Eugene Lin
@eugelin06.bsky.social
Nephrologist at the University of Southern California (@keck.usc.edu @schaeffer.usc.edu)
Health Policy Nerd
#nephbbq enthusiast
Health Policy Nerd
#nephbbq enthusiast
8/ Most importantly, we still don't know whether dialysis patients are helped or harmed by MA.
Unfortunately, our healthcare system isn't organized to put patient interests first. This study was a very interesting glimpse into how patients are ignored.
Unfortunately, our healthcare system isn't organized to put patient interests first. This study was a very interesting glimpse into how patients are ignored.
June 18, 2025 at 7:54 PM
8/ Most importantly, we still don't know whether dialysis patients are helped or harmed by MA.
Unfortunately, our healthcare system isn't organized to put patient interests first. This study was a very interesting glimpse into how patients are ignored.
Unfortunately, our healthcare system isn't organized to put patient interests first. This study was a very interesting glimpse into how patients are ignored.
7/ Third, I worry that focusing on MA plans ignores the clear financial incentive that dialysis organizations have to steer patients into MA plans
And that dialysis organizations have way more power to influence patients than MA plans
And that dialysis organizations have way more power to influence patients than MA plans
June 18, 2025 at 7:54 PM
7/ Third, I worry that focusing on MA plans ignores the clear financial incentive that dialysis organizations have to steer patients into MA plans
And that dialysis organizations have way more power to influence patients than MA plans
And that dialysis organizations have way more power to influence patients than MA plans
6/ Clinicians were alarmed - Add this to a deluge of evidence that business interests are running away from clinicians to the potential detriment of patients
Clinician leaders ARE an important bulwark, and we should be wary of ignoring the professionalism of clinicians
Clinician leaders ARE an important bulwark, and we should be wary of ignoring the professionalism of clinicians
June 18, 2025 at 7:54 PM
6/ Clinicians were alarmed - Add this to a deluge of evidence that business interests are running away from clinicians to the potential detriment of patients
Clinician leaders ARE an important bulwark, and we should be wary of ignoring the professionalism of clinicians
Clinician leaders ARE an important bulwark, and we should be wary of ignoring the professionalism of clinicians
5/ What are my additional takeaways from this interesting study?
First, it's important to recognize that MA is a story of heterogeneity - the large dialysis organizations are profiting heavily, but are the smaller ones? I'm not so sure
First, it's important to recognize that MA is a story of heterogeneity - the large dialysis organizations are profiting heavily, but are the smaller ones? I'm not so sure
June 18, 2025 at 7:53 PM
5/ What are my additional takeaways from this interesting study?
First, it's important to recognize that MA is a story of heterogeneity - the large dialysis organizations are profiting heavily, but are the smaller ones? I'm not so sure
First, it's important to recognize that MA is a story of heterogeneity - the large dialysis organizations are profiting heavily, but are the smaller ones? I'm not so sure
4/ Steering patients into MA is a no-brainer given how profitable it is
MA plans are profiting heavily as are dialysis organizations
MA plans are profiting heavily as are dialysis organizations
June 18, 2025 at 7:53 PM
4/ Steering patients into MA is a no-brainer given how profitable it is
MA plans are profiting heavily as are dialysis organizations
MA plans are profiting heavily as are dialysis organizations
3/ The authors found broad agreement that advertising could be misleading, false, and/or overwhelming
In some cases, participants described behavior that is hard to interpret as anything other than a bribe to induce MA enrollment
(here, DO = dialysis organization)
In some cases, participants described behavior that is hard to interpret as anything other than a bribe to induce MA enrollment
(here, DO = dialysis organization)
June 18, 2025 at 7:53 PM
3/ The authors found broad agreement that advertising could be misleading, false, and/or overwhelming
In some cases, participants described behavior that is hard to interpret as anything other than a bribe to induce MA enrollment
(here, DO = dialysis organization)
In some cases, participants described behavior that is hard to interpret as anything other than a bribe to induce MA enrollment
(here, DO = dialysis organization)
2/ This study was very broad! They interviewed over 50 executives and staff from MA plans, kidney care management companies, and dialysis organizations
Although it is a real limitation that patient perspectives weren't included. Hopefully forthcoming in paper 2?
