It's no secret that rehab providers have always faced some
tricky reimbursement challenges. Finding the funding for technology
advancements and quality-of-life improvements continues to be a
dilemma. And now that the Centers for Medicare and Medicaid
Services is revamping its mobility policies, those working in the
sector are adopting a wait-and-see attitude regarding payment for
the products and services they supply.
But the rehab industry is not standing still during the process.
With a focus squarely on patients, both providers and manufacturers
say it is smart business to pay attention to the needs of end-users
by offering solution-based products that can still meet payer
requirements.
Improving the System
“We realize as a company that you can't change the rules
of the game unless you're in the game,” says Tom Rolick, vice
president of sales and marketing for Permobil, Lebanon, Tenn.
“I don't think anybody is selling out by trying to make a
product that is fundable. The motivation behind product development
is to improve the whole system — that opportunity doesn't
exist if you're not in the game.”
One way product companies are looking to meet both patient and
provider needs is with “mix-and-match” products. These
can help avoid reimbursement denials for systems with components
that are not medically necessary according to funding source
guidelines.
Rolick says Permobil's new products are being developed with
that concept in mind to ensure that consumers get the proper
seating systems and mobility products, and that providers get
reimbursed appropriately as well. It is a common-sense approach
that enables rehab technicians to determine product needs
independently in the same way they conduct evaluations.
“Oftentimes, the seating requirements are quite different
from the mobility requirements — you can have very involved
seating and minimal mobility needs, or vice versa,” explains
Rolick. “So the goal is to be able to seamlessly match those
two components together in a final mobility system.”
Such new approaches are what rehab equipment providers are
seeking.
Provider Jerry Stevens of Advacare Medical Corp., Olathe, Kan.,
says manufacturers are doing their part in responding to coding
challenges.
“They have revised almost all of their order forms to
include the coding,” he says. “They have repackaged
their products to respond to it, and that has given us choices we
can offer our clients so that we can still have some decent
contribution to the bottom line.”
Adrienne F. Bergen, PT, ATP, ATS, who maintains Lubbock,
Texas-based The MED Group's National Rehab Network, says products
that offer an extended life-cycle caught her eye at Medtrade last
fall.
“I noticed that manufacturers … are moving in a good
way toward modular technology. For example, Sunrise is going to be
offering a whole new line of power chairs in which the bases
themselves [can] be reconfigured in different ways. This is a great
way to move, because it is going to open a window at the other end
for more things to come and be added so products won't be
dead-ended.”
According to Elizabeth Cole, Longmont, Colo.-based Sunrise
Medical's director of education, “We are seeing new
developments in power products, manual products, sports products
and seating products. Certainly, we are seeing innovative new
options for alternative ways to operate a power chair, not only to
drive the chair but also to operate powered seating and auxiliary
devices like communication devices, environmental control units and
computers.”
Cole says the industry is also witnessing new developments in
the use of materials such as titanium; sleeker frame designs for
manual mobility products; more dynamic options like suspension in
both chair frames and moving parts; and integration between product
lines.
“There are so many ways that new technology within this
industry could benefit the end-users, so our ultimate goal is to
create products that will improve people's function in their
everyday lives and to provide maximum independence and
comfort,” she explains.
Phil Mundy, president of Product Design Group, Vancouver,
British Columbia, also emphasizes the need for client function,
which maximizes independence, self-esteem and, therefore, quality
of life. “[Manufacturers] are continuing to focus on
maximizing client function,” he says.
“If we provide products that provide more client function,
then the system is going to save in the long run in terms of having
less caregiver time wrapped up in looking after people —
which costs a lot more money than the equipment does — and
also from the quality-of-life point of view. That's where the real
rubber meets the road.”
Invacare's Mark Sullivan, vice president and category manager
for the Elyria, Ohio-based manufacturer's rehab products, notes
that listening to customers and their needs is essential.
