Economic considerations in a changing anemia environment.

The need for cost-effective strategies to manage the anemia of chronic kidney disease, whether in nondialysis or dialysis-dependent patients, is apparent after new insights into safety issues and economic realities associated with the dosing of erythropoiesis-stimulating agents (ESAs). Current Medicare payment policies do not encourage efficient use of ESAs, which are now reimbursed as separately billable items. However, the Centers for Medicare & Medicaid Services is developing a new payment system that would bundle reimbursement for dialysis-related services currently reimbursed on a composite basis plus other services and drugs, such as ESAs. These issues prompted an analysis of the Dialysis Patients' Response to IV Iron with Elevated Ferritin (DRIVE) studies to determine the cost savings associated with the ESA-sparing effects of intravenous (IV) iron, which showed that administering a 1-g course of IV iron (sodium ferric gluconate) to ESA-treated patients with increased serum ferritin levels and low transferrin saturations, compared with administering an ESA alone, resulted in decreased ESA requirements. These findings suggest that a single dose of IV iron in patients with high serum ferritin levels and low transferrin saturations as defined in DRIVE represents a potential tactic for improving treatment efficiency in a bundled reimbursement environment.