In the not-so-distant future, calcimimetic drugs will be added to the Medicare ESRD Prospective Payment System (PPS) bundle. Findings from a new study, however, suggest hemodialysis (HD) facilities using calcimimetics to treat secondary hyperparathyroidism (SHPT) may face unexpected financial burdens.

According to an analysis of 2014 data from the Dialysis Outcomes and Practice Patterns Study (DOPPS), which included 10,521 patients from 203 HD facilities in the United States, the median proportion of patients prescribed the calcimimetic cinacalcet was 22% (interquartile range 13% to 30%), Douglas S. Fuller, MS, of Arbor Research Collaborative for Health, in Ann Arbor, Michigan, and colleagues reported in the Clinical Journal of the American Society of Nephrology. HD facilities that treated more patients who were black, younger than 65 years, and long-term dialysis users (3 or more years) prescribed cinacalcet more frequently.

Cinacalcet prescribing was 7.8% higher in facilities with the highest vs lowest quartiles of black patients. It was 7.3% higher in facilities with the most patients 65 years and older and 11.9% higher in facilities with the greatest proportion of patients with longer dialysis vintage. Patient-level case-mix variables, rather than facility factors (such as region and size) explained most of the associations.

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Adding calcimimetics to the bundle at a flat rate may reduce use of these drugs in favor of treatments outside of the bundle, such as phosphate binders and parathyroidectomy, Fuller and the team explained. Medicare has instituted payment adjustments to offset financial burdens due to patient age or recent dialysis initiation, but these adjustments may not fully account for imbalances, they observed. The investigators could not assess or rule out imbalances due to private insurance or Medicare/Medicaid dual coverage.

“However, the average PTH levels for United States patients on hemodialysis continue to rise, and in this complex scenario, the clinical effect of potentially inculcating calcimimetics (cinacalcet and recently approved intravenous etelcalcetide) into the PPS bundle is unclear,” Harish Seethapathy, MD, and Sagar Nigwekar, MD, of Massachusetts General Hospital commented in an accompanying editorial.

Study funding was provided by Amgen, Kyowa Hakko Kirin, and Baxter Healthcare.

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Fuller DS, Xing S, Belozeroff V, et al. Variability in cinacalcet prescription across US hemodialysis facilities. Clin J Am Soc Nephrol 14. DOI:10.2215/CJN.09550818

Seethapathy H and Nigwekar SU. Medication prescription patterns for secondary hyperparathyroidism: More questions than answers. Clin J Am Soc Nephrol 14. DOI:10.2215/CJN.15081218