Complex Rehab Offers Stability but is Not Easy Money

Throughout the years, the complex rehab industry has done a comprehensive job of addressing the unique physical conditions of people with motor and neurological function challenges due to spinal cord injury, stroke, multiple sclerosis, cerebral palsy, ALS, etc. Now, the industry is refining and improving its products based on demographic shifts and growth in digital technology, says Nicole Muehlenhaus, director of supplier Varilite. For example, in response to obesity, manufacturers are adding size options and robustness to their products, while the aging population will force products to become more consumer-friendly. “We are also seeing growth of digital applications to provide feedback to users,” adds Muehlenhaus. In general, complex rehab products are striving to keep up with consumer electronics and iPhone capabilities, such as control of thermostats and locks. Wheelchair manufacturers will increasingly integrate these capabilities into wheelchairs to enable clients to be more independent. “We’ve had that for a while, but now it’s more streamlined and wireless (using Bluetooth),” says Amy Morgan, national clinical education manager, Permobil. Like other HME categories, the complex rehab sector has its challenges. “It’s definitely not easy money, not easy business,” says Morgan. “I don’t want to discourage anyone from trying, but it will be a challenging process. It’s not business as usual. It’s a totally different group of people you are working with, and you need to have the appropriate resources,” including an assistive technology professional (ATP) on staff. Competition in complex rehab is heating up among larger players looking to take advantage of economies of scale in a fairly stable market. The climate can be challenging for a smaller player looking to enter the market and gain respect, Morgan adds. “Once you demonstrate you are qualified, you will get the business.” “We are seeing many smaller manufacturers and providers getting out of the business with larger companies consolidating and narrowing the products they offer,” says Sue Johnson, director of education, finance and IT, Columbia Medical. “But one benefit of these changes is that providers will become more efficient in their funding documentation. A benefit of product consolidation is that manufacturers and providers are taking 
a close look at the optimization of cost and quality. They recognize products 
must be durable to avoid repair and 
replacement issues that add more costs. Lower quality products will tend to be weeded out of the complex rehab mix.” Business activity just in the last few weeks reflects consolidation among suppliers. Recent moves include Quantum Rehab’s acquisition of Stealth Products and Permobil’s acquisition of manual wheelchair manufacturer TiLite.

Challenges of Reimbursement

Reimbursement is another issue. One recent reimbursement change is the reclassification of many complex rehab categories as capped rental. The change affects a range of DME items previously in the routinely purchased category, including adult manual tilt-in-space wheelchairs and pediatric wheelchairs. Columbia Medical’s Sue Johnson says these changes make no sense for a large portion of the population using the affected products, which are in many cases customized and primarily designed for persons with long-term or permanent disabilities. This change will have long-reaching effects on the cash flow of providers and manufacturers and will add financial costs and administrative burden, she says. In the last year and moving forward, creating complex rehab technology as its own Medicare funding category outside of general DME remains a vital goal for the sector. Complex rehab technology is highly individualized, orthotic-type technology, with very specialized products and services involved, says Mark E. Smith, consumer research manager, Quantum Rehab. Securing Medicare’s recognition of complex rehab as its own category will ensure patients access to vital technology and related services, he says. The “Ensuring Access to Quality Complex Rehabilitation Technology Act of 2013” (H.R. 92 and S.948) has been introduced and is gaining momentum in Congress. Recent victories include the carve-out of Adjustable Cushions (HCPCS codes H2622/E2623/E2624/E2625) from the Competitive Bidding Program, and several state Medicaid organizations have introduced and passed new complex rehab technology legislation, says Pete Coburn, president, U.S. commercial operations, Sunrise Medical. Industry leaders like Rita Hostak, Sunrise Medical’s vice president of government affairs, advocates for the industry and consumers as well as educating legislators and payers. In addition to the general Medicare supplier standards, complex rehab falls under the DMEPOS Quality Standards, requiring ATP certification, service standards and other levels of best practices, says Smith of Quantum Rehab. Increasingly, referral sources favor the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) SMS certification (Seating and Mobility Specialist) in addition to the ATP certification, focusing heavily on aspects of advanced seating and mobility technologies. Having staff certified to the highest industry levels can increase recognition among the referral source community, he says. The importance of the complex rehab market in the health care continuum highlights the need for providers to have a highly-educated, certified staff to address the sector. Referral sources must be cultivated, and a provider’s responsiveness to the needs of a rehab center’s patients speaks volumes. Johnson adds, “Investing in staff’s knowledge of reimbursement documentation requirements will go a long way toward success in the complex rehab market.” As the population ages, funding challenges become more acute. Industry organizations such as the National Coalition for Assistive and Rehab Technology (NCART) are leading the way on behalf of the complex rehab market. “The complex rehab industry must move from a defensive position to one that continues to bring creative solutions to the table,” says Muehlenhaus of Varilite. The financial difficulty that CMS finds itself in is not unique, and we can learn a lot from solutions beyond our own [national] borders. This is a global problem, not just a domestic one.”

