When President Bush signed the Medicare Modernization Act (MMA)
in December 2003, the nation focused on the law's unprecedented
prescription drug benefit for Medicare. But buried in the mammoth
legal document is a provision mandating competitive bidding for DME.
Bidding will begin in 10 top metropolitan statistical areas (MSAs)
in 2007 and move to 80 MSAs in 2009, after which the program could
expand nationwide.
The government isn't doing this in a vacuum. The law requires
the Centers for Medicare and Medicaid Services (CMS) to form a
Program Advisory and Oversight Committee (PAOC) to advise the
agency on implementing the competitive bidding program, along with
quality standards that providers will eventually need to meet in
order to maintain their Medicare supplier numbers. The committee
held its first meeting in the fall and will meet periodically
through 2009.
Observers have argued the group is ill-named: Some members say
they're playing a purely “advisory” role and have no
“oversight” over CMS. Other critics have said the
committee's supplier delegation is light: Only a few out of 22
people chosen for the panel represent DME providers. But no one
doubts the insight many committee members have. They come from both
public and private sectors, including providers and manufacturers,
state government and federal agencies.
Industry advocates are hoping CMS uses this insight to its
advantage, so HomeCare contacted PAOC's members to ask what
each personally hopes to bring to the table. A few didn't respond.
But 16 committee members did have something to say, and their
answers — some surprisingly candid — follow.
HomeCare's Question:
What is the main message you hope to convey to CMS about
competitive bidding and its implementation?
“We obviously don't support competitive bidding, but CMS
has no choice.
“Our objective is to make sure CMS understands as many
details as possible to make sure this does not dramatically alter
the marketplace. That's why the issue of quality standards is so
important. [Those standards] are the only thing that will ensure
that a beneficiary will have continued access to quality items.
When you sit through these committee meetings, you realize the task
is huge.”
— Cara C. Bachenheimer, JD, vice president, government
relations, Invacare, Elyria, Ohio
“The whole reason for my being on the committee is to give
some insight into the competitive bidding process, a process in
which we have extensive experience, both on the administrative and
clinical side.
“[The VA has] been successful, but that doesn't mean CMS
has to do the exact same thing. We have clinicians, and clinicians
make up the basis [of our process]. We don't necessarily go to the
lowest bidder; quality is a higher priority. Once we develop
technical specifications [for a product], clinicians test [sample
products] based on criteria we set up originally.
“With the purchasing power the VA has across the country,
we still get a good price. CMS can learn from that … They can
save money for the taxpayers and people on Medicare. If the price
of the products goes down, the price of the copay goes down,
too.”
— Robert Baum, program manager for the Prosthetic and
Sensory Aids Service, Strategic Healthcare Group, Veterans Health
Administration Central Office, Washington, D.C.
“It's important not to go to the largest models, such as
New York City. If there are downfalls and if there are negative
changes [with competitive bidding], there are huge populations of
people that could possibly be hurt.
“[CMS is] not going to realize the level of savings they
did in the demonstration model. Since the demonstration projects,
there have been cuts in reimbursements, which reduce the savings.
Do they want to talk to Congress about the competitive bidding
model, and is it truly going to modernize the Medicare
process?”
— Mary Benhardus, founder and controlling owner, Handi
Medical Supply, St. Paul, Minn.
Note: Between 1999 and 2002, CMS conducted two DME
competitive bidding demonstration projects in Polk County, Fla.,
and San Antonio.
“Quality standards have to be the driver here … It's
all theoretical until the standards are developed. Those standards
are going to define the scope of what gets competitively bid.
“CMS needs to go back and really look at what the
projected savings from competitive bidding can possibly be.
Congress enacted it assuming a certain baseline of savings. Now we
have a [Consumer Price Index] freeze through 2008. In addition to
that, starting January 1 there were additional cuts … On top
of that, suppliers are going to have to meet certain standards.
When you add all those things into the mix … you really beg
the question of whether it is realistic to expect any more
savings.”
— Asela Cuervo, JD, Law Offices of Asela Cuervo,
representing the American Association for Homecare, Alexandria,
Va.
“‘Think simple’ is the important thing to
remember. If [CMS makes the program] big and complex, they could
change the marketplace significantly — and change the DME
world forever. When [Utah Medicaid has] bid DME, we've done it by
single codes and simple products that were very easily defined
— no broad categories.
“Another thing [involves] practicality. Whatever we do
needs to be practical, doable and provide a service to the patient.
[CMS] needs to have [beneficiary] access on their
minds.”
