Americans on dialysis - have you heard about the bundle?

[Marina]

Rerun, 
the  bundle  means  more out of  pocket  money  from the  patients.    Yes  we  will have  co-pays  even though  we  have  medicare  and  a  supplemental  insurance   

The "Bundling" system sounds good to me.  Dialysis Centers don't need to rip off Medicare and Sick People.  Medicare is right and the "gaming" of this old system has to stop. 

It is just wrong if our care goes down but their salaries stay the same.  NO!  Everyone at the top needs a reality check about too much profit. 

In the old days my hematrict would get down to 9 before a blood transfusion.  Now they have a shit fit if it gets down to 11..  I bet that will change!   

Bundling System........ Bring it on!       

[Marina]

I  just  received  a  letter  from my  unit......  since the  "bundling"  health  reform  passed,  they  have  decided  to  sell the  unit. 
It's  between  satellite and  davita,   whomever  makes a  better  offer. 

[ChickenLittle56]

It so sad that many not-for-profit clinics might have to go out of business or transfer ownership to one of the big chains. I heard from a PCT who works pat time here at my clinic and full time at the other that they are unsure what is going to happen after the first of the year.

[paul.karen]

The new health care package we were sold by the oboma administration was suppose to lower the cost for the patient while making services for the patients better.

here in this bundle which is but a small part of the big overhaul seems to be looking like the patient will be paying more while getting less service.

Big corporations are bowing out of the health care plans or charging there employees more and more for the same if not less coverage then they were previously receiving.
So are we getting better services for less out of pocket money??

Funny how NONE of the people who supported this bill are out on the stump talking about it's  wonders.    Like Pelosi said you will see whats in the bill once you pass the bill.  And what is in it isn't what was promised. 

[Zach]

here in this bundle which is but a small part of the big overhaul seems to be looking like the patient will be paying more while getting less service.

Do you know this to be a fact?

That this bundle was, "... part of the big overhaul ..."

[paul.karen]

No Zach i cant say that with certainty.  I am not as up to date on this as so many others seem to be. 

But the bundle involves medicare. And medicare  is run by the government which wants to use a new health care format to save citizens money while creating a better system of care.

I dont think anyone can say anything with certainty on a system that seems to me to be still in the works.  I just have my opinion.

[BigSky]

Somehow I doubt the bundling will be a good thing for patients.


From what I have been informed by staff on units will be dinged for all kinds of stuff, even that which is out of their control like certain labs and fluid gain by patients.

These dings mean lower payments to units which means costs being cut which affects patient care.

As it is now medicare doesnt even cover the cost of the dialysis procedure itself.  Somehow I doubt it will get better with bundling.

[MooseMom]

Maybe DaVita executives could take a pay cut...

I thought that the whole idea was to cut government spending.  So, we don't like it when government spending on Medicare gets cut?  With mid-term elections coming up, the American electorate seems to be extraordinarily schizophrenic.  Who gets to pay for our very costly treatment, the American taxpayer or Corporate America?  It's really that simple of a choice.

[BigSky]

Maybe DaVita executives could take a pay cut...

I thought that the whole idea was to cut government spending.  So, we don't like it when government spending on Medicare gets cut?  With mid-term elections coming up, the American electorate seems to be extraordinarily schizophrenic.  Who gets to pay for our very costly treatment, the American taxpayer or Corporate America?  It's really that simple of a choice.

I think this and stuff like it is where people want cuts and oversight.

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aY5OQ5xv9HR8

[greg10]

What does Pentagon contractor fraud got to do with the new medicare bundling payments? 

It appears that the new bundling can reduce excessive epoetin and other drug use without affecting overall dialysis outcome, and save Medicare and tax payer money in the long run, I can't see there should be too much objection to the new law.

Maybe DaVita executives could take a pay cut...

I thought that the whole idea was to cut government spending.  So, we don't like it when government spending on Medicare gets cut?  With mid-term elections coming up, the American electorate seems to be extraordinarily schizophrenic.  Who gets to pay for our very costly treatment, the American taxpayer or Corporate America?  It's really that simple of a choice.

I think this and stuff like it is where people want cuts and oversight.

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aY5OQ5xv9HR8

[PVUgrad]

The "bundle" is coming. 

