The economic realities of erythropoiesis-stimulating agent therapy in kidney disease

The administration of erythropoiesis-stimulating agents (ESAs) in the United States provides a classic example of how economics drive practice. When epoetin was first approved for the treatment of anemia in 1989, its use in hemodialysis patients was very conservative as long as it was reimbursed at a single capitated rate of $40 irrespective of dose. Once epoetin was reimbursed at a rate of $11 per 1000 U in 1991, its use skyrocketed. Despite two iterations of clinical practice guidelines recommending subcutaneous (SC) over intravenous (IV) epoetin administration in hemodialysis patients based on ample evidence that the former is significantly more effective, 95% of hemodialysis patients in the United States receive epoetin IV because epoetin is a profit center for dialysis providers and Medicare has been willing to pay for it. Although darbepoetin is about twice as expensive as epoetin for the same therapeutic effect in patients with chronic kidney disease, darbepoetin has achieved significant market penetration despite the higher cost burden for patients with co-pays and data demonstrating that comparable dosing intervals can be achieved in a majority of patients treated with epoetin. It is likely that increased attention to costs of medications by providers through reimbursement bundling models, payment for performance systems, and competition by newer therapeutic agents will have a significant impact on current practice patterns.