Straight talk from a former HCFA Administrator

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Sunday, November 30, 2003

Bruce Vladeck, who was HCFA administrator from 1993 to 1997, recently characterized the spotty access to sophisticated durable medical equipment as a “continuing scandal.” But make no mistake: The current Professor of Health Policy and Geriatrics at Mt. Sinai University in New York doesn’t mince words when it comes to durable medical equipment in America today. We recently spoke with Vladeck, who will present the keynote address at Medtrade Spring in Las Vegas on March 17th at 7:30 a.m.

HME News: The HME industry has believed for a long time that if more were done in the home, Medicare might save more on hospital expenditures on the Part A side. Do you believe there’s an opportinity for HME...

BRUCE VLADECK: No.

HME: ...to play a greater role in the continuum of care?”

BV: Well, yes. There is an opportunity for HME to play a greater role, but there’s no savings for Medicare.

HME: There isn’t?

BV: There never has been. Home care has been promoted that way for 25 years, but it hasn’t saved Medicare a nickel and it won’t. That doesn’t mean it shouldn’t continue to grow. It just means that rationale is pretty feeble.

HME: Is that rationale such because there haven’t been studies that show it?

BV: There are studies that show to the contrary. But that logic doesn’t make any sense either. When you’re paying on a per case basis, what difference does a day or two length of stay make.

HME: I’m talking about home medical equipment where you’re doing more in the home, with ventilators, for example. If you can take people out of the hospital and put them in the home with this equipment, perhaps you’re reducing the number of days in hospital and you’re going to achieve some savings.

BV: I have real doubts about the extent to which you can adequately substitute for hospital care in the home without imposing enormous burdens on family members and just basically shifting the cost from the Medicare program to family members, which doesn’t strike me as particularly good public policy, but again, even the seventh or eighth days of a stay for someone with a respiratory problem is not the expensive part of the stay. There’s never been any successful saving of money by moving services from the hospital to other places because you end up providing more services, or you end up backfilling the hospitals.

HME: In a recent CNN interview you say, “It’s just really a continuing scandal in a society as rich as this one, folks can’t get the home care they need, they can’t get the drug coverage they need, they can’t get the more sophisticated kinds of durable medical equipment that would help them work or leave the house more regularly.” Where is that scandal?

BV: It really has to do with the limitations on personal care coverage for disabled people, which I think is what I was talking about. With the Medicare population, or the Medicare elderly population, there are real holes in personal care. The scandal I think I was referring to was the paucity of services for the disabled, including the disabled who could participate more actively in the community and some of them even to work if they had the necessary supports.

HME: Some in the DME industry are talking about a reconstruction of the Medicare fee schedule. Right now, Medicare just pays for the product. But people want there to be a recognition of the service component they provide and are proposing various ideas about...

BV: For years, the industry argued that the Medicare fees for DME included the service component, and that’s why we couldn’t procure it through competitive bidding, because we’d lose the system.

HME:So you think the service costs is in there?

BV: Historically, yeah. That’s what the industry has always contended.

HME: And that’s why you can’t do competitive bidding?

BV: That’s the argument the industry has made.

HME: Right now, the Senate is proposing that DME dealers become accredited by a recognized, independent accred organization. Do you think Congress should make accreditation a mandatory requirement for people who bill Medicare?

BV: I don’t know. I think it’s tied in with how much of what you have by way of expectations about how much service people are providing in addition to the equipment. I would put it a little more conditionally. If you are going to continue to reimburse for services, then you are going to need some kind of accreditation.

HME: Competitive bidding. Should DME dealers be subject to that?

BV: I don’t know why not. It seems to work well for the VA. It seems to work reasonably well for some of the larger private plans. The preliminary data from Polk County seems to be quite promising.

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