New Product Developments

“Our industry continues to spawn new products and improve existing ones,” says Johnson of Columbia Medical. “Reimbursement is a key factor in determining feasibility of product development, so many of the new products fit within existing codes with additional features and accessories that add a market advantage.” Columbia provides bathing, toileting, transportation and mobility products for children and adults with special needs. Columbia Medical’s new Innova CG Tilt Wheelchair was designed for families on the go. The wheelchair with tilt and complex positioning can be easily disassembled into a compact package to be transported in the family car, van or bus; the rigid frame has a folding wheelbase for compact transportability. “We designed it to fit in the truck of a Honda Civic,” says Johnson. A crash-tested transit model is also available for transport in a van or bus. The Innova wheelchair’s tilt allows the user’s center of mass to move with the wheelchair frame as it tilts, thus making it more stable and easier to propel than a standard tilt. The wheelchair frame can expand as a child grows from young child to teen to small adult sizes, with 14- to 18-inch seat widths and frame depths from 12 to 23 inches. The new Innova wheelchair expands upon Columbia Medical’s existing mobility line, which includes airline wheelchairs and mobility bases for car seats. Columbia Medical seeks to improve core products to keep them fresh while retaining basic quality and functionality. “Many of our successful product ideas come from complex rehab patients who want a customer item, and it makes sense to transfer the customization to our production.” For example, the company had a request to customize a tub sitter product by raising it 7 inches off the floor to accommodate positioning of a patient’s legs; the change later became a standard product. A custom need to interface a toilet shower-chair with a tub slider system has also yielded a new product. Providers should expand their focus to address the broader needs of a child, says Johnson. For example, if a child has outgrown his wheelchair, it is likely he has also outgrown his bath chair and/or his car seat. “Providing more than one piece of equipment at a time may be more efficient and increase the bottom line as well as establish the provider as a consultant for the family’s medical equipment needs,” says Johnson.

Medical Necessity, 
Quality of Life

Quantum Rehab is a global manufacturer of complex rehab solutions, specifically focused on complex rehab power bases, power positioning systems and high-end drive controls meeting the most advanced, individualized needs. Quantum’s Q-Logic 2 Drive Controls are engineered to meet the most advanced complex rehab needs. Fully programmable, with the ability to interface power seat functions and specialty drive controls, Q-Logic 2 also offers environmental access via built-in Bluetooth technology. As a result, Q-Logic 2 offers patients optimal levels of independence with their mobility technology and beyond. Complex rehab technology has evolved based on medical necessity and quality of life, says Smith. Products like power positioning seating systems have become increasingly refined around ergonomics, addressing issues like pressure sores while increasing overall patient functionality. The Varilite product line consists of postural support systems that provide excellent pressure distribution, comfort and stability in ultra-lightweight seat cushions and positioning backs for a variety of complex seating needs. Varilite developed the dual-chambered Meridian Air-Foam Flotation cushion to promote a neutral pelvis position for individuals with motor and neurological dysfunction who are prone to extensor tone or thrusting. The unique and independently adjustable front and rear chambers form a pre-ischial ridge that prevents the hip bones from sliding forward, preventing posterior pelvic tilt and sacral sitting. Releasing more air from the pelvic chamber than the thigh chamber provides added postural support by creating dump or squeeze that holds the client in place.

