ROHO In The Know : A Government Perspective

Author Bio:

J. David McCausland
Senior Vice President of Planning and Government Affairs – The ROHO Group

Background: From 1984 – 1991, employed by a national DME provider in several management roles associated with reimbursement, standards, sales and operations. Since 1991, employed by ROHO, Inc., a leading manufacturer of seating, positioning and full support surface products. Currently in charge of strategic planning, government, regulatory and legal affairs. Read More >>

Help save access to your medical products

I sincerely hope that I’m being “Chicken Little”, believing that the sky is falling when it really isn’t. However, I’ve been in the home care industry for almost 30 years now and I can’t recall a time when I saw the situation as dire as it is right now.

• Medicare  is implementing all kinds of programs that will reduce reimbursement and increase the cost of doing business in the home care industry with competitive bidding be at the top of the list. Most recently, Medicare proudly proclaimed that competitive bidding of DME will reduce Medicare expenditures by over $17 billion over 10 years (based on my math that equates to a cut of more than 15%).
• Many state Medicaid programs are in financial crisis and desperate to find ways to delay payments and cut costs. Multi-month lag on payments and payments with promissory notes is not out of the question.
• Medicare is implementing a variety of prepayment and post-payment audits that are causing providers an extraordinary burden. Imagine getting a letter requesting documentation on hundreds of patients over an extended period to time, just to prove that you have all the documents the auditor “deems necessary” for you to have been reimbursed! In addition, it is not at all unheard of that a provider will be place on 100% prepay audit / review for new claims while they’re being audited for their historic claims. If this happens the provider’s cash flow comes to a screeching halt. Their expenses continue but the money to pay those expenses is held up for months! Sadly, some providers cannot survive.

I know that the home care industry has it’s share of problems and rotten apples. At the same time, it also includes some of the most dedicated folks I’ve ever had the pleasure to work with, and I sincerely believe that the programs being implemented punish the innocent far more than the guilty. In addition, even with all the problems that may exist in home care, I still believe that it is an essential part of the solution to our health care challenges and a key component for the future of health care… so long as it is allowed to survive and thrive.

Left unchecked I don’t see how we can avoid a situation where the quality of goods and services, and the access to those goods and services, will be dramatically reduced. Ultimately, the consumers of these goods and services will suffer most. Yet, how do we get our message across when home care as an industry (whether it be goods or services, DME or HHA) has one of the smallest voices in the health care industry and other players are more than willing to throw dirt at home care?

Our current situation reminds me of a quote that has been credited to both Thomas Paine and Benjamin Franklin, “If we do not hang together we will most assuredly hang separately.” We may have different interests / involvements / allegiances in home care; but, we are all stakeholders (providers, referral sources, clients…) and we need to band together to overcome the common threats we are facing. For that reason I just signed up for the Save Homecare Now Campaign and I hope that you’ll consider doing the same thing. It’s being coordinated by AAH but the message is applicable to any home care stakeholders (AAH member or not). Below is the link if you’re interested in signing up to be an “advocate for home care”.

http://capwiz.com/aahomecare/mlm/signup/

Thanks for taking the time to let me get on my soap box. I hope that you’re all doing well and look forward to any opportunity to see each and every one of you.

Kind regards,

Dave

The Results Are In…

• CMS has moved forward with the round 1 competitive bidding “rebid” in nine metropolitan areas (Charlotte, Cincinnati, Dallas-Fort Worth, Kansas City, Miami-Fort Lauderdale, Orlando, Pittsburgh and Riverside-San Bernardino).

• There were nine product categories put up for bid:

1. Oxygen, Oxygen Equipment and Supplies
2. Standard Power Wheelchairs, Scooters, and Related Accessories
3. Complex Rehabilitative Power Wheelchairs and Related Accessories (Group 2 only)
4. Mail-Order Diabetic Supplies
5. Enteral Nutrients, Equipment and Supplies
6. Continuous Positive Airway Pressure (CPAP) Devices, Respiratory Assist Devices (RADs), and Related Supplies and Accessories
7. Hospital Beds and Related Accessories
8. Walkers and Related Accessories
9. Group 2 Support Surfaces (Miami-Ft. Lauderdale only)

• Unfortunately, despite all our efforts and rationale, adjustable seat cushions (HCPCS codes K0734-K0737) were still included in the rebid as an accessory for standard power and complex rehab power.

