Final Changes to the Bundle: What You Need to Know

On July 26, 2010 the Centers for Medicare & Medicaid Services (CMS) released their final rule for the new prospective payment system (PPS). As a caregiver or a patient who receives end-stage renal disease (ESRD) services, you should know how this affects you.


  • You Could See Changes as Soon as January 1, 2011: The new “bundling” system goes into effect beginning January 1, 2011, however facilities do not have to fully convert to the new system until 2014. All dialysis clinics will be required to fully operate under the new payment system by January 1, 2014. Do: Speak to your medical team about what these changes mean to you and what changes you can expect to see at your facility.
  • You Could See an Increase in the 20 Percent Cost of Your Care that Medicare Does Not Cover. Medicare will make a single payment for all services related to a single dialysis treatment versus paying separately for non-routine laboratory services and all ESRD- related Part B drugs along with their equivalent forms covered under Part D. Dialysis related lab tests were previously paid at 100 percent by Medicare, but under the bundle, patients may have to pay a portion of the cost for these tests. In 2014 when all oral medications are included in the bundle (such as phosphate binders and calcimimetics), patients may pay a portion of this cost as well. Do: Speak to your Social Worker about your Medicare coverage and the cost of your care. If you need help, start looking at your options now!
  • You Could See Changes in Your Prescriptions and How You Receive Your Medications:By 2014, dialysis facilities will be responsible for purchasing oral medications used to treat dialysis patients. Patients will either receive the medications in the facility or through the pharmacy the facility chooses. Do: Speak to your medical team (your nurses and doctors) about the medications you are taking. Take all of your medications in to the clinic (even those not related to your dialysis care) and have the staff verify your prescriptions. Ask if your medications will be changing. Write down what you take, any changes made to your prescriptions, and how it makes you feel. Discuss these changes with your medical team.


The changes mentioned above came after much deliberation on the part of CMS and the ESRD community. CMS received nearly 1,500 public comments in response to the ESRD PPS proposed rule that was first released in September 2009. Major concerns were raised by DCI (see our ‘Response to CMS’ link at the end of the page) and others. The major consistent concerns to be aware of were surrounding payments for home dialysis training; inclusion of additional payment adjustments for patient characteristics in the payment methodology; and inclusion of former Part D prescription drugs related to ESRD treatment in the payment bundle. Based on comments received, CMS did make adjustments from the first proposal to the final rule. In the final rule CMS:


  • Creates a home or self-care dialysis training payment adjustment specifically directed to patients trained by facilities certified to provide home dialysis training.
  • Finalizes payment adjustments for dialysis treatments furnished to adults for patient age, body surface area, and body mass index, onset of dialysis, and certain co-morbidities, but does not finalize adjustments for the patient’s sex or the patient’s race or ethnicity.
  • Finalizes a payment adjustment for dialysis treatments furnished to pediatric patients, based on patient age and dialysis modality, but not co-morbidities.
  • Finalizes a definition for renal dialysis services that includes ESRD-related oral-only drugs, but postpones payment for such drugs under the ESRD PPS until Jan. 1, 2014.

Dialysis Clinic, Inc. is committed to quality patient care. Our patients can rest assured knowing that DCI provides excellent care. For several years, the United States Renal Data System (USRDS) has found DCI to have the lowest patient mortality, lowest hospitalization rates and the lowest utilization of drugs and laboratory services among the national dialysis providers. The 2009 USRDS Annual Data Report (ADR) also ranks DCI as the national provider with the lowest monthly cost to CMS, at $1,366 per patient per month, compared to a national average of $1,425 per patient per month. Inspection of the USRDS data shows that DCI’s low costs reflect the most conservative laboratory testing and drug administration practices in the field. DCI also does an excellent job of anemia management. We are well equipped to help our patients and staff navigate the new bundle.


We know that Medicare changes can be confusing and difficult for patients to understand. We are dedicated to serving our patients’ needs and empowering them to make decisions every step of the way. We will share information as it comes available. We will make staff and resources available. And we are always here to discuss our patients’ concerns. We are a service organization. The care of the patient is our reason for existence.


DCI’s response to the End Stage Renal Disease Prospective Payment System Proposed Rule