THE EFFECT OF INSURANCE STATUS ON USE OF RECOMBINANT ERYTHROPOIETIN THERAPY AMONG END-STAGE RENAL-DISEASE PATIENTS IN 3 STATES

Recombinant human erythropoietin (rHuEPO) has been demonstrated to be effective in ameliorating anemia among persons with chronic renal fail ure, and is associated with improved functional status and quality of life. Access to rHuEPO has been examined by a variety of clinical, dem ographic, geographic, and facility characteristics. However, rHuEPO ut ilization based on insurance status has not been previously examined. All Medicare and Medicaid prevalent end-stage renal disease (ESRD) pat ients receiving dialysis services in California, Georgia, and Michigan in December 1991 were identified using state and federal administrati ve program data. The population in each state was stratified by insura nce status as follows: Medicare-entitled, Medicare/Medicaid dually ent itled, and Medicaid-only entitled. Insurance coverage of the ESRD popu lation by Medicaid, as either a primary or secondary payer, differed g reatly by state. In December 1991, the proportion of Medicaid-only and Medicaid/ Medicare dually eligible dialysis patients ranged, respecti vely, from 8% and 43% in California, to 3% and 26% in Michigan, and to 3% and 18% in Georgia. Compared with the Medicare-entitled population , the Medicaid/Medicare dually eligible and Medicaid-only populations disproportionately comprised women, black patients, and individuals yo unger than 20 years. Using Lee's two-stage binary legit model, dual-el igibility was found to be associated with an increased access to rHuEP O. Compared with their state-specific, dually eligible counterparts, t he odds of receiving rHuEPO was lower for Medicare-entitled patients i n California (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.7 6,0.93) and Georgia (OR, 0.65; 95% CI, 0.53,0.80), and lower for Medic aid-only patients in Georgia (OR, 0.02; 95% CI, 0.01,0.05) and Michiga n (OR, 0.34; 95% CI, 0.23,0.52). We hypothesize that the absence of su bstantial copayments associated with rHuEPO, approximately $1,000 per year for a portion of Medicare-entitled patients, resulted in increase d access among the dually eligible ESRD population. Dosing of rHuEPO w as associated primarily with patient hematocrit level (P < 0.0001) and was unrelated to insurance status. Regardless of insurance status, an unexpectedly large number of Medicare prevalent dialysis patients rec eiving rHuEPO in each state (31%, 42%, and 41% in California, Georgia, and Michigan, respectively) had hematocrit values lower than 0.28, in dicating inadequate treatment of anemia. Eleven percent of all patient s receiving rHuEPO in California and nearly 20% in Georgia and Michiga n were deemed to be severely anemic (hematocrit < 0.25). The wide vari ability in access to rHuEPO among the Medicaid-only populations may be indicative of state-specific differences in Medicaid prior approval, copayments, and other drug restrictions. We conclude that the Medicaid -only ESRD population excluded from Medicare coverage is particularly vulnerable to cost-containment measures that focus on expensive techno logies such as rHuEPO. (C) 1996 by the National Kidney Foundation, Inc .