Pulling Together On Capitol Hill

“We’ve got to be a team. Teamwork wins. If we don’t hang together, it’s for sure we’re going to hang separately.”
Shelly Prial, HomeCare magazine, November 1999

The question is, is the home health care industry, circa 2003, hanging together? Or is it still in danger of hanging separately?

Four years ago, just before the calendar flipped over into a new century, the industry — home medical equipment, home health agencies, home infusion, respiratory and rehabilitation — was in turmoil. Reimbursement was on a downhill slide. Federal mandates such as inherent reasonableness, competitive bidding, consolidated billing and the interim payment system were wreaking havoc in HME businesses and HHAs alike. Many simply shut up shop.

Key stakeholders prescribed one antidote for the industry’s critical condition: a unified voice.

“Until we have a unified voice in home health care, Congress through its bills and [the Health Care Financing Administration, predecessor of the Centers for Medicare and Medicaid Services] will continue to pick us apart, one thing at a time,” predicted Mario LaCute, then chairman of the Alexandria, Va.-based National Association of Medical Equipment Services.

Two months later, in January 2000, NAMES, the home care division of the Health Industry Distributors Association and the Home Health Services and Staffing Association merged to form the American Association for Homecare. Its mandate was to present a unified voice to legislators.

Fast-forward to October 2003. The industry is once again under assault, this time by the threat of national competitive bidding and a seven-year Consumer Price Index freeze. HME providers are also grappling with the issue of mandatory accreditation, and rehab is fending off Medicaid reimbursement blows.

By nearly all accounts, it is AAHomecare — which calls itself “the unified voice that represents all elements of home care under one roof” — that is speaking the loudest for home health care on Capitol Hill. But is it truly a unified voice? And if so, has it proven to be the best antidote for the industry’s condition?

The answers depend on whom you ask. Industry players have different perspectives on both issues. But they are in concert on what it will take to strengthen the industry — and it depends, they say, on you. Perspective: AAHomecare and a Key Legislator

Joel Mills, chairman of the board for AAHomecare and CEO of Advanced Home Care, Greensboro, N.C., believes the national association has indeed become the industry’s voice. And that has given home health more clout, he says.

“We are definitely stronger together than we were separately,” says Mills, who was home care market chair of HIDA when the AAHomecare merger came about. “When we go to Capitol Hill and talk to our legislators, all parts of our industry benefit. [HME] benefits because we now have a clinical component. We can talk about the clinical side of our business and not have the people on the other side of the table look at us and say we are only equipment people. It gives [us] an air of legitimacy. It gives us that much more clout. We have more resources that we are now able to pull together because we have more members. We have a little bit more money, and with more money you gain a little bit more influence on Capitol Hill.”

This year, Mills believes, has proven that. “We are no longer just a side part of the overall Medicare debate. AAHomecare is asked to participate and give its opinion, and it is seen as a real player on Capitol Hill. On previous issues, I’m not sure we had that.”

At least one key legislator agrees.

“I hear from a lot of individuals and organizations on various home care issues, but the American Association for Homecare does a very good job of representing all of the many providers who serve home health care patients,” says Sen. Charles Grassley, R-Iowa.

Grassley says he found AAHomecare particularly helpful when the Senate was debating Medicare prescription drugs legislation. The association was, he says, “creative and constructive in helping us work through issues of competitive bidding and consumer access.” Perspective: Providers

Providers’ viewpoints cover the spectrum.

Gary Miller, manager of Mt. Carmel Medical Equipment in Pittsburg, Kan., says no other association is representing the industry like AAHomecare. “We feel currently that AAHomecare is our representative voice on Capitol Hill,” he says.

But that doesn’t mean he agrees with the association’s stand on every issue. “I may have feelings on the current positions they have taken, but I am not sure what the options are,” says Miller, who supports the battle against competitive bidding, but is not a fan of either national accreditation or the proposed seven-year CPI freeze. “But I do believe that we have to give our legislators some … alternative to save money. We don’t want competitive bidding and we don’t want a freeze, but what else are we going to give them?”