Although it is a real limitation that patient perspectives weren't included. Hopefully forthcoming in paper 2?
June 18, 2025 at 7:52 PM
2/ This study was very broad! They interviewed over 50 executives and staff from MA plans, kidney care management companies, and dialysis organizations
Although it is a real limitation that patient perspectives weren't included. Hopefully forthcoming in paper 2?
Although it is a real limitation that patient perspectives weren't included. Hopefully forthcoming in paper 2?
I had the privilege of writing a commentary in @jamanetworkopen.com
on this very interesting qualitative study re: Medicare Advantage advertising in dialysis
In short, the flurry of ads are often misleading to patients, and it's unclear if patients are shortchanged
🧵 1/
on this very interesting qualitative study re: Medicare Advantage advertising in dialysis
In short, the flurry of ads are often misleading to patients, and it's unclear if patients are shortchanged
🧵 1/
June 18, 2025 at 7:52 PM
I had the privilege of writing a commentary in @jamanetworkopen.com
on this very interesting qualitative study re: Medicare Advantage advertising in dialysis
In short, the flurry of ads are often misleading to patients, and it's unclear if patients are shortchanged
🧵 1/
on this very interesting qualitative study re: Medicare Advantage advertising in dialysis
In short, the flurry of ads are often misleading to patients, and it's unclear if patients are shortchanged
🧵 1/
My daughter is too cute
May 28, 2025 at 1:57 PM
My daughter is too cute
This doesn't just impact the past - this year, @CMSGov
was legislatively obligated to roll all phosphate binders (which are oral only) into the bundle. That is, binders are now in TDAPA
This came with some trepidation by industry and in some cases legal action
21/
was legislatively obligated to roll all phosphate binders (which are oral only) into the bundle. That is, binders are now in TDAPA
This came with some trepidation by industry and in some cases legal action
21/
April 18, 2025 at 8:28 PM
This doesn't just impact the past - this year, @CMSGov
was legislatively obligated to roll all phosphate binders (which are oral only) into the bundle. That is, binders are now in TDAPA
This came with some trepidation by industry and in some cases legal action
21/
was legislatively obligated to roll all phosphate binders (which are oral only) into the bundle. That is, binders are now in TDAPA
This came with some trepidation by industry and in some cases legal action
21/
You can see the formal difference-in-differences (and triple differences) comparison in the following forest plot, with p-values for interaction
17/
17/
April 18, 2025 at 8:27 PM
You can see the formal difference-in-differences (and triple differences) comparison in the following forest plot, with p-values for interaction
17/
17/
One question is whether there was heterogeneity in the policy's benefit. And indeed we show that Black and Hispanic patients received the most benefit from the policy (for the nerds, we used a triple difference to do this)
16/
16/
April 18, 2025 at 8:26 PM
One question is whether there was heterogeneity in the policy's benefit. And indeed we show that Black and Hispanic patients received the most benefit from the policy (for the nerds, we used a triple difference to do this)
16/
16/
Using a difference-in-differences estimator (we used a 2-way fixed effects estimator in an event study), we show close to parallel trajectories among these 4 groups, but a relative increase in calcimimetic access, again based on the generosity of the subsidy
14/
14/
April 18, 2025 at 8:26 PM
Using a difference-in-differences estimator (we used a 2-way fixed effects estimator in an event study), we show close to parallel trajectories among these 4 groups, but a relative increase in calcimimetic access, again based on the generosity of the subsidy
14/
14/
So what were the overall trends in calcimimetic use?