“When we talk to some of the more senior consumers, not only
is mobility an issue but they are also very concerned about being a
burden on those around them,” he says, so products must be
easy for both patients and caregivers to deal with.
Responding to Need
Sullivan points out that although it is important to create
products that are reimbursable, manufacturers cannot forget
consumers' needs — even those that are not deemed
“medically necessary” by funding sources.
“Clearly, we try to make sure that you can get paid for
it, but you can't always do this in every case. Sometimes as a
manufacturer, you have to stop and ask if a feature is really a
true consumer need, and certainly things like portability and
power-elevated seats are true consumer needs,” he says.
“That's the fight we have on the power-elevated seat
option. It is not just nice to have; it's a very significant
feature for activities of daily living, both in and out of the
home.”
“Need always drives innovation in our business,”
emphasizes Cody Verrett, field product manager for Quantum Rehab, a
division of Pride Mobility Products, Exeter, Pa. “A
manufacturer that is able to offer unique solutions to providers,
clinicians and, most importantly, consumers, will always be a
driving force in the rehabilitation equipment industry.”
Verrett says there are numerous technological advancements in
the rehab market, including in drive motors, suspension,
electronics, drive interfaces and power positioning.
“Of all of these, the most innovative solutions that are
positively impacting lives are those involving power
positioning,” he says. “Unique innovations such as
lateral tilt and vertical elevators that rise to a full 10 inches
are assisting lives like never before, far beyond your standard
tilt-and-recline applications.”
As Sunrise Medical's Cole points out, products being brought to
market today are targeted toward independence and function for both
children and adults, depending on their needs. “The advances
in materials and frame designs are providing lighter and sleeker
chairs that might help prevent some of the long-term effects of
propelling a manual wheelchair and allowing people to go further,
faster and more efficiently,” she explains.
“Improved function can mean very different things to
different people. For some, it means being able to independently
maneuver around their house. For others, it means being able to
mobilize over all kinds of outdoor terrain [or] being able to go to
work or school or be involved in community activities. And for some
it means being able to sit in their chair for the whole day and be
safe, comfortable and stable.”
Sometimes, product advancements can be more accurately described
as evolutionary rather than revolutionary, according to Simon
Margolis, vice president of clinical and professional development
for National Seating & Mobility, Chattanooga, Tenn.
“There have not been a whole lot of innovations over the
past 15 years, but some of the same things have gotten better and
companies are now offering products that are performing the same
task but in a different way,” says Margolis.
Mundy believes these small improvements have widespread
benefits. “Certainly in some parts of the industry you see
lots of really interesting examples of changing technology and
dramatically improving technology, but there's way more stuff that
happens in little ways — little improvements and little steps
that make various bits and pieces of equipment more
functional,” he says.
For Mundy and others, it is the feedback they receive not only
from patients but also from providers that help guide the
manufacturing process. “You find new and better ways to do
things,” he says. “We spend a lot of time working in
clinics with therapists and working with [equipment providers] who
are really keen on achieving function for their clients. They are
quite demanding of us.”
Knowledgeable Patients, Nagging Problem
Rehab patients also are more knowledgeable about equipment than
they have been, largely due to media resources including the
Internet. “Like any consumer in this day and age, they want
what provides the latest in technological advances,” says
Cole.
But getting the products that offer the best solutions can be a
challenge for some.
“First and foremost, consumers need to work with a quality
RTS (rehabilitation technology supplier) who is knowledgeable of
product advancements in the industry and understands thoroughly
their implementation,” advises Quantum's Verrett.
“Additionally, they need to work with clinicians who
understand the justification process and adequately articulate
their client's specific medical necessity for the application being
sought.”
Cole agrees. “[Consumers] need access to the physical
product or products, as well as access to knowledgeable suppliers
and clinicians to determine if that solution is truly going to meet
their needs. This could be a challenge in some of the more rural
areas,” she explains. “Finally, they need funding for
these products, and this is certainly a challenge right now with
the continual changes going on in Medicare and the Medicaid
programs.”