Contrast Miller’s perspective with that of Sudi Freeland, manager of Boulevard Homecare Center in Bartlesville, Okla. She worries that the continuing demands and restrictions of the federal and state governments will prevent her from doing what she wants most to do: provide the best product possible for each of her customers. And she doesn’t believe any association has a voice strong enough to stop the relentless turning of the screw.

“[The industry] is so fractured that there is almost no voice speaking for it,” she says. “I don’t feel we have anyone who can go to the legislators and truly present what home care does …We don’t have anyone lobbying for us that we are the good guys.”

David Murray, ATS, CRTS, owner of Dave’s Wheelchair in Hyde Park, N.Y., largely agrees with Freeland. “I have never seen so much organized dysfunction in my life,” he says. “I think everybody’s on a different page. We all need to pull together — AAHomecare, [National Registry of Rehab Technology Suppliers, Rehabilitation Engineering and Assistive Technology Society of North America], whatever we can get together — to form a coalition, a unified voice.”

He acknowledges that AAHomecare does a “pretty good job” serving members who show up at its meetings, but that is, he notes, a limited audience.

Freeland believes AAHomecare speaks mostly for national providers. She thinks buying groups have potential for greater leverage because they likely hear more from smaller providers. “I think they might be the best voices,” she says, even as she acknowledges that many smaller providers don’t belong to buying groups — or any other association, for that matter.

Richard Wilcox of Wilcox Pharmacy/Option Care in Rutland, Vt., sees the industry’s various factions pulling together more than ever — even though his pharmacy specializes in respiratory and infusion and doesn’t always have the same issues as, say, mobility. “We’ve made strides toward a unified voice,” says the former president of the New England Medical Equipment Dealers Association.

The industry is also closer to delivering a single message, he says. However, he notes, “we are not there. But it may be impossible to get there given the fragmentation of the industry.” Perspective: Manufacturers

As director of government relations for Elyria, Ohio-based Invacare, David Williams has spent a lot of time in Washington. From his perspective, home care has not achieved a unified voice in the nation’s capital.

“I think things have improved,” he says. “We have a trade association that is trying to bring all the diverse voices together, but we won’t have a unified voice until we have more members. There are more than 10,000 potential members of AAHomecare, and there are less than 1,000 [actual members]. Of that 1,000, the work is done by less than 100. How do you have a unified voice if the message is shaped by a small minority?”

The issues also make it hard to achieve a unified voice, he says. “We can be unified on some things, but take accreditation. That’s all over the board. Even in rehab, there are differences. For most in rehab, it’s a must; for others, it’s anathema.”

Still, Williams acknowledges, outside of AAHomecare, “there is no voice coming from anywhere else with any power.” He believes the fruits of the association merger are just emerging, and that the situation will improve with time.

Rita S. Hostak, vice president of government relations for Longmont, Colo.-based Sunrise Medical, agrees that a single voice has not been achieved. “We are not where we envisioned we would be three years ago,” she says. “We have made progress, and communication has improved significantly.”

However, she suggests, “maybe one voice is no longer the ultimate goal. A more appropriate goal might be communication, negotiation and cooperative strategy implementation.”

Different associations exist to serve specific needs, Hostak says, noting that state associations focus on business practices in their specific states, such as Medicaid issues and state licensure. Other associations serve manufacturers or special-interest areas of the industry. “What is important are the well-laid-out processes and communication links that facilitate groups coming together to work on common issues.”

This is happening already, she says. “There has been a very purposeful effort made to develop communication between manufacturers and suppliers, the national association and state associations. We have learned that the upfront effort of talking issues through with groups on all sides, while it may seem long and painful at times, truly makes for a better outcome down the road.”

That could help with what Williams sees as another problem. “The picture that we are presenting is not clear,” he says. It leaves legislators asking, “‘What is it you want? Why should we pay attention to you and not to other interests?’ We fail to define our role.”