Engage With Manufacturers

Thomashilfen North America sells a range of German-manufactured pediatric rehab equipment, including the Swifty, tRide, EASyS, EASyS Modular and TheveoTwist products. The company also offers special needs car seats, such as Recaro ProSport Reha, and Recaro Monza Reha, and therapy chairs ThevoSiiS and ThevoTherapy. The tRide stroller-style pediatric wheelchair, launched in October 2013, is the newest in the line, responding to parents and caregivers who have said they need a stroller with the ability to grow. It is simple to use and adjust and has a variety of options. The tRide offers a full range of adjustments and doesn’t require tools to change the seat height and depth. The product also offers more storage space under the seat and comes in bright, child-friendly colors. The seat can be tilted using one hand while maintaining control of the child’s seat angle. Dealers should continue to stay educated about new products that meet a variety of needs, says Elisa Louis, president of Thomashilfen North America. With so many choices, it’s difficult to know about them all, but manufacturers and their local representatives can help answer questions, provide information or demos, in-services, etc. Louis encourages providers to engage with manufacturers about product needs and challenges. The feedback helps them meet customer needs and determine if dealers and end users are maximizing the use of products. “We want to be able to help, but we are unable to help unless we know there’s a challenge,” she says. “Sometimes we get a call from a family that really thinks they know the product they would like to try out, and the local dealer isn’t familiar with it or doesn’t have a demo on hand,” says Louis. “I see that as an opportunity. For our part, if it were one of our products, we would want to put them in touch with the local rep or provide a demo.”

Investment in R&D

Sunrise Medical emphasizes product innovation and customer satisfaction, including significant research and development (R&D) investments, says Coburn. Several years ago, the company introduced SpiderTrac Suspension on its QM-7 Series Power Wheelchairs, featuring independent six-wheel suspension for traction and handling across multiple terrains and e-in. cub climbs. Recent 
successful market introductions include the Zippie Voyage pediatric stroller, JAY X2 cushion, Quickie Pulse six multi-power option power wheelchair and the Quickie Q7 NextGEN adult rigid wheelchair. The current calendar year roadmap includes 10 introductions covering various product segments. Sunrise Medical develops, designs, manufactures and distributes manual and power wheelchairs with both standard and customized seating and positioning systems. Key products marketed under the Quickie, Zippie, Breezy and JAY brands are sold through complex rehab dealers and distributors in more than 130 countries. The Quickie 2 folding wheelchair is one of several flagship products. Originally launched in 1983, the Quickie 2 has been customized for more than 500,000 individuals over the past 30 years. The product can be configured in thousands of ways can be combined with a JAY cushion and/or backrest to meet individual needs. Providers can become more efficient and successful by adopting clinical best practices and through the use of new technology, says Coburn. Wireless tablet technology can greatly improve the clinical evaluation process and reduce the overall revenue cycle. Sunrise is also seeing a significant increase in utilization of its electronic order entry tools and services, helping to prevent errors and improve overall operational efficiencies.

