By Peter Laird, MD
The major concern voiced about the renal bundle prior to implementation was withholding needed medications to maintain basic vital processes. The renal bundle is largely due to the abuse of EPO for the maintenance of hemoglobin levels in dialysis patients. Erythropoietin comes from health renal tissues that are absent in the majority of patients on hemodialysis with the exception of many with polycystic kidney disease. Under the renal bundle, EPO went from a separately billable income generator to a cost center for dialysis centers.
In the latest USRDS report noted by Gary Peterson on RenalWeb, blood transfusions increased throughout the industry, but the greatest increase is among patients at DaVita, a for-profit dialysis company.
"Since adoption of the bundled payment system, the number of transfusion events has increased, reaching 24 percent by September, 2011. Some providers are associated with a significant increase in transfusion rates over the one-year time period (the rate increased 46 percent in DaVita units), while others show minimal changes (4 and 7 percent in Fresenius and hospital-based units, respectively)."
Looking at further indicators of why DaVita has such an outrageous transfusion rate, one of the answers to that issue is not only in the 37% reduction of EPO use, but much more in their concomitant severe reduction of IV iron products by a factor of 42%.
Tracing the history of EPO abuse at DaVita leading to the moniker, the King of EPO, their gratuitous allegiance to profiteering, now evidenced by the 46% increased transfusion rate is nothing short of a shocking indictment of this company and their business plan. We all understood that the renal bundle would dramatically lower the usage of EPO, but the majority of practitioners expected an increased usage of IV iron products to maintain quality of life in dialysis patients.
Scott Rasgon at Kaiser Sunset maintained stable Hb levels with simple over the counter Vitamin D-3 supplementation while greatly reducing EPO usage. I have been fortunate to maintain my Hb levels with IV iron supplementation for nearly six years of dialysis to date. Patients understand well the quality of life issues associated with higher Hb levels. Sadly, there are absolutely no studies comparing the risk and benefits of EPO to the risk and benefits of transfusions.
Since transfusions are no longer allowed in many free standing dialysis units, hospitals and third party insurance companies pick up the tab on most of the transfusions that DaVita generated since implementing the bundle. This may make great business sense for DaVita generating further profits for their investors, but it makes no sense at all for the dialysis patients suffering with such severe anemia that they need such a large number of transfusions. As a practicing physician, I readily understood the risks of blood transfusions not the least of which is the risk of transmissible agents such as hepatitis and HIV. It was my goal to minimize the need for transfusions whenever possible.
Alan Nissenson has promoted the benefits of the DaVita model securing high quality of care as their model. In this instance, I must challenge their allegations of high quality care when they not only severely reduced EPO usage, but also withheld IV iron which is an effective and safe alternative and adjunctive therapy for renal associated anemia. I am sure that this has greatly increased DaVita profits, but at what expense to their patients.