Wheeler dealer should turn certification gears

Friday, October 31, 2003

In light of the recent power wheelchair scam in Houston and the announcement by CMS of their crackdown on fraudulent providers of power wheelchairs, it seems appropriate to reiterate a position that I have advocated for some time now. I am speaking of the imperative need for our industry to bring itself to a higher professional plane through certification and accreditation.

I realize how divisive this issue is, even among friends within the industry. I also understand that no amount of law, regulation, licensure, or credentialing will completely put a halt to abusive and unethical people. Clear understanding of appropriate industry standards along with swift and sure enforcement of those standards will, however, go a long way in helping to decrease the instances of fraud and abuse in our industry.

Before I go any further, allow me to address two important perspectives. First, we must achieve a careful balance between practical, rational standards that make good business sense and challenging standards that afford both protection and professional service to the patient/client. Having standards that accomplish either, but not both simply does not make good sense. Second, sequencing is critical to the successful credentialing of the industry.

Ideally, I believe that individual certification of people in selected positions within a provider’s company should come first (followed by company accreditation). However, because we are well into the process and availability of accreditation, we should not delay the implementation of mandatory accreditation to wait for individual certification programs to catch up.

We can, however, be running on parallel tracks and when certification programs are in place, changes in accreditation standards to include certified practitioners would be both necessary and appropriate.

Having said that, I would like to address some of the specific objections that are being raised over mandatory accreditation. The first is “I’m a small provider and cannot afford accreditation.”

I don’t know how small “small” is. However, the cost of a three year accreditation survey process ranges from $3,300 for the smallest providers to $8,200 for the largest (single location, HME focused). There are preparation time and costs that may double that cost. So, perhaps a company’s cost is in the $15,000 range. A single location company is actually looking at only $5,000 per year. Now, I know one can argue these costs, but my point is that the cost/benefit of accreditation is not really cost-prohibitive as has been demonstrated by the many firms that are and continue to be accredited year in and year out.

Another question that is posed relates to the number of providers that would need to be accredited and the lack of the ability of the current accrediting entities to handle such a demand.

When discussing numbers of providers in the industry with some of the largest manufacturers, they tell us that they have approximately 12,000 dealers on their rolls. The 80-20 rule is in effect as only two to three thousand comprise the lion’s share of their volume. So, one might conclude that 75-80% of the HME business is being conducted by fewer than 3,000 companies.

According to the JCAHO Web site, approximately 5,600 home care organizations have been accredited by the JCAHO. However, one must realize that in addition to home medical equipment, clinical respiratory, pharmacy services (home i.v.), and rehabilitation technology services, the JCAHO includes clinical/consultant pharmacists services, freestanding ambulatory infusion services, home health services (nursing), home personal care and/or support services, hospice, long-term care pharmacy services, pharmacy dispensing services, and contracted services.
The majority of that 5,600 number are not HME/rehab/respitory providers from our industry.

Now add those providers that have been accredited by ACHC and CHAP. We are in the 3,000 range of accredited companies in our industry. ACHC, CHAP nor JCAHO is at full capacity and could accredit more companies if the demand was present. When one takes these numbers into consideration, the task becomes much more manageable. In addition, other accrediting bodies may enter the market, as well.

Another question centers around the efficacy of accreditation: Will accreditation actually help decrease fraud and increase patient care while improving business operations?

This is a legitimate question and deserves a more detailed answer than space allows. The answer is yes and no. Local health departments inspect restaurants yet there are still roaches in the kitchen of many. There are attorneys who have passed the bar and are licensed and still end up in jail for fraud. There are banks that are mega-regulated that still rip off the public. There are speed limits on the highway and laws against drinking and driving, yet speed and drunk drivers combine to be the largest causes of traffic accidents. And, there are physicians who regularly practice fraud and abuse the system (until they are caught and punished).

But, we don’t simply throw out all the regulations, laws, licenses and certifications that are in existance today because Enron, Worldom and Arthur-Andersen had some crooks in them. There is, in fact, accountability when professional standards are well-defined, implemented and enforced. And, the higher the standards, the more likely abuse will decrease, patient care will be at least optimally provided and businesses will be improved.

Shouldn’t certification (individual credentialing) preceed company accreditation?

As stated above my preference is to see individual certification come first in the credentialing sequence. In any case, a combination of individual certification (ATS, ATP, RRT, RN, etc., plus new certifications for various positions within our industry) and company accreditation is a must. An analogy: A physician may be a skilled surgeon, but without an operating room that meets certain healthcare standards, he or she could not perform appropriately. Yet a hospital without the appropriate trained and certified personnel cannot offer the services it must offer. The same parallel should be drawn in our industry. Accreditation alone is not enough. Credentialing of individuals performing within the industry is also necessary.

Why not employ licensing by the individual states instead of requiring certificatgion and accreditation?

State licensing would likely not cover both fronts and would vary from state to state, making it much more difficult and costly administratively for federal payors such as Medicare to manage. In addition, while a strong proponent in most cases for local governance and states rights, I believe that a single standard needs to be set at the federal level for the sake of consistency and clarity.

A complex subject to be sure, isn’t it? Therefore, it is more important than ever that we work together to determine the best long-term course of action for our great industry.

- David Miller is CEO of The Med Group.