Exactly what one would expect: large increases in calcimimetic use related to how generous the change was in drug coverage
Note, we saw a small decline among patients with the full subsidy
13/
Exactly what one would expect: large increases in calcimimetic use related to how generous the change was in drug coverage
Note, we saw a small decline among patients with the full subsidy
13/
April 18, 2025 at 8:26 PM
So what were the overall trends in calcimimetic use?
Exactly what one would expect: large increases in calcimimetic use related to how generous the change was in drug coverage
Note, we saw a small decline among patients with the full subsidy
13/
Exactly what one would expect: large increases in calcimimetic use related to how generous the change was in drug coverage
Note, we saw a small decline among patients with the full subsidy
13/
Before showing results, it's worth showing that >40% of the population had large OOP exposure to calcimimetics
12/
12/
April 18, 2025 at 8:25 PM
Before showing results, it's worth showing that >40% of the population had large OOP exposure to calcimimetics
12/
12/
Put another way:
TDAPA's generosity is inversely related to the patient's LIS benefit
We thus exploited this differential policy benefit using a standard difference-in-differences design
11/
TDAPA's generosity is inversely related to the patient's LIS benefit
We thus exploited this differential policy benefit using a standard difference-in-differences design
11/
April 18, 2025 at 8:25 PM
Put another way:
TDAPA's generosity is inversely related to the patient's LIS benefit
We thus exploited this differential policy benefit using a standard difference-in-differences design
11/
TDAPA's generosity is inversely related to the patient's LIS benefit
We thus exploited this differential policy benefit using a standard difference-in-differences design
11/
Luckily, there is a program that offsets cost sharing for many patients called the low-income subsidy (LIS)
LIS is complicated, but beneficiaries qualify for full, partial, or no subsidies based on income.
ssa.gov/policy/docs/...
9/
LIS is complicated, but beneficiaries qualify for full, partial, or no subsidies based on income.
ssa.gov/policy/docs/...
9/
April 18, 2025 at 8:25 PM
Luckily, there is a program that offsets cost sharing for many patients called the low-income subsidy (LIS)
LIS is complicated, but beneficiaries qualify for full, partial, or no subsidies based on income.
ssa.gov/policy/docs/...
9/
LIS is complicated, but beneficiaries qualify for full, partial, or no subsidies based on income.
ssa.gov/policy/docs/...
9/
I was shocked when I first learned this because of how many of our patients need prescription drugs
And, even patients with Part D often have large out of pocket costs at the point of pharmacy.
Here's a snapshot of how complicated Part D is
kff.org/medicare/iss...
8/
And, even patients with Part D often have large out of pocket costs at the point of pharmacy.
Here's a snapshot of how complicated Part D is
kff.org/medicare/iss...
8/
April 18, 2025 at 8:24 PM
I was shocked when I first learned this because of how many of our patients need prescription drugs
And, even patients with Part D often have large out of pocket costs at the point of pharmacy.
Here's a snapshot of how complicated Part D is
kff.org/medicare/iss...
8/
And, even patients with Part D often have large out of pocket costs at the point of pharmacy.
Here's a snapshot of how complicated Part D is
kff.org/medicare/iss...
8/
Before 2017, calcimimetics were paid outside the bundle as an add-on through Part D
From 2017-2020 (during TDAPA), calcimimetics were paid as an add-on through Part B
Why should we care? Because >20% of ESRD patients don't have a Part D plan!
usrds-adr.niddk.nih.gov/2024/end-sta...
7/
From 2017-2020 (during TDAPA), calcimimetics were paid as an add-on through Part B
Why should we care? Because >20% of ESRD patients don't have a Part D plan!
usrds-adr.niddk.nih.gov/2024/end-sta...
7/
April 18, 2025 at 8:24 PM
Before 2017, calcimimetics were paid outside the bundle as an add-on through Part D
From 2017-2020 (during TDAPA), calcimimetics were paid as an add-on through Part B
Why should we care? Because >20% of ESRD patients don't have a Part D plan!
usrds-adr.niddk.nih.gov/2024/end-sta...
