Durable Medical Industry’s Proposal to Fix Medicare’s Competitive Bidding Program

Guest blog post by Bob Vogel

The current Centers for Medicare and Medicaid Services (CMS) competitive bidding program is deeply flawed and jeopardizes wheelchair users ability to get the seating and mobility equipment we need. Furthermore, competitive bidding will put the entire Durable Medical Equipment (DME) industry in jeopardy. Dave McCausland, Senior VP of Planning & Government Affairs for The ROHO Group explains that 244 leading economists, including several Nobel Prize winners, have examined the current competitive bidding program and all signed a document stating that the current competitive bidding system will fail, it is not a question of “if,” it is a question of “when.” What makes this all the more dangerous is that DME industry may be irreparably damaged in the process.

CMS competitive bidding has DME dealers bid to provide equipment in a certain category for the lowest price. The winning bidders get the contract to be the exclusive Medicare providers for a specific area for the product category(s) they win. For wheelchair users, this category is “power and manual wheelchairs and accessories.”

Round I of competitive bidding is already in place in 9 regions. Round II of competitive bidding is looming on the near horizon and will include 91 regions, including the largest cities in the country.

Congress’ plan was that competitive bidding would lower prices for DME, thereby reducing Medicare and beneficiary costs, while ensuring that beneficiaries (you and I) have access to quality items and service we need. But because competitive bidding is based on price alone, it is likely to create unrealistic and unsustainably low prices, the result will be that beneficiaries won’t have “access to quality items and service.” This means you and I won’t be able to get the equipment and service we need to stay healthy. McCausland explains that in it’s current state, competitive bidding isn’t really competitive. There is no accountability for bids, there is nothing in place to ensure bidders are truly qualified to provide the equipment and service needed in the areas they bid, and low-ball bids are likely to drive prices to an unreasonably low level that won’t provide a living wage for DME dealers.

But there is a plan to fix these flaws with competitive bidding. The American Association for Homecare (AA Homecare, the largest association of DME manufacturers and providers) worked with DME manufacturers and providers and created a plan to fix the problems that arise with competitive bidding. They created a legislative proposal called the Market Pricing Program (MPP). AA Homcare submitted the MPP to Congress and is asking that the proposal be included in the final doc fix bill to be sent to the President.

The current competitive bidding system allows a company with no physical presence in an area, to still submit a bid for that area. This encourages low-ball bids and there is no accountability. A dealer with no physical presence can submit a ridiculous low-ball bid that guarantees that the dealer wins the contract. Let’s say a local dealer needs to sell a product for $100 to stay in business. Another out-of-town dealer submits a low-ball bid for $50 to guarantee a wining bid and get the contract. Because actual reimbursement prices are based on the median price of bids, the winning bidder will get paid at the median price, lets say that ends up at $80. Now, the winning bidder from out-of-town looks at the reimbursement price of $80 and decides if they can make a profit. If they can, great they accept the contract and move into the market. If not, they can just walk away. But the rate is still set at $80  — CMS doesn’t adjust the price, they just go to the next bidder, and the next, until they find somebody desperate enough to take the bid  — the problem is that a dealer can’t survive by being reimbursed $80 for a specific product in that specific market. The only way for a desperate dealer to survive in this situation is to substitute the cheapest equipment and services allowed within Medicare guidelines, at the expense of the health and mobility of wheelchair users. This is explained in an earlier blog post, “Why You Need to Ask for Your Cushion by Name.“

To address low-ball bidding and accountability, and make sure only serious DME dealers bid, the MPP requires bids to be binding. This means that the dealer must accept the offer presented by CMS, rather than being able to pass it off to another dealer. The MPP also requires bidders to put up a cash deposit with their bid. If the dealer wins the bid, it is binding and they must accept it. If the dealer walks away, they loose the cash deposit. This wipes out the out-of-town speculators and low-ball bidders. In addition, the MPP insists that the final price of a DME item be based on the “market clearing price” rather than the median price. This helps ensure that the winning bid allows enough profit to provide a living wage for the DME dealer and enable them to provide the proper equipment and services for wheelchair users.

