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.
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.
Guest blog post by Bob Vogel
In my experience with DME (durable medical equipment) dealers, competition leads to quality. I was injured in 1985 — a T10 complete paraplegic — my first cushion and wheelchair were covered by Medicaid and provided by a local DME dealer. In the 90’s I worked as a sales rep for a wheelchair manufacturer, selling to and working with DME dealers. After that I worked as a sales rep for a DME dealer.
In my experience, a good DME dealer has the knowledge and takes the time to properly fit and provide the best cushion, wheelchair, etc., to meet their client’s needs. DME dealers strive to provide the best service and best products to meet our needs because it’s the right thing to do, and because it’s good business. We have the power to take our business to another DME dealer and word of mouth — good or bad — is powerful when it comes to business.
Unfortunately, because of competitive bidding, this paradigm is changing. The CMS (Centers for Medicare and Medicaid Services) competitive bidding program has DME dealers bidding to see who can provide equipment in a certain category for the lowest price — for you and I this category complex rehab, from cushions and wheelchair backs to manual chairs and high-end power chairs. Round I of competitive bidding is already in place in 9 regions. Round II of competitive bidding is looming on the near horizon with 91 regions including the largest cities in the country.
Under competitive bidding, instead of Medicare beneficiaries having five to ten Medicare providers to choose from that compete based on the quality of the products and service they provide, we may only have one in our region — eliminating the competition and the need to provide quality products and service. Have a local DME dealer who didn’t win the bid that you have been going to for years? Tough. Don’t like the way the winning bid DME dealer does business? Tough. It’s not just Medicare — Medicaid and many private insurance companies have track records of following the Medicare competitive bidding guidelines.
The way competitive bidding is set-up encourages DME dealers that are only concerned with profit to underbid DME dealers that are truly concerned with providing the right product for their client. As an example, let’s take a look at a common type of cushion. Let’s say your skin and seating requires a ROHO® HIGH PROFILE® Single Compartment Cushion — the government HCPCS (Healthcare Common Procedure Coding System) code for this type of cushion is E2622. Now let’s say there is a dealer who is only in it for profit, winning the bid, and becoming the only game in town. Medicare’s Pricing, Data Analysis and Coding (PDAC) for E2622 includes 915 different cushions. According to this data, every cushion on the list will protect your skin just the same. If dealer only who is in it for profit carefully goes through the list they will find some real “bargains,” including a layered foam cushion with a 1/4″ gel cover that retails for $39. But hey, it fits into the code so it “should” protect your skin just like a ROHO HIGH PROFILE Single Compartment Cushion — right? Wrong!
When I left rehab in 1985, my therapist sent me home on a memory-foam cushion saying it “should” protect my skin just as well as the ROHO HIGH PROFILE Single Compartment Cushion I had requested. Despite regular weight shifts, I developed a tiny pressure ulcer within 3 months. Regular mirror-skin checks enabled me to catch it right away — I got the ROHO Cushion and was able to heal at home, feeling like I had dodged a bullet.
A dealer only interested in profit could submit a lowball bid of say $250 for this category — win the bid and start shoving $39 cushions under clients while collecting $250 per cushion from Medicare.
This is why it is vital that you, working with your clinician, request the exact cushion that you need on a doctor’s prescription/documentation. Because even if you are in an area that already has competitive bidding, there is a clause in competitive bidding that says if a doctor’s prescription specifies the make, model and product, then the winning bidder — the DME dealer — has to provide that cushion, or find another winning bidder DME dealer that will provide the cushion. As competitive bidding looms, it is more important than ever for each of us to advocate for our proper seating. Make sure your prescription includes exactly what your seating needs are, for example ROHO® HIGH PROFILE® Single Compartment Cushion (4″). Make sure the size of the cushion needed is included on the prescription, for example 16″ x 16″.
In addition, there is still time to phone, email, or write your representative and senators and tell them you do not want competitive bidding. Explain that while competitive bidding may save money in the short term, the wrong cushion risks life threatening pressure ulcers that will cost taxpayers in excess of $50,000 per occurrence in hospitalization alone.
So what can you do to change the outcome?
1. Send letters to your representative and senators. It’s OK if you don’t know what to write, we have a letter already written and all you have to do is fill in the blanks.
2. Go to competitivebiddingconcerns.com and fill out a form to record your personal struggles with getting mobility equipment.
To view the list mentioned in this blog, go to the Medicare Pricing, Data Analysis and Coding list (PDAC) https://www.dmepdac.com/dmecsapp/do/search. Next, scroll down to the green bar that says “Search DMEPOS Product Classification List.” Under the green bar to the right, type in E2622 and click on the purple GO button and all 915 cushions that meet the criteria for this code will appear.
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 ROHO Group, manufacturer of support surface products for medical and consumer applications, is introducing a new non-powered ROHO® SOFFLEX® 2 Mattress Overlay System, designed for individuals who require skin protection.
The SOFFLEX 2 Mattress Overlay System provides the same effective ROHO® Shape Fitting Technology® pressure redistribution known throughout the industry. The SOFFLEX 2 is designed to meet the needs of individuals who require skin/soft tissue protection or other medical needs. It has three sections to conform to the individual’s body shape, size and needs. The three non-powered sections easily snap together to form a complete mattress overlay.
“SOFFLEX 2 represents the first of a new generation of support surfaces coming from ROHO that use new materials science to provide the same ROHO® quality,” Sr. VP of Sales and Business Development, Pat Chelf said.
Made from flame-retardant polyurethane, the new SOFFLEX 2 only weighs 6.5 pounds (2.9 kilograms) and is 36 inches (91.5 centimeters) wide by 81.75 inches (207.5 centimeters) long by 3.5 inches (9 centimeters) tall.
The SOFFLEX 2 comes with a hand inflation pump, operating instructions and a repair kit. It also has two cover options: ROHO® Reusable Mattress Overlay System Cover or ROHO® Mattress Overlay Enclosure Cover. The SOFFLEX 2 has an 18-month limited warranty and has a Medicare Part B HCPCS code of E0371 Group II Support Surfaces.
The ROHO Group specializes in Shape Fitting Technology®, manufacturing cushioning and mattress products for medical applications as well as for recreational and commercial vehicle use. For more information, visit The ROHO Group’s website at www.therohogroup.com or contact customer service at (800) 851-3449 in the US, or at (618) 277-9150 if outside the US.
For more information, contact:
The ROHO Group, Inc.
1-800-851-3449, ext. 2220
Learn about ROHO: http://www.therohogroup.com/corporate/about.jsp