I don’t understand this explanation - you wouldn’t have to have an entire unit on an EOD schedule. You could do it by shift - everyone on the evening shift goes EOD, the rest of the shifts stay 3x/week. Then on Sunday you run two shifts of dialyzors, that would be the only odd day. You could also think of it in terms of stations, maybe out of 9 chairs and four daily shifts, three are used for EOD. On Sunday you’d need to provide 12 treatments so you could set up two shifts running 6 stations.
But why would units do this? Because the bundle provides a $90 bonus for every treatment provided above the standard 3/week.
The way I’d say it is, the Bundle has two components: the current composite rate and 1/156th of the total yearly amount spent on formerly separately billable items. As we know some of the separately billable items are routinely given monthly, like iron maybe or routine labs, and some each treatment, like Epo (assuming the three day a week schedule) and some quarterly or semi annually, for instance other labs e.g. PTH, Hep B. So to get the whole payment for the care a unit historically provided a patient over the course of a year the unit will need people to be in their chair every treatment.
Medicare did not create any sort of fractional payment scheme so if you get medically justified additional payments you’ll get the 1/156th of the total yearly amount spent on formerly separately billable items as a sort of bonus. that’s about $90. That’s a big bonus and it would more than cover whatever additional labor costs come with opening on Sundays. So for those treatments you provide on Sunday you get a reimbursement premium , you spread the fixed costs of bricks and mortar over seven days instead of six (effectively lowering the cost of every treatment the unit provides) and with higher doses you can anticipate lower med costs - particularly post 2014 when oral drugs are included.
In general a conservative analysis of the impact of more dialysis would assume the total yearly amount spent on formerly separately billable items doesn’t change much with frequency - if you dialyze more than 3x week you don’t get more or fewer labs or more or less frequent doses of medications. This sets up a dynamic where the per treatment revenue is the same for each treatment over three a week but the cost of each treatment over three a week drops dramatically - the cost of the forth fifth sixth seventh treatment is much less because the weekly cost of all the formerly separately billable items have been paid by the first three treatments.
The other side of the of the “less medications need with more dialysis” coin, is that if people skip or vacation at units that skimp on medications or, importantly if people are frequently hospitalized, those separately billables not provided will have to be provided once the person is back in the chair. ANd if they’ve been getting less dialysis they’ll need additional formerly separately billables. One concern I have is that people won’t be readmitted after a long hospital stay, and/or if they like to take frequent vacations, and/or skipping may be seen as costing the unit even more money and result in involuntary dismissals.
So in light of this dynamic I think it is time units started expecting 3.5 payments a week.
It is a good business decision and from a clinical point of view it would be much better so I don’t know what would stop it. In a business the obvious thing to do is upsell existing customers. If you switched someone from 3x week to EOD you would be increasing sales from 156 a year, to 182/183 a year. The per treatment revenue is the same for each EOD treatment but the cost of the 157th to 183th treatment is much less because the cost of all the formerly separately billable items have been paid by the first 156 treatments.
Importantly an EOD schedule would cushion units from the cost of skipping, hospitalizations and travel. So long as people on an EOD schedule dialyzed 156 times in the year the unit would be fully paid for the cost of the formerly separately billable items in the bundle, and every treatment delivered above 156 would be much more profitable. The other nice thing is that this infusion of resources into the industry can be manifested entirely through the actions of providers. It can occur outside the rules of budget neutrality and the machinations of congressional action.