Martin Szmal, director of government affairs for Pride Mobility Products, Exeter, Pa., believes definition of home care’s role is closer with AAHomecare acting on the industry’s behalf.

“AAHomecare has done a great job in putting together a single voice,” he says, noting that the industry has achieved a single message as well when it comes to such legislative issues as competitive bidding. “I think that just by virtue of having a few speak for so many, it helps in [creating] a better understanding of … what the industry wants to do.”

Williams notes there is another source of leverage for the home health care industry. “There is some solace to be found in that those of us who do hire professional lobbyists … are getting those guys together on a regular basis so they are not sending conflicting messages.” Perspective: State Associations

Bob Achermann, executive director of the California Association of Medical Product Suppliers, believes the industry has more clout in Washington these days. “I think the single voice has been accomplished [through AAHomecare],” he says. “I don’t think there’s a problem anymore.”

While the industry might have a single voice, Achermann is not sure its message is getting across. “We need more awareness of what we do and how we do it and why it is important. We don’t just drop off equipment at people’s homes. We don’t just drop-ship everything. It’s a very sophisticated industry, and we don’t get enough play about how we impact health processes,” he says.

That lack of awareness translates into big problems for state associations as they combat threats of plunging Medicaid reimbursement. It’s one of the reasons CAMPS encourages its members to belong to AAHomecare, he says. “Some people think, ‘I’ll belong to one or the other,’ but that doesn’t help both aspects of your business. It doesn’t affect both the national and state issues.”

Mt. Carmel’s Miller, who is also president of the Midwest Association of Medical Equipment Suppliers, agrees. “We support AAHomecare, and we encourage our members to send letters [to legislators],” he says. “We’ve got to stay in touch with our legislators. I think there are still some out there [who] don’t get it.”

As important as it is to connect with state legislators, it is perhaps more vital to be a part of AAHomecare, Miller says. “AAHomecare has to take the position that the majority of its board members ask it to,” he says. “It is up to the smaller members to let their positions be knon.”

Joel Marx of Medical Service Companies, Cleveland, Ohio, and president of the Ohio Association of Medical Equipment Services, is also concerned that the voice of smaller providers is not being heard. “We are becoming more unified as an industry and HME in general,” he says, but adds that there isn’t enough grassroots strength. “The small companies are involved at a state level addressing state issues, but they are not involved at the national level to a great extent.”

He believes that AAHomecare, in order to present a strong, unified voice, must find ways to draw small providers, who can’t always see the benefits of belonging to a national association. They can, he says, justify membership fees to belong to a state association, where they can go for networking, information and advice on running their businesses.

To get the smaller provider involved and thereby strengthen the industry’s voice, Marx believes AAHomecare must provide something of tangible value. He points to AARP, which has a formidable lobbying arm. People, he says, do not join AARP because it wields so much power on Capitol Hill. “People join so they can get the magazine, get cheap insurance and get prescriptions at a discount. The challenge is to present what AAHomecare does in a more practical sense … something that’s of dollars-and-cents value to the member.” Perspective: Buying Groups

Jim Walsh, president of Waterloo, Iowa-based VGM Management Ltd., doesn’t believe the industry has achieved a single voice, nor does it need to.

“We are a disparate group of entrepreneurs and approach the market from many different backgrounds and philosophies,” he says. “There are a myriad of different specialties involved, and every company has its own focus and direction. To expect this group to have one voice on all issues is both naive and unproductive.”

Walsh stresses that “there is no need for one voice on everything,” but adds that “it is critical that legislators do not get the idea that there is division within the industry on important policy issues.”

For example, when legislators hear from what Walsh calls “rogue or fringe elements” that competitive bidding is a good idea because it would save money, “they quickly adopt it and use it as an additional argument to support what is, in effect, the taking away of Medicare benefits.”

Don Clayback, vice president, network, for The MED Group, Lubbock, Texas, believes AAHomecare has brought about significant improvements by involving various sectors of the industry. Though he notes there are “still some factors out there that aren’t quite as unified behind AAHomecare, I think we have a solid voice, even if we do not have a single voice. A single message is probably where we have gained ground.”