Starting 1/1/2011, Medicare will change how it pays for dialysis.  The center gets one fixed rate per patient, per treatment, to cover meds, labs, personnel costs, supplies.  If you spend less per treatment than you receive, you make money.  If you spend more, you lose money.  Medicare took an average payment, then knocked 2% off it.  So everyone is looking for ways to provide the same care for less money.

This sounds dangerous for some. They will cut corners on some patients, won't they, to save a buck?

Sort of like McDonald's the other day. I got my order with NO napkins, and when I asked for one, well that is what I got ONE!

So if you are bleeding...just apply pressure on the bandage, as there is only per patient. 

[greg10]

Not necessarily cutting corners, but clinics will have to utilize their resources properly to ensure each patient get the best care.  Whether the clinics can adapt to do that is another matter, and I am sure some clinics will cut corners to the detriment of the patient - and the patients will have to take their business and health care elsewhere.

For too long the national clinics in particular had a blank check on some approved drugs such as epoetin, so much so that they would flush as much of that into the dialysis cartridge of every patient they could find, to the detriment of the health of those patients because the result of too high levels of hemoglobin (above 12g /dl) can cause clotting and other vascular problems - a major cause of morbidity and mortality in hemodialysis.  And guess what these same clinics were doing meanwhile to make a few more bucks off the patients - they were trying to reuse the filter cartridge 3 times a week because Medicare said they could, even though cartridge reuse is known to cause a lot of problems - immune and pyrogenic reactions, infections and disinfectant sensitivity.

Now, with the new bundling, hopefully the clinics will become more result oriented - better health of the patients means more payment and more business.  It is important however to let the patient have a choice of home care.  The patients should also have the choice of doing home dialysis, which is a preferred choice when the patient and his family or partner are able.  The clinics will therefore have to compete with each other as well as with the patients themselves.

The "bundle" is coming. 

Starting 1/1/2011, Medicare will change how it pays for dialysis.  The center gets one fixed rate per patient, per treatment, to cover meds, labs, personnel costs, supplies.  If you spend less per treatment than you receive, you make money.  If you spend more, you lose money.  Medicare took an average payment, then knocked 2% off it.  So everyone is looking for ways to provide the same care for less money.

This sounds dangerous for some. They will cut corners on some patients, won't they, to save a buck?

Sort of like McDonald's the other day. I got my order with NO napkins, and when I asked for one, well that is what I got ONE!

So if you are bleeding...just apply pressure on the bandage, as there is only per patient. 

[Zach]

For those interested in the bundle and what it entails, here is a good article from Renal Business Today:
http://www.renalbusiness.com/articles/2010/10/the-dialysis-industry-faces-bundling.aspx

For those who are incorrectly linking the ESRD bundle to "Obamacare," the "Medicare Improvements for Patients and Providers Act of July 15, 2008 (MIPPA)—directed CMS to change the reimbursement for ESRD care and effectively bring it in line with the original approach to include all elements of treatment in one “bundled” payment."

[ChickenLittle56]

The executives at the upper level will get their millions and the shareholders will get their dividends at the cost of our care. They will continue to cut corners at the smallest detail such as rubber gloves(they keep on running out of medium and large gloves that sometimes I have to fit into a small glove and they tear too easy). What if they have a rule that everyone has to use a clamp to hold their site because they don't want to use another gauze/band aid if the patient starts to bleed(even though your not suppose to use a clamp, it can damage the graft or fistula due to pressure). Changes like this can be a detriment to our lives and health.

As far as closing clinics, what if your in a small town and you no choice but that clinic and it closes down. In rural southwest Texas where I am at you could easily travel 75-150 miles each way to your nearest clinic if they happen to close the clinic in your town.(I did that several years back when I came for vacation for 3 weeks several years ago). I am pretty sure that is case in vast areas of the country where the D clinics are owned by non-profit agency or small hospital. earlier this past summer I spent 2 weeks in Karnes City, TX and when it came to dialyze I had to travel to San Antonio because the Fresenius clinic in Floresville closed down. That was a 60 mile trip each way. Going to Floresville would have been a 25 mile trip. So that closure more than doubled my trip. Now that closure might not been due to the bundle but it does show how closure of a clinic would put hardship on those living there.

I am for cutting costs but not at the level that I feel that bundling would cause. There will be unhappy patients and workers

[Bill Peckham]

For those who are incorrectly linking the ESRD bundle to "Obamacare," the "Medicare Improvements for Patients and Providers Act of July 15, 2008 (MIPPA)—directed CMS to change the reimbursement for ESRD care and effectively bring it in line with the original approach to include all elements of treatment in one “bundled” payment."