Reimbursement challenges are certainly not new to rehab.
Industry veteran Margolis calls the situation a “perennial
issue.”
“Pricing is what it is, and we have to figure out a way to
work within that. That requires us to be much more conscious of
cost, both the cost of the products we buy and the cost of doing
business,” he says, adding that providers must look for ways
to decrease their costs, including understanding which products
they can actually provide profitably. “I don't think we have
to provide products that we can't afford to,” Margolis
explains.
Gerry Dickerson, CRTS, director of rehab technology for Medstar,
College Park, N.Y., says when he entered the business 30 years ago,
he spent 20 percent of his time on paperwork and 80 percent in
direct contact with his patients. Now, he says, those numbers are
reversed.
“I like to get dirty. I get down on the floor and I don't
mind the dirty, greasy motors and the screaming little kids and the
smells and the anxious parents … that's part of what I
do,” he says. “But the majority of my time is spent on
processing paper or reprocessing paper because [the requirements]
are constantly evolving. Nobody understands it, so what may be
appropriate on Monday may not be appropriate on Friday because
something has changed.”
Dickerson and other rehab providers say that, while CMS' current
coverage and coding review is welcome, they still have some real
concerns about the future. At their base is the fear that available
technology may never reach patients because payer sources are not
properly educated about their value.
On the other hand, he says, “there is an understanding
among all the parties involved that there are good people on both
sides of the fence, and good people that are reasonable can get
good and reasonable things done.”
In an industry sector filled with both optimists and realists,
one thing is for sure: It is business as usual for many rehab
providers who say difficulty in dealing with changing codes and
reimbursement is what they have come to expect.
States Advacare Medical's Stevens, “I don't think any of
us who do [rehab] regularly have changed the quality of our service
one minute amount. I think we're all committed to providing the
same level of service in the most timely way that we can given the
funding constrictions that we have.” But, he continues,
“I don't know how much longer we can continue to go to homes
and provide service and work on people's equipment and receive
pretty miserable reimbursement for our labor hours and, in some
cases, parts that we install.”
In the end, he concludes, “Those of us who do rehab
exclusively have learned to bob and weave. It doesn't make it any
easier, but we are so accustomed to change that we all try to adapt
as best we can.”
A Push for Certification
Required certification is another top issue for rehab providers.
Employing certified rehab technology suppliers creates client
satisfaction, reduces fraud and saves payer sources money, say
proponents.
According to Darren Jernigan, director of government affairs for
Permobil, Baylor University tracked an individual who was given an
inappropriate wheelchair for three years, including the resulting
surgery that came from that chair and the follow-up visits. The
study showed that Medicaid paid $368,000.
“If he had been given an appropriate chair to begin with,
it would obviously not have cost a dime except for the chair that
he should have had,” says Jernigan. “So, certification
not only protects the consumer but it also saves Medicaid or the
funding source a tremendous amount of money.”
Jernigan says Permobil's push for certification — the
company now requires its providers to employ personnel certified
through RESNA (Rehabilitation Engineering and Assistive Technology
Society of North America) or registered with NRRTS (National
Registry of Rehab Technology Suppliers) — is gaining support
from national organizations. NCART (National Coalition for
Assistive and Rehab Technology) now has a template available for
states to use to initiate legislation that would require
certification of rehab providers.
Visit these Web sites for more information:
www.ncartcoalition.org - National Coalition for
Assistive and Rehab Technology (NCART)
www.cliniciantaskforce.org - Clinician Task Force,
Coalition to Modernize Medicare Coverage Policy for Mobility
Products
www.resna.org
- Rehabilitation Engineering and Assistive Technology Society of
North America (RESNA), which administers the Assistive Technology
Practitioner (ATP), Assistive Technology Supplier (ATS) and
Rehabilitation Engineering Technologist (RET) designations
www.nrrts.org
- National Registry of Rehabilitation Technology Suppliers, a
registry of Certified Rehabilitation Technology Suppliers
(CRTS)