While that might not be enough to halt threats like competitive bidding, it might at least allow the industry to have a strong say in what the regulations are, he says. “If accreditation is going to be required, then maybe we can help by making sure those requirements are as practical as they can be,” he points out. Finding Your Own Voice

So, is the industry hanging together? It certainly is trying. But for HME to be an industry with muscle in Washington, providers must break away, at least occasionally, from the demands of day-to-day operations and get involved, insiders say.

AAHomecare’s Mills says the association needs more members. “The more members we have, the more it increases the revenue of the association, which increases the amount of money we can spend on advocacy on Capitol Hill,” he says. “There are lots of people across the country who are sitting on the sidelines watching while others fight for their livelihood. If we could get the grassroots involved, then we would be a cohesive entity.”

Marx of OAMES believes that HME providers and others in the industry have to sideline their reticent personae and show the heart of the industry. “We haven’t done a good job of letting the public know what we do,” he says. “We haven’t been successful in showing the compassionate side of the individuals in the industry. Every business … in this industry writes off thousands of dollars a year because the [end-user’s] insurance is discontinued, the patient can’t pay, the social worker asks them to help out.

“There are a lot easier ways to make money. We wouldn’t do this if we didn’t care. What we haven’t done is educate legislators or consumers that we should be held in higher regard than we are.”

Boulevard Homecare’s Freeland thinks something like a $25 membership fee would get more small providers into AAHomecare and give it more force. She also suggests it is time for legislators to hear from end-users. “Maybe we really need to make this our focus with Congress, of getting these people to say what this service has done [for them].”

Mills also champions that strategy. “I think it comes down to relating personal stories,” he says. “It’s very easy to talk to a legislator who has had a family member who has used the services of a home health care company. It is not easy to talk to a legislator who has not had that experience. Emphasizing the patient stories — inviting legislators on a home visit to see what effect we have on a person’s life — would make it hit home.”

Sen. Grassley likes the idea. “I encourage groups to continue presenting issues of concern from the perspective of the patients being treated,” he says. “Congress needs to know how federal programs fare in the real world, outside of Washington, D.C.”

In the end, though, it all goes back to the provider.

“AAHomecare can give you the resources, the letters, the instruction, but you need to mobilize your customers to get that message across to the legislators,” says MED’s Clayback.

Szmal of Pride feels there is still work to be done in raising awareness of legislative issues and strengthening the industry in Washington. For example, he notes, if no Medicare reform measure comes out of this Congress, it may be back to business as usual for now, but “the issues of competitive bidding or a CPI freeze will be raised again, whether they are part of a prescription drug plan or stand-alone legislation.” That threat, he says, should be more than enough to spur those within and without the industry to get involved.

“From manufacturers who are able to have people in positions like mine (director of government affairs) to providers talking with their local representatives to informing seniors and beneficiaries of these issues, there needs to be a heightened awareness. This is an industry problem, and everybody needs to contribute to provide a solution.”

“We think that someone else will fix it,” concludes Murray of Dave’s Wheelchair. “The someone else isn’t there. We need you. If you are reading this, you’re the person we need. No matter how much we are in competition, we still have to be a group.”

A View from Other Organizations

Val Halamandaris, president of the National Association for Home Care, Washington, D.C., sees three groups as representing home health care: NAHC, the American Association for Homecare and the Visiting Nurses Association.

“I think all three trade organizations representing the home care industry are singing from the same hymnal, and we are effectively representing our members,” he says, noting that the three have also agreed on strategies and priorities. As positive as that is, however, Halamandaris still believes “we would be better off … if we had one voice.” But beyond that, “even though we would be better off having one organization, we would be much better off if the people who don’t belong to anything would belong to at least one of them.”

