"Bundling" and the renal community in the US

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.

"Bundling" and the renal community in the US

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upon by the 'powers that be', it was felt the way medicare/medicaid paid for services to the dialysis companies was outdated and needed modernizing.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

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madwife2002

About madwife2002, BSN, RN

RN with 26 years of experience many of those years spent in dialysis. I have worked in acute care, home, ICHD as a CN, FA, and currently a director.

26 Articles   4,777 Posts

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Excellent information. I believe that 'bundling' was how we were reimbursed 30 years ago - one payment fits all.

Do not set up for the chronic no-shows until you see the whites of their eyes. Let them know that they if they show up on time for X number of treatments you will start to set up their machine earlier.

And chronic dialysis can be a very emotionally draining job, as the patients are frequently very needy and demanding. I did mainly acute dialysis, but as you noted, the repeat offenders are hospitalized or treated in the inpatient area for their specialized needs.

Nothing like being on-call, and end up in the ER at 2 AM treating that fluid-overloaded, high K patient that was too busy to get to their treatment yesterday.

And did you know that the first part of 'watermelon' is WATER?!!!! (But I only had one can of soda the entire day, nurse!)

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All what you say is true. But what you failed to mention is that most renal centers are for profits centers. There mission is to turn a profit for the stockholders.There is not a shortage of cash, but a shortage of profit for the share holders.

In the hospital things are similar, bundling and global payments are a way of life. Unlike renal nursing you can't turn one way.

Tough times in the health care.

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Specializes in RN, BSN, CHDN.

I agree with what you are saying Ginger's mum. There was so much to write and so much information I couldn't get everything into my blog.

I just find it very interesting the changes that have evolved this year for the renal patients, as a nurse I often forget that we have to make a profit for the shareholders.

My main concern is how hard it has been to nurse the patients maintain quality of care in the dialysis center this year, all the cuts that have been made and the constant changes that have occurred this year because of bundling.

I do however think that the reimbursements were not as low as the 'shareholders' expected.

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I agree, in my area most of the hospitals have been bought by a "for Profit" agency. I think it changes the landscape of healthcare. Good quality care may not mean big profits.

As a nurse, I just want to care for my patients without thinking of the bill.

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Specializes in Critical Care.

Yes we get some dialysis frequent fliers who skip their appointments and some have been barred from private centers, so guess what they turn up at the ER when they become SOB and of course the ER can't refuse them treatment. Most have behavioral disorders and are mentally ill. We had one patient in particular who was violent and mentally ill dialysis patient! When he was at the hospital it filled me with dread hoping I wouldn't get stuck with that nasty person!

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Madwife - - This was truly an excellent article, and I have now had time to read some of the links, as well. I truly feel that making reimbursement dependent on outcomes is not 'fair' when some of the patients are not responsible in their diet and fluid issues, let alone making their appointments.

But I also feel that many more patients SHOULD be doing at-home modalities, that at-home dialysis should be offered as the standard. When I worked in units that had large numbers of at-home patients, they were staying out of the hospital at a much higher rate then the in-center patients.

Years ago, I lived in another country where in-home was the standard - - if there was anyone over the age of 14 that could be trained, then that was the expectation. We live in a time and place where we expect everything to be done FOR us, and not BY us. And that attitude carries over to diet and fluid issues - - why not have those potato chips? I will dialyze tomorrow! And that 2nd can of soda with dinner? Why not?

I found that many at-home patients were more more cautious in their choices.

Again, thanks for the good info, and well-written article.

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Specializes in Nephrology, Cardiology, ER, ICU.

CMS is pushing for more home modalities: PD and home hemo. Companies get paid higher for these and training is paid for too at a higher reimbursement rate.

Madwife is totally right with everything.

I think we (both as JohnQPublic as well as healthcare providers) need to watch this closely. There is already talk about maybe not offering dialysis to those over age such-and-such - have seen ages mentioning ranging from 70 (with co-morbids) to 80. Many variables need to be factored in.

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Back in the 70's and early 80's there were some 'unofficial' ways of not dialyzing certain patients, especially those over 65-70 with multiple co-morbidities. And we need to always ask ourselves why we are doing or NOT doing certain things.

Dialysis is not the savior when multiple body systems are failing, and just because it is possible to do something doesn't mean it has to be done.

Many years ago, a retrospective study was done of all dialysis modalities in the ICU setting, and the results were disheartening. Regardless of modality, acute renal failure had a nearly 80% morbidity rate. Despite those findings, we were in the ICU all the time, dialyzing patients who were already multiplitly compromised.

I hope it is better today.

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Specializes in cardiac, ICU, education.

Bundling is starting in hospitals as well in the next few years. One of the facilities in my area is starting in 2 years because they contracted with the government as a testing site for the idea. Not sure why any facility would volunteer.

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Specializes in this and that.

Thanks Madwife for this great article.I did Peds Chronic HD, Acute and Chronic HD in the 90s with on call..i enjoyed my experience at that time. I came back recently to do PD/ HD and during my orientation...left pretty much alone with a PD TECH to train a lot of 85 something HD patients to do home PD.....the docs on the unit get $$$$$$$$ if they can recruit one of the chronics to do home PD or home hemodialysis.....i was so sick everyday till i finished my 90 day probation because i was jumping from doing chronic hemodialysis with only two weeks classroom training to shadow the techs ...at the same time help with training of the newly recruited 80 something chronics with co morbidities including dementia and no fixed care giver to do home pd or home dialysis so docs make more $$$$$$$$$$$$$$ after PD training.....Left the company faster than the speed of light and so glad i did to protect my license...

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Specializes in Dialysis.

Something about penny wise and pound foolish comes to mind with medicare's efforts to control costs in the dialysis community. I forsee a competition for the "good" patients you can make a profit on and the abandonment of those you can't. The situation in Ohio with clinics losing money on medicare patients and depending on private insurance patients to bridge the gap is unsustainable. Especially if the insurance companies start applying the same criteria for reimbursement that the government uses. And none of this is centered on what's best for the person at the "sharp end of the needle". The only positive thing in that post was the link to Bill Peckham's blog. Thanks.

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