Ever since CMS adopted a new set of codes for seat backs and seat cushions in 2004 — which included creating 20 new “K” codes based on skin integrity features, positioning features, product dimensions and other defining criteria — both manufacturers and providers have focused on working with the new codes and on how they can best apply the products in them to their customers' needs.
There are some positives under the new structure, points out Bruce Shapiro, director of therapeutic support services for Medline Industries. For example, he notes, any patient who is physically compromised and qualifies for a wheelchair also qualifies for a pressure-reducing cushion.
But Michael Wright, Invacare Corp.'s product manager for seating and positioning, says some confusion still exists. “There is still a lot of confusion regarding reimbursement, especially around the new codes. The providers that really understand the codes and the implications of the reimbursement are going to figure out which combination of products will keep them profitable,” he explains.
A Push for Prevention
What holds true is the fact that preventing decubitus ulcers — the focus of seating and positioning products — is more cost-effective than treating them.
Estimates of the surgical cost to repair these lingering wounds range from $40,000 to $125,000, which leads one to question why any payer would not spend a few hundred dollars on appropriate seating and positioning products to prevent such an astronomical expenditure.
“In seating and positioning, we really do have two unique dynamics. Through the proper application of assisted technology, we can reduce the nation's health care spending and improve the quality of life and medical conditions of those who use wheelchairs,” says Tom Whelan, Sunrise Medical's vice president for seating and positioning. “That's a powerful thing.”
And according to Shapiro, within the home care community, “there is more awareness that [prevention] is an issue that needs to be addressed more vigilantly.”
“These products are not merely comfort-based products — they are very important to lifestyle and to health, and the system needs to recognize that it's not just the cheapest product that is going to do the job,” adds The Roho Group's Tom Borcherding, senior vice president of global medical sales.
“Supplying a cheap product that does not meet the health and lifestyle needs of these important users is just going to create a lot of health issues and increased medical costs in the system after the fact.”
But, as with other HME product sectors, reimbursement issues remain a stumbling block. Just last month, the new cushion codes were repriced, “and I guarantee you it's ugly,” says Roho's Dave McCausland, senior vice president of planning and government affairs. With cuts ranging from 10 to 40 percent, he says, “ultimately it does become an issue of patient access.
“We have a lot of providers that operate on pretty narrow margins already in order to provide the most appropriate products for their patients' needs,” he continues, “but you get to a point where you can't sell at a loss and make it up in quantity.”
Before the recent reimbursements were released, “we had already seen double-digit cuts, some well over 20 percent, and now we're seeing it come around again,” McCausland says. And though he says CMS is doing the best it can with the hand it must play, “it all ties back to a [gap-fill pricing system] that everybody acknowledges is flawed but that still continues to be used.”
Meeting Market Needs
“These days it seems that value is really the name of the game,” says Invacare's Wright. “Clinicians want products they can feel comfortable and confident putting underneath their clients, and providers want to keep the therapist happy while at the same time they need to mind their store and its profitability. So, creating a product that has clinical value and at the same time has a funding-friendly component really appeases both parties.”
He adds that both patient and provider needs are affecting product innovation along with reimbursement restrictions.
“The expansion of the HCPCS codes for seating really has given the manufacturer the chance to develop new products and create some new opportunities,” he says, explaining that the new codes have separate clinical indicators and, thus, offer more incentive for innovation.
For example, he notes, a “general use category product” that is designed for prevention has a lower reimbursement, so it should cost less to manufacture and supply than those products that are designed specifically to offer both skin care and positioning.
The situation “changes the way you think about product development in that you really need to formulate a combination of the product materials and features that work most cost effectively but also allow room for the provider to have some profitability,” says Wright.
Currently, the most common improvements in seating and positioning products involve material and shape, says Whelan of Sunrise. “There are some new materials that have been brought into the marketplace, and I think we are going to see even more. There are a lot more products with a lot of different design variations than there used to be.”
Shapiro says Medline is now using visco-elastic memory foam in its seating products, which enables “a very cost-effective cushion using this material — the visco-elastic memory foam does a good job distributing pressure away from the bony prominences and conforming to a patient's body.”
Invacare's newest seating and positioning products, set to be released this summer, include the InTouch Stabilite and Flovair cushions that utilize a foam base with a thin layer of air for pressure relief and a thin layer of fluid for shear reduction.
Roho has recently teamed with Tempur-Pedic, which makes consumer mattresses and support surfaces, to create its Triumph product line, and the companies have further product launches scheduled for this summer.
However, although research and development is ongoing, Abraham Goldstein, president of Wenzelite Rehab, a division of Drive Medical, says he has not seen any “major breakthroughs” in product innovation due to the market's wariness concerning reimbursement. “People are waiting for funding issues to be resolved before they bring new technology to market,” he says. The company has recently introduced its Seat2Go, a lightweight positioning seat for children that need support.
Education and Support
In addition to offering new products, Invacare's Wright believes seating and positioning manufacturers also must offer education to show providers “how to remain profitable.”
According to Wright, “Providers are very knowledgeable about the products themselves, applications for the products and use of the products, and they are very comfortable with knowledge of recommending which products are appropriate to their clients. But they look to manufacturers for assistance with updates on the coding, updates on how to file claims and with lobbying with them at the state level — or even at the level of private insurance — if the state Medicaid or a private insurance is not paying an allowable consistent with Medicare or is not following the national HCPCS codes that follow Medicare guidelines.”
Another example of educational support is Medline's Educare hotline, which gives providers access to enterostomal therapists who can answer clinically based questions and assist with product selection.
Sunrise's Whelan feels that selecting products that are appropriate and effective can be challenging. “It is a difficult situation because it is a highly technical environment that is sometimes handled by people who do not have standardized technical knowledge to service the market,” he points out.
“The solution is continued development of testing, continued development of education on the science behind the products and continued commitment by the manufacturers to drive that information into both products and the marketplace.”
Whelan also believes clinical trials would go a long way toward showing the efficiency and effectiveness of sophisticated seating and positioning products.
“A fear for the industry — the same thing that happens with other coded reimbursement items — is whoever can deliver the least expensive product to the market is going to take some market share based on price,” he explains.
“Inevitably, when you have a level of a competition between some very highly effective recognized products and some not as highly effective products that are far less costly to manufacture, you're going to get that trend in the market … toward a natural split where there are going to be people who are clinically involved making good decisions and other people who are looking for an opportunity to make [only] profits.”
Whelan notes that standardized testing that establishes a benchmark to compare products is in its infancy in the U.S. However, he says, such testing would strengthen the evaluation process and have a significant impact on clinical outcomes.
Along with education, some manufacturers are offering programs that affect the economics of providers' business plans — an essential component in today's environment.
Many offer next-day shipping on products, an important service that helps providers respond to end-users' needs. “There is creativity that exists in the delivery of the product to the customer,” says Wright. “An example of that would be a factory-direct ship program. This allows providers to minimize their costs by reducing the amount of inventory they need to purchase as well as stock.”
Experts Interviewed:
Tom Borcherding, senior vice president of global medical sales, and Dave McCausland, senior vice president of planning and government affairs, The Roho Group, Belleville, Ill.; Abraham Goldstein, president, Wenzelite Rehab, a division of Drive Medical, Port Washington, N.Y.; Bruce Shapiro, director of therapeutic support services, Medline Industries, Mundelein, Ill.; Tom Whelan, vice president for seating and positioning, Sunrise Medical, Longmont, Colo.; and Michael Wright, product manager for seating and positioning, Invacare Corp., Elyria, Ohio.