Simon Margolis, CO, ATS, ATP, has been involved in rehab for decades. The vice president for clinical and professional development of National Seating and Mobility, Chattanooga, Tenn., and president and founding member of the Rehabilitation Engineering and Assistive Technology Society of North America, Margolis thinks that today’s rehab dealers have an even more difficult time getting their message across than home medical equipment providers.

“I don’t believe there is any entity at this moment that speaks for rehab,” he says. “There is a good-faith effort on AAHomecare’s part to include rehab in its communications, but I am not sure those intentions are bearing fruit for us at this point.”

“Ultimately, rehab is going to require a separate organization, and that organization is going to have to work very closely with AAHomecare,” he says. “We cannot go up to the Hill in lockstep with HME and everybody, but I do think those messages can be intertwined.”

Daniel D. Lipka of Millers’ Sales, Rental and Service, Akron, Ohio, and president of the National Registry of Rehab Technology Suppliers, says while AAHomecare has “done a very good job in consolidating a number of people’s opinions, [it] cannot possibly represent all interests of all people involved in home care and rehab. They can only represent their constituency. And there are other constituencies that might not have the same view as AAHomecare.”

Buy a Ticket

Ever hear of the man who complained he never won the lottery? He never bought a ticket. The same holds true in home care. Before complaining, at least buy a ticket — and get involved. Following are the phone numbers/Web sites for AAHomecare and state associations across the country. They’re waiting for your call.

American Association for Homecare
703/836-6263
www.aahomecare.org

Alabama Durable Medical Equipment Association (ADMEA)
205/942-7722
www.admea.net

Arizona Medical Equipment Suppliers Association (AZMESA)
651/439-2944
[email protected]

Big Sky Association for Medical Equipment Services (Idaho, Montana, Wyoming)
208/433-3050
www.bigskyames.com

California Association of Medical Product Suppliers (CAMPS)
916/443-2115
www.campsone.org

Colorado Association of Medical Equipment Services (CAMES)
303/755-1294
www.cames.org

Florida Association of Medical Equipment Services (FAMES)
407/895-5573
www.famesonline.org

Georgia Association of Medical Equipment Services (GAMES)
706/369-0131
www.gameshme.org

Illinois Association for Medical Equipment Services (IAMES)
630/369-7782
www.dmerc.com/regionb/iames.htm

Association of Indiana Home Medical Equipment Services
317/844-6630
www.ind-homecare.org

Maryland-National Capital Homecare Association (MNCHA)
703/535-1885
www.mncha.org

Medical Equipment Suppliers Association (MESA) (Texas, Louisiana, Arkansas, Oklahoma)
972/934-8785
www.mesanet.org

Midwest Association for Medical Equipment Services (MAMES) (Iowa, Kansas, Missouri, Nebraska)
651/351-5395
www.mames.com

New England Medical Equipment Dealers Association (NEMED) (Connecticut, Maine, Massachusetts, New Hampshire, Vermont)
508/993-0700
www.nemed.org

New York Medical Equipment Providers Association (NYMEP)
800/248-6372
www.nymep.org

Nevada Association of Medical Product Suppliers (NAMPS)
702/294-6680

North Carolina Association of Medical Equipment Services (NCAMES)
919/387-1221
www.ncames.org

Ohio Association of Medical Equipment Services (OAMES)
614/876-2424
www.oames.org

Pacific Association for Medical Equipment Services (PAMES) (Oregon, Washington)
503/253-9691
www.pames.org

Pennsylvania Association of Medical Suppliers (PAMS) (includes Delaware)
717/795-9684
www.pamsonline.org

South Carolina Medical Equipment Services Association (SCMESA)
803/731-9216
www.scmesa.com

Tennessee Association for Home Care (TAHC)
615/885-3399
www.tahc-net.org

Utah Association of Medical Equipment Services (UAMES)
801/237-0187

Virginia Association of Durable Medical Equipment Companies (VADMEC)
804/285-4431
www.vadmec.org

West Virginia Medical Equipment Suppliers Association (WVMESA)
304/344-5316

Wisconsin Association of Medical Equipment Services (WAMES)
715/366-7500
www.wames.org