Bundling…..Will we survive?
Thomas E. Amitrano BSN, MPA, RN
Bundling…..Will we survive?
Bundling How Will We Survive ?
A bit of History
In 1972 Congress enacted legislation to create a
way to finance End Stage Renal Disease (ESRD)
 In 2008 Congress passed the Medical
Modernization Act (MMA) as well as the
Medicare Improvements for Patients and
Providers Act (MIPPA) these acts required the
Centers for Medicare and Medicaid Services
(CMS) to look at the elimination of payments
that were separately paid for dialysis services
and drugs.
 Bundling is the solution CMS has proposed

Estimated point prevalent ESRD patients
Figure 11.3 (Volume 2)
December 31 point
prevalent ESRD
patients; non-Medicare
status determined from
payor sequence.
USRDS 2009 ADR
Total Medicare dollars spent
on ESRD, by type of service
Figure 11.5 (Volume 2)
ESRD spending obtained from Medicare ESRD claims, & includes all Medicare as primary payor claims as well as
amounts paid by Medicare as secondary payor.
USDRS 2009 ADR
Total Medicare ESRD
expenditures, by modality
Figure 11.6 (Volume 2)
Period prevalent ESRD patients. Modalities determined using Model 1 methodology. Includes Medicare paid claims for ESRD patients, starting
at first ESRD service date & continuing until death or the end of the study period. Patients with Medicare as secondary payor are included.
USRDS 2009 ADR
Total Medicare spending
on injectables
Figure 11.13 (Volume 2)
Period prevalent
dialysis patients..
ESAs: erythropoiesis
stimulating agents.
USRDS 2009 ADR
Why change?

In a separately billable system certain
services are billed for as “composite” and
others are billed for as “separately
billable”. This system left some question
as to the profit margin some dialysis units
reported. If all services were equal why
did some units make more money than
others?
Proposed* Changes
 Payment will be on a per treatment basis
 All drugs and labs will be included
– All renal service oral drugs including Phosphorus
binders
– All labs ordered by Nephrologists or others
 Reimbursement would “trim 2% of the
estimated payments that would have been made
in 2011 under the previous payment system”
 No adjustment for Race/Ethnicity
 Wage Index Adjustments are likely
Proposed* Changes
(con’t)
 Units will have the option of easing in over 4
years or going 100% at one time
 The Math……
– 2007 claims data proposed the 2011 rate would be
$261.58
– CMS is proposing a 21.73% reduction = $204.74
– Proposed Outlier Adjustment 1% reduction = $202.69
– MIPPA required a 98% reduction = $198.64
Problems
Old data may have been used – cost
reports etc. in some cases are dated
 No consideration of inflation
 Certain areas of the country will get less
reimbursement for the same services
 Potential for decreased care based on
decreased reimbursement exists

New Quality Indicators on or after
July 1,2010
Kt/V must be reported for both HD and PD
Access type must be reported for HD
– Modifier
– Modifier
– Modifier
– Modifier
– Modifier
V5:
V6:
V7:
V8:
V9:
Vascular Catheter
Arteriovenous Graft
Arteriovenous Fistula
Infection present
No Infection present
Worries/ Concerns
Will Practice be a result of Payment
 Will Quality and Performance
Improvement Change
 Will Hospitalizations be decreased or
shortened for the wrong reasons
 Will units close and leave gaps in service
 Will we have to do more with less

Our Role in Bundling
Maintain high standards of care
 Encourage each patient to maintain their
optimal level of health
 Educate patients to be proactive and
preventative not reactive regarding their
health
 Work diligently to prevent patient illness

Our Role in Bundling
(con’t)
Accurately document all information on all
forms….. co morbid conditions are
important
Look for ways to improve efficiency
Make patient safety and well being a
major priority and goal
– Decrease hospitalizations
– Decrease infections
– Manage medications
Our Role in Bundling
(con’t)
Remain in close communication with the
Hospital Dialysis Units maintain continuity
thru the continuum of health/illness
 Develop Policies and Practices that are
evidence based to ensure high standards
 “No missed Treatment” philosophy offer
alternate times/days

Planning for Change
Assess current practices and critically
analyze the ability of the practice to
survive
 Develop strategies that promote patient
well being across the continuum of health
 Incorporate Evidence Based Practice into
Policies and Practices

Planning for Change
(con’t)
Analyze QAPI data for trends and patterns
– Deming cycle
Planning for Change
(con’t)
Read, Read, Read
Actively engage your colleagues in a Spirit
of Change
– Buy in on all levels will be critical
– Team work is essential to success
– Embrace the opportunity to help your unit
succeed
Summary
Bundling is going to happen in some form
We will need to be ready in some way
We will all be effected some how
We can all do something to prepare for
the change
– Review practice
– Educate patients
– Set high Standards
Resources
http://www.annanurse.org
 http://www.cmms.hhs.gov
 http://www.usrds.org
 amitrant@sjhmc.org
