Learning Objectives. To Review..What Is CRT?

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Winfred Green
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An Update on the Separate Benefit for Complex Rehab Technology Under Medicare (and Competitive Bidding) ISS 2013 Presented by: Laura Cohen, PT, PhD, ATP/SMS Elizabeth

under Medicare Describe the basic steps that have been completed to date on this project Identify actions steps that can be completed at a grassroots level to support

Medically necessary and individually configured: Requires evaluation, configuring, fitting, adjustment, training, or programming Specialized manual and power

1 An Update on the Separate Benefit for Complex Rehab Technology Under Medicare (and Competitive Bidding) ISS 2013 Presented by: Laura Cohen, PT, PhD, ATP/SMS Elizabeth Cole, MSPT, ATP Learning Objectives Identify the products that are included in Complex Rehab Technology and discuss the need for a separate benefit for these products under Medicare Describe the basic steps that have been completed to date on this project Identify actions steps that can be completed at a grassroots level to support this initiative 2 To Review..What Is CRT? Medically necessary and individually configured: Requires evaluation, configuring, fitting, adjustment, training, or programming Specialized manual and power wheelchair systems Adaptive seating and positioning systems Other specialized items (standers, gait trainers) Designed to meet the individual's specific and unique medical, physical, and functional needs Provided through an interdisciplinary clinical and technology team (physician, therapist, ATP) 3 1

2 DME Manual wheelchairs Standard, hemi Lightweight Highstrength lightweight Power wheelchairs Group 1 Group 2 Seating General use Skin protection Positioning Skin protection and positioning CRT Manual wheelchairs Highstrength lightweight Ultralightweight Tilt in space Power wheelchairs Group 3 Group 4 Hand rim power assist Seating Adjustable skin protection Adjustable protection and positioning Custom Why Is SBC Needed? CRT and DME all under DMEPOS benefit Subject to same policies and regulations Across-the-board reimbursement cuts Non-applicable coverage criteria Restrictions (i.e., in-the-home) Documentation burdens No recognition for level of service, expertise and expense involved in provision Access is threatened because differences are not recognized 5 Why Is SBC Needed Need to separate CRT out, like P and O Coverage criteria based on function Appropriate access for those in need Adequate payment A Separate Benefit Category will improve and protect access to CRT products and services for individuals with significant disabilities and medical conditions within Medicare and then flow to Medicaid and other payers 6 2

3 Objectives for the SBC Clearer, more appropriate coverage policies Stronger, enforceable supplier standards Formal recognition of product-related services and costs for appropriate funding Future payment stability to ensure continued access to products Improved system that can serve as model for Medicaid/other payers Coverage Changes Require CRT evaluation for beneficiaries with certain diagnoses and/or clinical presentations Base coverage criteria on individual s functional abilities and limitations Eliminate in-the-home restriction for CRT Shift primary weight for clinical documentation from the physician to the OT or PT Create appropriate documentation requirements Cover CRT in SNFs for individual s who could transition home if provided with these products Supplier Standards Changes The CRT company will be required to: Have capability to service and repair all equipment it supplies Employ at least one qualified rehab technology professional (RTP) per location who shows additional evidence of competency in provision of seating and mobility. ATP certification plus.. Additional credential to show specialty in seating and mobility (certification? certificate? Other?) 3

4 The SBC Steering Committee Representing consumers, clinicians, suppliers and manufacturers Don Clayback, NCART, Laura Cohen, PT, PhD, ATP, Elizabeth Cole, MSPT, ATP, U.S. Rehab, Gary Gilberti, ATG Rehab, Walt Gorski, AA Homecare, Rita Hostak, Sunrise Medical, Alan Lynch, ATP, A.T. Mobility Services, Simon Margolis, NRRTS, Paul Tobin, United Spinal Association, 10 History of SBC Initiative To establish SBC first requires legislation from Congress, then regulatory work with CMS Work began in September 2009 (steering committee, consultants, work groups) Two years spent soliciting input and advice, developing detailed proposal, and creating supportive information and tools Broad stakeholder engagement and support (consumers, clinicians, suppliers, manufacturers) 11 Consumer Support ITEM Coalition United Spinal Association ALS Association National Council on Independent Living American Association of People with Disabilities Paralyzed Veterans of America Christopher and Dana Reeve Foundation Spina Bifida Association And many others

