In the midst of economic turmoil in 2009, the manual wheelchair market managed to march along at a stable and even boring pace. Untouched by the vagaries of DMEPOS competitive bidding and the 9.5 percent cut that affected so many products, prescriptions for K4 and K5 custom manual categories remained steady.
“The fact that manual wheelchairs were not included in competitive bidding has given our partner providers some opportunities,” says Mike McCarthy, ATP, national sales manager for custom manual wheelchairs and Synergy seating products at Quantum Rehab, a division of Pride Mobility Products Corp. “For those who've chosen to add manual wheelchairs to their business model, it has brought some measure of balance back to the 9.5 percent cut.”
While acknowledging that the competitive landscape has not changed a lot in the past year, McCarthy contends that the custom manual prescription climate is significantly more welcoming than the market for commodity-type prescriptions or rental chairs. After just crossing the five-year mark with its ultra-lightweight folding chair, the Litestream XF — a K5 custom manual — officials at Pride believe they are well-positioned for the new year.
McCarthy attributes the manual segment growth at Pride to targeted product enhancements such as a recently launched depth-adjustable frame package.
“There are also variations in armrest configurations, which was a big request from our customer base,” says McCarthy. “Custom configurable wheel and tire packages were also a big hit, and those things have really been the catalyst for our growth.”
Rita Hostak, vice president of government relations for Sunrise Medical, contends that the absence of manual wheelchairs from competitive bidding has helped to foster new ideas in this segment.
“Innovation has continued at a higher rate than in those segments hit hard by reimbursement cuts and the anticipated impact of competitive bidding,” says Hostak. “This is positive for individuals with disabilities, and it promotes competition at the manufacturer and supplier level that is based on more than price. Product quality and technological solutions for consumers are still high priorities in this product segment.”
Late last year, Sunrise added a number of enhancements across its Zippie pediatric manual wheelchairs — the Iris, GS2, Kidz and TS — including hub locks, angle adjustable push handles, colorful spoke guards and color options like “Glow in the Dark” and “Root Beer.”
According to Judson Cummins, product manager for custom manual wheelchairs at Invacare, the Elyria, Ohio-based manufacturing giant has added more than 40 improvements to is Solara 3G and pediatric Spree 3G wheelchairs, the latest in its tilt-in-space franchise.
“Since the Solara 2G wheelchair launched roughly five years ago, we have kept a massive list of requests, suggestions, interesting ideas and configuration challenges” culled, Cummins says, from people who have a stake in tilt-in-space wheelchair prescription. Features on both chairs now include color-coded hardware for adjustment indicators, bilateral contracture footplates, a seat pan system that can be converted from flush-mount to drop-mount or vice versa using the same hardware, and configurable seat-to-floor heights.
The updates are a “manifestation of the impact that providers, caregivers ad clinicians can have,” says Cummins.
With competition likely to increase among manual wheelchair manufacturers, he hopes that competition will benefit providers and consumers.
“Hopefully it will result in more innovation instead of a race to the bottom to provide the lowest-priced product,” says Cummins. “Consumers should be demanding progress and design, and then it is up to us to educate the providers on how to spec it out and why it is an improvement and/or a better product. For some providers, it may be time to move on to the next generation of manual wheelchairs.”
The Hard Way
The annual X Games has spawned massive interest in so-called extreme sports involving bike and skateboard stunts. It's hard to tell whether these sports, and the resulting injuries, have contributed to a rise in manual wheelchair use, but experts say it is a plausible theory. Combine this with advanced therapy techniques, safer vehicles and possibly less severe spinal injuries as a result, and you have a recipe for increased manual wheelchair use.
It's a grim notion, but it underscores the fact that human behavior influences injury rates. In the case of obesity, poor food choices have led to a growing need for bariatric products.
Demographics have always fueled medical trends, and Georgie Blackburn, vice president, government relations and legislative affairs for Blackburn's, Tarentum, Pa., agrees that bariatrics will only grow.
