Over the weekend I received an email:
I am a bit confused by the “broader” bundling plan proposed by CMS. This would be Figure 1 in the CMS’ recent report to Congress on bundling. If things like outpatient access procedures are included in the bundle, wouldn’t that essentially turn the dialysis provider (ie; the owner of the unit) into a sort of HMO? For instance, it seems that, under this proposal, the dialysis provider (Davita, for instance) would need to provide payment to (ie; write a check) to the interventional radiologist or surgeon (or nephrologist, I suppose) who was performing the procedure. Is this really an appropriate structure for treating patients? That is, to change the role of a service provider to one of a managed care organization? I imagine that organizations such as Davita don’t really have the expertise for this, and it would seem more appropriate to keep CMS as the central payer to these individual entities. Perhaps I am not interpreting the proposal correctly?
I think you have it right - the broader or maximal bundle option proposed by CMS (PDF link) includes all routine Part B payments related to ESRD. And yes, I agree, this would be a bad idea. I have a hard time processing all it would imply - each dialysis unit would have to establish novel business relationships with numerous medical practices. The theory must be that dialysis units could save money on vascular care through spending elsewhere. I'm not sure what the rationale is for including the nephrologist in the bundle. This seems hugely problematic and it is not clear at all that this would increase viable fistulas or save money on hospitalizations.
I admit I haven't read the section dealing with the maximal bundle because it didn't even get a mention in the Executive Summary. I think it is in the report to give the impression that all options were considered - We considered all three options: should the deck chairs be in groups of four, six or eight? * The executive summary as I read it the second time Sunday is less enthusiastic about a bundle then I remember it being when I read it Wednesday
The first three paragraphs give program background then in the last two paragraphs we get this:
The Government Accountability Office (GAO) and the Medicare Payment Advisory Commission (MedPAC) have endorsed expanding the current partially bundled payment system to include separately billable services under a fully bundled ESRD PPS. CMS issued a report to Congress in 2003, summarizing the state of research at that time, concerning the feasibility of developing a bundled ESRD PPS. The research contractor, the University of Michigan Kidney Epidemiology and Cost Center (UM-KECC), in its 2002 report clearly outlined the magnitude of the task and provided information on many of the important issues that would need to be addressed before a bundled ESRD PPS could be developed. UM-KECC also indicated that existing data are adequate for proceeding with the development of an expanded or bundled ESRD PPS [2].
The MMA required that the Secretary issue a report to Congress detailing the design and implementation of a bundled ESRD PPS for services furnished by ESRD facilities that includes to the maximum extent feasible, both composite rate and separately billable services. This report discusses the research and development of a bundled ESRD PPS based on the following features: a base per treatment rate of $234.66 (in 2006 dollars) representing combined composite rate and separately billable services; a facility-level adjustment for the wage index; and patient-level adjustments for age, gender (female), body surface area, low body mass index, duration of renal replacement therapy, and 12 comorbidities.
Which I translate to:
This wasn't our idea, our contractor UM_KECC says it is problematic but you demand a way to expand the bundle so here is what we came up with: a base per treatment rate of $234.66 (in 2006 dollars) representing combined composite rate and separately billable services; a facility-level adjustment for the wage index; and many Ptolemaic rings of influence to adjust for patient characteristics and comorbidities
That's not a ringing endorsement of the expanded bundle concept and it doesn't even mention the six or eight deck chair bundle option.
The report contemplates a maximal bundle but that's as far as it goes, they end up recommending a bundle that represents current routine payments to dialysis providers with additional case mixing. I'm fairly sure the maximal bundle is off the table; to the extent it is discussed it will be as a stalking horse for the recommended bundle. However, I'm not sure a maximal bundle would be a problem for the two large dialysis organizations.
The maximal bundle would reward purchasing power gained from economies of scale. I think the LDOs would be more than happy to manage all of their dialyzor's healthcare needs. Imagine the efficiencies - have your dental work done while dialyzing!
*The five year survival rate on incenter hemodialysis is a bit better then the survival rate on the Titanic.
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