ATLANTA — Members of a newly formed oxygen coalition sifted through provisions of several plans last week looking for common ground on reform of Medicare's oxygen benefit and repeal of the 36-month rental cap.
"The big push now is to get a unified voice," said Mike Calcaterra, Montana state chairman and legislative/DAC chair for the Big Sky Association for Medical Equipment Services, which covers Idaho, Montana and Wyoming. With industry advocates headed to Washington this week for the American Association for Homecare's lobby day, "we need to make sure we are on message there with something that is giving us immediate relief. We are already seeing providers closing their doors," Calcaterra said.
AAHomecare convened the New Oxygen Coalition, or NOC, after a number of state HME associations said they could not support the long-term plan unveiled in January by AAHomecare and the Council for Quality Respiratory Care. Some state leaders said the plan lacks specifics and does not immediately address the 36-month cap and the post-cap payment rules, which took effect Jan. 1.
AAHomecare leaders fear, however, that Congress won't budge on the cap before a reform plan is in place.
"While everyone would like to eliminate the 36-month cap or get a better set of payment rules, both are difficult targets to achieve in the current political environment," said Tyler Wilson, president of AAHomecare. "Many within the oxygen community view the likelihood of more cuts to oxygen as an imminent threat. The big challenge right now is to develop a consensus plan that will address both the immediate issues and the longer-term goal of reform.
"All of us face real peril at the hands of Congress and CMS if the oxygen provider community does not present at least a core of common principles to address the issues."
Members of the new coalition — which includes some state associations, VGM, The MED Group, the CQRC and AAHomecare — all agree long-term reform is needed and the cap must be repealed, but they are at odds over how those things can be accomplished. State association representatives held a conference call last week to make sure they were "all on the same page," said one state exec, and participated in calls with AAHomecare to try to hammer out their differences before lobbying in Capitol Hill offices Wednesday.
"There are different versions of what reform might look like," said Teresa Tatum, executive director of the Georgia Association of Medical Equipment Services. "There is some agreement, but the major disagreement is on the payment methodology."
In addition to the AAHomecare/CQRC plan, two other reform plans have been proposed by Big Sky AMES and Jason Rogers, president of GAMES.
"We think we have a vehicle that can give us an immediate fix [to the rental cap]," said Calcaterra about the Big Sky plan. "AAHomecare brought their proposal they worked on with CQRC — and a lot of work, a lot of time went into that — but we didn't see any immediate fixes in it," Calcaterra said. "It's big-scale reform, and that's going to take a while. We are worried about providers being there when the reform takes place. We feel we have the plan for realignment on how they pay for the service that would eliminate both the cap and competitive bidding."
The AAHomecare/CQRC plan, developed with the help of former CMS acting administrator Leslie Norwalk, repeals the cap, changes the status of oxygen entities from "suppliers" to "providers," exempts oxygen from competitive bidding and would reimburse providers for patient services, as well as equipment and supplies, in a bundled payment. In addition, the plan is budget-neutral, a plus AAHomecare points out considering the nation's current economic pressures (see AAHomecare Unveils Oxygen Overhaul Plan, HomeCare Monday, Jan. 12).
But the overhaul plan includes a case-mix adjusted payment system that bases reimbursement on patient ambulation, liter flow and modality — a methodology some providers have said they are wary of.
According to Calcaterra, the Big Sky plan rearranges monies in the benefit to reimburse more appropriately for service and realigns payments so they aren't "front-loaded." Dubbed the "oxygen flip plan" by some stakeholders, the plan "flips" priority of payment dollars from stationary to portable.
Rogers said his "blended" plan "is an attempt to unite the several plans put forward." His plan includes elements from both the AAHomecare and Big Sky plans and addresses other concerns he has heard from providers and groups around the country. It also provides for possible implementation of a prospective payment system.
Even as they grappled with how to move forward, stakeholders were preparing to visit lawmakers Wednesday to urge repeal of the oxygen cap. They will be armed with a sign-on letter generated by Rep. Tom Price, R-Ga., who last year introduced legislation to repeal the cap. While the content of the letter had not been finalized as of Friday, it was believed to assert that the Deficit Reduction Act, which mandated the rental cap, also instructed CMS to establish adequate payments for oxygen.
"That's where we have the problem," said Tatum. "After 36 months, there aren't adequate payments."
Price was expected to ask his colleagues to contact CMS and appeal to the agency to address the issue administratively. "It appears that everybody [in the oxygen coalition] agrees that those post-cap payment policies should be addressed through the authority that CMS already has," said Tatum. "I feel like we are all going to come together behind this letter."
Calcaterra is hopeful that the industry can reach agreement as well on a long-term plan. "We truly want to reform it, but we are also trying to make Congress and CMS understand that there is so much more to what we do than just [deliver] a piece of equipment," Calcaterra said. "There is absolute disconnect between the requirements to be a provider and the payment modality …
"It is critical to get the industry behind whatever [the reform plan] ends up looking like," he added. "We're already seeing problems for beneficiaries being able to travel, relocate." Calcaterra said he's heard of one provider wanting to charge as much as $4,000 to take care of a "snowbird" seeking relief in Florida from the cold in his home state. "I haven't seen proof of that yet," he said. "But the bottom line is that the beneficiary is caught in the middle of that."
So are providers. "The cap is still the cap," lamented Bill Baker, RRT, president of RxO2 in Tucson, Ariz., "and every month [means] thousands of dollars lost. We still have to provide the services at no fee … so the bleeding is still perfuse. The members of this industry are hemorrhaging to death in red ink."