“I think it safe to say the bariatric chairs are more in demand because we see so many more obese individuals,” says Blackburn, who also serves as vice chair of the American Association for Homecare. “I read a [Research and Markets] report out of Dublin, Ireland, that stated the worldwide wheelchair market will grow from $3.9 billion in 2009 to $7.9 billion in 2015.” Although the report includes all wheelchairs, the growth is there, she says.
Blackburn has seen an increase in manual mobility at her own shop, and envisions continued growth in 2010. “I think reasons for demand are directly related to the state of health in our society,” she adds. “While we will always have anomalies and onset of disease processes like ALS, MS and Parkinson's, another reason for the climbing demand is a commentary on lifestyles resulting in obesity, adult diabetes, drug and alcohol addiction and even the proliferate use of guns. Gunshot wounds often result in the long-term use of a wheelchair — manual or power.”
Tim Pederson, CEO of WestMed Rehab, says the bariatric products he sells in his South Dakota store are getting bigger than ever as the weight capacity for standard gets higher.
“Items that we had considered in the past to be bariatric, such as 20-inch wide wheelchairs, are becoming thought of as more standard,” says Pederson, who also chairs AAHomecare's Complex Rehab and Mobility Council.
“Even if we deem that bariatric as we know it today is not growing, growth would only be considered flat because we have expanded our definition of what we would consider standard. Things that were formerly considered bariatric are now being thought of as standard.”
At Baltimore-based Chesapeake Rehab Equipment, Gary Gilberti, president, says he is “definitely” seeing an increase in the bariatric market. As for manual wheelchairs overall, he thinks there will be a slight increase in 2009.
As always, lower costs lead to greater profits, and providers have never been so focused on efficiency and wise purchasing, he says. “Suppliers are trying to standardize their product offerings to keep their cost-of-goods down,” says Gilberti, president of the National Coalition for Assistive and Rehab Technology. “The movement by some other manufacturers into the standard and custom manual product areas has provided some competition and more options for suppliers. In selecting product, price should be a factor, but quality/value for that price is critical.
"As with any product, you want to make sure that you don't lose money by having to do a lot of warranty work or end up replacing inadequate product. Many suppliers will just buy the cheapest product they can find. In the long run, they spend more money in repair/replacement costs over the life of the product."
The weight of patients isn't the only thing in flux. According to Invacare's Cummins, manufacturers have worked to lighten their chairs, but it is common for consumers and even therapists to place too much emphasis on how much a chair weighs.
"Most people consider weight of the chair to be most important by far," laments Cummins. "In reality, weight is an important factor among a lot of other important factors. Getting the right fit in the right frame with proper wheels and tires is as important as weight. At the end of the day, it all comes back to how is that chair fitted to the person it was designed for."
State of Reimbursement
The recession has undoubtedly affected state coffers due to lost tax revenue that has rippled through state Medicaid budgets. In some states, reimbursement levels for custom chairs are getting cut, downcoded and delayed.
Despite the challenges, providers are getting paid. Blackburn contends that one of the typical mistaken beliefs is that the ultra-lightweight category (K5) will not be reimbursed by Medicare. It will, but it's a matter of understanding Medicare documentation requirements and thinking in terms of the CMS algorithm, she noted.
"If that is the only chair that answers the needs of the beneficiary," says Blackburn, "the medical record must demonstrate that."
For Pride's McCarthy, the biggest misconception about the manual wheelchair market is the notion of reduced profitability. He says acquisition costs are a reason for this perception, and providers have to be willing to find superior products at a reduced cost.
"A rental fleet of K4 products is a terrific example of something that can boost cash flow that many providers do not take advantage of," McCarthy points out. "Add in durability, adjustability, and aesthetically pleasing products — because consumers pay attention to how it looks. Aesthetics are a decision-maker for a lot of consumers."
On the lower end, Pederson believes, all manual chairs are essentially becoming a commodity. From a commonality standpoint, and a volume-purchasing perspective, it makes sense to source lower-end manual wheelchairs from the same manufacturer.
