Within the rehab industry, the importance of appropriate and effective seating and positioning is well known. Through the use of new technologies and materials, efforts to reduce the occurrence of pressure ulcers and enhance function for those with disabilities have been effective. But the challenge of ensuring that users obtain the most appropriate products continues to be a struggle.
"The biggest challenge facing suppliers in this market is being able to provide clinically appropriate products and remain financially viable in the current reimbursement environment," says provider Gary Gilberti, CEO of Chesapeake Rehab Equipment.
Gilberti, who is also president of the National Coalition for Assistive and Rehab Technology, says the HCPCS code sets and fee schedules do not effectively recognize the variety of products or technologies that can be employed in providing seating and positioning.
"This situation severely restricts suppliers and clinicians and forces them to use items that might not necessarily provide the best functional benefit or outcome for the patient," he says.
Tom Borcherding, president of The Roho Group, adds that the current funding environment and proposals working through federal and state government programs that will "further reduce funding to catastrophic levels" are also a strong threat to the industry.
"The monster of such programs is the poorly constructed competitive bidding program, which, if implemented, will result in widespread funding cuts and restrictions to access to all but the most low-cost equipment," he says.
Borcherding's concerns about the impact competitive bidding will have on those who rely on such products range from access to detrimental health outcomes.
"CMS seems to accept that users who rely upon seating and positioning and advanced mobility solutions will be able to maintain independence under a health care benefit that essentially accepts the lowest common denominator when it comes to equipment selection," he explains. "Should this ill-fated bidding program become reality, CMS is in for a rude awakening when the true impact of its actions — diminished access to necessary equipment, increased hospitalization and treatment costs, and loss of productivity — becomes established."
Restrictive reimbursement fees will likewise require providers to change their operational practices.
"Suppliers no longer can absorb the cost of a variety of seating into the cost of the mobility base because the margins have gotten so tight across the board," says Gilberti. "Every line item has to be accounted for on the system now."
Another issue facing providers relates to the vast array of products and HCPCS codes, according to Melissa Gonsalves, associate product manager for Invacare.
"In the current seating and positioning market, one of the foremost issues is the availability of a large number of products. Currently, in the skin protection and positioning code alone, there are over 100 different HCPCS coded products. How does one choose? Creating awareness through educational programs like training, seminars, in-services, online education and brochures can help providers, clinicians and consumers make better choices, but it is still an overwhelming process," says Gonsalves.
She adds that the current coding structure is not consistent and requires additional work.
"For example, K0736 reflects coding for an adjustable, skin protection cushion; however, there is no code for an adjustable positioning cushion. Moreover, the diagnostic qualifications listed for each code makes it difficult for some individuals to meet the criteria for the products that they really need. More specific codes that are consistent and cover the spectrum of individual's needs have to be addressed in order to face these challenges head on," she says.
Another issue with HCPCS coding, according to Borcherding and Gonsalves, is its effect on product development.
"The current reimbursement structure does not restrict the use of new technologies, rather it curbs the design of products," says Gonsalves.
"Unfortunately, the antiquated coding system used by CMS makes it very difficult to establish groundbreaking technology," he says. "When was the last time a new code was added to seating, to allow access to new technology? With payment allowables under pressure, new and innovative technology will struggle to find an avenue where it will be appropriately funded."
'Really Difficult' for Bariatric Patients
From a population-specific perspective, the bariatric segment is providing some significant challenges in terms of balancing the mobility device and issues such as foot positioning as well as reimbursement.
"The reimbursement structure is really difficult with the bariatric population as it is very restrictive. The bases are under- or inadequately funded," says Jill Kolczysnki, Quantum Rehab product manager for Pride Mobility Products. "The positioning products are not differentiated by those for lighter-weight individuals and those for this population."
Because of the struggles to get paid for bariatric seating and positioning products, Kolczysnki says providers tend to shy away from these clients, which leads to less product development from manufacturers.
Still, Kolczysnki says a trend in development is to make seatbacks narrower than seat widths that bring in the span of the arms, thus reducing the overall width of the unit.
"The overall width of the unit can be a pretty significant challenge for this group of people as they still need to get through doorways and up ramps. This provides additional access options to complete their activities of daily living," she says.
On other advances in the market, Gonsalves says technology is helping to improve the quality of different materials, such as foam, gel and air, that can be used in seating products.
"We are now better at dialing into the firmness and density of foam to … experiment with different types of foam, and technology also helps in developing lightweight seating systems due to improvements in hardware design and materials," she says. "Additionally, by combining different modalities including foam, fluid/gel and air, more effective seating solutions are also being developed."
Going forward, Gonsalves sees a move to new materials that can improve product functionality. "In the next year or two, with the help of technology, we may begin to see newer materials, or a combination of materials, with improved qualities being used in seating systems," she says.
