Is Medicare reimbursement policy for erythropoietin in ESRD flawed?

[angieskidney]

Article from TheHeart.org
http://www.theheart.org/article/764131.do

"Boston, MA - In 2005, epoetin alfa for the treatment of anemia in end-stage renal disease (ESRD) was the highest-expenditure drug in all of Medicare Part B, and financial incentives may be leading to overuse of epoetin, writes Dr Robert Steinbrook (Dartmouth Medical School, Hanover, NH), a national correspondent for the New England Journal of Medicine (NEJM). His thoughts appear as a Perspective in the January 4, 2007 issue of the Journal."

[Zach]

Sadly, this problem of Dialysis Centers profiteering off of EPO has been occurring since the drug first became widely available in the late 1980's and early 1990's.

[BigSky]

Personally I see more flaws in how studies on done on the epo and patients than treatment itself with the drug.

One being that patients with higher hemoglobin rates because of epo have higher mortality rates.  This is due to blood clots primarily.  They use this as a basis to claim over treatment with epo.

I think they overlook the fact that many dialysis patients are fairly sedentary.   Even those that are healthy are at a greater risk for blood clots if they are sedentary so why wouldn't the same be true for dialysis patients?   Epo may indeed compound the problem but science needs to look past their narrow focus on epo alone.




Here once within ideal blood range they lower they so ever so slightly until it drops about of desired range then readjust accordingly.

I think the bigger problem is far too many doctors are narrow sighted in treatment.  The concept that it is one drug alone and only one that should be used in treatment of anemia is shortsighted to me.

Studies have been done showing that Anabolic therapy when used in conjunction with erythropoietin therapy produce far better results in all around well being of dialysis patients and those on that therapy needed much less erythropoietin than those who were not on such dual therapy.

[Rerun]

I think they could cut back on a LOT of Epogen if they would clear the blood lines.  They throw away LOTS of red blood cells.  I see pink lines going to the garbage time after time.

Before Epogen they wanted the patient to get back ALL their blood back, and the lines were clear........CLEAR! - NOT PINK!

                    

[jbeany]

I think they could cut back on a LOT of Epogen if they would clear the blood lines.  They throw away LOTS of red blood cells.  I see pink lines going to the garbage time after time.

Before Epogen they wanted the patient to get back ALL their blood back, and the lines were clear........CLEAR! - NOT PINK!

                    

I notice a difference from nurse to nurse on that.  Some of them very carefully watch the tubing until it is clear to within an inch or two of the needle; others disconnect me while everything is still red back almost to the machine.  I hadn't thought about the effect on my hemoglobin.  I do see the difference in my dry weight, though, since I get far less saline if they don't try to perfectly flush the lines.

[kelliOR]

 Quote by Rerun:

I think they could cut back on a LOT of Epogen if they would clear the blood lines. 

               
Less epogen would be used, and save money if it was administered subQ.  Epogen is 20-30% more effective subQ than IV.  Less could be given and it wouldn't have to be given as often to reach desired results.  I fought with my dialysis center to give it myself, since the center was out of network and I had to pay 40% of dialysis bills for the first three months. (I Lost).  Apparently IV epo increased their profit margin.

Kelli

Fixed Quote.  Rerun/ Moderator

[jbeany]

I had the same argument, kelli - only I won.  I'm still taking mine sub-q every other week.  I've been on it at the same dose and schedule for years.  I couldn't see any logical reason to change that just because I started dialysis.  Plus, with my dosing schedule, I get to avoid the side effects I get from it on a weekly basis, and for the most part, sleep thru the shaking it gives me, since I take it just before bed time.  If they gave it to me in-center, I'd be shaking like crazy on the drive home.  I refused to sign the consent form for them to give it to me, so they can't bill medicare for it.  They are still not happy about it, but they got over it!

[kelliOR]

I had the same argument, kelli - only I won. 

Good for you!  My problem was compounded by the fact that the Fresenius facility was the only hemo center within a 150 mile radius and they wouldn't budge on their policy.  When I have to go back on dialysis, I will be loaded with ammo.

[BigSky]

I think they could cut back on a LOT of Epogen if they would clear the blood lines.  They throw away LOTS of red blood cells.  I see pink lines going to the garbage time after time.

Before Epogen they wanted the patient to get back ALL their blood back, and the lines were clear........CLEAR! - NOT PINK!

                    

Here from what I have seen they let it run clear.  In my case though they let me decide when to stop it.

Less epogen would be used, and save money if it was administered subQ.  Epogen is 20-30% more effective subQ than IV.  Less could be given and it wouldn't have to be given as often to reach desired results.  I fought with my dialysis center to give it myself, since the center was out of network and I had to pay 40% of dialysis bills for the first three months. (I Lost).  Apparently IV epo increased their profit margin.