5 Clinician Support AOTA APTA RESNA Clinician Task Force American Academy for Cerebral Palsy and Developmental Medicine American Academy of Physical Medicine and Rehabilitation American Congress of Rehabilitative Medicine And others.. 13 SBC Legislation H.R The Ensuring Access to Quality Complex Rehabilitation Technology Act of 2012 Introduced April 2012 by Congressman Joe Crowley (D-NY) on Ways and Means Committee Creates separate DMEPOS benefit category for CRT to improve access and safeguards Summary of Bill, text of Bill, and other information available at Bill must be re-introduced in the 2013 Congress 14 SBC Legislation (cont d) Key provisions of H.R. 4378: Creates separate category for CRT within the Medicare DMEPOS benefit (similar to O&P) Recognizes specific HCPCS codes as CRT and allows new CRT codes as needed Eliminates the in-the-home restriction for CRT Increases supplier standards regarding credentialed staff and repair capabilities Exempts CRT from competitive bidding 15 5

House Support as of 12-31-12 39 House members signed on Bipartisan support 30 Democrats and 9 Republicans

Disabilities Caucus Both Republican and Democrat Co-Chairs signed on 16 Legislative Roadmap Going Forward

4378 re-introduced in 2013 Get additional co-sponsors from the House especially from key committee

and comments Get official scoring by Congressional Budget Office (CBO) to identify cost Attach bill to

6 House Support as of House members signed on Bipartisan support 30 Democrats and 9 Republicans Key committees support 8 Ways and Means Committee Members 5 Energy and Commerce Members House Bipartisan Disabilities Caucus Both Republican and Democrat Co-Chairs signed on 16 Legislative Roadmap Going Forward Get H.R re-introduced in 2013 Get additional co-sponsors from the House especially from key committee members Get Senate companion bill and co-sponsors Work with staff of key committees to address questions and comments Get official scoring by Congressional Budget Office (CBO) to identify cost Attach bill to larger Medicare-related legislation Get bill passed! 17 Key Congressional Medicare Committees In the House Ways and Means Energy and Commerce In the Senate Finance HELP (Health, Education, Labor, Pension) 18 6

7 2103 Marketing/Lobbying Efforts Produce vignettes of CRT consumers Consider national spokesperson (user/advocate) Provide webinars, podcasts or YouTube videos Leverage any 2013 fly-ins to Capitol Hill Utilize National Call-In Day Participate in fundraising events as needed. Encourage CRT suppliers/clinicians to invite key Congressional members for on-site visits Develop testimonials from previous visits Provide assistance in scheduling, preparing and actual attendance, if appropriate Upcoming Conferences Medtrade Spring (March, Las Vegas) CRT Leadership & Advocacy Conference (April, DC) AAH Legislative Conference (May, DC) VGM Heartland (June, Waterloo) United Spinal Legislative Conference (June, DC) RESNA (June, Seattle) NCIL Annual Conference Medtrade Fall (October, Orlando) Abilities Expos Medicaid Medical Directors Conference We need your help!!! 21 7

8 Call To Action H.R will only get passed if enough Members of Congress hear from people in their own districts and states. All stakeholders need to take action. Step 1 - Go to Step 2 - your members of Congress Step 3 - Follow up until your members sign on Step 4 - Spread the word (using the one page Call To Action) and get others engaged 22 Contacting Congress Via phone- call the U.S. Capitol Switchboard at and ask for your member s office. Once connected, explain you are calling on a Medicare issue and ask for the Health Legislative Assistant. Via - go to and use the Contact Congress link..personalize the template..and send. In person make appointment at local office For your Representative to ask questions or sign-on, contact Nicole Cohen at Congressman Crowley s office or nicole.cohen@mail.house.gov 23 Visiting Your Members of Congress You don t have to go to DC Schedule appointments in their home offices You might meet with a health legislative aid and not the actual Representative or Senator This is OK they are the gatekeepers for these issues Bring a consumer with you May be the Member s/la s first exposure to CRT Bring a story or case study with you Pictures of actual products and people are invaluable Don t be intimidated Remember that you elect them 24 8