• On July 1^st CMS (Medicare) announced the winning bid rate for each code in each of the nine metropolitan areas.  Currently, the Medicare allowable for “K0734 – adjustable skin protection seat cushion for wheelchair” (this is the code that the ROHO Single Valve HIGH PROFILE is assigned to, along with a wide variety of other products) is $299.98 when used with a power wheelchair.  Yet, the winning bid rates for adjustable seating varied by over 24% from one metropolitan area to another (from $225.00 in Miami to $293.98 Cincinnati).  Based on the winning bid rates I believe it is going to be very difficult, if not impossible, to obtain a high quality, adjustable cushion as of January 2011 in Dallas, Ft. Worth, Miami, Ft. Lauderdale or Orlando.

• In addition, since 2004 when the new seating policy was implemented by Medicare we’ve already seen the reimbursement for adjustable seating cut by over 20%.  As such, it’s not going to be easy to obtain a quality product, let alone the accompanying services, in any of the competitive bidding areas.   (Why we continue to see cuts in the reimbursement for products intended to reduce the incidence of skin breakdown, when the cost to heal a wound can cost thousands to tens of thousands of dollars, is beyond my understanding.)

• We are continuing to try and get adjustable seating pulled out of round 1 of competitive bidding but the chances of this occurring is becoming less and less likely.  I really believe that “deep down” the folks we’ve met with probably agree with our arguments; however, I also believe they are unwilling to pull adjustable seating out of round 1 because they are afraid that this will create a precedent and create an uproar from other products included in bidding.  Yet, I’m not willing to say that all our efforts are in vain and we will continue to fight for their removal from round one.  In addition, as much as I hate to see what has occurred in these nine metropolitan areas, I do believe that our messages and the round one results may help us to avoid adjustable seating being included in round two, which includes 91 of the largest metropolitan areas in the U.S. (including New York, Los Angeles and Chicago).

• We will continued to argue that the competitive bidding of adjustable skin protection seat cushions:

• Will not maintain, let alone enhance, beneficiary access to the goods and services they need.
  • Choice is critically important to address the unique need of each individual requiring skin protecting seat cushions.  No one product meets everyone’s needs.  As such, there are over 4000 products of unique sizes, shapes, materials, configurations, functions and acquisition costs collectively assigned to the four adjustable skin protection seat cushion codes.
  • Service is essential to effectively select the appropriate product and insure that the product is correctly adjusted to the individual.
  • These two variables cannot be effectively addressed under the existing competitive bidding framework.  To win a provider must be one of the lowest bidders.  This incents the provider to submit bids based on the products that cost them the least to obtain without consideration for the needs and variables described in point 1 above.  Further, there are no service requirements included in competitive bidding.  This incents the provider to reduce or eliminate any services they possibly can in order to lower their bid.

• Will result in an increase in incidence and prevalence of wounds and the other medical complications associated with wounds. Recently, the results of a randomized controlled trial performed by the University of Pittsburgh have started to be announced.  This is a landmark study for skin protection seating including multiple facilities and over 200 participants.  In the study four different seat cushions, all claiming some skin protecting features, were used.  While not all of the data has yet to be fully analyzed and reported, the information presented so far already re-enforces our position.  During the study there were nineteen incidences of ulcers on the sacrum / coccyx.  For three of the included cushions the incidence of sacrum / coccyx ulcers ranged from fourteen to twenty percent.  However, there were no sacrum / coccyx ulcers for the individuals utilizing the ROHO cushion that was included in the study.  While we are very pleased with how the ROHO served the individuals utilizing it during this study it is not my intent to claim that ROHO cushions are the only effective product.  This is certainly not the case.  I merely point this out to illustrate the need to select the right cushion to address the individual’s needs and the impact on wound incidence if this does not occur.

