Myths and Realities about Medicare's Competitive Bidding Program for Home Medical Equipment and Services

Consumer Groups, Economists, Members of Congress Oppose Badly Designed Bid System

WASHINGTON, Aug. 19, 2011 /PRNewswire-USNewswire/ -- As Medicare expands a controversial "competitive" bidding program for home medical equipment and services, economists, consumer groups, and members of Congress have gone on record to oppose that program citing reduced patient access to care, flaws in the program design, and impact on local jobs.

"There's a reason why more than 30 patient advocacy groups, 244 economists and auction experts, and 145 members of Congress oppose this program: it undermines quality of care and it increases costs," said Tyler J. Wilson, president of the American Association for Homecare. "Because of this bidding program, beneficiaries will spend more time in expensive institutions, rather than in the far more cost-effective setting for care - their own homes."

New restrictions and unsustainable prices based on this controversial bidding system took effect on January 1, 2011, in nine of the largest metropolitan areas including Charlotte, Cincinnati, Cleveland, Dallas-Ft. Worth, Kansas City, Miami, Orlando, Pittsburgh, and Riverside, Calif.  Another 91 areas throughout the U.S. will be subjected to the bidding program starting later in 2011.  The bidding system affects providers and users of home medical equipment and services such as oxygen therapy, respiratory devices, hospital beds, wheelchairs, and other medically required equipment and supplies needed by seniors and people with disabilities in the Medicare system.

Proponents of the bidding system have conveyed misleading information that exaggerates the benefits and ignores the severe shortcomings of the program.

MYTH #1: Medicare overpays for home medical equipment and services, and the bidding system improves the method for setting reimbursement rates for that equipment and service.

REALITY:  Proponents of the bidding system use out-of-date reimbursement rates and false comparisons of retail costs versus Medicare costs to argue their case.  For many years, CMS has set reimbursement rates for home medical equipment through a fee schedule. Over the past decade, those reimbursement rates have dropped nearly 50 percent because of cuts mandated by Congress or imposed by CMS. 

The costs of delivering, setting up, maintaining, and servicing medically required equipment in the home are obviously greater than the cost of merely acquiring the equipment. But Medicare does not recognize the costs of these services. So comparing the cost of the equipment to the larger cost of furnishing the full array of required equipment, supplies, and services is false and misleading. 

Moreover, 167 experts, including two Nobel laureates and numerous economics professors from leading universities, have warned Congress that this bidding system will fail.  The experts, who do not otherwise oppose competitive bidding to set Medicare prices, point out that the system has four fatal flaws:

The bidders are not bound by their bids, which undermines the credibility of the process. 

Pricing rules encourage "low-ball bids" that will not allow for a sustainable process or a healthy pool of equipment suppliers.

The bid design provides "strong incentives to distort bids away from costs." 

There is a lack of transparency in the bid program that is "unacceptable in a government auction and is in sharp contrast to well-run government auctions."

These concerns have been shared with the federal Centers for Medicare and Medicaid Services (CMS), which designed the bidding system. But the agency has dismissed the concerns. 

A September 30, 2010, New York Times' "Freakonomics" article by two of the 167 economists addresses the bidding issue.  Yale University economist Ian Ayres and University of Maryland economist Peter Cramton, conclude: "The mystery is why the government has failed over a period of more than ten years to engage auction experts in the design and testing of the Medicare auction. ... We suspect the problem is that CMS initially did not realize that auction expertise was required, and once they spent millions of dollars developing the failed approach, they stuck with it rather than admit that mistakes were made." 

MYTH #2:  The bidding program will make healthcare more cost-effective.

REALITY: The home is already a highly cost-effective setting for post-acute and long-term care. For many years, home medical equipment providers competed in Medicare on the basis of quality and service to facilitate the hospital discharge process and enable patients to receive cost-effective, high-quality care at home. As more people receive quality equipment and services at home, patients and taxpayers will spend less for hospital stays, emergency room visits, and nursing homes. Home medical equipment is an important part of the solution to the nation's healthcare funding crisis. Home medical equipment represents approximately 1.5 percent of total Medicare spending.  So while this bidding program would make even more severe cuts to reimbursement rates for home medical equipment, that will ultimately result in much higher spending in Medicare and Medicaid for hospital and nursing home stays and for physician and emergency treatments.