9 Senate Finance Committee CO Michael Bennet DE Thomas Carper (2) FL Bill Nelson (2) MA John Kerry (2) MD Ben Cardin (2) MI Debbie Stabenow (2) MT Max Baucus (Chair) NJ Robert Menendez (2) NY Chuck Schumer (1) OH Sherrod Brown OR Ron Wyden (2) WA Maria Cantwell (2) WV John Rockefeller (2) IA Chuck Grassley (2) ID Mike Crapo (2) KS Pat Roberts (2) NC Richard Burr (2) NV John Ensign SD John Thune (1) TX John Cornyn (1) (2) UT Orrin Hatch WY Michael Enzi (2) 25 CO Michael Bennet CT Chris Murphy IA Tom Harkin (Chair) (2) MA Elizabeth Warren MD Barbara Mikulski (2) MN Al Franken NC Kay Hagan (2) OR Jeff Merkley (2) PA Robert Casey (2) RI Sheldon Whitehouse (2) WA Patty Murray (1) WI Tammy Baldwin Senate HELP Committee VT Bernard Sanders (2) AK Lisa Murkowski (2) AZ John McCain GA Johnny Isakson (2) IL Mark Kirk KS Pat Roberts KY Rand Paul (2) NC Richard Burr (2) TN Lamar Alexander UT Orrin Hatch (2) WY Michael Enzi (2) 26 House Ways and Means Committee CA Linda Sanchez CA Mike Thompson (2) CA Xavier Becerra (1) CT John Larson GA John Lewis (1) IL Danny Davis MA Richard Neal MI Sander Levin (Ranking Member) NJ Bill Pascrell (2) NY Charles Rangel NY Joe Crowley (1) OR Earl Blumenauer (2) PA Allyson Schwartz TX Lloyd Doggett WA Jim McDermott WI Ron Kind (2) AR Tim Griffin CA Devin Nunes (2) FL Vern Buchanan (2) GA Tom Price (2) IL Aaron Schock IL Peter Roskam (1) (2) IN Todd Young KS Lynn Jenkins (1) LA Charles Boustany MI Dave Camp (Chair) MN Erik Paulsen NE Adrian Smith NV Dean Heller (2) NY Tom Reed OH Pat Tiberi PA Jim Gerlach (2) PA Mike Kelly SC Tim Scott TN Diane Black TX Kevin Brady TX Sam Johnson (2) WA David Reichert (2) WI Paul Ryan (2) 27 9

10 House Energy and Commerce Committee CA Anna Eshoo CA Doris Matsui CA Henry Waxman (2) CA Jerry McNerney CA Lois Capps (2) CO Diana DeGette Fl Kathy Castor GA John Barrow IA Bruce Braley IL Bobby Rush IL Jan Schakowsky (2) MA Edward Markey MD John Sarbanes MI John Dingell (2) NC GK Butterfield NJ Frank Pallone (2) NY Elliot Engel (2) PA Michael Doyle TX Gene Green UT Jim Matheson (2) VI Donna Christensen VT Peter Welch CO Cory Gardner FL Gus Bilarkis GA Phil Gingrey (2) IL Adam Kinzinger IL John Shimkus (2) KS Mike Pompeo KY Brett Guthrie (2) KY Ed Whitfield (2) LA Bill Cassidy (2) LA Steve Scalise MI Fred Upton (Chair) (2) MI Mike Rogers (2) MO Bill Long MS Gregg Harper NC Renee Ellmers NE Terry Lee NJ Leonard Lance (2) OH Bill Johnson OH Bob Latta (2) OR Greg Walden PA Joe Pitts (Health Chair) (2) PA Tim Murphy (2) TN Marsha Blackburn (Vice Chair) (2) TX Joe Barton (2) TX Michael Burgess (Health Vice Chair) (2) TX Pete Olson TX Ralph Hall VA Morgan Griffith WA Cathy McMorris Rodgers (1) (2) WV David McKinley 28 Message To Congress CRT products are individually configured for people with complex disabilities Requires evaluation, configuring, fitting, adjustment, training, or programming Provided through an interdisciplinary clinical and technology team (physician, therapist, ATP) Needed by these individuals to maintain daily function, medical health and mobility, and to stay out of SNF These products and services are different than standard DME (consumer products) CRT is specialized...like O and P 29 Show Them the Differences Complex vs. Standard Manual Wheelchairs Standard Manual WCs 94% of Medicare Intended for short-term use Minimal to no adjustability NO positioning NO deformity accommodation NO pressure management Complex Manual WCs 6% of Medicare Intended for long-term use High adjustability Provide positioning Accommodate deformity Provide pressure management 30 10

