Managing anemia in for-profit dialysis chains: when ethics and business conflict

The treatment of anemia in dialysis patients improves patient well-being and reduces the need for transfusions. Nevertheless, the hypothesis that normalization of hemoglobin via erythropoiesis-stimulating agents (ESAs) would improve cardiovascular health and survival has largely been refuted by randomized trials showing increased cardiac events and mortality with higher Hgb targets and higher doses of ESAs. Given these observations, one would expect restraint in ESA use. However, profits for dialysis facilities depend greatly on charging insurers for medications, and ESAs are the most profitable. Consequently, for-profit dialysis chains have an incentive to use high ESA doses. This practice was supported by the 2006 and 2007 Kidney Disease Outcomes Quality Initiative anemia guidelines; both versions promote higher hemoglobin targets and greater ESA use than the FDA and European Medicines Agency recommend. Under a Medicare bundled payment system in 2011, ESAs will move from being profitable to being an expense, and for-profit dialysis centers will have motivation to reduce use of ESAs and other medications. Nephrologists, as caregivers and dialysis facility medical directors, have an ethical responsibility to protect the health and welfare of patients under all payment systems. This article reviews the financial and ethical issues involved in the treatment of dialysis-related anemia and offers recommendations for maintaining ethical patient-centered anemia management.