— Dr. Don Hawley, program director, Utah Department of
Health, Division of Utah Health Care Financing, Salt Lake
City
“What I hope to convey is that there need to be specific
standards and qualifications for anybody who's going to compete in
the competitive bidding process, and those should be outlined and
understood before the program is implemented.
“Second, I think it's important that the whole process be
run by an independent organization, not one tied to an insurance
company or other health care provider. They were considering the
DMERCs, but clearly the DMERCs have conflicts. Plus, it's not
really their jobs. They're not operations people.
“Finally, we need to take a look at what [CMS'] real
incremental savings will be. Considering [cuts on respiratory drug
reimbursement] along with the FEHBP-based cuts, [CMS] may find
that, within the biggest areas where they could save money, they
have already made cuts. [CMS] needs to do a study of what
additional savings they're going to find in the midst of
[competitive bidding's] administration costs.”
— Lawrence Higby, president and CEO, Apria Healthcare,
Lake Forest, Calif.
Note: For 2005, CMS cut reimbursement for certain high-volume
items based on the percentage difference between 2002 Medicare
rates and the median pricing of Federal Employees Health Benefits
Plans (FEHBPs).
“Our challenge as a committee is to recognize that
competitive bidding has been mandated by Congress. CMS has been
given the directive to implement competitive bidding, and our
responsibility is to assist CMS by highlighting the positives and
negatives that exist today in competitive bidding in the government
and private sector. We need to find a way to implement this within
the timeframe that CMS has been mandated that will not impede
access and maintain the quality that beneficiaries deserve.
“It's not as much about influencing CMS' decisions but
about helping them uncover information, seek the right information
and analyze things from a perspective that allows them to see the
impact — not only on the operational side inside CMS but also
the quality, choice and clinical outcomes for
beneficiaries.”
— Rita Hostak, vice president, government relations,
Sunrise Medical, Longmont, Colo.
“I really want to convey that we need to work toward the
development of good quality standards to elevate the industry in
the eyes of legislators and beneficiaries. I'm a strong supporter
of quality standards and mandatory accreditation, and I look
forward to developing that criteria moving forward. One of the
ideas being discussed is to include minimum quality standards for
individuals associated with specific products. I predict standards
will come out in a general form for all DMEPOS providers, then
there will be individual criteria for specific items, such as
oxygen or wheelchairs.
“[Regarding competitive bidding], the highest-cost,
highest-volume items always seem to be on the chopping block for
reductions. I don't think that when CMS figures out how to
implement competitive bidding that they will be able to do it and
save any real money to make it worthwhile, taking into account the
significant administrative costs that will go into running such a
program.”
— Seth Johnson, director, government affairs, Pride
Mobility Products, Exeter, Pa.
“Two things need to be addressed: One is that with the
FEHBP cuts that went into place the first of this year, we need to
ask, ‘Are the savings from the demonstration project still
valid?’ You're not going to get the same savings because the
cuts may have taken care of that.
“If they're going to continue with competitive bidding,
they're going to have to develop standards prior to implementation.
It doesn't appear the law gives them enough time to do that.
Developing standards for this industry is a difficult
task.”
— Dave Kazynski, president, Van G. Miller &
Associates' Homelink division, Waterloo, Iowa
“My message will be: If you're going to set up a system of
continuity of care, make sure you look at the total picture, not
just the Medicare picture. Competitive bidding is going to change
the industry. [If certain] providers [in an area] receive a
contract, Medicare business will go to those contractors —
and what isn't Medicare business will also go to those contractors
because of [the appeal of] one-stop shopping. No one likes to go to
several places to meet their needs when they could go to one place.
[This trend may] reflect on Medicaid and private insurance business
as well. You have to watch that you don't swallow up the
competition and have a monopoly.”
— Alan McMullen, cost reimbursement analyst, Medical
Assistance Administration, Department of Social & Health
Services, State of Washington, Olympia, Wash.
“My overriding message to CMS is: You have an amazing
brain trust in this committee. Tap into it by truly being involved
in a collaboration to develop the best program, making the best use
of CMS resources to provide beneficiaries good access to DMEPOS
supplies and services. The variety and quality of people on the
committee is amazing.
“While CMS has presented and requested feedback, I haven't
felt they have really made best use of individual talents of the
committee members. There are people on the committee who've been
involved in competitive acquisition in the private sector who have
huge resources of the actual cost savings. These guys know when
they're spending good money — and when they're not. Committee
members could give [CMS] a really good, hard-number
analysis.”
