Americans on dialysis - have you heard about the bundle?

[Nephrologista]

The "bundle" is coming.  I'm sure that some of you are very up on this, but I haven't seen too much discussion here.  And some of the recent topics I think are related to the coming changes.

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.  Which is the idea - harness the profit motive.  Medicare will be looking very carefully to make sure quality isn't going down and that units aren't gaming the system.

Some things you will probably notice:
Epogen, Epogen, Epogen.  It's the most expensive thing about dialysis and units will be doing everything they can to get the dose down.  Which is really a good thing - too much Epo leads to its own set of problems.  Some data suggest that subcutaneous injection lets you use lower doses, which is why some units are changing.  The data isn't very convincing, though.  Catheters, old transplanted kidneys, old grafts - all these can make the body less sensitive to Epo.  Patients may be referred to have these removed.  Lots more iron, driving the transferrin saturation up to 30%.  Iron is cheaper than Epo.  Again, none of these are really bad things.  If you need 15,000 units of Epo three times a week, you should be checked over very carefully to make sure something else isn't going on.  But it will be much more aggressive starting in January.

Labs: may be less frequent.  53 separate labs are included in the bundle.  Nephrologists love labs, and we have a bad habit of ordering too many.  We just love the numbers.  We'll have to look more closely to see if we really need all those numbers.  Plus, drawing all that blood drives the blood counts down, and that gets back to Epogen.

Dialyzers, bloodlines, medications - all the chains are cutting deals to get those supply costs down.  So you may see changes in your unit in terms of what's being used.

More patients will be encouraged to consider PD.  This is a LONG time in coming, the US has always lagged way behind the rest of the world in PD.  It was always a money loser under the old system, and now that will change.  Nephrologists will be learning more about PD and encouraging more patients to try it.

Certain diagnoses cause the payment to be multiplied (by 1.1, 1.2, up to 1.4.)  There will be a lot of tests looking for multiple myeloma, bacterial pneumonia, sickle cell anemia.  Labelling a patient with one of those diagnoses, making sure the label is proper, is guaranteed extra money.

It is strange to act as both physician and careful steward of community resources.  I do think that most of the bundle will drive care in good directions.  But I'm also sure many patients will interpret things as evil penny-pinching.  It's true that dialysis is for the most part a for-profit proposition.  I've worked in both non-profit and for-profit and a good, caring for-profit company brings a lot of good resources and improves care in a lot of ways. 

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.

[Riki]

can I ask you a question.. Why Epo?  Why not Aranesp?  Wouldn't it be cheaper?  I could be wrong, but I was just wondering

[Rerun]

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!       

[MooseMom]

Bill Peckham is our man; his website "Dialysis from the sharp end of the needle" keeps us educated.

I'm all for fewer labs; I'm not on dialysis yet, but I have labs done every two to three months.  I've been doing this for 6 years now and don't know why my blood lipids have to be checked so damn often.  Since I've been on statins and Zetia, my numbers have been fab and have remained the same all these years.  And I hate fasting; it makes me grumpy.

I'm very concerned about what you've said about NxStage because that is the modality I am planning to use myself.  My neph agrees that this would be a good option for me.  We discussed PD, but I really don't want to do that because rightly or wrongly, I feel that home hemo gives better clinical results.   Besides, I already have my fistula placed.  I'll be keeping my eye on the future of NxStage use.

I don't mind dialysis centers making money as long as my life isn't being threatened as a result.

[boswife]

Sooo, do you think this could be a possible reason that we're (hubby and i) are getting pushed back to start home hemo until 'next' year???  What would that mean to us.  Would it be to our bennifet to pUSH ourselfs to getting started this year??  I mean, i am pushing anyway  but dont know if i should quit pushing or push harder...     or even give it up now as it may cost us what we cant do 

[greg10]

..

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.

Even though many here are on NxStage, I think this may be news to many users that NxStage cartridge cost is much more than Fresenius.  Could you give us a rough comparison?

[Rerun]

I would think the cost of the cartridge would come down once this takes affect and the company starts losing business.

[paris]

My Arenesp shots cost much more than Epogen.  But we went to Arenesp when my numbers were stable and it is longer lasting. 

Thanks for sharing the information.  I am sure many of us are aware of the changes coming -- this is one "on top of things" group!   Check out Bill Peckhams site.  He is the expert here!  He has a lifetime of experience. 

I think a lot of our nephrologists get sick of all our questions and our "whys".   But, in the end, we are probably the most educated group around. 

It will be interesting to see if anyone notices the changes.  Hopefully, everyone will let us know if they have problems.    One charge I have always questioned, is the $500 neph charge for a 2 minute stop during dialysis.  (for each patient)   At least that is what my nephs group charges. 

[okarol]

can I ask you a question.. Why Epo?  Why not Aranesp?  Wouldn't it be cheaper?  I could be wrong, but I was just wondering

Amgen manufactures Procrit, Epogen and Aranesp. Do the prices vary much?

[greg10]

Amgen manufactures Procrit, Epogen and Aranesp. Do the prices vary much?

