: phosphate binders, 2007
54ii
65-74
0
White
45-64
Race
3
2
55ii
Age
0.4
PPPM net costs for Part D-enrolled tx
pts: phosphate repletion agents, 2007
Age
100
0.3
80
60
0.2
40
20
0
20-44
100
45-64
65-74
75+
Race
80
PPPM expenditures (in dollars)
Costs for phosphate binders are relahC
4
PPPM expenditures (in dollars)
cholecalciferol, ergocalciferol,
and other precursor vitamin D products are categorized as vitamins and
are excluded from the standard Part D
benefit; we thus do not include them
in these figures. Doxercalciferol, paricalcitol, and calcitriol, in contrast, are
considered hormones under Part D
and are covered under the standard
Part D benefit, but individual plans are
not required to carry all three products
or all dosage forms. In 2007, the majority of dialysis patients received intravenous versions of these products during
dialysis sessions. Dialysis-administered
IV vitamin D is covered under Medicare Part B, not Part D, so these costs
are also excluded from these figures. In
2007, use of oral vitamin D hormone
was low in both the dialysis and transplant populations (see Chapter Five,
Figures 5.33–34); PPPM costs were also
comparatively low. p!DBPM@N†
QCCN?ECDMP?L?JWRGA?JKCRFMBQPoint
prevalent ESRD patients, enrolled in Part
D all of 2007.
PPPM expenditures (in dollars)
Oral
hO
PPPM net costs for Part D-enrolled
transplant patients: oral vitamin D, 2007
53ii
0.1
0.0
20-44
0.4
45-64
65-74
75+
Race
0.3
60
0.2
40
0.1
20
0
0.0
White
Af Am
Other
White
Af Am
Sevelamer
Lanthanum
Calcium acetate
>JNONJA@I?NO<B@M@I<G?DN@<N@
overview of medicare part d costs (continued)
Other
PPPM net costs for Part D-enrolled dialysis
pts with diabetes: diabetes agents, 2007
56ii
Age
60
40
40
20
20
PPPM expenditures (in dollars)
PPPM expenditures (in dollars)
60
PPPM net costs for Part D-enrolled tx pts
with diabetes: diabetes agents, 2007
57ii
0
20-44
60
45-64
65-74
75+
Race
40
20
Age
As shown in Table 11.a, insulin therapy
gA
0
20-44
60
0
Af Am
Other
White
Insulin
Sulfonylureas
Metformin
TZDs
1.2
100
1.0
80
0.8
60
0.6
40
0.4
20
0
120
45-64
65-74
75+
Race
100
80
PPPM expenditures (in dollars)
PPPM expenditures (in dollars)
59ii
Age
20-44
Af Am
Other
Insulin
Sulfonylureas
Metformin
TZDs
PPPM net costs for Part D-enrolled
dialysis patients: calcimimetics, 2007
120
75+
20
White
58ii
65-74
40
0
45-64
Race
Age
0.2
0.0
20-44
1.2
45-64
65-74
75+
Race
40
0.4
20
0.2
0.0
White
Af Am
Other
the sole calcimimetic on the market,
rivaled that of sevelamer in 2007. Net
costs decrease with age, from $107.86 in
patients age 20–44 to $32.34 in those 75
and older. Costs by race are highest in
African Americans, at $92.16 compared
to $50.83 in whites and $52.20 among
patients of other races.
In the transplant population, PPPM
costs for diuretics are relatively low, despite high use (see Chapter Five, Figure
5.40). This reflects the wide availability of generic diuretics. Costs increase
with age, paralleling patterns of use.
KCRFMBQPoint prevalent ESRD patients,
enrolled in Part D all of 2007. “Any” category includes a number of combination
drugs that have more than one type of
diuretic; these are excluded from the
other three categories.
0.8
0.6
gPPPPM costs for cinacalcet, currently
p!DBPM@N†QCCN?ECDMP?L?JWRGA?J
1.0
60
0
PPPM net costs for Part D-enrolled
transplant patients: diuretics, 2007
is among the top three Part D prescription drugs by both frequency and net
cost. Among dialysis patients with diabetes, PPPM net costs for insulin decline
as age increases, although the percentage of patients using insulin does not
vary as much by age (see Chapter Five,
Figure 5.37). This suggests that newer,
more expensive insulin products are
being used in younger dialysis patients.
By modality, insulin PPPM costs are
higher in transplant patients, also suggesting a greater use of new agents.
In the transplant population, costs
for thiazolidinediones (TZDs) are far
lower than those for insulin. Costs are
closer in the older dialysis population.
No generic TZD products were available
during 2007. p!DBPM@N†QCCN?EC
DMP?L?JWRGA?JKCRFMBQPoint prevalent
ESRD patients with diabetes, enrolled in
Part D all of 2007.
White
Af Am
Other
Any
Loop
Thiazide
Potassium-sparing
K<B@
In 2008, the one-year change in total
Medicare spending on ESRD rose to 9.8
percent, up from 3.6 percent the previous
year.—BPM@
Between 2007 and 2008, estimated organ
acquisition costs fell 2.2 percent, to $648
million; transplant costs, in contrast, rose
nearly 18 percent, to $786 million.—BPM@
Inpatient/outpatient costs for MarketScan
patients with a transplant during 2008
reached $12,815 — 66 percent more than
the $7,733 incurred by their Medicare
counterparts.—BPM@
Per person per year total costs are greatest
for patients with a catheter or arteriovenous
graft, at $90,110 and $79,337 in 2008; costs
for patients with an AV fistula are 28 and 18
percent lower, at $64,701.—BPM@
In 2008, African American dialysis patients
incurred $6,277 per person per year for
erythropoiesis stimulating agents, 15 percent
higher than the $5,465 incurred by white
patients.—BPM@
Per person per year costs for cardiovascular
hospitalizations have converged over time for
white and African American dialysis patients,
reaching $7,534 and $7,375 in 2008.—BPM@
Costs for erythropoiesis stimulating agents
are noticeably higher for hemodialysis (both
matched and unmatched populations) than
for peritoneal dialysis, and greater in African
Americans than in whites.—BPM@
PNM?N
<IIP<G
?<O<
M@KJMO
QJGPH@
ORJ
esrd
K<B@
>JNONJA@I?NO<B@M@I<G?DN@<N@
summary