Recent gains won't slow down industry leaders
by Tom Ryan
January 2, 2019

With the November 2018 release of the much-anticipated ESRD/DMEPOS Final Rule, 2018 saw the culmination of an intensive multiyear campaign. AAHomecare and other HME stakeholders worked to secure reforms for future rounds of the competitive bidding program and provide relief for suppliers in rural and other non-bid areas.

Industry advocacy efforts ultimately resulted in more than $1.5 billion that will be added to the Medicare benefit, with a significant portion of that earmarked for rural suppliers and those in non-contiguous (i.e., Hawaii and Alaska) areas. While we’re proud of these results and the association’s role in helping marshal an unprecedented surge of grassroots advocacy by the HME sector, we’re determined to renew our efforts to deliver more sustainable reimbursement rates from Medicare and other payers in the years ahead.

Put simply: We’ve made significant gains for HME, but there is more to do.

While relief for rural suppliers for the next two years is certainly welcome, the failure to address reimbursement rates for other suppliers in the gap before the next round of the bidding program takes place is unacceptable.

Congress has made it clear they believe all non-bid areas should receive the 50/50 blended rate that rural areas are getting in previous legislation, in sign-on letters from both the House and the Senate, and in direct outreach to CMS from many Congressional offices.

In the weeks after the Final Rule was released, we were back on Capitol Hill laying the groundwork for addressing this issue in the 116th Congress. We’re fully aware of the challenge in getting Congress and the administration to allocate more Medicare dollars to HME, as well as the amount of effort that it will take to educate and engage the 100-plus new members of the House and Senate. Nonetheless, advocating for sustainable reimbursement rates from all payers, including Medicare, remains a top priority for AAHomecare for 2019 and beyond, so we’re ready to take up this fight again in Congress and with CMS.

Not the Time for Additions to the Bidding Program

Shortly after the release of the ESRD/DMEPOS Final Rule, CMS requested comments on adding ventilators and several back- and knee-brace orthotic products to the next rounds of the bidding program.

The prospect of adding ventilators to the bidding program has been especially alarming to patients, caregivers and clinicians who depend on these highly specialized and service-intensive products as literal life support systems.

In the event that CMS doesn’t change course after reviewing comments from the many HME stakeholders and impacted patient groups who oppose these changes, we will make sure that Congress is aware of the potential for disruption for patients and caregivers who rely on these products. With all the work remaining to be done to implement new bidding reforms, this is not the time for CMS to add ventilators, braces or any other new product categories to the bidding mix.

Other areas of focus for AAHomecare’s regulatory affairs team for 2019 will include monitoring and influencing subregulatory guidance for the next bidding round, providing education and analysis to help suppliers prepare for that next round (more on that below), and working with DME MACs and CMS to improve the Targeted Probe and Educate (TPE) audit program.

Preparing for the Gap Period and the Next Bidding Round

CMS’s decision to delay the next bidding round gives all suppliers in competitive bid areas a chance to serve Medicare beneficiaries during the gap period which is expected to run through the end of 2020, albeit at currently in-effect rates that many companies will not find appealing or manageable. How the industry responds to this opportunity will be one of the most interesting developments to watch in the early part of this year.

The gap period also gives HME suppliers a chance to re-evaluate their approach to the next bidding round. AAHomecare has joined other HME stakeholder groups to develop dmecbpeducation.com, an online educational resource designed to help suppliers navigate changes in the program. With a new lead item bidding methodology as part of the process and with bid bonds now required in the next round, suppliers will need to better educate themselves on these changes.

Payer Relations’ Growing Importance

2018 ushered in a new requirement that the overall federal Medicaid reimbursement to states for HME cannot exceed what Medicare would have allowed for these items in total. Working in concert with state and regional association leaders, we have been successful in convincing 18 states to resist the urge to simply lower Medicaid rates to match Medicare pricing, and we will continue to work with six other states that are still analyzing their data and deciding how to respond.

We plan to reinforce success in payer relations by devoting more resources to this area in 2019, so we can continue to make our case for sustainable rates with state Medicaid authorities, limit the spread of sole-source and narrow network contract arrangements, and we will continue to represent HME interests to TRICARE and managed care payers.

We also plan to develop strategies and best practices for working with the Medicare Advantage space. With 20 million enrollees nationwide, Medicare Advantage impacts the care of 34 percent of the Medicare population. And that market is primed for additional growth, as evidenced by the 18 percent increase in the number of plans that will be offered this year as compared with 2018.

We Need Better Data to Make Our Case

What will it take to get CMS or Congress to make a serious commitment to improving Medicare reimbursement rates? In addition to the persistent and credible advocacy efforts that our industry has shown we’re capable of in recent years, I’m convinced that we need more concrete data on how the bidding program and reimbursement cuts are impacting access to HME and patient outcomes.

We are looking to strengthen relationships with clinicians and hospital organizations who have expressed frustration with access to HME since the bidding program began, especially in terms of impacts on the discharge process. We hope to work with these stakeholders to convince CMS to develop and implement better real-time monitoring practices that capture the true impacts of reimbursement cuts. I believe that a transparent monitoring program based on quantitative data, feedback from case managers and measures of beneficiary satisfaction will show that current reimbursement rates aren’t just hurting suppliers; they’re causing real problems for patients, caregivers and clinicians, too. With better data in hand, I think we’ll have the evidence we need to get Congress or CMS to deliver additional relief.

One thing I can count on is that HME advocates from all over the country and every segment of our industry are again going to answer the call to fight for better public policy in 2019. This industry has demonstrated that we are capable of restoring significant dollars to the Medicare benefit, and I know that we’re all hungry for even more.