1. Bundling…..Will we survive? Thomas E. Amitrano BSN, MPA, RN

2. Bundling…..Will we survive?

3. Bundling How Will We Survive ?

4. A bit of History In 1972 Congress enacted legislation to create a way to finance End Stage Renal Disease (ESRD) 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. 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 Bundling is the solution CMS has proposed

5. 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

6. 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

7. 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

8. Total Medicare spending on injectables Figure 11.13 (Volume 2) Period prevalent dialysis patients.. ESAs: erythropoiesis stimulating agents. USRDS 2009 ADR

9. 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? 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?

10. Proposed* Changes Payment will be on a per treatment basis Payment will be on a per treatment basis All drugs and labs will be included 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” 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 No adjustment for Race/Ethnicity Wage Index Adjustments are likely Wage Index Adjustments are likely

11. Proposed* Changes (con’t) Units will have the option of easing in over 4 years or going 100% at one time Units will have the option of easing in over 4 years or going 100% at one time The Math…… 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

12. Problems Old data may have been used – cost reports etc. in some cases are dated Old data may have been used – cost reports etc. in some cases are dated No consideration of inflation No consideration of inflation Certain areas of the country will get less reimbursement for the same services Certain areas of the country will get less reimbursement for the same services Potential for decreased care based on decreased reimbursement exists Potential for decreased care based on decreased reimbursement exists

13. New Quality Indicators on or after July 1,2010 Kt/V must be reported for both HD and PD Kt/V must be reported for both HD and PD Access type must be reported for HD Access type must be reported for HD –Modifier V5: Vascular Catheter –Modifier V6: Arteriovenous Graft –Modifier V7: Arteriovenous Fistula –Modifier V8: Infection present –Modifier V9: No Infection present

14. Worries/ Concerns Will Practice be a result of Payment Will Practice be a result of Payment Will Quality and Performance Improvement Change Will Quality and Performance Improvement Change Will Hospitalizations be decreased or shortened for the wrong reasons Will Hospitalizations be decreased or shortened for the wrong reasons Will units close and leave gaps in service Will units close and leave gaps in service Will we have to do more with less Will we have to do more with less

15. Our Role in Bundling Maintain high standards of care Maintain high standards of care Encourage each patient to maintain their optimal level of health Encourage each patient to maintain their optimal level of health Educate patients to be proactive and preventative not reactive regarding their health Educate patients to be proactive and preventative not reactive regarding their health Work diligently to prevent patient illness Work diligently to prevent patient illness

16. Our Role in Bundling (con’t) Accurately document all information on all forms….. co morbid conditions are important Accurately document all information on all forms….. co morbid conditions are important Look for ways to improve efficiency Look for ways to improve efficiency Make patient safety and well being a major priority and goal Make patient safety and well being a major priority and goal –Decrease hospitalizations –Decrease infections –Manage medications

17. Our Role in Bundling (con’t) Remain in close communication with the Hospital Dialysis Units maintain continuity thru the continuum of health/illness 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 Develop Policies and Practices that are evidence based to ensure high standards “No missed Treatment” philosophy offer alternate times/days “No missed Treatment” philosophy offer alternate times/days

18. Planning for Change Assess current practices and critically analyze the ability of the practice to survive 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 Develop strategies that promote patient well being across the continuum of health Incorporate Evidence Based Practice into Policies and Practices Incorporate Evidence Based Practice into Policies and Practices

19. Planning for Change (con’t) Analyze QAPI data for trends and patterns Analyze QAPI data for trends and patterns –Deming cycle

20. Planning for Change (con’t) Read, Read, Read Read, Read, Read Actively engage your colleagues in a Spirit of Change 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

21. Summary Bundling is going to happen in some form Bundling is going to happen in some form We will need to be ready in some way We will need to be ready in some way We will all be effected some how We will all be effected some how We can all do something to prepare for the change We can all do something to prepare for the change –Review practice –Educate patients –Set high Standards

22. Resources http://www.annanurse.org http://www.annanurse.org http://www.cmms.hhs.gov http://www.cmms.hhs.gov http://www.usrds.org http://www.usrds.org amitrant@sjhmc.org amitrant@sjhmc.org