Outdoor and Indoor

Innovation in Motion provides rehab equipment to dealers in North America, distributing Magic Mobility Power chairs including the X8 Extreme, a 4X4 power chair; and the V6 Frontier, a mid-wheel-drive power chair. The chairs are manufactured and designed in Australia, with final assembly done in Innovation in Motion’s facility in Angola, Ind. The chairs provide a range of complex rehab solutions with aggressive outdoor capability to empower users with the freedom of mobility in diverse terrains. Magic Mobility has continued to improve its rehab seating option to cover a range of needs to allow more users to enjoy the freedom the chairs offer. Innovation in Motion also distributes the Ormesa line of rehab products in North America. Products from the Italian manufacturer include the Grillo gait trainer, New Bug tilt-in-space stroller, Dondolino prone stander, Dynamico gait trainer, Birillo pre-gait trainer, Clip and New Novus foldable strollers, Standy and Mini Standy standers, and the Guidi tilt-in-space long-term care chair. The V6 Frontier has been designed to provide mobility to users who would like to pursue outdoor activities and is maneuverable enough to be used as a primary indoor chair. The V6 can accommodate full rehab seating options, and custom orders can address individual needs. Design of the V6 allows it to be fitted with narrow indoor tires for typical weekly activities and then be transformed into a weekend adventure chair by installing the outdoor tires using a simple one-bolt system. Innovation in Motion’s power chairs have evolved from a single, simple four-wheel drive model with tilt to eight models to serve individual needs. Innovation in Motion also offers a complete line of power seat functions, such as 50-degree tilt and space, 12-inch lift, power recline and power leg rests. “Every customer has different needs, and sometimes standard products do not work, so we also make custom parts to the dealer’s specs,” says Todd Libey, general manager, Innovation in Motion. Permobil, a power wheelchair manufacturer serving the complex rehab category, just acquired TiLite, a custom manual wheelchair company. The combined companies broaden the company’s scope to provide manual wheelchairs as well as power wheelchairs, which might be an opportunity for a dealer to expand their product line. Permobil offers front-, rear- and mid-wheel drive bases. One of Permobil’s claims to fame is the Corpus 3G seating system, which can accommodate a variety of client needs in a standard seating system without requiring extra supports, cushions, back rests. Known for its comfort, the seating system can support clients with various postural deformities and asymmetries. It also lends itself to addition of components for lateral trunk or back support. The sleek system “doesn’t look big and medical,” says Morgan. The power seating module with intelligent control system (ICS) takes the client through an appropriate series of positions in the correct order for pressure relief and to increase the care and compliance of the user. Coming this fall is a Virtual Seating Coach, a phone app programmed by the clinician that works with the power positioning system to measure and provide visibility into compliance with use of power positioning.

Importance of Control Systems

Active Controls’ Center Drive system replaces joysticks and redeploys the controls of a power wheelchair into a mid-line operating position (in the center of the chair), which improves posture, pressure distribution and operation of the device. The modular mounting system accommodates a variety of drive controls and accessories. It improves postural positioning for power wheelchair patients and enlarges the overall patient population that can benefit from power mobility. The Center Drive System can be utilized with the many specialty rehab drive controls found in the Active Controls Rehab Solutions product line. The advanced control technologies in this product line are enhanced by the modular, robust mounting provided by the Center Drive System. The company has strategic alliances with drive control manufacturers in the industry, including Switch-It and Stealth Products. The various control/input devices drop in easily. During a product assessment, a customer could try out 10 different input devices; Active Controls sells kits to the dealers for assessments. Active Controls’ new Enhanced JoyBar works with expandable electronics from PG Drives and Q-Logic. A 9-pin connection into an enhanced display (monitor) enables all chair functions and can also allow use of Bluetooth connectivity to control environmental elements such as the lights and TV remote. Russ Rolt, vice president of sales and business development, Active Controls, observes less innovation taking place in the market because of competitive bidding. More products are being built around the lower allowables, and everyone is focused on margins. Related to lower reimbursements, many are waiting for the “other shoe to drop,” says Rolt. “Almost everyone feels that complex rehab will be affected. The question is when.” “Our industry is composed of good, conscientious people who are patient advocates at their core,” says Rolt. “You’re rewarded for that in most industries, but not in ours. It’s a conflict for many providers to take off their patient advocate hat. It changes how people are running their businesses.” To succeed in complex rehab, Rolt urges providers to “approach every client you see as if they were a family member.” He says providers should also be open-minded and not limit themselves from an opportunity perspective. “Build relationships with clinicians so that you are the go-to person to call. It takes time and effort, and you have to prove yourself to them.”