The Centers for Medicare and Medicaid Services (CMS) recently proposed a rule to end the transitional drug add-on payment adjustment (TDAPA) for calcimimetics and incorporate these drugs into the dialysis bundled payment beginning on January 1, 2021. Now new research suggest this change may disproportionally affect specific dialysis facilities and patients with secondary hyperparathyroidism (SHPT).

Investigators analyzed calcimimetic use among Medicare beneficiaries receiving maintenance dialysis using all Part B claims for cinacalcet and etelcalcetide in 2018. Of 373,874 beneficiaries, 28% used a calcimimetic for 90 days or more that year. Black patients used calcimimetics more than all other racial or ethnic groups: 39.5% vs 22.1%, Mark Gooding, associate principal of Market Access at Avalere Health in Washington, DC, and colleagues reported in Kidney360. Similarly, patients eligible for both Medicare and Medicaid displayed 30% higher use (32.0% vs 24.6%). In addition, clinicians prescribed calcimimetics nearly 3-fold more in patients with a dialysis vintage longer vs shorter than 3 years (41.8% vs 14.3%).

Calcimimetic use among dialysis facilities also varied. Payments for cinacalcet and etelcalcetide accounted for 10% of total Medicare dialysis spending in approximately 20% of dialysis facilities (1304 centers) across the United States in 2018.

“Incorporation of calcimimetics into the bundle rate that does not appropriately account for these variations in utilization could disproportionately impact vulnerable patients who most need treatment,” Gooding’s team wrote.


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Under CMS’ proposed rule, $12.06 would be added to the per-patient-per-dialysis treatment base rate for calcimimetic therapy, not counting any adjustments. Dialysis facilities in which 36% of patients took one 30-mg tablet of cinacalcet daily (75th percentile of use) would see an estimated 3.69% reduction in Medicare payment with the bundled payment compared with separate TDAPA payment. In contrast, facilities with 17% of patients taking cinacalcet (25th percentile of use) would see just a 0.8% increase in Medicare payments under the proposed bundle.

“Due to the financial pressure many dialysis facilities face, how calcimimetics are incorporated into the bundle may have a direct impact on facility reimbursement for and patient access to therapy,” Gooding and colleagues wrote. “Careful consideration will be required to ensure vulnerable patients requiring treatment for SHPT do not face barriers to appropriate care.”

This clinical trial was supported by Amgen. Please see the original reference for a full list of authors’ disclosures.

Reference

Gooding M, Desai P, Owens H, et al. Calcimimetic use in dialysis-dependent Medicare fee-for-service beneficiaries and implications for bundled payment. Kidney360. August 2020. doi:10.34067/KID.0003042020