ASK ANY HOME health care player why the industry needs a unified voice, and you're likely to get a Cliff Notes version of Bartlett's Quotations: "Less is more." "There's strength in numbers." "The squeaky wheel gets the grease." "United we stand; divided we fall."

The last axiom could be the most accurate of them all. The Alexandria, Va.-based National Association of Medical Equipment Services' call for a unified voice comes at a time when all the entities of the home health care industry-home medical equipment, home health agencies, home infusion, respiratory and rehabilitation-have been battered by hard-hitting legislative and regulatory changes.

Reimbursement is on the downswing in every market segment, and federal mandates such as inherent reasonableness, competitive bidding, consolidated billing and the interim payment system have thrown the home care industry into a tailspin. Unable to withstand the assault, all too many businesses have closed their doors.

"I don't know if anyone who sits on Capitol Hill really understands, but if they did a timeline, they'd see how many hits they've made on this industry," says Rita Hostak, vice president of government relations for Sunrise Medical, Longmont, Colo. "This poor industry has really been squeezed."

Coulda, Woulda, Shoulda? WOULD A UNIFIED voice have derailed such hits? Most industry insiders say no, but they do agree it couldn't have hurt.

"NAMES' whole initiative is that, until we have a unified voice in home health care, Congress through its bills and [the Health Care Financing Administration] will continue to pick us apart, one thing at a time," says Mario LaCute, NAMES chairman of the board. "They're going to attack us through oxygen cuts, competitive bidding and inherent reasonableness. Until we can get a unified voice to demonstrate to both legislators and regulators that home care is medically efficacious, cost effective and, most important, consumer preferred, we haven't done our job. And that's the whole focus of our single-banner approach."

The "single-banner approach" largely refers to the concept of joining the two major associations in the HME industry: NAMES and the Health Industry Distributors Association, also in Alexandria. But it doesn't stop there. LaCute and others champion the eventual uniting of most, if not all, of the associations related to the home health care industry.

"I think you need one governing body that sits down and says, 'What are the issues, what do we need to do?' It's better than having multiple groups out there saying sometimes the same thing, but it sounds different," says Hostak.

Among the industry gurus, no one disagrees on the need for a unified voice. "It is important that the home care community speak with a unified voice," says Val Halamandaris, president of the National Association for Home Care, Washington.

"There's no question that we would be better served by having a unified voice," says Cara Bachenheimer, vice president of membership services for HIDA.

"The fact of the matter is that this industry gets largely ignored or overshadowed because we don't speak with one voice," says Dave Williams, director of government relations for Invacare Corp., Elyria, Ohio. "We have mixed messages and mixed messengers, and it's easy to discount someone when they don't have their act together."

Hostak agrees. "We look too segmented. The message on [Capitol] Hill comes across as too confusing," she says, adding that she sees a "real weakening of this industry."

And the timing is right for a unified voice, Hostak says. "We've got to get together as an industry."

What Goes Around . . . IF YOU'VE BEEN in the business long enough, that get-together mantra may sound familiar. Home health folks have been repeating it for years. In 1991, for example, after some years of toying with the idea, NAMES and HIDA announced that discussions of a merger were on.

"There's not one specific reason for the discussion," Jim Robinson, then NAMES chairman, told HomeCare Magazine. But people in the industry had been asking why the two organizations couldn't become one, he said, so they were exploring the possibility. And, he added, "We've listed the pros and cons, and decided there are more pros than there are cons."

Not enough, apparently. The two associations never merged. And the industry never moved further toward that unified voice. Egos, turf protection and a host of other legitimate considerations got in the way, industry players say. Some also note that there was no crisis, no compelling reason for all the entities to band together.

"The industry was not in a destabilized situation," says Don White, vice chairman of NAMES. "Today, we're talking about an industry that has been totally destabilized by the Balanced Budget act of 1997." He cites the 30-percent cut in oxygen reimbursement, Congress' granting HCFA expanded inherent reasonableness power, the competitive bidding demonstration project in Florida, the elimination beginning in 1998 of reimbursement raises tied to the Consumer Price Index, and the time-consuming, frustrating appeals process for denied Medicare claims.

"They not only took the money away, they took things away from the industry that will keep it off balance and destabilized for a long time," White says. "You need a strong voice to go in to Congress and say, 'Enough! Look what you've done to us!'

"Maybe this crisis will unite the industry; maybe it won't," he adds, "but it's the best opportunity we've had in a long time."

Brian Seeley, president of the Florida Association of Medical Equipment Services, is even more blunt. "It's not an option any more," he says.

So the question now is, will it happen? And if so, how will it work?

How Does Working Together Work? WHILE VIRTUALLY EVERY key member of the industry agrees on the need for a unified voice, there is no such consensus on how that can best come about.

