Baylor College of Medicine, Section of Nephrology, Houston, TX.
Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
Med Care. 2023 Nov 1;61(11):787-795. doi: 10.1097/MLR.0000000000001924. Epub 2023 Sep 18.
Whether market competition influences health care provider responses to national reimbursement reforms is unknown.
We examined whether changes in anemia management after the expansion of Medicare's dialysis payment bundle varied with market competition.
With data from the US dialysis registry, we used a difference-in-differences (DID) design to estimate the independent associations of market competition with changes in anemia management after dialysis reimbursement reform.
A total of 326,150 patients underwent in-center hemodialysis in 2009 and 2012, representing periods before and after reimbursement reform.
Outcomes were erythropoiesis-stimulating agent (ESA) and intravenous iron dosage, the probability of hemoglobin <9 g/dL, hospitalizations, and mortality. We also examined serum ferritin concentration, an indicator of body iron stores. We used a dichotomous market competition index, with less competitive areas defined as effectively having <2 competing dialysis providers.
Compared with areas with more competition, patients in less competitive areas had slightly more pronounced declines in ESA dose (60% vs. 57%) following reimbursement reform (DID estimate: -3%; 95% CI, -5% to -1%) and less pronounced declines in intravenous iron dose (-14% vs. -19%; DID estimate: 5%; 95% CI, 1%-9%). The likelihoods of hemoglobin <9 g/dL, hospitalization, and mortality did not vary with market competition. Serum ferritin concentrations in 2012 were 4% (95% CI, 3%-6%) higher in less competitive areas.
After the expansion of Medicare's dialysis payment bundle, ESA use declined by more, and intravenous iron use declined by less in concentrated markets. More aggressive cost-reduction strategies may be implemented in less competitive markets.
市场竞争是否会影响医疗服务提供者对国家报销改革的反应尚不清楚。
我们研究了在 Medicare 透析支付捆绑包扩大后，贫血管理的变化是否因市场竞争而有所不同。
利用美国透析登记处的数据，我们采用差分法（DID）设计来评估市场竞争与透析报销改革后贫血管理变化的独立关联。
共有 326150 名患者在 2009 年和 2012 年接受了中心血液透析，分别代表报销改革前后的时期。
结果为促红细胞生成素刺激剂（ESA）和静脉铁剂量、血红蛋白<9g/dL 的概率、住院和死亡率。我们还检查了血清铁蛋白浓度，这是体内铁储存的一个指标。我们使用了一个二分类的市场竞争指数，其中竞争较弱的地区定义为实际上只有<2 家竞争的透析提供者。
与竞争激烈的地区相比，竞争较弱的地区的患者在报销改革后 ESA 剂量的下降幅度略大（60%对 57%）（DID 估计值：-3%；95%CI，-5%至-1%），静脉铁剂量的下降幅度略小（-14%对-19%；DID 估计值：5%；95%CI，1%-9%）。血红蛋白<9g/dL、住院和死亡率的可能性与市场竞争无关。2012 年，竞争较弱地区的血清铁蛋白浓度高出 4%（95%CI，3%-6%）。
在 Medicare 透析支付捆绑包扩大后，ESA 的使用减少更多，而集中市场的静脉铁使用减少更少。在竞争较弱的市场中，可能会实施更积极的成本降低策略。
