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:
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www.ncartcoalition.org - National Coalition for Assistive and Rehab Technology (NCART)
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www.cliniciantaskforce.org - Clinician Task Force, Coalition to Modernize Medicare Coverage Policy for Mobility Products
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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
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www.nrrts.org - National Registry of Rehabilitation Technology Suppliers, a registry of Certified Rehabilitation Technology Suppliers (CRTS)