As described previously, another problem area in the current competitive bidding system is that there is nothing in place to ensure bidders are qualified to provide the equipment and service that beneficiaries need in the areas they bid. A quality DME dealer has spent years developing relationships with therapists, rehab centers and hospitals in the area, has established a working relationship with wheelchair users they service and are well equipped to handle the equipment and service needs of their area. With the current system, speculative dealers with no physical presence in a market can submit low-ball bids all over the country with no knowledge of the equipment or service needs of the area  — these bids may overwhelm local dealer’s bids. And, if a speculative dealer wins a bid they can turn it down if there is no profit, or they can swoop in and grab it, leaving wheelchair users at their mercy.

The MPP says that in order to bid in a market area, DME dealers must have a history of doing business and providing equipment to the population — based on Medicare records — in that area. This will ensure the winning bidder has a presence and working relationship in the region.

AA Homecare is asking all of its members — DME manufacturers, dealers and providers — to contact their Representatives and Senators to support the Market Pricing Program proposal and ask that it be included in the upcoming doc fix legislation.

The Market Pricing Program proposal is one example of the many ways the DME industry is working to insure that beneficiaries like you and I have access to the equipment we need. Thanks to the ongoing hard work by many individuals and groups within the rehab sector, Congress passed legislation to specifically exclude complex power wheelchairs from competitive bidding. And recently, CMS officially announced that ultra-light weight manual wheelchairs, power assist accessories for manual wheelchairs and adjustable skin protection cushions will be removed from the upcoming round of the competitive bidding program!

Working together we can make a difference!

More information on the Market Pricing Program can be viewed here.

 

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Bob Vogel, 51, is a freelance writer for the ROHO Community blog. He is a dedicated dad, adventure athlete and journalist. Bob is in his 26th year as a T10 complete para. For the past two decades he has written for New Mobility magazine and is now their Senior Correspondent. He often seeks insight and perspective from his 10-year-old daughter, Sarah, and Schatzie, his 9-year-old German Shepherd service dog. The views and opinions expressed in this blog post are those of Bob Vogel and do not necessarily reflect the views of The ROHO Group.

Irony of the best-known wheelchair user

Guest blog post by Bob Vogel

Ironically, the best-known wheelchair user these days doesn’t even use a wheelchair. Non-disabled actor Kevin McHale plays Artie Abrams, a 16-year-old high school student in a glee club who became a paraplegic in a car crash at age eight. Each week over eight-million TV viewers tune in and watch Artie on the hit TV show Glee on FOX Broadcasting Network. Hiring a non-disabled actor to play Artie has stirred up a lot of controversy in the disability community. The huge TV audience, along with the controversy prompted New Mobility Magazine to name Artie as their Person of the Year.

What bothers me about Artie’s character is, it appears that (at least for the first two seasons) the TV show didn’t bother hire a consultant (a physical therapist, occupational therapist or paraplegic) to create an accurate portrayal of a paraplegic. This is glaringly apparent by Artie’s ridiculous seating and positioning. The promotional photos of Artie — including the ones in New Mobility — are typical of Artie’s seating for the first two seasons, lower body contorted to the right, and his right leg is jammed against frame of the chair. Most of his weight is shifted onto his right side — right ischium — and he is sitting on a foam cushion. Apparently the folks involved with Glee thought this made Artie “look” paralyzed.

I took a small unofficial poll of wheelchair users and therapists and asked them what they thought of Artie’s seating and positioning, most quickly noticed that his seating was poor, and was an inaccurate portrayal of the way an average paraplegic sits.

“If an actual para sat like that he would quickly end up with multiple pressure ulcers that would likely land him in the hospital for months and cost $100,000,” Delia Freeny an occupational therapist registered/licensed (OTR/L) and an assistive technology professional (ATP) says. “Proper seating and positioning are preventative — it helps prevent pressure ulcers and orthopedic problems. Spending the time and money to get the proper equipment for each wheelchair user is inexpensive compared to the serious medical problems and huge hospital bills the wrong equipment will cause.”