11 Show Them the Differences Complex vs. Standard Power Wheelchairs Standard Power WCs 93% of Medicare As seen on TV For ambulatory limitations Basic joystick ONLY NO positioning NO deformity accommodation NO pressure management NO ventilator accommodation Complex Power WCs 7% of Medicare NOT seen on TV For progressive condition Advanced electronics Provide positioning Accommodate deformity Provide pressure management Accommodate ventilator 31 Tell Them Why SBC Needed CRT and DME all under DMEPOS benefit Broad Medicare DME policies and codes do not address needs of people with complex disabilities Non-applicable coverage criteria Restrictions (i.e., in-the-home) Documentation requirements No recognition for level of service, expertise and expense involved in provision Across-the-board reimbursement cuts Access is threatened because differences are not recognized 32 Tell Them What SBC Will Do Separate CRT from DME, like P and O Recognition of differences Coverage criteria based on function Appropriate access for those in need Adequate payment A Separate Benefit Category will improve and protect access to CRT products and services for individuals with significant disabilities and medical conditions within Medicare and then flow to Medicaid and other payers 33 11

12 Remind Them of Congressional Precedents Congress has recognized that CRT is different several times in the past few years Congress gave partial exemption from Competitive Bidding for only one class of CRT Congress exempted complex PWCs from capped rental legislation Congress exempted K0005 MWCs from Round 1 rebid of Competitive Bidding Recognition needs to be expanded through the establishment of a SBC for CRT 34 SBC Supporting Documents Additional details and documents can be found at or Call To Action Position Paper Legislation Proposal Paper Other information Don Clayback, Executive Director, NCART dclayback@ncart.us 35 What Else Can You Do? Join with a supplier and a consumer to become part of a champion team to gain support from your specific members of Congress Let organizations know of your support APTA, AOTA, RESNA.. Talk it up on listserves Write articles for newsletters Support inclusion in PT and OT curriculum Inform your colleagues Inform your patients Inform your friends and family 36 12

13 Pursuing State SBC 37 Separate Recognition Remember, it s about separate recognition Can be accomplished in a variety of ways Strategy and actions are dependent on STATE laws and regulations Don t proceed without a plan 38 Steps In The Process Identify what specific changes you want Coverage Coding Payment Supplier standards Get stakeholder input and support Suppliers/Manufacturers Clinicians Consumers Others 39 13

14 Steps (cont d) Identify state contacts Champion(s) Influencers Decision makers Determine potential pathways Legislative Regulatory Develop written proposal and plan 40 Available Resources Medicare SBC materials NCART State Position Paper NCART State Outline NCART strategic advice and assistance 41 In WA State, It s Already Happening House Bill 1445 Introduced by Rep. Eileen Cody, Chair of House Health Care and Wellness Committee Legislature to create separate recognition for CRT within WA state Medicaid program Protect access Institute additional safeguards around provision and payment 42 14

15 If You re From WA. =1445 Click on green box in center of the page that says "Comment on this bill" Click on "Support button and add your "concise" (1000 words) personal reasons for support in box provided Click on blue "Submit Comment" box at bottom 43 Competitive Bidding Competitive Bidding (NCB) Required by Medicare Prescription Drug, Improvement and Modernization Act 2003 Suppliers in specific geographical area (MSA) must submit bids to win contracts to provide certain DME items to Medicare beneficiaries in that MSA Only contract winners can provide these items to Medicare beneficiaries in that MSA Winners are paid a specific single payment amount for each item Contracts are for 3 years 15

16 How Will it Roll Out? Round 1 Began Jan 1, MSAs Bids for re-compete have been submitted Round 2 To begin summer of MSAs Bids have been submitted, contracts have been offered and single payment amounts posted Round 3 Must be in effect by 2016 Includes remainder of MSAs around the country Round 1 Product Categories Oxygen supplies and equipment Respiratory assist devices and CPAPs Walkers Standard power wheelchairs, scooters Group 2 complex rehab power wheelchairs Hospital beds Enteral equipment and supplies Group 2 support surfaces (Miami MSA only) Mail order diabetic supplies Round 1 Re-Compete Categories Respiratory equipment Oxygen, oxygen equipment, CPAP, respiratory assist devices, standard nebulizers Standard mobility equipment Walkers, standard power and manual wheelchairs, POVs General home equipment Hospital beds, Group 1 and 2 support surfaces, TENS, Commode chairs, patient lifts, seat lifts Enteral nutrients, equipment and supplies Negative pressure wound therapy External infusion pumps and supplies 16