"There will be a higher focus on materials that allow for management of heat and moisture in addition to current seating goals. Perhaps there may also be a move toward covers and cushion materials which have cooling properties that help maintain skin integrity," Gonsalves adds.
More Cost-Cutting to Come
But even with advances in product development, reimbursement will continue to be a factor. As a provider, Gilberti sees several scenarios that will affect product choice and operational management.
"Over the next few years, manufacturers will be trying to bring the cost of their products down even more. This will drive more generic, standardized or modular items that can fit the least-costly-alternative mindset," says Gilberti. "Lower margins for manufacturers and suppliers will stunt research and development of new products and drive a one-size-fits-all mentality."
He also believes that manufacturers will partner with providers to cut non-product costs out of the system.
"Single invoicing and assembly programs may become available to make it possible for the supplier to spend less time on the final aspects of the delivery process," he says. "Until there are changes that allow the coding and payment to better reflect current technology and to allow for evolving technology, there will continue to be downward pressure on the suppliers."
While the industry continues its effort to have Congress repeal the competitive bidding program (see sidebar), providers still need to focus on how to increase referrals and customer satisfaction.
Gilberti says clinicians and referral sources must continue to work together to provide the most appropriate product for the client within the limitations of the current reimbursement environment.
"Suppliers need to be transparent and upfront with referrals about what can or cannot be reasonably provided. Likewise, referral sources need to understand the limitations and that there will now be formularies and other limitations on products," he says.
The teamwork approach is exactly what Gonsalves advises. "Incorporating a team effort right from the start can help develop seating solutions that are effective and work best for the individual," she says. "Working together, [providers and referral sources] can best meet the patient's needs and wants and translate them into products that are the most appropriate solutions for them."
Rehab Industry Works toward Separate Benefit
If there is an upside to the unprecedented funding challenges facing rehab providers, says Tom Borcherding, president of The Roho Group, it is that the situation "has united industry stakeholders like never before. Today, manufacturers, providers, clinicians, and consumers are aligned and engaged. The industry is finally preaching a single message that is absolutely critical if we are to influence positive outcomes in Congress and CMS."
That message involves two crucial issues.
"On the immediate horizon, supporting H.R. 3790 and establishing a new benefit category for complex rehab must be industry priorities," Borcherding says. "We are overdue for a key victory in our battles to retain adequate funding and deliver appropriate technology solutions to consumers that rely on such equipment for independence."
The importance of such a goal cannot be understated, according to Borcherding.
"Unfortunately, all signs paint the scenario that price will continue to take on a more dominant role in determining product selection. The pendulum will only swing back to product performance and consumer benefits when CMS and other payers recognize that solutions for seating and mobility are not commodity items," he says.
Gary Gilberti, CEO of Chesapeake Rehab Equipment and president of NCART, emphasizes the need for establishing a separate benefit for complex rehab equipment. The project is being pursued jointly by NCART, the American Association for Homecare's Complex Rehab and Mobility Council, the National Registry of Rehabilitation Technology Suppliers, the Rehabilitation Engineering & Assistive Technology Society of North America and the Clinician Task Force.
"A primary goal of the current complex rehab separate benefit category project is to establish more appropriate and effective coding, coverage and payment criteria for all complex rehab mobility and seating and positioning devices," Gilberti explains. "The premise is that the principles used in establishing codes, fees and coverage policies for DME are not applicable when considering complex rehab products. If rehab were removed from the DME benefit, more appropriate methodologies could be used."
Editor's Note: You can read a discussion paper on the separate benefit for complex rehab on the NCART website at www.ncart.us. Questions and comments on the discussion paper can be directed to Don Clayback, NCART executive director, at dclayback@ncart.us or 716/839-9728. You can also post questions and comments to the "Separate Benefit" blog at http://complexrehabtech.blogspot.com/.
RESNA Offers ATP/SMS
The Rehabilitation Engineering & Assistive Technology Society of North America is now offering a specialized certification in seating, positioning and wheeled mobility.
Certification as an Assistive Technology Professional (ATP) is a prerequisite to take the Seating and Mobility Specialist exam; the new designation will be ATP/SMS. No additional continuing education will be required for the SMS, according to RESNA. However, some of the continuing education required for the ATP renewal must include seating and mobility training. Applicants for the new credential must also meet two of seven professional criteria, including: continuing education; presentations/formal instruction; mentoring/supervision; client service delivery; advocacy; leadership; and publications.
For more information, see www.resna.org.
Experts Interviewed
- Tom Borcherding, president, The Roho Group, Belleville, Ill.
- Gary Gilberti, CEO of Chesapeake Rehab Equipment, Baltimore, and president of the National Coalition for Assistive and Rehab Technology
- Melissa Gonsalves, associate product manager, Invacare Corp., Elyria, Ohio
- Jill Kolczysnki, Quantum Rehab product manager, Pride Mobility Products Corp., Exeter, Pa.