"When you get below the K4 category, it is a commodity item," says Pederson. "We try to have the same brand all the way through for the mid- to upper-end manual wheelchairs. The brand we carry offers the full spectrum from the K1/K2 standard mall chair on up to your standard lightweight on up to your K4 high-strength lightweight. And then there is the specialty niche of K5 ultra-lightweight — even pediatric manual tilt-in-space."
Ultimately, manufacturers and providers agree that boosting sales in a fairly stable market requires effort and changing things up.
"Get out and serve your clients," enthuses McCarthy. "Some of those opportunities could be expanding your service delivery areas. We have seen some of our partner providers go into an expansion mode with terrific success. It could be something as small as taking a service delivery area that is 100 miles in diameter and making it 150 miles in diameter."
- Read the "New Codes on the Horizon?" sidebar to learn more about the possibility of a new batch of manual wheelchair codes.
Experts Interviewed
- Georgie Blackburn, vice president, government relations and legislative affairs, Blackburn's, Tarentum, Pa.
- Judson Cummins, product manager, custom manual wheelchairs, Invacare, Elyria, Ohio
- Doran Edwards, MD, Advanced Healthcare Consulting, Columbia, S.C.
- Gary Gilberti, president, Chesapeake Rehab Equipment, Baltimore
- Rita Hostak, vice president of government relations, Sunrise Medical, Longmont, Colo.
- Mike McCarthy, ATP, national sales manager, custom manual wheelchairs and Synergy seating products, Quantum Rehab, a division of Pride Mobility Products Corp., Exeter, Pa.
- Tim Pederson, CEO, WestMed Rehab, Rapid City, S.D.
New Codes on the Horizon?
A fresh batch of new manual wheelchair codes would go a long way toward clarifying some occasionally dicey claims for providers. However, when the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) gave way to the Pricing, Data Analysis and Coding (PDAC) contractor, new priorities took over, and the initiative seems to have been largely set aside.
Officials at Pride Mobility Products contributed their thoughts during the process previously and would welcome the chance to do it again.
"We will fully support the initiative when it comes back to the table," says Mike McCarthy, ATP, the company's national sales manager for custom manual wheelchairs and synergy seating products. "We would love to have some definitions that separate the complex custom manual side from the commodity side."
If PDAC officials plan to use the input that has already been collected, they have yet to tell managers from some of the nation's largest manufacturers. At Invacare, Judson Cummins, product manager for custom manual wheelchairs, says it is still unknown as to whether the government contractor will use what it has or completely start over.
"We are all just kind of waiting to hear something," says Cummins. "I hope that the PDAC engages Invacare and other wheelchair manufacturers like the SADMERC did so that it is a collaborative process. What we presented a couple years ago as a recommendation was something that the group could agree on. Ultimately, we did not do it in isolation. The codes are limited today, and we hope to change that. Whether or not the PDAC is going to finish the job, I do not know."
With a product line that ranges from K5 and up — ultra-lightweight, pediatric chairs and tilt-in-space chairs — Cummins says the expanded codes would eliminate confusion caused by the narrowly defined K5 code.
"The K5 sometimes does not distinguish itself enough from a K4," he explains. "The new codes would separate that K5 code out. At first it would be confusing, such as what happened with the power codes in 2006, but it would eventually be clearer because the criteria would be much more defined. That was a goal of the original work group. You would have more codes, better criteria and a better understanding of where a product would fall into those different codes."
It's not only manufacturers who can't predict the PDAC's intentions. Former SADMERC Director Doran Edwards, MD, says he has "no idea" if the PDAC will pursue new codes in the future.
"CMS has been bogged down with trying to implement Round 1 of competitive bidding, so I'm sure manual wheelchair reform is not high on their list of priorities right now — but that is not to say that it is necessarily dead," says Edwards, who now heads Advanced Healthcare Consulting, a private consulting firm based in Columbia, S.C. "I do know that the industry is very interested in having that go forward because there are at least a couple areas of coding vagueness that they would like to have addressed. When you start getting into the higher-end wheelchairs that are primarily used for complex rehab patients, some of those are not as well defined as they need to be."