MYTH #3: The bidding program will eliminate fraud.

REALITY:  CMS continues to describe the bidding program as an anti-fraud tool. In reality, it is a price-setting mechanism that has nothing to do with fraud prevention.  In fact, the exact opposite is true, according to the 167 market experts who warned Congress that the CMS bidding program "will lead to a 'race to the bottom' fostering fraud and corruption." 

The real solution to keeping criminals out of Medicare is better screening, real-time claims audits, and better enforcement mechanisms for Medicare. Two years ago, the American Association for Homecare proposed to Congress an aggressive, 13-point legislative action plan to combat fraud, and many of those provisions have been included in legislation passed in Congress. Moreover, two important anti-fraud requirements for home medical equipment providers - accreditation and surety bonds - took effect nearly two years ago, in September 2009.

MYTH #4:  Only the home medical equipment sector opposes the bidding system.

REALITY:   In addition to the 167 economists and bidding experts who

have expressed grave concerns about the bidding program, 30 consumer and patient advocacy organizations have called for a halt to the bidding system. Those groups include the ALS Association, the Brain Injury Association of America, the Christopher and Dana Reeve Foundation, the International Ventilator Users Network, the Muscular Dystrophy Association, National Emphysema and COPD Association, the National Council on Independent Living, the National Spinal Cord Injury Association, and United Spinal Association, among others.

These consumer groups support H.R. 1041, a bill in the U.S. House of Representatives that would eliminate the bidding program. The bipartisan bill has 145 cosponsors so far, including roughly equal

proportions of Republicans and Democrats.  

MYTH #5:  The bidding system is good for Medicare beneficiaries.

REALITY: In January 2011, round one of the bid program was implemented in nine metropolitan areas.  Since then, more than 500 patients, clinicians, and homecare providers have reported:

Difficulty finding a local equipment or service provider; .Delays in obtaining medically required equipment and services; .Longer than necessary hospital stays due to trouble discharging patients to home-based care; .Far fewer choices for patients when selecting equipment or providers; .Reduced quality; and .Confusing or incorrect information provided by Medicare.

The American Association for Homecare represents durable medical equipment providers, manufacturers, and others  in the homecare community that serve the medical needs of millions of Americans who require oxygen equipment and therapy, mobility assistive technologies, medical supplies, inhalation drug therapy, and other medical equipment and services in their homes. Members operate more than 3,000 homecare locations in all 50 states.  Please visit www.aahomecare.org/athome.

SOURCE American Association for Homecare

http://www.medicalnewstoday.com/releases/233088.php

 The Friendlier Skies

Improved oxygen delivery technology is giving patients with lung disorders such as Alpha-1 and COPD greater freedom-including the freedom to take to the air.

 By: Joseph Lewarski, BS, RRT, FAARC, and Robert Messenger, BS, RRT

For many years, long-term oxygen therapy (LTOT) users often faced myriad challenges when attempting to travel by air. Until the introduction of portable oxygen concentrators (POCs), compressed cylinders and/or portable liquid vessels were the only available lightweight, ambulatory oxygen systems. These devices contain bulk amounts of oxygen under pressure and can be considered hazardous. Therefore, they are not permitted on board any commercial aircraft.

As a result, LTOT users wishing to travel by air were required to purchase oxygen for use in flight from the airline. Unfortunately, some airlines did not provide this service; and, of those that did, the cost of the in-flight oxygen could be quite expensive, often exceeding the ticket fare. This combination of complex rules and high cost often discouraged patients from air travel or, in the worst cases, forced some patients to travel without their needed oxygen.

Over the last decade, there have been a number of important advances in home oxygen technologies, and arguably, one major milestone has been the introduction of the portable oxygen concentrator, which for the purpose of this article includes both lightweight (<10 pounds) pulse-dose POCs and the larger, transportable POCs that can provide up to 3 LPM of continuous flow as well as pulse-dose oxygen delivery.

The POCs are unique, because they introduced the first truly self-generating, portable oxygen system. The POC does not operate under high pressure, does not produce or store bulk amounts of oxygen, and operates on the same mechanical principles as stationary oxygen concentrators-systems that have a proven track record of high performance and clinical efficacy. These are some of the key reasons POCs proved safe and ideal for commercial air travel.

