In the renal community life has changed drastically since the 1st January 2011 a new and dreaded word became the norm, the word which strikes fear into the hearts of our community is "Bundling".
So what does Bundling mean to you?
Wikipedia describes Bundling as...
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Bundling, or tarrying, was the traditional practice of wrapping one person in a bed accompanied by another, usually as a part of courting behavior. The tradition is thought to have originated either in the Netherlands or in the British Isles and later became common in Colonial America,[1][2] especially in Pennsylvania Dutch Country. When used for courtship, the aim was to allow intimacy without sexual intercourse.
InvestorWords.com describes Bundling as...
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The practice of joining related products together for the purpose of selling them as a single unit. This is generally carried out when the seller thinks that the characteristics of two or more products and services are such that these products might appeal to many consumers more as a package than as individual offerings e.g. local and long distance services. Bundling arrangements usually feature a special pricing arrangements which make it cheaper to buy the products and services as a bundle than separately.
For a Renal Nurses bundling means the new way we get paid for providing dialysis for our patients.
The initial concept was decided upon by the 'powers that be', it was felt the way medicare/medicaid paid for services to the dialysis companies was outdated and needed modernizing.
It was thought by changing the way that the government pays for dialysis they could also control the way of improving quality of care provided to the patient by the dialysis companies.
Payment before was given regardless of whether companies provided adequate dialysis or not. Now everything is measured by achievement of certain standards of care!
Prior to 2011 dialysis companies could bill separately for lab work, medications, supplies etc. Now it is combined into one payment called 'bundling'. The payment for dialysis is now one amount, that amount depends on certain measurements being achieved for each patient. If they are not met then the already low payment is reduced by a percentage, which forces the dialysis companies to make sure each facility reaches these targets.
The payment is so low that Medicare/Medicaid patients receiving dialysis in Ohio are being dialyzed at a loss to the dialysis company.
The private pay insurance patients keep the units afloat, and financially viable!
Dialysis units now have to be extremely careful when documenting results. New patients certain hospital admissions & discharge diagnoses, co-morbidities can all increase payments to dialysis companies.
So in reality what does this all mean? It means cost cutting exercises every single day of every single month for the renal unit.
Cheaper supplies because this is a controllable cost, also educating and teaching staff to be more vigilant when using supplies.
Medications are costly so strict control of anemia is important as Epogen used to help control anemia is very expensive. Prior to 2011 Epogen was separately billable so it was given more freely, although renal units always tried to control anemia levels and had objectives to reach there was no financial pressure to control anemia. Once dollars became an issue renal units all over the country suddenly became very focused on controlling anemia by focusing on how to control anemia within a certain range.
Staff is the single most expensive commodity, so this year staff have been streamlined, in a effort to control costs. The renal community is small, staff are transient and the work is difficult.
Careful recruiting of new staff has become important, retention being top of the list.
Overtime is another area being focused on, although in my opinion I rarely see overtime unless warranted.
Training new staff is costly so if companies cannot keep staff then it is a vicious circle of training and losing. All sorts of pre employment tests are becoming utilized in the recruitment process in an effort to recruit the right staff.
Many new recruits have no concept of how busy, stressful and hard work, dialysis units can be. A lot of staff come into the job thinking it is an easy job after working in hospitals where the work can be a lot heavier. So when reality hits sometimes finding the doorway out is they way staff run! Although for me dialysis is in my blood so to speak and I have enjoyed a long and happy career as a renal RN.
Dialysis is far from being a 'cushy' number. The patients are chronically ill and like no other patients you have ever dealt with. They have to come to a dialysis unit 3 days a week for up to 5 hours of treatment each visit, these hours do not include the time spent travelling, waiting to get on to dialysis and the time spent after dialysis. They get very impatient and fed up if they are not on dialysis at their appointment time-in their mind they lose their whole day 3 times a week, so every minute is precious.
They are experts in their own care, they know what they like and they know they can transfer to the dialysis unit down the road if they don't get what they want.
So keeping your patient happy and content is a dialysis unit's main priority, not only because they deserve it but because a patient is a commodity.
You only get paid if the patient turns up for treatment, that seems obvious doesn't it?
To set up a dialysis machine, is costly if the patient doesn't show for treatment. You cannot charge anybody for the cost of getting the machine ready for the patient it is an immediate loss to the company. Staffing costs are huge, in my unit we can pay $100 per treatment in staffing costs alone, so if a patient doesn't turn up for treatment this can be higher because we don't get paid for no shows.
If you increase the amount of treatments per day they the staffing costs fall, some units in my company only have $67 per treatment staffing costs. So it is a daily battle to keep staffing costs down by increasing treatments and reducing the patients calling off. We attempt to reschedule the patients each time they fail to show for treatment but sometimes this is a losing battle.
Some patients are chronic no show patients, they frequently call off with almost no notice and by that time the machine is all ready to go!
This means everything has to be thrown away, empty chair no revenue.
These patients also tend to be the patients, whose lab results are poor, causing the reimbursement from Medicare/Medicaid to be cut.
These patients are also very non compliant, don't follow a diet, fluid restrictions and don't take meds correctly. This results in patients having frequent hospital admissions complaining of SOB, generalized edema, and very high potassium's which can be life threatening.
Dialysis units get penalized because of preventable hospital admissions. Education of the patient is of vital importance not only for their health but to ensure patients do not call off dialysis which as stated before is a huge loss of revenue.
Some companies will eventually give 30 days notice to a patient to find another unit if they are frequent no shows. They cannot afford to carry patients who's financial costs can cripple a unit especially if there are a lot of them.
It is too early to say if patient care has suffered by 'Bundling' I believe any financial cuts in health care will result in effecting the patients.
Loss of money means somebody somewhere suffers.
Loss of jobs, patient morale, staff morale-more pts = more work and less time for the individual patient.
Control of epogen not a bad thing as it is now known to have carcinogenic repercussions which some renal experts believe out ways the positive benefits
Lastly but not least is a great link where a pt describes his experiences and recommendations for his future and future of renal patients.
This link contains many other links concerned with dialysis which are very helpful and all in one place.
Dialysis from the sharp end of the needle
