What can we learn from the U.S. expanded end-stage renal disease bundle?

Health Policy. 2013 May;110(2-3):164-71. doi: 10.1016/j.healthpol.2013.01.011. Epub 2013 Feb 16.


Episode-based payment, commonly referred to as bundled payment, has emerged as a key component of U.S. health care payment reform. Bundled payments are appealing as they share the financial risk of treating patients between payers and providers, encouraging the delivery of cost-effective care. A closely watched example is the U.S. End Stage Renal Disease (ESRD) Prospective Payment System, known as the 'expanded ESRD bundle.' In this paper we consider the expanded ESRD bundle 2 years after its implementation. First, we discuss emerging lessons, including how implementation has changed dialysis care with respect to the use of erythropoietin stimulating agents, how implementation has led to an increase in the use of home-based peritoneal dialysis, and how it may have contributed to the market consolidation of dialysis providers. Second, we use the expanded ESRD bundle to illustrate the importance of accounting for stakeholder input and staging policy implementation. Third, we highlight the need to consider system-wide consequences of implementing bundled payment policies. Fourth, we suggest how bundled payments may create research opportunities. Bundled payment policies offer opportunities and challenges. Their success will be determined not only by impacts on cost containment, but also to the extent they encourage high quality care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cost Control / organization & administration
  • Delivery of Health Care / economics
  • Delivery of Health Care / organization & administration
  • Humans
  • Kidney Failure, Chronic / economics*
  • Kidney Failure, Chronic / therapy
  • Medicare / economics
  • Medicare / organization & administration
  • Prospective Payment System / economics
  • Prospective Payment System / organization & administration
  • Reimbursement Mechanisms* / economics
  • Reimbursement Mechanisms* / organization & administration
  • Renal Dialysis / economics
  • Renal Dialysis / statistics & numerical data
  • United States