On July 12, 2005, the Federal Aviation Administration (FAA) published Special Federal Aviation Regulation (SFAR) 106 in the Federal Register.1 The regulation delineated the initial rules governing the safe use of POCs on board aircraft to the airlines, passengers, and oxygen device manufacturers. The initial rule also recognized the first two POCs the FAA approved for use. Numerous updates to SFAR 106 have added 10 more FAA-approved devices. The Table is a current list of the 12 POCs currently approved by the FAA. One major weakness of SFAR 106 was that the FAA could not mandate airlines to allow POCs on board; it simply approved the use and provided guidelines for the use of POCs on commercial aircraft. As a result, many airlines chose to continue their practice of not allowing POCs for use on board their aircraft.

The Department of Transportation (DOT) introduced a proposed rule in 2005 mandating POC use aboard commercial aircraft.2 The proposed rule, DOT NPRM Docket OST-2005-22298, was issued on September 7, 2005. After a long public comment period, DOT 14 CFR Part 382: Nondiscrimination on the Basis of Disability in Air Travel-Final Rule was published on May 13, 2008.3 This rule requires all commercial airlines taking off and landing in the United States to allow the use of FAA-approved POCs before and during takeoff/landing and in flight.

Like most government regulations, both SFAR 106 and the DOT rule are quite comprehensive. Here are some of the highlights from the regulations that most home oxygen users and providers should be familiar with:

• Passengers should notify the airline of their intent to bring a POC on board at least 48 hours in advance of the planned flight.
• Passengers using POCs may be restricted from sitting in an emergency exit row, or in a seat that restricts other passengers' access to an emergency exit or aisle of the passenger compartment.
• Approved POCs may be used in flight and during taxi, takeoff, and landing if required by physician's statement.

Patients must possess a physician's statement that includes documentation of three requirements:  Ability to see/hear alarms and appropriately respond; 1) When oxygen is required (all or a portion of the trip); 2) Maximum prescribed flow rate during flight  3) Patients are responsible for bringing a sufficient number of fully charged batteries to cover not less than 150% of the expected maximum flight duration.

Patients can use but must properly stow the POC during taxi, takeoff, and landing. This is typically in the carry-on storage area below the seat in front of the patient. The DOT does not mandate that carriers allow users to plug the POC into the aircraft power supply.

Clinical Effects of Altitude

 While the use of oxygen at ground level is well established, there are limited published data to guide the use of oxygen at altitude, particularly for patients who are hypoxemic at ground level. Most commercial aircraft keep the cabin pressure at or below 8,000 feet, although the pilot has the authority to increase the cabin pressure to 10,000 feet if required to fly at higher than typical altitudes.

The partial pressure of oxygen in the ambient air is a product of the barometric pressure and the atmospheric fraction of oxygen (0.209) as represented in the equation: barometric pressure x 0.209 = atmospheric Po2. At sea level, this is represented as: 760 x 0.209 = 159 mm Hg.

At 8,000 feet, the partial pressure of O2 in the cabin is 564 mm Hg x 0.209 = 118 mm Hg. Gas density at 8,000 feet is almost 30% lower than at sea level. With less driving pressure available, the clinical effect is similar to that if breathing approximately 15.1% O2 at sea level.4 For most healthy people, there are few noticeable symptoms associated with short-term exposure to altitude. Normal cardiopulmonary responses to altitude include:

•  Modest fall in Pao2
•  Increased respiratory rate
•  Increased tidal volume (and therefore an increased minute ventilation)
• Increased heart rate
• Increased cardiac output
• Preferential redistribution of perfusion to essential organs and diminished perfusion to other organs  │Vasoconstriction of the pulmonary arteries

For many travelers, the only noticeable side effects of short-term altitude exposure are headache, fatigue, and some mild dehydration. It is possible that a small percentage of patients on very long flights (i.e., >15 hours) may be at risk for developing altitude sickness, although data supporting this is very limited.

Oxygen Use in Flight

There is no single, evidence-based method of predicting blood oxygen levels at altitude, especially for patients with chronic lung disease. As a general rule of thumb, it is estimated that inspired

Pao2 declines approximately 5 mm Hg per 1,000 feet ascended.

