Cumulative Impact of Reform Mandates Will Do Some Damage

WASHINGTON — The health care reform package that slid
through Congress last week is packed with mandates affecting the
home medical equipment sector, and many have the potential to be
very damaging, stakeholders said.

Congress adopted the Senate version of the health reform bill,
with fixes, late March 21. Signed into law by President Obama, the
measure contains a trio of industry hits including the acceleration
of competitive bidding, elimination of the first-month purchase
option for power wheelchairs (see “Lose-Lose
Situation with Strike of Power Wheelchair Purchase Option“) and
a tax on medical
device manufacturers.

Tucked into the law’s 2,309 pages, however, are additional
threats, among them:

• Requirement of a face-to-face physician exam for all HME
  equipment and supplies billed to Medicare;
• Establishment of an autonomous Medicare advisory committee with
  authority over payments; and
• A productivity adjustment that would result in a lower annual
  HME update by about 1 percent.

“We believe all this could have a cumulative impact [on HME
providers], a disproportionate hit,” said Walt Gorski, vice
president of government relations for the American Association for
Homecare.

While much is unknown about how some of the mandates would play
out, concern is escalating in the provider community.

Rose Schafhauser, executive director of the Midwest Association
of Medical Equipment Services, said more and more often, she is
getting questions from MAMES members about the face-to-face
requirement. Requiring someone with a lifelong requirement for,
say, oxygen or a power wheelchair to return to the doctor every six
months for a face-to-face evaluation seems costly and unnecessary,
she said.

“Is this going to increase the cost to the Medicare
program?” Schafhauser questioned. “You want to make sure there is a
medical need. But with technology, there are other ways for this to
be accomplished. And what is the necessity of every six
months?”

Beyond that, she said, providers are wondering how they are
going to get physicians to abide by the requirement.

“Once again, providers are going to be expected to be the
policeman. It just keeps getting weirder and weirder. How are they
going to have the control to make sure patients go back and see
their doctors? How do we enforce that?”

Gorski said the association is also troubled by the face-to-face
requirement.

“We think that is a very serious issue for HME providers,” he
said. “We don’t believe a face-to-face exam is necessary, and what
we would prefer is that rather than making the face-to-face exam
for HME and home health agencies a requirement, Congress would give
CMS the discretion to require a face-to-face exam — if they
are going to do it at all.”

Providers also have misgivings about the establishment of an
independent Medicare advisory committee, what some have dubbed a
“MedPAC with
muscle.”

“A number of provider community groups are very concerned with
this policy,” Gorski said. “In essence, Congress ceded payment
authority to a non-elected body, and we believe that Congress
should have maintained control rather than ceded its authority to
this panel. They are trying to take the politics out of it, but the
Medicare advisory commission is not accountable to anyone.”

“The commission is a scary feature,” acknowledged John
Shirvinsky, executive director of the Pennsylvania Association of
Medical Suppliers. “It vests a whole lot of authority that to this
point has been vested in Congress with an un-elected and largely
unaccountable body.

“It’s still too early to know what the operating rules will be,
who will serve on it,” he added, “but it’s the kind of thing that
should make an industry like ours nervous … It creates a lot
of potential for a lot of bad things to go on. It could be very bad
over the long haul.”

That also makes Shirvinsky nervous.

A productivity adjustment could also be detrimental. Under the
new law, the 2 percent add-on payment for HME (above the CPI)
— which was included in the Medicare Improvements for
Patients and Providers Act (MIPPA) in 2008 and was set to take
effect in 2014 — would be eliminated. Instead, there would be
the productivity “adjustment.”

“It is a tool to award productivity, but at the same time it
will likely reduce fee schedule payments … by about 1 percent
a year,” explained Gorski.

Questions abound as to how productivity will be measured and
against what standards. “It’s a measure by the Bureau of Labor
Statistics and it has yet to be determined how it applies,” Gorski
said.

That also makes Shirvinsky nervous.

“I don’t know what this is going to mean,” he said. “It’s the
kind of thing that once again provides abundant opportunities for
mischief … It’s very disconcerting.”

Still, Gorski sees the possibility for change.

“There may be other opportunities to address these issues over
time,” he said. “I think there are going to be a number of vehicles
[to add legislation to combat the threats] we can look at. That’s
why we are asking for full engagement in the HME community,” he
continued.

Providers who meet with their legislators and lay out for them
the impact of such measures can make a difference, he said.

“I think we are more well positioned than most, but we need to
step it up a notch,” Gorski said.

For more on HME provisions in the health reform bill, see
AAHomecare Vows Fight
on Health Reform Provisions.