Seating Perspectives
Funding Update
Q&A with Dave McCausland, The ROHO Group
Because access to assistive technology is invariably tied to funding, we also chatted
with The ROHO Group’s Dave McCausland, senior VP of planning & government
affairs, The ROHO Group, to catch up on the funding issues currently challenging
this critical market segment. — Ed.
Q: What’s the current funding atmosphere
for wheelchair seat cushions,
particularly those designed for
complex rehab clients?
Dave McCausland: I would say that
the funding system for cushions, like
DME in general, is — I can’t think of
another way to describe it, except to say
it’s in crisis. The reason is that seating
has been included, along with a lot of
other products, in various portions of
competitive bidding, and no one can
assume that competitive bidding is
strictly limited to the initial nine metropolitan
areas for Medicare patients.
Because of the way the law is structured,
first of all, whoever wins the bids
in those nine metropolitan areas has
to offer, by contract, the same products
to all their patients. Which means
whatever products are not available
to Medicare patients through those
providers, should not be available to
any patients by those providers in those
metropolitan areas.
Q: So if I’m a provider in round 1,
I have to offer the same cushions
to all my clients, even if they aren’t
Medicare beneficiaries? I can’t offer
different cushions to clients who
have different funding?
DM: Not if you’re a bid winner and
you accept the Medicare money under
the bid. And the question becomes if
you’re not a bid winner, how many
other providers will continue to be able
to provide those products when the
Medicare portion (of reimbursement) is
removed? More importantly though and
more disconcerting is that more and
more payors are already taking some of
the data from the initial round one that
got thrown out (in 2008) and using it as
an opportunity to cut their own reimbursement
without significant consideration
of what the impact’s going to be
on quality access and choice.
The recession has hit the states
incredibly hard. I live in one of the
worst states as far as our financial situation
here in Illinois, and everybody
is desperate to find ways to cut their
expenditures. Adopting some of these
bid rates is starting to become a popular
way to cut that reimbursement.
Q: Other payors are using the payment
rates from 2008’s failed round 1 as the
basis for setting their own reimbursement
rates?
DM: In some cases, they absolutely are.
And they’re also looking very carefully
at the winning bid rates that have been
announced recently for the new round 1.
Let me see if I can illustrate the
scope of the problem. Right now in
the entire United States, there are two
separate fee schedules for all the wheelchair
accessories including wheelchair
seating. There’s the fee schedule for
when all those products are associated
with wheelchairs that are not included
in competitive bidding — specifically,
there’s a fee schedule when they’re associated
with manual wheelchairs. There’s
another fee schedule when they’re associated
with power wheelchairs — and
because MIPPA threw out the original
round 1 bidding, whenever those accessories
are tied to a power wheelchair,
the allowable has been cut by 9.5
percent. That’s the pay-for that was used
to get MIPPA implemented.
So right now you have two fee
schedules throughout the United States for seating.
Now let’s go into the round 1
bidding. In those nine metropolitan
areas, you had two product categories
associated with the power wheelchairs
rebid. You had standard power and you
had complex power — complex rehab
was excluded, but only the Group 3
power chairs. There were still Group
2 power chairs that are included, so
they rebid that product category. And
they rebid all the accessories again in
both categories. So now in those nine
metropolitan areas, you won’t have two
fee schedules. You’re going to have four
for accessories. You’re going to have
the allowable when it’s tied to a manual
wheelchair; the allowable when it’s tied
to a high-end complex power wheelchair,
Group 3; the allowable when it’s
tied to a complex power wheelchair,
not Group 3; and the allowable tied to
a standard power wheelchair. So for
these items that are first of all pittance
in dollars and narrow in margin, any
provider who wants to offer those now
has four fee schedules to deal with.
And an end-user in those metropolitan
areas, as of January when they
call in and say, “I need a cushion” —
the first thing the provider is going to
say is “What kind of wheelchair do
you have?” Because if it’s a high-end
complex power wheelchair or a manual
wheelchair, anybody can provide it. If
it’s a complex Group 2 power wheelchair,
only the bid winners will be
able to provide it, and if it’s a standard
power wheelchair, only the bid winners
for the standards will be able to supply
that cushion.
What’s astounding is giving a very
conservative estimate, the total expenditure
for wheelchair seat cushions in
the last year we were able to get data
from Medicare, which was 2008, was
under $20 million total, nationwide. So
on a product category that’s less than
$20 million, you’re going to have four
different fee schedules and three sets of
rules regarding how a patient can obtain
the product.
Q: And on top of that, other payors
are watching Medicare and potentially
basing their allowables on what
Medicare’s allowables are?
DM: The real fear here: That’s what you
see with the Medicaids. They’re not
saying, “OK, we’re only going to pay
this amount for a cushion when it’s tied
to this.” They’re just taking the lowest
price they can find and saying, “That’s
what we’ll provide.” If I’m not mistaken,
in Miami the winning bid rate for an
adjustable skin-protection cushion is
around $228. You’re not going to get
a high-end adjustable skin-protection
cushion for $228. It’s not going to
happen. So what happens to quality
access and choice in those areas?
This article originally appeared in the SCI Handbook October 2010 issue of Mobility Management.