Unfortunately, there is no such general rule governing potential changes to Spo2 among people with lung disease traveling at altitude for brief periods. One recent study examining the effects of aircraft-cabin altitude on the oxygen levels of healthy subjects suggests that altitude lowered blood oxygen saturation by 4% when compared to their baseline, ground level Spo2.5 There have been a number of predictive, regression equations derived from various clinical studies, but they may not prove accurate or effective as part of an individual patient evaluation for predicting blood oxygen levels during flight.6-8 A hypobaric challenge, also referred to as a high altitude simulation test or HAST (having a patient breathe 15.1% gas), while at sea level may prove to serve as an effective predictor of blood oxygen levels during flight. Unfortunately, HAST is not commonly used because of the need for specialty gases and a closed breathing system.

LTOT Patients and Air Travel

 For patients prescribed LTOT for use at home, there is no evidence-based or expert consensus guideline for prescribing oxygen for use in flight. A patient's baseline hypoxemia, oxygen prescription at ground level, respiratory reserve, level of hemoglobin, and general clinical condition prior to flight are all key variables influencing in-flight oxygen use. Stoller9 notes that despite the protean effects of altitude exposure, relatively brief exposure to altitude (<12 hours) encountered during commercial flights seems to be well tolerated, even among patients with chronic lung disease.

It is generally accepted that patients with a ground level Pao2 of >80 mm Hg will experience no difficulty during flight and patients with a Pao2 of <60 mm Hg at ground level will need oxygen at altitude. Patients predicted to have an in-flight Pao2 ?50 mm Hg are clearly candidates for using supplemental oxygen during flight.9 Depending on their clinical condition at the time of flight, LTOT users may need to increase their oxygen dose (flow setting or setting on the oxygen conserving device) to ensure adequate oxygenation during flight, as their fraction of inspired oxygen (Fio2) will likely decline due to the lower molar volume of oxygen in the ambient cabin gas at altitude.

The decision to prescribe oxygen during flight for a patient who is normoxic at ground level or the decision to alter an LTOT patient's ground level oxygen prescription for use during flight is one best made by the patient's attending physician after an evaluation. It is prudent and good practice that all patients with chronic lung disease be seen and evaluated by their physician prior to scheduling any air travel.

Using POCs in Flight

 POCs operate on the same mechanical basis as standard concentrators: pressure swing adsorption (PSA). Since PSA systems separate the nitrogen from the oxygen, the performance at ground level is essentially the same as the performance at altitude, although working with fewer total moles of oxygen. While the commercially available POCs operate from the same mechanical and theoretical platform, all have slightly different performance specifications, although the majority of commercially available devices are rated for use at altitudes of 8,000 feet or higher. Like many oxygen and respiratory technologies, all devices may not be ideal for all patients under all circumstances. It is important to remember that patients using a nasal cannula typically derive >90% of their inspired gas volume from the ambient gas, which has much more influence over the Fio2 than the oxygen delivered from the cannula. Therefore, patients prescribed a POC for air travel should be educated and evaluated with the specific device being used. They should also be informed that their prescription at altitude may differ from that at ground level due to breathing the lower partial pressure of oxygen in the ambient gas at altitude.

Summary

 It has been more than 5 years since the FAA approved POCs for use on commercial aircraft. Although there is no published data, there are thousands of anecdotal reports of LTOT users experiencing smooth and very successful trips using a POC in flight and during their travels.

Despite the DOT and FAA rules, there remains some occasional confusion or misinformation regarding the use of POCs on commercial aircraft. There are a number of excellent resources available to help patients and providers navigate the system. Most POC manufacturers have detailed information about their products and the FAA and DOT rules on their Web sites. Patient organizations, such as the National Home Oxygen Patient Association (NHOPA), provide LTOT users with travel information via their Web site, www.homeoxygen.org.

The founding fathers of LTOT always envisioned lightweight, self-generating oxygen technologies that would empower oxygen users with the ability to live an active and productive life. Modern home oxygen therapy systems can help a patient live a life close to the way they did before they needed a prescription for oxygen, including travel by air.

TELL CONGRESS TO PROTECT ACCESS TO AT-HOME OXYGEN!