 

I think shouting Obamacare is a Pavlovian response among some to any healthcare complaint, anywhere.

Nephrologista I don't know why the bundle would be bad for NxStage - you lost me there. If NxStage pencils out pre bundle what has changed post bundle?

I think the bundle final rule was a huge win for HHD and since NxStage is the only approved HHD device right now it was a huge win for NxStage.

The bundle retains medical justification for additional treatments and there is a training adjuster. So training is now reimbursed at a much higher level. You have to understand that you get a forth and fifth BUNDLED payment a week which includes about a $180 bonus which is in addition to the extra $33 or so dollars per treatment Medicare included as a training add on.

The Bundle has two components the current composite rate and 1/156th of the total yearly amount spent on formerly separately billable items. Some of the separately billable items are routinely given monthly,  like iron maybe or routine labs, and some each treatment, like Epo (assuming the three day a week schedule) and some quarterly or semi annually (other labs). So to get the whole payment you'll need people to be in their chair every time but if you get medically justified additional payments you'll get the 1/156th of the total yearly amount spent on formerly separately billable items as a sort of bonus.

What this means is the allowed reimbursement of a week of training is about $330 a week higher under the bundle. This then means that the payback for the large unreimbursed upfront cost of training people to go home will be a bit less large. Currently the cost of training has to be made up over time by the person staying at home - I've heard 11 to 20 months. that time period is now shorter. If the person has ongoing medical justification as allowed by the FI/MAC then I don't even have to run the numbers to know NxStage, or home more frequent dialysis generally, would be a huge win for the unit.

This idea that the bundle includes 1/156th of the total yearly amount spent on formerly separately billable items is potentially much more of a problem for people incenter who travel or are hospitalized or who skip treatments. The total yearly amount spent on formerly separately billable items doesn't change much with frequency - if you skip you'll need those items when you do show up (and if you dialyze more than 3x week you don't get more). So if you skip or are hospitalized or travel (and the unit you visit doesn't provide or skimps on the formerly separately billables) your unit won't be getting those fractional payments.

My concern is that people won't be readmitted after a long hospital stay or if they like to take frequent vacations. Skipping may be seen as costing the unit money and result in involuntary dismissals.

That's what I worry about. NxStage did very well under the bundle - check out their  stock performance since the bundle was announced in 9/09.

[Bill Peckham]

The "bundle" is coming.  ..
The one bad thing I see about the bundle is that NextStage is almost a guaranteed loser.  The cartridge cost is just too much, even with the lower nursing costs, Epogen, etc.  I really worry what the bundle will do to home hemodialysis.

Just wondering if any of this is news.  It's your treatment and your tax dollars, and I don't think any of it should be (or is) secret.

Thanks to okarol for posting this: 'Portable dialysis gives grandma at-home care'
http://ihatedialysis.com/forum/index.php?topic=20531.msg0;topicseen#new

"For Blanchard, the bill for a single session at the clinic was $964, while her at-home sessions (NxStage) cost the government $310, for supplies."

I wouldn't rely on those numbers.

The article also said it was a twice a week procedure ... those billing numbers are no more informed.

[Lillupie]

The fluctations of the labs bother me personally. I know medicine, especially renal is a practice. Since starting 3 years ago, they have changed the lab values, and now I am finding it harder to trust the medical community. For example is my calcium has ran high. At 9 it was high and now 10 is normal. What the?  Make up your mind people! Is my calcium high or normal?! Same with the PTH.
Lisa

The problem with the strategy of measuring the success by the labs of the patients is that no center will put up with marginal patients and may refuse to treat them. It bothers me because there are fluctuations in labs that no one can anticipate or explain. And some patients are sicker than others.

[greg10]

Thank you Bill for the always detailed and helpful analysis.  But what are the numbers? in center versus NxStage for an average patient, if there is a such thing as average.  I find it interesting that we have a popular thread here on "What are you paying for gas" and there is no similar thread on "What are you paying for dialysis" (at least not very popular).

I can only say for certain that the with Medicare part A&B  without supplemental insurance for my elderly father, we were billed by a national chain monthly:
Total fees:  $40,000 to $60,000 claimed for thrice weekly dialysis.
Primary paid:  $2200 to $3000 paid (Medicare paid)
balance due: $550 to $850 (patient pays)

For NxStage, without supplemental insurance, in a different clinic (not national), we signed a contract to pay additional $250 to $300 per month to make up for the lack of a supplemental.