• Will increase overall expenditures for Medicare beneficiaries and the Medicare system.

• If the competitive bidding of adjustable seating results in an increase in the incidence of wounds any gross savings derived from their being included in competitive bidding will be overwhelmed by the cost associated with treating those wound.  It is not an exaggeration to say that the prevention of one wound can pay for over one hundred skin protection seat cushions.
• Regarding the costs for beneficiaries, the competitive bidding of adjustable skin protection seat cushions may force them to make a choice between increasing their risk of skin breakdown and purchasing the cushion they need privately.  Either way their out of pocket costs go up.  Beneficiaries are already finding it more and more difficult to find a provider willing to take assignment on an adjustable skin protection seat cushion.  In many cases they are being forced to purchase the product privately, or purchase the product from a provider on a non-assigned basis.  Under the existing fee-for-service structure the beneficiary can at least recoup 80% of the Medicare allowable for the product they purchase.  However, under competitive bidding they lose this right.  They must obtain a cushion from a winning provider who accepts assignment in order to obtain any reimbursement from Medicare.  If they cannot get the product they need from a winning bidder they must choose to take what they can get or pay 100% of the cost to get what they need.

• Our message remains the same:
  • It is not too late to pull adjustable seating out of round one of competitive bidding (K0734-K0737)!
  • It is imperative that this occur to insure beneficiary access to the goods and services that they need and to avoid serious medical complications for these beneficiaries, including an increase in the incidence of skin breakdown!
  • Do not compound this mistake by including adjustable seating in round two of competitive bidding!

If you’re interested in helping in this fight please contact your Senators and Representative and share your concerns and our message.  Please feel free to use any of the information in this update in developing your own message.

Once again, thank you all for your ongoing interest and support.  I’ll keep you posted!

Dave

Help keep your access to therapeutic seat cushions

Through your efforts we crashed Beth Stein’s e-mail at Senator Harkin’s office last November. As a result, Senator Harkin committed to taking action to try and get adjustable skin protection seat cushions removed from competitive bidding. However, to date no action has been taken.

Let’s keep up all of your hard work!

We must to reinforce the need for his part in order to avoid a reduction in the access to, and quality of, therapeutic seat cushions available to individuals that need them, and all of the health related complications that would result.

WE NEED THIS ISSUE ADDRESSED ASAP!

If you wish to reach out to Senator Harkin, here are some specific points that you could personalize and communicate in your message.

• We need help NOW!  Left unchecked, this issue will affect your access to the products and services you need!
• We are concerned about the competitive bidding of adjustable skin protecting seat cushions assigned to Medicare codes K0734 through K0737.
  • These Medicare codes are not distinct enough to bid.
  • These products require unique selection, adjustment and support.
  • Bidding these items will diminish the quality and access of adjustable seat cushions for all users, not just Medicare beneficiaries in competitive bid areas.

The key message needs to be: Adjustable skin protection seat cushions, assigned to Medicare codes K0734 – K0737, should be excluded from DMEPOS competitive bidding!

Your message needs to be personalized but you can certainly use the points we’ve listed above to focus your message. Stress that you wish this matter brought to the immediate attention of Senator Harkin.

Here is contact information for Senator Harkin and specific staff members involved in this issue:

• Senator Harkin’s contact page: http://harkin.senate.gov/contact.cfm
• The staff member drafting the Senator’s position: Lee Perselay, lee_perselay@help.senate.gov
• Previously cushion users sent messages of concern to Beth Stein in Senator Harkin’s office: Beth_Stein@Harkin.senate.gov

Washington, D.C. office information:
731 Hart Senate Office Building
Washington, DC 20510
Phone:  202-224-3254
Fax:  202-224-9369

Iowa offices:
Cedar Rapids
Phone: 319-365-4504
Fax: 319-365-4683

Davenport
Phone: 563-322-1338
Fax: 563-322-0417

Des Moines
Phone: 515-284-4574
Fax: 515-284-4937

Dubuque
Phone: 563-582-2130
Fax: 563-582-2342

Sioux City
Phone: 712-252-1550
Fax: 712-252-1638

For more information on competitive bidding visit the Advocacy Page.