Ensuring access and proper maintenance of oxygen equipment

In January, a new program called Competitive Bidding was implemented. This program requires suppliers of durable medical equipment, including oxygen, to be awarded contracts by Medicare in order to continue providing certain equipment. Not all suppliers were awarded contracts. This caused some Alphas to have to change companies. If more than one type of equipment is being used, some Alphas even have to choose multiple companies. This has caused unnecessary confusion and anxiety for those with Alpha-1 over how they should receive supplies and maintenance of their oxygen equipment.

The bill H.R. 1041 has been introduced in Congress. It will repeal the Competitive Bidding program and help ensure that access and proper maintenance of oxygen medical equipment is guaranteed. Your voice is critical to achieving passage of the bill.

What You Can Do:
It is simple to take action. Call your elected official in the House of Representatives and ask them to protect access to oxygen.
Make sure you tell him/her that:
• You are a constituent.
• You have a rare genetic (inherited) condition that may result in serious, chronic lung and/or liver disease.
• You would like your Representative to become a Co-Sponsor of H.R. 1041, a fiscally responsible measure that will protect the health and well being of the 1.5 million home oxygen users in the U.S.

Who is my representative?
Visit www.house.gov and enter your zip code in the small box at the top left and click “GO”. The next page will direct you to your representative.

Click here to write your legislator. You will be transferred to the CAPWIZ program created by the COPD Foundation. It will allow you to write to your elected officials, including the president, members of Congress, governors, state legislators, local officials, and more. Please feel free to use the template they have provided.

AARC’s New Patient Guide for Aerosol Delivery

Helping Patients Improve Their Breathing Treatments

The AARC has great educational resource called “A Patient’s Guide to Aerosol Drug Delivery” to help our respiratory patients understand today’s confusing world of aerosol drug delivery.

The growing number of aerosol medications and devices coming to market over the past few years has been great for offering various methods of delivering aerosols, but it has also added layers of complexity to educating patients on how to take these medications. As respiratory care professionals, it is vitally important we help our patients learn everything about using their aerosol devices effectively so they can keep their symptoms under control and breathe easier.

This guide, recommended by respiratory care professionals and patients alike, offers clear and simple tips for respiratory patients, as well as provides several diagrams showing how to take aerosol medications correctly.

Please be sure to share this guide with your patients to help them improve their quality of life. Click here for the complete patient aerosol delivery guide.

2/18/2011

FAA Orders Removal of Oxygen Tanks from Airplane Bathrooms

All 6,000 U.S. aircraft completed the transition March 4th.

FAA Orders Removal of Oxygen Tanks from Airplane Bathrooms

In what officials say was a security move, all U.S. airlines were given orders by the Federal Aviation Administration to de-activate or remove oxygen masks from all airplane bathrooms within 21 days under an Air Worthiness Directive issued in February.

All 6,000 U.S. aircraft completed the transition March 4, the FAA says.

The agency says it decided not to make the issue public due to the possibility that someone could use the information to cause harm to passengers. "The action was done proactively in response not to a specific threat but to general concerns that a terrorist could use the lavatory oxygen to start a fire or ignite a bomb, an FAA official tells MSNBC.

The FAA feared that non-action could have caused disaster and this alteration, "will help keep travelers as safe and secure as possible," the FAA says in a prepared statement given to AOL Travel

Not everyone is satisfied about this quick change. "I'm in shock," said Kate Hanni, executive director of Flyersrights.org, talking to MSNBC. "We get reports of mid-air decompression events all the time. So now going to the bathroom on a commercial flight can kill you? I'm panicking just thinking about this."

Although a loss of cabin pressure is rare, the FAA and airline manufactures are working to create a safer oxygen delivery system, officials said. In the meantime, the FAA is asking airlines to inform passengers that oxygen masks will not be available in the bathrooms.

Click here for more information

2/18/2011

Concentrators that have been approved by the DOT

Meeting applicable DOT safety, security and hazardous materials requirements for safe use aboard aircraft.

