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May 5, 2008 The Honorable Dave Camp The Honorable Fortney H. Stark Dear Chairman Stark and Ranking Member Camp: The undersigned members of the Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition write to request your assistance in ensuring that the Medicare competitive bidding program does not decrease access to and the quality of assistive devices. The ITEM Coalition is a consumer-led coalition of disability-related organizations with the goal of improving access to assistive devices, technologies and related services for individuals with disabilities of all ages. We are suggesting a series of proposals that we believe will relieve some of the potential access problems that are likely to occur when competitive bidding is implemented on July 1,2008. These proposals include exempting certain devices and technologies which are uniquely fit to the individual from being competitively bid, allowing beneficiaries with complex technology needs to opt-out of the competitive bidding program and continue to access their current supplier, and requiring Medicare to establish a dedicated community ombudsperson and a toll-free number to assist and track beneficiaries that are negatively impacted by competitive bidding. Competitive Bidding and Quality Issues The competitive bidding program for Durable Medical Equipment, Orthotics, Prosthetics and Supplies ("DMEPOS") was enacted as part of the Medicare Modernization Act of 2003 ("MMA"), and CMS is currently in the process of implementing the first round of the program. CMS has recently announced acceleration of implementation of Round 2 of the program. The Administration estimates that the program will save Medicare approximately $1 billion annually once fully implemented. ITEM Coalition members, however, are concerned that a portion of that savings will result from beneficiaries not receiving the appropriate device to meet their medical needs. Often individuals with spinal cord injuries, multiple sclerosis, cerebral palsy, amyotrophic lateral sclerosis ("ALS"), and other severe disabilities require assistive devices that must be fitted and/or programmed to meet their individual needs. In addition, technology assessments and home evaluations are often performed in order to ensure that the appropriate equipment is provided. The first round of the DMEPOS competitive bidding program would significantly cut reimbursement for the 10 targeted product categories. In fact, CMS estimates that on average, the price Medicare will pay suppliers is 26% lower than current payment rates. As a result of this dramatic price reduction, we suspect that suppliers will have difficulty purchasing, servicing, and providing the same quality devices and associated services to consumers. The likely decrease in the quality of assistive devices and technologies, especially complex devices and technologies which are highly individualized and fitted, threatens the consumer's function and independence. Additionally, the use of improper equipment could result in related medical complications bed sores, shoulder injuries) for the individual. Because many private payors take their reimbursement cues from Medicare, we expect that individuals with private insurance will eventually face many of the same quality issues as Medicare beneficiaries when competitive bidding is implemented. While we support efforts to appropriately reduce the copayments paid by Medicare beneficiaries and the costs of assistive devices and technologies paid by Medicare, we cannot support a system where quality is compromised as a result. To do so would be to undervalue the importance of appropriate assistive devices and technologies to the health and independence of individuals with disabilities and chronic conditions. Competitive Bidding and Access Another primary concern of ITEM Coalition members is that individuals requiring assistive devices and technologies will face supplier access problems as a result of the significant decrease in the number of suppliers available to them. We understand that in the bidding process, suppliers offered CMS an estimate of the percentage of the population in a metropolitan statistical area (MSA) that they believed they would be able to serve, and CMS has used those estimates to determine who has been offered competitive bidding contracts. CMS apparently conducted no independent verification of these supplier estimates. ITEM Coalition members are very concerned that the huge decrease in the number of suppliers in MSAs and the arbitrary way in which CMS has determined the number of suppliers necessary in each MSA will result in serious access problems on day-one of the competitive bidding program. Additionally, the process in which CMS has determined the number of suppliers necessary in MSAs and the arbitrary way in which CMS has determined the number of suppliers an area denies many beneficiaries the opportunity to continue long-standing relationships with their current supplier. Imagine that you are a complex power wheelchair user who has gone to the same supplier, located just four blocks from your home, for over 20 years. This supplier has detailed knowledge of your disability and related conditions and, as a result, has a history of providing you with the most appropriate wheelchair to meet your needs. However, because this supplier was not selected as a contractor in the Medicare competitive bidding program, as of July you will have to start all over with a new supplier who has no historical knowledge of your particular disability and related needs, does not carry your specific brand of wheelchair, and is located more than five miles from your home. For consumers with long-term needs who heavily depend on their current suppliers for appropriate devices, evaluations, and consistent services, the competitive bidding program simply does not make sense. ITEM Coalition Requests for Members of Congress Given the serious concerns expressed above, ITEM Coalition members offer the following proposals for how Congress and CMS can work to help ensure that individuals with significant disabilities are not harmed by the DMEPOS competitive bidding program. We are proposing two potential options to accomplish this goal. The first option, a general carve-out for complex devices, is a focused proposal, while the second, an opt-out provision, is a beneficiary-centered proposal.
The ITEM Coalition also requests that Medicare be required to establish a separate toll-free number specifically for beneficiaries regarding competitive bidding questions and concerns. CMS should also assign an ombudsperson to help monitor and resolve access and quality concerns. Currently, Medicare is instructing individuals with competitive bidding concerns to call 1-800-Medicare. Unfortunately, this is the general number for Medicare-related questions and, as a result, consumers often face long waits and operators who may not be knowledgeable in the specific area in which they have questions. We suspect that leading up to and following the implementation of the competitive bidding program, consumers will have numerous and important questions regarding the changes in the DMEPOS benefit. We feel that a specific toll-free number for such questions staffed by individuals knowledgeable in the new competitive bidding program, as well as access to an ombudsperson, is an important safeguard in implementation of this program. Additionally, the ombudsperson and toll-free number could prove to be a vital tool in monitoring the first round of the competitive bidding program. The information gathered could then be used to assess whether or not should move forward with implementation of the second round or whether a delay should occur to allow CMS and stakeholders appropriate time to study and address any and all access problems that arise. Conclusion The Medicare DMEPOS competitive bidding program is a massive experiment set to impact one of the nation's most vulnerable populations -individuals with disabilities and chronic conditions. Yet, despite a lack of knowledge of the program's impact, CMS is moving forward with its implementation at an accelerated pace. The ITEM Coalition is extremely concerned that competitive bidding will significantly threaten access to and quality of assistive devices, technologies and related services that are vital to the health and independence of We hope that Congress will work with CMS to implement appropriate safe guards to insure that individuals with disabilities are not harmed or overly burdened by the upcoming changes. And it is vitally important that the concerns of consumers are addressed as quickly as possible given that we are now merely two months away the first round of the programs' implementation. We thank you for your continued attention to the health and independence of people with disabilities and chronic conditions. We look forward to working with you to ensure that the Medicare DMEPOS competitive bidding program does not harm the vulnerable population which this benefit was designed to serve. Please contact the ITEM Coalition at (202) 349-4260 with any questions. Thank you for your consideration, American Academy of Physical Medicine and Rehabilitation cc: The Honorable Charles Rangel
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