17 Round 2 Product Categories Oxygen supplies and equipment Respiratory assist devices and CPAP Walkers Standard power and manual wheelchairs, POVs Hospital beds Enteral nutrients, equipment and supplies Group 2 Support surfaces Negative pressure wound therapy How Does It Work? Suppliers submit bids for items (by HCPCS code) in one or more product categories Submit amount they would accept for each code Indicate the % of geography they can service (capacity) CMS starts with lowest bid and adds others above it until 100% capacity for that MSA is reached Only these suppliers are offered contracts Can accept or reject the offer New payment amount is median of the bids from the bid winners Example Supplier Bid Amount % of MSA They Can Service Total % of MSA Served Supplier I $160 15% 130% Supplier H $150 10% 115% Supplier G $140 20% 105% Supplier F $130 10% 85% Supplier E $120 20% 75% Supplier D $110 10% 55% Supplier C $100 15% 45% Supplier B $95 20% 30% Supplier A $90 10% 10% Normal auction single payment amount = $140 Competitive bidding single payment amount = $110 Suppliers E, F and G will get less than their bid 51 17

18 A Flawed Program Contracts are not binding Encourages low ball bids Payment amount is median of bids from suppliers initially offered contracts At least 50% of those who accept contracts will receive payment amounts lower than their bids Lack of transparency How payment amounts are calculated How winners are selected These are issues pointed out in numerous studies such as one signed by over 200 economic/auction experts including 4 Nobel Laureates!! Studies on Competitive Bidding Cramton study Bloomberg study 10/medicare-s-competitive-bidding-moving-ahead GAO report Cal Tech study The Harsh Reality Significantly decreases number of suppliers Loss of business results in loss of jobs Suppliers going out of business altogether Forces individuals to switch suppliers Suppliers win some bids but not others Cannot supply all individual s needs Individual must go to several different suppliers Difficulty finding contract suppliers Delayed discharges / hospital admissions Problems coordinating delivery of items Long waits for equipment and/or repairs 18

The Harsh Reality Payment amounts severely decreased Suppliers cannot provide same

and/or lack of previous presence in that MSA Risk of inappropriate equipment Risk of

suppliers in the 9 MSA s Down from 2,363 suppliers Among these 356 companies: 43 had no

MSA 9 had neither 450 DME providers have already closed locations, sold to larger

19 The Harsh Reality Payment amounts severely decreased Suppliers cannot provide same level of service Forced to provide cheaper products Some winners have no experience and/or lack of previous presence in that MSA Risk of inappropriate equipment Risk of inability to service the MSA The Results of Round 1 Contracts were awarded to 356 DME suppliers in the 9 MSA s Down from 2,363 suppliers Among these 356 companies: 43 had no previous experience with the product 44 had no previous experience in the particular MSA 9 had neither 450 DME providers have already closed locations, sold to larger companies or gone out of business entirely Are you in a Round 1 MSA? What has been your experience? 57 19

20 Round 2 So Far According to CMS 14,654 contracts were offered Represents a total of 867 providers with 3,109 locations who must service 91 MSAs Includes some of the most populated areas in the U.S. ~ 62% of those offered contracts are small businesses 87% of suppliers who were offered contracts currently furnish contract items in the area What We See.. Payment amounts that are absurdly lower than the current fee schedules Product Category % Decrease Oxygen and equipment 41% Standard MWC, PWC, scooters 36% Enteral nutrients and supplies 41% CPAP and RAD 47% Hospital beds 44% Walkers 46% Group 2 support surfaces 63% NPWT 41% Mail-in diabetic supplies (all states) 72% A Better Alternative Market Pricing Program (MPP) Created by auction experts in collaboration with industry stakeholders Will be monitored by qualified experts with substantial government auction expertise Requires bid deposit and bids are binding Payment amount would be the clearing price bid Non-local bidders cannot overwhelm local bidders Ensures transparency through financial and performance standards, capacity allocation, bidding rules, winning awards and performance accountability Allows any supplier to provide items in 8 of 10 categories 20

21 Where Are We Now? Bill introduced by Rep Price in Sept 2012 H.R. 6490, the Medicare DMEPOS Market Pricing Program Act of 2012 Had 27 co-sponsors at end of 2012 Will be re-introduced by Rep Price in 2013 What Can You Do? Contact your members of Congress Provide them with links to the studies Explain flaws in competitive bidding program and effects on their constituents Use modified pre-written message or your own Ask them to sign onto new bill Especially those who signed onto H.R.1041 What Can You Do? Give them this link to show that program is HARMFUL, not successful -Stories.php Report issues on competitive bidding iclenbr=

Page 1 of th Congress - House Committee on Energy & Commerce

Page 1 of th Congress - House Committee on Energy & Commerce Page 1 of 12 The committee list below (in order by State and first name) was compiled from www.energycommerce.house.gov and www.visi.com/juan/congress/. Each member has an electronic mail webpage as well