Historically, items like hospital beds, oxygen tanks and concentrators, wheelchairs, commodes, ambulatory aids, compressors and other items that could be used to support a medical need on an ongoing basis were referred to as DME. This is clearly an accurate, but one-dimensional definition.
Health insurance carriers, Medicare included, covered these items as a “DME” benefit when a doctor indicated that there was medical necessity requiring the use of any of these items.
This one-dimensional view of DME never took into consideration that the item is DME, but providing these items is HME services. Providing medical equipment services to patients in their homes has never been one-dimensional.
From the beginning, HME services has always been multi-dimensional. In almost all cases, the patients needing DME required the following:
2. A home assessment to verify the appropriateness and safety of the prescribed item.
- On use and operation with return demonstration.
- How to seek assistance in the case of operational failure.
- How to report changes in medical conditions
5. Assistance in verifying insurance coverage.
6. Gathering needed documentation to support the medical necessity for such items.
7. 24/7 availability of assistance for emergency after hours and holiday service.
8. Billing insurance carriers on behalf of the patients and caregivers.
9. Advocating on behalf of the patient where reimbursement was challenged by the insurance carriers.
10. Eventually, in most instances, the retrieval of such DME items where purchase was not met.
This is HME services. This is what has always been required, this is what patients and their insurance carriers were paying for, never was it only the DME.
For a provider to adequately support patients with HME services, the providers needed to do the following:
1. Hire and train staff in the following disciplines:
- All insurance carriers coverage criteria for all DME items
- Communication with medical professionals
- Communication with ailing patients and non-medical caregivers.
- The operation and maintenance in all types of DME items.
- Sanitation and reconditioning of returned DME items.
- Safe vehicle practices and maintenance processes.
2. Establish communication processes that make the provider available to patients 24/7 for emergency service.
3. Establish processes for internal communication on handling patient needs
4. Procure necessary transportation equipment
5. Procure necessary communication equipment and services such as pagers, cell phones, computers, and answering services.
6. Where required, become licensed and/or certified in their state to operate.
7. Undergo elaborate, expensive accreditation preparation and surveys.
8. FDA licensure for oxygen
9. Have associates go through rigorous manufacturer training programs to become proficient in the operation and maintenance of all DME items.
DME is one-dimensional; it refers only to the items. HME services is multi-dimensional and specific to the home and everything that is necessary to help patients maintain themselves safely in their own places of residences.
A 1,000-bed hospital facility can operate with an economy of scale. They can inventory and staff accordingly, knowing that their patients are in a compact, defined area. HME providers run 1,000-bed hospitals in 1,000 different locations. They need to inventory, staff and maintain the logistics and communication procedures to service 1,000 patients in 1,000 different locations when needed, 24/7.
Since 1965, when Medicare was implemented, the array of medical equipment designed to maintain patients at home has exploded. Items have become more technical, more reliable, easier for patients and caregivers to use, and more accessible to patients in need in a timely manner.
In 1965, HME services were provided by delivery technicians and, occasionally, respiratory therapists. Today, HME services are more sophisticated and technical, and need to be provided by highly trained clinicians with multiple disciplinary backgrounds: pharmacists, nurses, dieticians, diabetic counselors, physical therapists, respiratory therapists, etc.
In 1985, the average length of stay in a hospital was 8.5 days. Today, the average length of stay is less than 4.5 days. One of the main reasons for this drastic reduction in the length of stay is because of the development and availability of more sophisticated HME items to help get and maintain sicker patients back to their home environment sooner.
Healthcare costs are soaring out of control in the skilled environments. In such environments, patients incur costs for their health care, their healthcare items, their room and their board. At home, the only costs are the healthcare services that keep them safely at home.
Today, HME services are still viewed by payers and legislators as DME, a one-dimensional line item, and reimbursement rates are shrinking to the point that the following is happening:
1. There is almost no R&D to develop new technology to help even sicker patients get home sooner.
2. The provider base has been reduced so that timely availability of services is more and more difficult to find.
3. Patients are staying longer in skilled environments due to lack of accessibility.
4. Providers that are still in business are forced to cut back staff and, therefore, services.
5. The ill patients and caregivers are being forced to find ways to get to providers for services or go without.
6. Providers are forced to buy equipment based upon cost, not reliability.
CMS can talk all they want about how the quality of care has not been affected by lower reimbursement rates, but the reality is that nowhere in the country where there is national competitive bidding are Medicare patients being cared for as well as areas not yet affected by NCB.
If Medicare wants to create a warehouse in each state where patients can go and take what they need off the shelf by themselves, take it home, learn how to safely use it, then you can talk about DME. By definition, ailing patients can’t do that and need individual and personal care to save money by keeping and maintaining safely in the cost effective environment of their home.
HME services is multi-dimensional and needs to be recognized and reimbursed as such to be effective. DME is a tool requiring HME services to make it work.
Between 2007 and 2013, by Medicare’s own figures, the cost of Part A increased 70%. In that same time frame, Part B remained flat despite more people turning 65 daily. Contrary to the common wisdom, Part A and Part B are related. If HME services are not recognized and supported, Part A will continue to spiral out of control.
DME is what we use, HME services is what we do. HME services saves lives—and healthcare dollars.
George Kucka is president and CEO of Fairmeadows Home Health Care. He is a member of AAHomecare’s board of directors and chairs the association’s HME/Respiratory Therapy Council. He is also a member of AAHomecare’s Regulatory Council and its State Leaders Council. Additionally, Kucka is secretary for the Great Lakes Association of Home Medical Equipment Services and treasurer for the Indiana Pharmacist Alliance.