To gain credibility: HME must exhibit its value

The big, bold headline on the front page of HME News' December issue said it all: "An industry under siege." That story detailed how Senate leaders proposed eliminating the capped rental option for durable medical equipment as a way to shave about $910 million from the 2006 Medicare/Medicaid budget. The result, if enacted, reportedly would suppress the average provider's annual revenue by 3% to 5%. On the same page, another story detailed how CMS slashed the respiratory-med dispensing fee from $57 to $33 a month--much lower than the HME community expected. These are just the latest in a series of measures designed to strip Medicare and commercial insurance dollars out of the HME industry. What has the industry done to deserve all of this? Denver pulmonologist Tom Petty contends the issue is more about what the industry hasn't done. "The industry doesn't always do the right thing, and that is noticed by decision-makers," said Petty, known in medical circles as the "father of home oxygen" because he advocated and prescribed its use for nearly 40 years. He is also an oxygen patient himself. "The industry isn't looked at with high esteem." It certainly appears that way. For comprising such a small percentage of the Medicare budget, HME gets targeted a lot for fiscal reductions. Many have said HME gets clobbered disproportionately when compared to hospitals, physicians, pharmacy and even the industry's home health counterpart. The attacks are relentless and appear impervious to association lobbying efforts. The industry has orchestrated major PAC drives over the years, but the money raised by HME is peanuts compared to the mega-millions delivered by Big Pharma, the AMA and AHA. Its impact is tantamount to whispering in a hurricane. AAHomecare's President Kay Cox relates the uphill lobbying battle the industry faces: "Big Pharma has 535 lobbyists on Capitol Hill and the AMA has been around since 1847, so they have had time to learn the political game," she said. "Our industry doesn't have the visibility of a large medical center or physician office. The miracles that happen in the home aren't readily seen. If we had been around since the mid-19th century, perhaps our message about how we're part of the solution to the healthcare crisis might be clearly understood by now." Bob McCoy, managing director of Apple Valley, Minn.-based Valley Inspired Products, emphasized how that lack of visibility translates into a lack of credibility. "We don't have a connection with the ivy-covered walls of academia," he said. "There is no brick-and-mortar facility that serves as a center of excellence." It isn't just HME's miniscule size and relative obscurity that makes it the low-hanging fruit that legislators pick for their annual budget harvest: it's perception. The perception on Capitol Hill and in Baltimore at CMS is that HME exists to profit from the Medicare program. The perception among those in the medical establishment is that HME providers are not peers and not a legitimate part of the healthcare continuum. Those working in the HME industry know these perceptions are wrong, but the cold, hard truth is that perception is reality. Until that perception can be changed, experts say, HME is destined to be the "untouchables" of the healthcare caste system. Seeds of contempt HME has a negative image that goes back at least 40 years to the establishment of Medicare. For a long time, it operated as an unregulated business, giving rise to what long-timers refer to as "the golden commode era." During the 1960s and '70s, the industry was mainly "bent metal," consisting of product sales and delivery. Artificially high reimbursement amounts assured tidy profits for practically everyone. Clinically intensive markets like respiratory were on the rise, but most companies concentrated on basic DME--wheelchairs, beds and walkers. "That was the time of the dreaded 'D' word--dealer," said Patrick Dunne, founder of Anaheim, Calif.-based Healthcare Productions. "Reimbursement was responsible for setting the industry up in that format. When Medicare Part B developed in the '60s, the patient had a bed and an oxygen tank in the home. For the most part, welders were schlepping the oxygen. It has since evolved into high tech, but it's anchored in that past." Not only did Medicare create the HME system that exists today, its designers allowed almost anyone to become a provider, which not surprisingly opened the door to some unscrupulous operators. Trouble is, the sins of a few tainted everyone else, and it's a blot that has been hard, if not impossible to remove. Providers have unwittingly exacerbated their negative image through actions that make them appear greedy, uncaring and non-clinical, such as focusing on the highest-paying products and services; taking a "no reimbursement-no service" attitude and vigorously fighting mandatory certification and accreditation. "I'm not sure we're the untouchables we once were, but we have a long way to go," said Joe Lewarski vice president of clinical and government affairs for Santa Barbara, Calif.-based Inogen. "The perception that still exists today was created by a handful of people who did horribly fraudulent things. That got a lot of press, and it plagues us today. Ironically, what doesn't get the press is the thousands of good things HME providers do, like helping the hurricane victims this year." Behind the eight ball Ironically, if it weren't for the abusers, HME would be virtually invisible given its size. Even with the anticipated explosion of the homecare market due to the aging baby boomers, HME has a disadvantage with policy-makers and medical professionals who don't have a clear understanding of what providers do. "When you look at the complexities of the market now, the thing that amazes me is the naivete about what goes on after a provider delivers the equipment," said Tom Williams, president of Scottsdale, Ariz.-based Strategic Dynamics. "Medicare and commercial payers say they won't cover any service after the fact, but when you look at the reality of the patient base--people over the age of 65--they don't have the mental faculties to deal with anything other than an on/off switch." Payers see oxygen as a commodity that doesn't require providers to perform clinical services, McCoy added. "All the payers see is the three-month cost, and they think all the provider does is drop it off," he said. "If no services are needed, why not then make oxygen an over-the-counter item?" Likewise, prescribing physicians aren't familiar with home oxygen provision or the benefits of new respiratory equipment, said Dr. Dennis E. Doherty, professor and chief physician at the University of Kentucky's Division of Pulmonary and Critical Care Medicine. "Somewhere between 60% and 70% of oxygen is prescribed by general practitioners and the rest is prescribed by pulmonologists," he said. "Primary care physicians are very busy and don't appreciate the intricacies of home oxygen. Neither do a large number of pulmonolgists. It's just not on our radar screen." Time for new tactics Despite all the Washington fly-in lobbying blitzes that are organized each year to blanket Capitol Hill with information about the harmful effects of reimbursement cuts and competitive bidding, the message just doesn't seem to be permeating the marble walls. The main problem, sources say, is that the industry uses unsubstantiated anecdotes instead of hard scientific data to explain its position and that needs to change. "In the absence of hard data all you have is what you hear," said Vernon Pertelle, national respiratory manager for Lake Forest, Calif.-based Apria Healthcare. "Unfortunately, the only thing many have heard is negative." Pertelle has been on a yearlong crusade to change the way the HME industry communicates its role in health care, professing the value of scientific, evidence-based outcomes data as a persuasive force. He recently had an article published in the November issue of Chest, a clinical peer review journal published by the American College of Chest Physicians. Pertelle presented this data to show home respiratory therapists' interventions with COPD patients help prevent hospital readmissions. "Hopefully, it's the first step toward getting more of these submissions," said Pertelle, who is currently working on an outcomes book with Lewarski. "A lot of people didn't know this type of research is being done in home care. The more of these programs that are submitted, the better chance we have to publicize it and get home care on the map." Indeed, hard science gives the HME industry a more defensible position with decision-makers, McCoy said. "We need to do more science," McCoy said. "Without it, our information is seen in a 'fox guarding the henhouse' way.'"