..
Thanks to okarol for posting this: 'Portable dialysis gives grandma at-home care'
http://ihatedialysis.com/forum/index.php?topic=20531.msg0;topicseen#new

"For Blanchard, the bill for a single session at the clinic was $964, while her at-home sessions (NxStage) cost the government $310, for supplies."

I wouldn't rely on those numbers.
The article also said it was a twice a week procedure ... those billing numbers are no more informed.

[Zach]

I find it interesting that we have a popular thread here on "What are you paying for gas" and there is no similar thread on "What are you paying for dialysis" (at least not very popular).

Here are some "old" threads about dialysis cost:
http://ihatedialysis.com/forum/index.php?topic=154.msg660#msg660
http://ihatedialysis.com/forum/index.php?topic=1994.msg27668#msg27668
http://ihatedialysis.com/forum/index.php?topic=13273.msg229434#msg229434
http://ihatedialysis.com/forum/index.php?topic=1102.msg12803#msg12803

[Bill Peckham]

After 2011 Medicare's average allowed payment will be $250 per treatment. Medicare pays 80%

If dialyzing conventionally incenter the unit will bill on average for 13 treatments a month - the Medicare allowed rate on average will be $3,250 per month (on average) and the copay or amount billed to secondary insurance will be $650 (on average, after 2011 in units that choose to go full-in, or after 2014 for everyone else).

That's incenter. If you are on NxStage dialyzing 6 times a week the unit can bill for at least that much ... as if you were dialyzing 3x week $3,250 ($650 secondary/$2,600 Medicare) but with NxStage and more frequent HHD there is the possibility of being paid for medically justified additional treatments.

Medicare doesn't actually handle claims and check writing. There are 15 (as of 2011) fiscal intermediary (FI) or Medicare administrative contractors (MACs) that actually make the coverage decisions. I hear some FI/MACs are more lenient than others. Some units routinely bill and are paid for more frequent treatments other FI/MACs have more stringent "Medically Justified" criteria.

But let's assume we're talking about someone with a congestive heart failure diagnosis and who's dialyzing six times a week thus qualifying to receive medically justified additional treatments (home or incenter) they will generate on average $250 per treatment for every treatment. For someone doing 6x that would be $6,500 ($1,300 secondary/$5,200 Medicare) per month.

That is a huge difference compared to what is being paid today even with medical justification.

My prediction is that it will be more common to be given four day a week incenter schedules. The weekend is wholly unsupported if you look at the data. People are much more likely to be hospitalized/die after their dialysis weekend.

Further I don't think any FI/MAC would refuse to reimburse for every other day (EOD) dialysis post 2011. If the payment rules stay the same or get more liberal I bet we'll start seeing EOD schedules and units staying open 7 days a week.

As a business, it would be a good business decision  and from a clinical point of view it would be much better so I don't know what would stop it. In a business the obvious thing to do is upsell existing customers. If you switched someone from 3x week to EOD you would be increasing sales from 156 a year to 187 to 189 a year. The per treatment revenue is the same for each EOD treatment but the cost of the 157th to 187th is much less because the cost of all the formerly separately billable items have been paid by the first 156 treatments.

An EOD schedule would also cushion units from the cost of hospitalizations and travel. At some point administrators are bound to figure this out.

[boswife]

dont mean to sound really dence but.................... right now we pay nothing for his treatments, we are going on NxStage very soon, comming first of the year, does this mean that we'll be paying a protion for either in center or home dialysis if right now we dont??? 

edit to add :-)  i just today got my paperwork for next year... Doesnt show any changes for that so keeping fingers crossed...  thanks if you know something different though.

[Bill Peckham]

dont mean to sound really dence but.................... right now we pay nothing for his treatments, we are going on NxStage very soon, comming first of the year, does this mean that we'll be paying a protion for either in center or home dialysis if right now we dont??? 

edit to add :-)  i just today got my paperwork for next year... Doesnt show any changes for that so keeping fingers crossed...  thanks if you know something different though.

There should be no change unless something with your secondary insurance changes independent of the change in Medicare reimbursement. The expanded bundle makes dialysis slightly less expensive (the 2% haircut) and more predictable so I'd say it is an improvement from the point of view of secondary insurers.