Medicare coverage for erythropoiesis-stimulating agents: the perfect storm.

Medicare policy changes have an immediate impact on health plans with regard to setting payment policy for providers. So when Medicare tightened payment guidelines for a lucrative class of anemia drugs-erythropoiesis-stimulating agents-an ambitious set of rules was put into effect. Health plans often follow suit in short order, enforcing public guidelines on private payors, even when saving money is not a consideration. However, when Medicare takes an unreasonably hard line, plans tend to focus on members and physicians more fervently, attempting to soften the hard line. In this first part of the interview, Dr Silver examines the coverage decisions set by the Centers for Medicare & Medicaid Services for the use of erythropoiesis-stimulating agents and discusses the issues surrounding their adoption, indications versus off-label use, as well as lingering questions about their role in tumor progression and other risk factors.