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Abstract: SA-PO326

Market Competition and Anemia Management in the United States Following Dialysis Payment Reform

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis


  • Bhatnagar, Anshul, Baylor College of Medicine, Houston, Texas, United States
  • Winkelmayer, Wolfgang C., Baylor College of Medicine, Houston, Texas, United States
  • Erickson, Kevin F., Baylor College of Medicine, Houston, Texas, United States

Group or Team Name

  • Baylor College of Medicine

Hemodialysis markets are highly concentrated. It is unknown whether market competition influences how dialysis providers respond to reimbursement reforms. We examined whether changes in anemia management following the 2011 expansion of Medicare’s Prospective Payment System (PPS) for end-stage kidney disease varied with market competition.


From the US dialysis registry, we identified patients undergoing in-center hemodialysis in 2009 and 2012, representing periods before and after reimbursement reform. We used a difference-in-differences (DID) study design to estimate the independent associations among market competition and changes in erythropoiesis stimulating agents (ESAs) and intravenous iron dosage, the probability of having a hemoglobin <9 g/dl, and hospitalizations. We also examined serum ferritin concentrations, an indicator of the body’s iron stores, in 2012 to understand patient management practices. Market competition was represented as a dichotomous variable, with less competitive areas defined as with those with ≤2 competing dialysis providers.


Among 326,150 patients identified, 39% received dialysis in less competitive areas. Compared to areas with more competition, patients in less competitive areas had slightly more pronounced declines in ESA dose (60% versus 57%) following reimbursement reform (DID estimate: -3%; 95% Confidence Interval (CI) -5% to -1%) and less pronounced declines in intravenous iron dose (-14% versus -19%; DID estimate: 5%; 95% CI 1% to 9%). The estimated likelihoods of hemoglobin <9 g/dl, mortality, and hospitalization did not vary with market competition. Serum ferritin concentrations in 2012 were 4% (95% CI 3% to 6%) higher in less competitive areas.


Following expansion of the ESRD PPS, ESA use declined by slightly more and intravenous iron use declined by less in less competitive markets. These changes reflected a shift in anemia management towards more intensive use of intravenous iron relative to ESA and higher serum ferritin concentrations in areas with less market competition. While this suggests greater changes in cost management occurred in less competitive markets, there were no associated adverse effects on observed health outcomes.


  • NIDDK Support