Kelli

When we were given epo it was usually sub-q.  Some nurses did give it IV but it was usually only when it was large amounts of epo.  Now I believe since we are on Aranesp it is all given sub-q.

Did you try showing them the studies that say sub-q is better?  Might try that.  I would think it would be hard for them to refute your request for sub-q when it can be medically shown to be  better.

[Zach]

Apparently IV epo increased their profit margin.

You've got it!

Case closed.
 

[sandman]

I have some questions about this so please forgive me if I don't have all the facts straight.  Epogen or Eprex is used to help the body produse red blood cells and help elevate your hemoglobin levels, correct?  And the closer your hemoglobin is to normal levels, the more energy you have to perform your normal, everyday chores.  Am I still correct?  I am let to believe that if you have taken to much epogen or eprex, that your blood will become thicker and would clot much easier.  So a doctor would need to keep a close eye on the hemoglobin levels in their patients blood lab results.

From what I gather, hemoglobin levels of 12 to 15 for females and 14 to 17 for males is normal.  Is that correct?  Is that a maximum limit or a healthy persons normal limit?  I have seen a few of Angie's lab results and her hemoglobin was usually with-in the lower end of those boundaries.  One or two that I have seen, were actually just below those limits yet I have never seen her lines run clear.

I know I am missing a point here so maybe someone can explain it to me.  I know that the pink you see in your lines after rinceback is red blood cells but if your taking a form of erythopoeitin to help boost your bodies red blood cell production, why is it so important for the patients to recover every last drop of blood?

Added* 
And if you take less epogen, wouldn't that lower your energy levels because of a lowered amount of oxygen being carried though your system because of a lack of red blood cells?

[Rerun]

Sandman   

But, the topic of the thread is the cost of epogen to the tax payers is exacerbated when clinics are careless or do it IV instead of subQ to waste it and use more Epigen up, thus spending more money needlessly.

[sandman]

Sorry rerun.  Didn't mean to carry this thread off topic but when you said what you did here, http://ihatedialysis.com/forum/index.php?topic=2617.msg36911#msg36911.  It just made me want to ask these questions.  It just looked like an opportune moment to ask.  My apologies if I should have started a new thread.

[angieskidney]

Sorry rerun.  Didn't mean to carry this thread off topic but when you said what you did here, http://ihatedialysis.com/forum/index.php?topic=2617.msg36911#msg36911.  It just made me want to ask these questions.  It just looked like an opportune moment to ask.  My apologies if I should have started a new thread.

Actually those were VERY good questions and I think you should start a new thread. Maybe called "Trying to understand the whole Erythropoietin thing" or something like that.

(by the way, erythropoietin is Epogen / Eprex)

Just copy paste your post to the new thread.

[sandman]

Thank you for the advice Angie and rerun.  My question will be continued here.
http://ihatedialysis.com/forum/index.php?topic=2652.msg37552#msg37552

[thegrammalady]

Less epogen would be used, and save money if it was administered subQ.  Epogen is 20-30% more effective subQ than IV.  Less could be given and it wouldn't have to be given as often to reach desired results.  I fought with my dialysis center to give it myself, since the center was out of network and I had to pay 40% of dialysis bills for the first three months. (I Lost).  Apparently IV epo increased their profit margin.

Kelli

Fixed Quote.  Rerun/ Moderator
[/quote

again my question would be shouldn't it be however your doctor wants.  I'm fully aware that centers differ, mine gives meds via iv and the center I use when I visit my parents in Oregon gives all meds sub-q. However the first time I was there and questioned it they said they would be glad to do it iv if I was more comfortable with it that way.  I HATE NEEDLES, a pin cushion I am not!!!!!!!!

[kitkatz]

I keep telling my center, I am not a pin cushion and I will not have it given to me Sub-Q.  It hurts and why the hell would I want to hurt again? Isn't dialysis bad enough, we have to add to it?  The nurse tried to tell me as a Kaiser patient I have to have it given Sub-Q, I told him no way and I know the center at Fresenius gives it through the IV lines, becasue I have friend who goes to dialysis there. So, hah!

[angieskidney]

I keep telling my center, I am not a pin cushion and I will not have it given to me Sub-Q.  It hurts and why the hell would I want to hurt again? Isn't dialysis bad enough, we have to add to it?  The nurse tried to tell me as a Kaiser patient I have to have it given Sub-Q, I told him no way and I know the center at Fresenius gives it through the IV lines, becasue I have friend who goes to dialysis there. So, hah!

Ya I have it given in my Fresenius Machine. There is a port in the venous line for it.