National Summit on Disability Policy to be held July 25-27 in Washington, DC

The National Council on Disability-sponsored National Summit on Disability Policy to meet and develop recommendations for improvements in disability policy and programs will take place on July 25-27 at the Renaissance Washington, DC Downtown Hotel. This year commemorates the 20th anniversary of the signing of the Americans with Disabilities Act. Several different topics will include: Civil Rights, Education, Healthcare, Housing, International Affairs, Telecommunications and more.

This year’s theme will be Living, Learning and Earning designed to launch a dialogue on disability policies and programs in the 21st century. This year marks the 20th anniversary of the signing of the Americans with Disabilities Act.

The invitation-only event has a limited number of scholarships available for consumer delegates (those not representing an organization). For more information on the National Summit visit the National Council on Disability Web site, e-mail ncdsummit@neweditions.net or call 866-538-9521.

Dear ROHO Friends, Customers and Stakeholders…

Dear ROHO Friends, Customers and Stakeholders,

We are at a pivotal point in the history of health care for the United States.  However, the future of health care in our country is far from clear.  There are a variety of forces at work that each have their own vested interest and are actively trying to influence policy makers to insure that their interests are a part of that future.  This is certainly true regarding durable medical equipment (DME) and specifically for seating (ROHO cushions).  We believe that DME and high quality, effective skin protection seat cushions are a part of the solution to spiraling health care costs.  For example, over 100 adjustable skin protection cushions could be purchased for less than it would cost to heal one wound.  As such, if using an effective skin protection cushion reduces the incidence of wounds by one percent then overall health care expenditures are reduced as well.

Unfortunately, the DME industry, and more specifically our little piece related to seating, has a very weak voice amongst the clamor of groups trying to influence public policy.  Instead of being viewed as part of the solution, all too often DME (and seating) is viewed as an opportunity for reimbursement cuts to pay for other areas that have the loudest voices.   Since 2004 the Medicare reimbursement for adjustable skin protection seating has been cut by twenty percent or more and additional cuts are looming in the near future.  All of these have had a negative impact on your ability to obtain the specific goods and services that you need.  Yet, all of the cuts to date pale in comparison to the threat that looms in our future.  The threat that I’m referring to is competitive bidding.  Clearly the principle behind competitive bidding makes sense but please consider the following facts to determine whether it makes sense for seating… right now:

• Medicare’s rules for competitive bidding include the following:
  • Bid prices must be lower than the current Medicare allowable or their bid is thrown out.
  • Bidders do not have to have a physical presence in the geographic area that they are bidding for.
  • The median price of the “lowest” bids submitted determines the winning bid price.
  • No bidder is obligated to accept a contract should they be identified as a bid winner.

As such, there is no risk, and every incentive, for a bidder that has nothing invested in a specific market to bid very low.  Once the winning bid rate is determined they can decide if it’s worth them taking the contract and setting up operations in the area.  If it’s not a price they are willing to take they can walk away… but the winning bid rate is still locked in place.

• Competitive bidding is performed using the existing Medicare coding system, (HCPCS coding).  Under the HCPCS coding system there only four codes for adjustable seat cushions:
  • K0734 – adjustable skin protection seat cushion (currently 927 cushions of various sizes, shapes, materials and performance are assigned to this code).
  • K0735 – adjustable skin protection seat cushion, ≥ 22” wide (679 cushions assigned)
  • K0736 – adjustable skin protection and positioning cushion (1385 cushions assigned)
  • K0737 – adjustable skin protection and positioning cushion, ≥ 22” wide (1162 cushions assigned)

All of these cushions meet Medicare’s “minimum requirements” for assignment to the code but they vary dramatically in materials, durability and performance.  Bottom line, these codes are far too generic to be effectively bid.  This would be akin to bidding a “powered vehicle with four wheels”.  The resulting bids would include everything from a powered skateboard to an SUV, but the lowest bid wins so everyone ends up with the powered skateboard.