In 2009 the Department of Transportation (DOT) released the long awaited amendment to the Air Carrier Access Act that establishes mandatory rights for passenger-owned portable medical oxygen concentrators that meet applicable DOT safety, security and hazardous materials requirements for safe use aboard aircraft. The DOT rule will also apply to foreign carriers that begin or end their flights in the United States.  The Air Carrier Access Act enacted by Congress in 1986, prohibits airlines from discriminating against disabled passengers and now will include a provision long requested by oxygen advocates. To see the Individuals on Home Oxygen: Rights and Safeguards, please click here.

The following concentrators have been approved by the DOT for patients to carry-on aircraft.  

• AirSep FreeStyle
• AirSep LifeStyle
• Delphi Central Air
• Devilbiss iGo
• Inogen One
• Inogen One G2
• International Biophysics LifeChoice
• Invacare XPO2
• Invacare SOLO 2
• Phillips Respironics EverGo
• SeQual Eclipse
• Oxlife Independence

For information on oxygen reimbursement issues, please click here.

2/17/2011

Travelling with oxygen

Traveling with oxygen can be accomplished comfortably and safely.

Traveling with oxygen can be very intimidating but with proper planning it can be accomplished comfortably and safely.  You don't have to give up the adventure of travel. You just have to make your arrangements in advance and be willing to take the extra time to confirm details prior to your trip. 

Air Travel

Most U.S. air carriers and many overseas carriers can provide service for passengers requiring oxygen.  The FAA requires a physician's statement of your oxygen needs in order to fly on a commercial airline. You cannot bring your own oxygen on board, you must use airline supplied oxygen. Requirements vary from carrier to carrier but, they all require arrangements be made in advance and they all charge for in-flight oxygen. Some airlines require only 48 hours advance notice while others require seven days. The best rule of thumb is make arrangements as far in advance as possible. All airlines charge for oxygen, but the charges vary. Some charge per canister, but most charge per for each leg of the flight.  The charges generally range between $50.00 and $150.00 per leg.  This means if you have to change planes on your trip you will be charged twice.  Therefore, if possible it is better to take a direct flight or even one with an extra stop, but no plane change. Airlines don't provide oxygen for in terminal use even during layovers.  You are responsible for making these arrangements separately. (Note: Some first aid stations in airports have oxygen available.)  Some cylinders have a flow meter that adjusts from two liters to eight liters, while others offer either a low flow (2LM) or high flow (4LM). You cannot check oxygen containers with baggage, but most airlines will allow you to carry an empty portable tank either on board or checked with baggage. 

Cruises

Most cruise lines will accept passengers who require oxygen.  Advance notice of at least 10 days is required.  A doctors letter is required and you must arrange and provide you own equipment and oxygen. To get specific requirements of the cruise line of your choice, contact their reservation number and ask for special services or medical department. If you would like to go on a cruise, but would like to have support available, Medical Travel offers a variety of group sailings each year designed specifically for oxygen users.  Website: http://www.medicaltravel.org  E-mail: oxygen@medicaltravel.org

Train Travel - Amtrak

Oxygen equipment can be brought on board, but you cannot rely solely on on-board electrical power. You must have at least a 12 hour backup supply of oxygen that does not require the use of on-board electrical power. Oxygen tanks and associated equipment must be underwriter's Laboratory (U.L.) or Factory Mutual (F.M.) listed.  No more than two 75 pound or six 20 pound tanks are permitted on-board per passenger.  You should be aware of the total time of your trip so you can bring an adequate supply.  You should also bring at least 20% additional in case of delays.  If you are unable to bring enough oxygen (which maybe necessary if your oxygen is in use continuously), you will need to arrange with oxygen supply companies to resupply you at enroute stations. Check with a reservation sales agent to be sure that your train is stopping at those stations long enough to allow for the oxygen delivery.  You must notify Amtrak that you will be bringing oxygen on-board at least 12 hours in advance, but I highly recommend that you make your reservations as far in advance as possible and confirm the arrangements a day or two prior to departure.

Bus Travel - Greyhound

You must give Greyhound 48 hours notice if you are traveling with oxygen. However, it is a good idea to make reservations as far in advance as possible. When you're making reservations, ask to speak with someone in the Greyhound customer relations department. Request a copy of "Traffic Bulletin TFB2-86," which details Greyhound's policy for passengers traveling with oxygen. For more information contact:  (800) 822-2662 or (800) 752-4841, Customer Relations