— Jean Minkel, founder and president, Minkel Consulting,
New Windsor, N.Y.
“We'd like the transition to be seamless for the
beneficiaries and suppliers [to participate], and to position the
program in a way that would allow the objectives to be met and
still allow small businesses to be part of the program — not
just in the bidding but [to be able to succeed] in being a winning
bidder.
“Community pharmacists are a varied group. Many provide
complementary services [to HME], such as long-term and home health
care in the community where they practice. [The bidding program
will] have a significant impact, especially in the area of diabetes
management. In many instances, people will come to their community
pharmacies to pick up their medications and, at the same time, pick
up testing strips, lancets and glucose meters. Those items will
potentially be discussed for bidding, so we're concerned about
[beneficiary] access.”
— William Popomaronis, P.D., vice president,
long-term/home health care pharmacy services, National Community
Pharmacists Association (NCPA), Alexandria, Va.
“My primary objective is to assure that quality standards
are realistic and appropriate and that the way that standards are
evaluated is equitable for all providers. When people are
developing standards, they can set the goals for the standards too
high for the reality of the situation.
“[Also], one complete set of standards will not be
appropriate for all. For example, ventilation support [providers]
have additional standards that are important — it's a
life-sustaining service. There's a great range, and to think that
one size fits all is really not going to be the case.
“I am hopeful that CMS will have the quality standards and
the methodology for evaluations in place no later than May of this
year. It is essential to give providers the opportunity to see what
the standards are. [JCHAO] will need time [to prepare for standards
implementation], but providers are the ones who will really need
the time. It will be a great disservice the longer and longer we
wait before we know what the standards will be.”
— Maryanne Popovich, executive director, Joint Commission
on Accreditation of Healthcare Organizations (JCAHO), Oakbrook
Terrace, Ill.
“Although a lot of factors need to be taken into
consideration, competitive bidding can work. It can save money to
the program if the contracting is done well. If there is
consideration of quality measurements in the contract … and
the contract can be well-managed — which is the other piece
— I think there can be savings in a number of areas. For
wheelchairs, [Minnesota Medicaid] had contracts with manufacturers,
not suppliers [though the state has since stopped such
contracting]. I think moving toward a supplier-directed contract
would have fewer problems.”
— Chris Reisdorf, manager, Benefit Policy Unit, Minnesota
Health Care Programs: Medical Assistance, General Assistance
Medical Care, and Minnesota Care Programs, St. Paul, Minn.
“The Department of Veterans Affairs brings to the table a
combination of clinical management expertise and experience in the
competitive bidding process on all levels. This enables our
patients to get the best-quality product or service at a reasonable
price.
“By sharing our experience and listening to the experience
of other organizations at the table, CMS will be able to take away
elements for a successful program.”
— David Van Sleet, VISN 1 prosthetics manager, Department
of Veterans Affairs, New England Healthcare System, Bedford,
Mass.
“The main message that the committee is trying to convey
is [for] CMS to continue to focus on the quality initiative …
The number one focus is getting a quality provider.
“The second [goal] is to identify Congress' intent in
mandating competitive bidding … We should carefully examine
each item we consider for competitive bidding. The law gives the
[HHS] Secretary the right to exempt items [that won't yield
significant savings]. My message is that, for each item, we
consider and carefully analyze the latest data, know we will not
affect quality, affect [beneficiary] access and will, in fact,
achieve savings …
“Using [only] the government's own data, bidding [power
wheelchairs] might save Medicare money. But if we identify someone
who needs a power wheelchair, and they can achieve their
independence [with that chair], we might prevent a fall that would
have led to a $100,000 hospital bill. We need a
‘big-picture’ look at the situation.”
— Dr. Don Vliegenthart, medical director, Hoveround,
Sarasota, Fla.
Additional PAOC members include Henry Claypool, expert to
Social Security Administration's Deputy Commissioner to advise on
Interim Medical Benefits, Washington, D.C.; Anthony Filippis,
president and CEO, Wright & Filippis, Rochester Hills, Mich.,
and practicing certified prosthetist/orthotist; David Gray,
associate professor of neurology and associate professor of
occupational therapy, Washington University School of Medicine, St.
Louis; John Prassas, director, corporate provider development &
contracting, PacifiCare Health Plans, Cypress, Calif.; Dr. Ken
Viste, medical director, physical rehabilitation unit, Mercy
Medical Center, and staff physician, St. Agnes Hospital, Fond du
Lac, Wis.; and Daniel Waldmann, director of federal affairs,
Johnson & Johnson, Washington, D.C.
