New payment rules for dialysis services could further erode the use of erythropoietin-stimulating agents (ESAs), already under scrutiny for potential safety risks. The US Centers for Medicare & Medicaid Services are changing how Medicare pays for end-stage renal disease services. From 1 January 2011, payment will bundle equipment and drugs into a single base rate, which will be increased from $198 to $229.60. This single rate will include injectable ESAs, prescribed to stimulate red blood cell production, which are currently reimbursed separately. “The move could affect prescribing patterns for ESAs and may discourage healthcare providers from using large doses of erythropoietin for patients as it could lead to financial loss,” says Aparna Krishnan, senior research analyst at IHS Global Insight in Lexington, Massachusetts. Makers of all versions of epoetin alpha are likely to be affected. The US Food and Drug Administration already requires a risk evaluation and mitigation strategy for ESAs, following studies linking an increase in tumor growth or risk of cardiovascular events to the drugs (Nat. Biotechnol. 28, 303, 2010). With the new rules, “Companies that manufacture ESAs will be forced to reduce drug prices or risk loss [of] market share,” says Swetha Shantikumar, research associate at Frost & Sullivan, Chennai, India.