Some have suggested that the answer might be a single lobbyist paid by all the associations. Most of the associations-which include NAMES, HIDA, NAHC, two infusion associations and five home health groups-have their own lobbyists, and many encourage their members to do grassroots lobbying as well. However, while hiring a single lobbyist might heighten industry visibility and result in a common message, it has its drawbacks, say industry experts.

"Hiring a full-time lobbyist to work for a loose federation of associations not only would not work, it would be counterproductive," says Halamandaris.

"A single lobbyist paid for by everybody is ridiculous," adds Invacare's Williams. "The issues are too complex for one person." And, he notes, "The nature of lobbying is that you have friends, and you have enemies. If you put all your eggs in one basket, there are some [legislators] that are not going to get your message."

LaCute believes in one organization that would initially include HME providers, HHAs, and respiratory, pharmaceutical and infusion companies. One way to bring that about, he suggests, would be to structure it like some corporations. "You can have a holding company and then branches underneath, and they would operate under their own steam," he says. "But I would see that only as a first step.

"Another possibility would be to simply have a number of associations that would come together and merge," he continues. Under that plan, he says, the associations would agree on how many board seats each would have, how dues would be collected and how budgets would be allocated based on which issues affected the most members. Such an organization would depend on task forces to deal with pressing problems, after which they would disband.

But some industry players are skeptical. "How do you preserve the unique perspective that eachgroup has while trying to have a unified voice?" asks Lorrie Kline Kaplan, executive director of the National Home Infusion Association, Alexandria, Va. "The top five issues that mean the most to my membership might be very different from those of a home health agency."

She recognizes, however, that some interests overlap, such as competitive bidding, consolidated billing and a reimbursement system that does not recognize the service component of home health. And she acknowledges that economics is a critical consideration. "There's a fixed or shrinking pie of resources available," she says, "and it's really going to make the associations look at things differently. There's just not enough to send them off in two parallel directions."

Ann Howard, vice president for policy at the American Federation of HomeCare Providers, Silver Spring, Md., also has reservations about having one massive association. "I don't know whether you'll get to the point of one association representing everyone, and I'm not sure that's even the most desirable," she says. "Maybe some grouping of some of the associations would make sense as a starter.

"Rather than all the health agencies merging together," she adds, "I think it would be more likely that groups that share concerns would work together. You have state associations that are a combination of HHAs and HME providers. I think that's a model."

Considering the Coalition ANOTHER MODEL, SEVERAL people point out, is the Homecare Coalition. The coalition, which dates to 1991, is a group of about 20 people from various home health care organizations that works to promote the industry and meets monthly to tackle mostly legislative issues, says HIDA's Bachenheimer, who is a member of the coalition.

"The Home Care Coalition has served a pretty unique role, and it just keeps getting stronger and stronger," she says. On the issue of consolidated billing, for example, "we have a 100 percent unified statement [against it]. And I would say that is a key reason why we are getting so much congressional support for getting rid of that provision."

Kaplan thinks the coalition might provide the foundation for a unified voice. "We would need it to take a different role, but I don't think that's an impossibility," she says.

Sunrise's Hostak is divided on the issue. "It seems to work fairly well in terms of putting all the issues out there on the table and having people from various associations within home care represented," she says. "I think that could be a good model, but it could also be why some people have concerns about one organization. You have to realize that sometimes we're going to be talking about issues that affect me personally and sometimes we're going to be talking about issues that don't."

Howard, too, sees the coalition as a "model for working together," but she doesn't believe it is designed to be the umbrella organization over several other associations. "It's a wonderful, flexible coalition where everybody leaves their egos at the door," she says. "But it's not a merger for any of the organizations.

For his part, Halamandaris says NAHC would support an initiative to bring together the service and equipment sides of the home care industry, but it must be "accomplished on an organizational level" rather than "worked out on a committee basis.

"There already is a loose affiliation that serves as an umbrella," he says, referring to the coalition, "but it is far short of the legal integration of entities that is needed if there ever will be a united voice in the home health industry."

The Imperative LACUTE STILL HOLDS to the single association idea. And he'd like to see it happen before the end of the year, he says.

NAMES has already taken steps to accomplish that. Job responsibilities have been shifted and the work of some departments has been outsourced. The association is also looking for a new leader who champions the unification vision to replace William Coughlan, the former chief executive officer who left in May.

Whatever happens, says Shelly Prial, president of the Homecare Providers Co-op, Melbourne, Fla., "we've got to be a team. Teamwork wins."

That team concept had better catch on, he adds, employing yet another maxim to illustrate the consequences of a divided house: "If we don't hang together, it's for sure we're going to hang separately." HC

Hospitals are looking for more Medicare reimbursement-and have a stronger, more unified and better funded lobbying presence than the HME industry.

Decision-makers in Washington have a limited budget-and are looking to offer BBA relief to the much-beleaguered HHA industry before HME providers.