OBJECTIVES: Approximately 570,000 patients live with end-stage renal disease (ESRD) in the US. Of these, approximately 400,000 undergo dialysis three times per week. Estimates of the amount spent on care exceeds $25 billion. Internationally, costs for ESRD have continued to rise. Policymakers are seeking ways to decrease cost without decreasing quality. Under the 2011 prospective payment system (PPS), Medicare reimburses dialysis providers with bundled payments that include dialysis-related services and medications that treat anemia. Additional examination is needed regarding the impact on anemia therapy and cost. The objective of this study was to determine the post-PPS trends in utilization and cost of ESA and IV Iron use per dialysis session among Medicare and commercially insured lives.                         METHODS: Trends in use and cost were examined from 2011-2015. Data was derived from USRDS claims files and commercial health plans. Use per session, cost per session and dose per session was reported. Patients with ESRD were defined as patients with one or more paid dialysis facility claims or those who filed a Medical Evidence Form establishing kidney failure. Total paid amounts included the amount paid by the member and by the plan. Descriptive statistics were used to describe overall and state-specific expenditure trends. RESULTS: Regarding cost, drug spending decreased by $30 per session, or about 6 times the mandated reduction in the base payment rate of $5. Specifically, use of peritoneal dialysis increased in 2011 and the following years, while home hemodialysis also increased. Use of erythropoiesis-stimulating agents declined substantially after the new PPS debuted and this trend remained over the four years examined in this study. On the other hand, there was an increase in the use of IV iron. CONCLUSIONS: The expanded bundle incentives seem to have motivated dialysis providers to move toward lower cost methods of care in their choice of treatment modalities.