Based on this incentive for providers that have no risk to submit “low ball” bids, and the generic nature of the coding that adjustable seat cushions are assigned to, we have every reason to believe that the winning bid rates for these codes will be set too low to cover the cost of many higher quality, adjustable cushions.  As a result, access to these high quality seat cushions that customers and stakeholders have relied upon in the past will become very limited.

The bids from the first round of competitive bidding for nine metropolitan areas are currently being reviewed.  Unless something is done, the winning bid rates will be announced in the next 2-3 months and will go into effect in January 2011.  Do not assume that this doesn’t affect you because you’re not in one of the nine bidding areas! The results from this initial round of competitive bidding by Medicare will ultimately affect all of us.  Consider the following:

• All states are suffering financially.  Several state Medicaids have already started cutting their fee schedules based on bid rates that were obtained in the past.  We have every reason to believe that state Medicaids across the country will see the winning bid rates from the first round of bidding as an opportunity to cut their own reimbursement rates.

• The recently passed Health Care Reform legislation requires Medicare to accelerate competitive bidding to include 91 more metropolitan areas by 2013 and to implement competitive bidding rates nationwide by 2016.

Competitive bidding can work, but modifications to the rules / requirements and clear, distinct coding must occur first.  However, for those items included in the original nine metropolitan areas (including adjustable seating) the damage may already be done.  As such, we believe that the best hope for adjustable seating is to get it pulled out of the first round; and, we have very clear, sound arguments to support this position.

• The use of adjustable skin protection seat cushions actually saves the Medicare system and Medicare beneficiaries’ money by reducing the incidence of wounds.

• The HCPCS codes that adjustable skin protection cushions are assigned to are not distinct enough to be competitively bid.  Bidding these products, under their current coding structure, will reduce, if not eliminate, access to the specific products that have the most clinical evidence and history demonstrating effectiveness.

If you agree and you want to get involved now is the time! There is still a chance to prevent this from happening but time is running out!  We need to contact individuals who are in a position of authority regarding the competitive bidding program and request that adjustable skin protection seat cushions be removed from round one of DMEPOS competitive bidding for the reasons we’ve given above.  In addition, we need to stress that these products should not be included in competitive bidding until the coding structure they are assigned to is expanded to allow for distinct, homogenous groups of products.

Your message needs to be personal but you can certainly use any of the information included in this message.  Probably the best individuals to send a message to would be your local Senators and Representative.  If you do not know who your Senators and Representative are, or how to contact them, here are internet links you can use to obtain the information you need:

Senate: http://www.senate.gov/general/contact_information/senators_cfm.cfm

House: http://www.house.gov/house/MemberWWW_by_State.shtml

In addition, the Secretary of Health and Human Services, Kathleen Sebelius does have considerable authority and discretion regarding the competitive bidding program.  Here is her contact information should you desire to send her a message as well, or copy her on Congressional letters:

Secretary Kathleen Sebelius

Secretary of Health and Human Services

Office of the Secretary

Hubert H. Humphrey Building

200 Independence Avenue, SW

Room 615F

Washington, DC 20201

To provide you with even more information on the issues and our arguments we are setting up a new “Advocacy” section of the ROHO website:

http://www.therohogroup.com/BeAnAdvocate.jsp.

On it you’ll find flyers, position papers, and documents that go into detail on specific issues.  In addition, we’ll use this site to keep you informed on any news regarding competitive bidding or other areas that may affect DME access and quality.  Finally, please feel free to contact us with any questions, comments or news you might have.  Send your messages to advocacy@therohogroup.com.

Thank you in advance for your assistance and support and please let us know if you choose to become an “Advocate”!

Dave

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