Like it or not, television and media define much of our reality. The way Artie has been portrayed teaches the general public — including policy makers that decide on equipment funding — that a contorted seating position and sitting with all of your weight on one ischium on a foam cushion is the norm. We never see what would really happen with this kind of seating, a lengthy and expensive hospital stay with life threatening pressure ulcers.

Unfortunately, failure to see the importance of proper seating and positioning is not limited to TV shows. Although some progress has been made, it seems the people who create Medicare policy have also failed to see how crucial proper seating and positioning is. They’ve failed to see the difference between standard durable medical equipment (DME) like a wheelchair or foam cushion you can purchase at a drug store, and complex rehab equipment — a cushion, wheelchair etc., specifically fitted by a rehab team and prescribed by a physician to address the seating requirements of a specific individual. New Mobility provides an in depth explanation of complex rehab vs. standard durable medical equipment here.

This why it is important for each of us to continue calling, emailing and writing our senators and legislators, elected officials that work for us, and tell them we do not want complex rehab equipment included in competitive bidding. The continuous efforts of everyone so far have mattered because on December 27, 2011, CMS officially announced that cushion codes E2622–E2625 have been removed from the competitive bidding program! To find out how to contact your senators and legislators are see, “A Step-by-Step Guide to Contacting U.S. Representatives and Senators.”

Back in the TV world of Glee, after enduring two seasons of poor seating and positioning, Artie’s seating improved in season three. He is sitting straighter, his legs are no longer contorted to the right and his right leg is no longer pressed against the frame. It also appears he is sitting on some type of complex rehab cushion that addresses his seating needs, rather than the foam cushion. I imagine this change came about because folks at Glee either hired a consultant, or took heed of criticisms — including mine — about Artie’s seating. Either way — good for them!

In my imagination, one of two story lines transpired in Artie’s TV world to change his seating.

In my first storyline, Artie ends up in the hospital with massive pressure ulcers on his right calf and his right ischium. He develops osteomyelitis in his right ischium and almost dies. The kids at McKinley High School hold a constant vigil for Artie during the weeks he is in intensive care on strong antibiotics to kill the infection. He manages to beat the infection and undergoes surgical skin flaps to repair the wounds and spends another three months in the hospital to recover.

Once healed, Artie’s physician refers him to a much-needed evaluation at a seating and positioning clinic. At the clinic, Artie’s wheelchair and cushion requirements are evaluated by a team including a physical or occupational therapist, as well as an ATP and a physical medicine and rehab (PM&R) physician. After the evaluation, his PM&R physician carefully writes a prescription for his new equipment needs making sure to write the exact manufacturer, brand and size, of each piece of equipment to ensure he gets exactly what is prescribed. Because of Artie’s hospitalization, the physician is sure to write “to prevent re-hospitalization” on the prescription — key words that quickly get his equipment requests authorized and delivered. Artie is now sitting straighter and enjoys a successful season three.

In my less dramatic, but much more hopeful storyline, Artie notices a red area on his right ischium and right calf during his daily skin check. His parents make an immediate appointment with his primary care physician — she looks at the red areas and writes a referral to the seating and positioning clinic (described in the previous paragraph). Artie gets a full seating evaluation and a prescription for the proper equipment. Over the summer he does extra weight shifts, and extra skin checks until his new equipment arrives. When his new equipment arrives, his seating is improved, he has no more red “hot spots” and enjoys a successful season three.

 

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Bob Vogel, 51, is a freelance writer for the ROHO Community blog. He is a dedicated dad, adventure athlete and journalist. Bob is in his 26th year as a T10 complete para. For the past two decades he has written for New Mobility magazine and is now their Senior Correspondent. He often seeks insight and perspective from his 10-year-old daughter, Sarah, and Schatzie, his 9-year-old German Shepherd service dog. The views and opinions expressed in this blog post are those of Bob Vogel and do not necessarily reflect the views of The ROHO Group.