By Rich Smith
As Medicare inches closer to implementing new documentation guidelines for power wheelchairs (including seating and positioning), it grows clearer just how unclear everyone is about what to expect once the changes take effect.
And if experience is any gauge, confusion will likely persist long after CMS' 42 CFR Part 410 rules are finalized sometime later this year, predicts Larry Rice, chief operating officer of a Dallas-based company that provides rehabilitation and DME wares. "The way it always seems to work with Medicare is the documentation they find acceptable today will be declared unacceptably inadequate tomorrow, depending on who is in charge of making the decisions at any given point in time," he muses.
In a more serious vein, Rice has sought to prepare himself and his company for the coming rules revisions by, among other things, attending seminars on the subject. From what he has been able to glean so far, the biggest challenges for rehabilitation technology suppliers will arise from Medicare's insistence on significantly more detail in the doctor progress notes from which a determination of medical necessity for the prescribed wheelchair (and its related modifications) is made. "If the doctor puts down on paper that the patient would benefit from a molded seating system, Medicare is going to start wanting the doctor to provide to us, the supplier, the patient's medical history, physical examination details, diagnostic test results, summary of findings, diagnoses, and treatment plans, in addition to the power mobility device prescription."
That is all very helpful. But the problem as Rice perceives it is that doctors will, as in the past, be developing this supporting documentation from evaluations conducted by physical therapists or occupational therapists who know "everything about anatomy, but a lot less about products and applications," he says. "If we can improve their understanding of the wheelchair choices and the seating-and-positioning possibilities, then we can help the referring doctors produce progress notes with the kind of information Medicare and other payors will find acceptable, and we'll be better able to cost-effectively help the client receive a PMD in which they can be comfortable and functional."
Thus, the most essential step in response to the impending Medicare documentation demands could be improved education for doctors and, especially, therapists about wheelchairs and seating-and-positioning options. "The process of educating therapists in that way will require a redoubling of the efforts many of us are already undertaking to give therapists a better understanding of what it takes for us to fulfill their seating-and-positioning specifications," says Rice.
Having PTs and OTs on staff would appear at first to be a way to make such education efforts more manageable. However, Rice finds fault with that strategy. "Once you bring a therapist aboard as a member of your staff, that practitioner loses a certain amount of their credibility—among many doctors and payors—as an objective voice when it comes to specifying products," he cautions.
SURVIVING CUTS Mark Grillo, CRTS, does not worry much about Medicare's proposed progress notes guidelines because 90% of the business at the Sacramento, Calif-based wheelchair manufacturer where he is employed comes from Medicaid—or MediCal as it is called in the Golden State—and no such similar changes are contemplated by that particular payor at this juncture. Still, these are roiled times for the company. Over the past 18 months, MediCal has reduced reimbursements across the board. "It used to be we were getting full retail for all of our wheelchairs, since all the codes for them and for the seating-and-positioning products and services were unlisted," says Grillo. "Now they have got codes. And now we no longer can expect to be paid the retail price, only the MediCal allowable. As a result, my revenues are down 25%."
That, says Grillo, is why these days he seldom does better than break even on seating-and-positioning work. "In some cases I've had to tell clients I can't afford to sell them that provider-specified product because the MediCal allowable is too low," he laments.
There is, however, an upside to this dilemma. Limiting selection has meant larger volume on the items still offered, and that in turn qualifies the Sacramento-based wheelchair company for better discount pricing. "The discounts aren't a lot, but they're enough to help offset the losses caused by the reimbursement cuts," Grillo reports.
Even so, Grillo finds it necessary to talk more with therapists about product pricing—something he admits he is not thrilled to do. "Having specification decision-making influenced by dollars is uncomfortable for therapists," says Grillo. "Many of them feel like it drains the compassion from their work. But if they understand the complications of reimbursement, they'll understand why this or that specification is no longer feasible."
Alas, there is no guarantee such understanding will be attained, because therapists by and large are clinicians, not business executives or number crunchers. Still, the best time to broach the subject of financial limits is, in Grillo's view, before the evaluation of the client—that at least will help set some boundaries when the therapist starts developing specifications. "In 2006, survival means you just have to become a lot smarter about what you provide and how you go about providing it," he says.
WANTING TO CASH OUT Working smarter is an approach that can work for any company—especially those facing the mother-of-all Medicare challenges—national competitive bidding. However, it can be tough to smarten up when wracked by pessimism, as are many of Rice's colleagues across Texas and in other states. "A lot of people out there want to cash out because they are worried about their chances of survival," he says, adding that nonrural home care companies generating less than $5 million a year in revenues are those fated to suffer most under the policy shift.
Because his company is of sufficient size to bear up against national competitive bidding, smaller outfits at a rate of about two a week have been contacting Rice to inquire whether his firm would like to buy them out. Rice discloses that at least some of those will indeed be snapped up his company. "The kinds of companies that would be of interest [as acquisition candidates] are those that have a good reputation, a large and diverse client base, profitability, a respiratory component, and—most important—well-trained, hard-working, loyal personnel," he says.
Rice expects a consequence of this sell-out mania (and the resultant upsizing of buyers) to be a reduction in the quality of seating-and-positioning services offered by the companies still around in the era of national competitive bidding. "The big company comes in, spends a lot of money taking over a smaller company, and then finds itself unable to afford to employ the best-trained RTS people," he explains. "Because of that, they will be selling mobility and positioning products without having the technical ability to make sure the product is appropriate for the patient's situation and capable of being modified appropriately to give the patient optimal comfort and functionality. In other words, the patient will experience a decreased quality of life, if not serious health risks as in the case of muscular dystrophy patients who by virtue of their condition must be positioned right or else breathing will be adversely affected, which could lead to pneumonia and other respiratory diseases.
"I think national competitive bidding is very shortsighted on the part of Medicare," Rice continues, "and the other payors that follow in lockstep. In the long run, this is going to cost them more because they will be forced to pay for services that before [patients] wouldn't have needed as much of. It is going to cost them more than they could ever hope to save."
The unsettled state of industry affairs manifests in other ways as well, such as in the paucity of seating-and-positioning product innovation. "I was at the most recent Medtrade exhibition, and I saw lots of seating-and-positioning product on display—but there wasn't much that was cutting edge," says Rice. "The reason is that manufacturers are responding to the worsening reimbursement climate by instead focusing their R&D efforts on finding substitute materials and alternative manufacturing processes so that they can continue making what's already in their product lines, only at lower costs."
This is not to say there was zero innovation on parade at Medtrade Atlanta 2005. But some might argue the meager lineup of futuristic product merely reflects the fact that the industry is approaching the far end of the innovation curve, and the enormity of technological advancement in previous years now leaves little room for breakthrough wares in the seating-and-positioning sector. Rice disagrees. "With billions of people on this planet, you're always going to encounter medical conditions and needs in unexpected combinations that have never before been seen, and for which there will be a need for innovative solutions. I'd hate to see manufacturers rest on their laurels. I'd like to see them continue to make progress on seating-and-positioning materials."
And if they do not, then look for innovation to come from the opposite direction, from the grass roots—from the workbenches of the RTSs who will be forced to develop new products on their own. After all, necessity still is the mother of invention. Not even a Medicare rules change can alter that basic fact of business.
Rich Smith is a contributing writer for Rehab Management.