Zach has been ahead of everybody here on Medicare bundling cost.  His thread here has the numbers and URL:

"Now you can see what EPO actually costs Medicare, not what your dialysis facility charges--or your pharmacy charges."
http://ihatedialysis.com/forum/index.php?topic=20271.msg339289#msg339289

J0882   Darbepoetin alfa (Aranesp®), esrd use   1 MCG 2.899                        
                     
J0886   Epoetin alfa (EPOGEN®) 1000 units ESRD   1000 UNITS   9.682   

New Medicare Rules May Curb Use of Anemia Drugs for Dialysis « on: July 27, 2010, 12:12:06 PM »
http://ihatedialysis.com/forum/index.php?topic=19643.0

Subcutaneous Injections Of Epogen Could Save Medicare $537M « on: October 30, 2006, 08:14:09 PM »
http://ihatedialysis.com/forum/index.php?topic=1692.0

[calypso]

Darn, I was hoping to go on NXstage too. Medicare should encourage home hemo not discourage it.

[boswife]

im still not clear as to how this is suppose to go about the nxStage.  Does it mean if we chose that mode we will end up paying for some of it?

[Zach]

I don't believe NxStage is problematic with the new bundle payment system.
Perhaps Nephrologista is just throwing a hand grenade into the conversation.

[boswife]

thanks Zach!!  ohhhhhhhh, and by the way,,,,,,,,,,  Guess what we had for dinner?  um hum.....ZACHs chillie!!!  i tell ya, it's the BEST ever!!!  hubby sais it every time i make it.  I'd like to say it's 'my' chili, but nope, i always give you the credit!!  It's soo yummy, and thanks for sharing..

hum,, i have adult attention deficit..my excuse for always changing subjects in a thread.. sorry

[Zach]

thanks Zach!!  ohhhhhhhh, and by the way,,,,,,,,,,  Guess what we had for dinner?  um hum.....ZACHs chillie!!!  i tell ya, it's the BEST ever!!!  hubby sais it every time i make it.  I'd like to say it's 'my' chili, but nope, i always give you the credit!!  It's soo yummy, and thanks for sharing..

I'm really glad you folks like the chili.
Wait till I get around to post my Lasagna recipe!

 

[boswife]

ZACH  you can send that strait away to me RIGHT NOW!!!  ohhhhh, i cant wait!!

[greg10]

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."

[Nephrologista]

No hand grenades intended!  I couldn't log in for a day or so.

The med costs, and I suspect the NxStage cartridges, can also vary from chain to chain.  The two LDOs with the biggest market share can sometimes cut a better deal than the smaller chains.  Hopefully NxStage will work with all the chains to make sure patients have access to home hemo, which I think is the best modality for many patients.

I don't have any info on the comparison with other home hemo machines.  My chain has some patients on NxStage in various units, which is why I think they ran those numbers.

I don't think patients who have access to home hemo now will lose it.  I do think it might make units like mine, that want to start offering home hemo, pause.  We would need to make the numbers work better before we could start.  That is what has me bummed out.

[MooseMom]

I just want to thank you again, Nephrologista, for joining IHD; you've lent a different kind of voice to our discussions, and I am very glad you take the time to post here.

My neph runs his own clinic; it's not affiliated with the DaVitas of the world.  It offers NxStage right now, and since that is the modality I think I will want, I intend to ask him about its continuing availability the next time I see him.  Thanks for the heads up.

[Lillupie]

More patients will be encouraged to consider PD.  This is a LONG time in coming, the US has always lagged way behind the rest of the world in PD.  It was always a money loser under the old system, and now that will change.  Nephrologists will be learning more about PD and encouraging more patients to try it.

I do find it hard to believe that they are going to encourage PD. According to  my own PD unit, CMS is making life hard for those on home dialysis with all of their rules and regulations. I feel as a patient we have to jump through these hoops just to stay on PD. I hate CMS with the passion and wish more then anything I could contact someone in office there about s few of their rules and regulations. So much has changed in the 3 years that i have started dialysis (all the rules and regulations)but my quality of life is not getting any better, but worse because of all these rules put  on the center and passed on to the patients.
 Every time I turn  my head there is a new rule by the damn government called CMS. It is almost as though they do not want people on home dialysis. It might be cheaper for me, but they are making our lives a living hell. 

Lisa

[gregory]

In 2012 medicare will be looking at patients labs to make sure there getting the right treatment and if not they will be penalized 2-3% of their payment. I recently was told my unit will not be giving carnitor after the first of the year.

[okarol]

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.

[Zach]

 I recently was told my unit will not be giving carnitor after the first of the year.

J1955   Inj levocarnitine per 1 gm   1 GM   $4.997
                       
J0886   Epoetin alfa (EPOGEN®) 1000 units ESRD   1000 UNITS   9.682 

It's much cheaper than EPO.

[calypso]

 I recently was told my unit will not be giving carnitor after the first of the year.

J1955   Inj levocarnitine per 1 gm   1 GM   $4.997
                       
J0886   Epoetin alfa (EPOGEN®) 1000 units ESRD   1000 UNITS   9.682 

It's not a replacement for EPO. So it would be an additional cost. It is to replenish an amino acid that becomes depleted due to the use of an anticonvulsant medication. This is a reminder that almost any therapy you undergo often has negative effects along with the positive you take it for.

It's much cheaper than EPO.

[Zach]

It's not a replacement for EPO. So it would be an additional cost. It is to replenish an amino acid that becomes depleted due to the use of an anticonvulsant medication. This is a reminder that almost any therapy you undergo often has negative effects along with the positive you take it for.

I understand levocarnitine is not a replacement for EPO.

It's Medicare approved use is for either:

1) Hypotension during dialysis
2) Low response or resistance to EPO.

http://content.karger.com/ProdukteDB/produkte.asp?Doi=89449

Maybe gregory can convince his unit to exchange 1,000 units of EPO (from his usual dose) for 1 gram of Levocarnitine (Carnitor).