7/
From 2017-2020 (during TDAPA), calcimimetics were paid as an add-on through Part B
Why should we care? Because >20% of ESRD patients don't have a Part D plan!
usrds-adr.niddk.nih.gov/2024/end-sta...
7/
This resulted in a CMS transition program in 2017 (called TDAPA) to bring calcimimetics into the bundle because of the IV equivalent.
That is, calcimimetics transitioned from Part D to Part B
Important🌟: TDAPA is paid outside the bundle as an add-on payment
6/
That is, calcimimetics transitioned from Part D to Part B
Important🌟: TDAPA is paid outside the bundle as an add-on payment
6/
April 18, 2025 at 8:23 PM
This resulted in a CMS transition program in 2017 (called TDAPA) to bring calcimimetics into the bundle because of the IV equivalent.
That is, calcimimetics transitioned from Part D to Part B
Important🌟: TDAPA is paid outside the bundle as an add-on payment
6/
That is, calcimimetics transitioned from Part D to Part B
Important🌟: TDAPA is paid outside the bundle as an add-on payment
6/
Before 2017, cinacalcet (an oral drug) was the only calcimimetic, and thus was paid in the Part D carve out
In 2017, Amgen got FDA approval for a new IV calcimimetic, etelcalcetide, which was superior to cinacalcet at reducing PTH levels
jamanetwork.com/journals/jam...
5/
In 2017, Amgen got FDA approval for a new IV calcimimetic, etelcalcetide, which was superior to cinacalcet at reducing PTH levels
jamanetwork.com/journals/jam...
5/
April 18, 2025 at 8:23 PM
Before 2017, cinacalcet (an oral drug) was the only calcimimetic, and thus was paid in the Part D carve out
In 2017, Amgen got FDA approval for a new IV calcimimetic, etelcalcetide, which was superior to cinacalcet at reducing PTH levels
jamanetwork.com/journals/jam...
5/
In 2017, Amgen got FDA approval for a new IV calcimimetic, etelcalcetide, which was superior to cinacalcet at reducing PTH levels
jamanetwork.com/journals/jam...
5/
An important ESRD drug is the calcimimetics, which work by binding the calcium sensing receptor in the parathyroid gland and reduce PTH secretion
Importantly, these drugs prevent hypercalcemia and can reduce parathyroidectomies
(from kireports.org/action/showP...)
4/
Importantly, these drugs prevent hypercalcemia and can reduce parathyroidectomies
(from kireports.org/action/showP...)
4/
April 18, 2025 at 8:22 PM
An important ESRD drug is the calcimimetics, which work by binding the calcium sensing receptor in the parathyroid gland and reduce PTH secretion
Importantly, these drugs prevent hypercalcemia and can reduce parathyroidectomies
(from kireports.org/action/showP...)
4/
Importantly, these drugs prevent hypercalcemia and can reduce parathyroidectomies
(from kireports.org/action/showP...)
4/
First, what is TDAPA? Before getting there a primer on ESRD (dialysis) payment
Dialysis is paid under Medicare Part B, the outpatient part of Medicare, through a bundle that includes the treatment and related medications
From MedPAC, this is the bundle
2/
Dialysis is paid under Medicare Part B, the outpatient part of Medicare, through a bundle that includes the treatment and related medications
From MedPAC, this is the bundle
2/
April 18, 2025 at 8:22 PM
First, what is TDAPA? Before getting there a primer on ESRD (dialysis) payment
Dialysis is paid under Medicare Part B, the outpatient part of Medicare, through a bundle that includes the treatment and related medications
From MedPAC, this is the bundle
2/
Dialysis is paid under Medicare Part B, the outpatient part of Medicare, through a bundle that includes the treatment and related medications
From MedPAC, this is the bundle
2/