Many of you have seen – and signed – a petition that circulated recently about preventing Medicare from applying competitive bidding prices to complex technology; an action that will likely reduce access to wheelchair features many of our family members depend on. This effort has now evolved into a legislative effort and we urge all members of our community to take action by urging your members of Congress to support H.R. 3229 in the House and S. 2196 in the Senate.
But why? What does Medicare pricing have to do with Duchenne?
When most people with Duchenne are covered by either private insurance, the Medicaid Waiver, or both — how does this issue directly impact our community?
The Center for Medicare & Medicaid Services (CMS) is the federal regulatory body that sets insurance formularies (the algorithms that help determine reimbursement). What that means is that when new technologies and therapies are approved by the FDA, they then go through the regulatory process at CMS to determine whether they will be added to insurance policies and at what reimbursement rate. Items such as complex medical equipment (wheelchairs with lots of features) are considered complex because each item on that chair is costed out separately (as is reflected when your letter of medical necessity is written and each feature is justified. Each of these features are considered to be complex rehab technology (CRT). CMS then sets their pricing (the rate that they will pay for those products and each CRT feature) - and whether they will at all.
Private insurance companies then look at those prices and negotiate their price points, or determine which ones they believe to be justified and worthy of adding to their coverage and which ones they will not add to their coverage. Or - at which levels of coverage certain items are available. However, if CMS determines that reimbursement isn’t worthwhile (that there isn¹t enough of a medical justification for an item or not enough financial reimbursement to outweigh the cost of keeping an item’s technology updated), they can remove it from the formularly.
Where CRT is most vulnerable is that durable medical equipment (DME) providers who do a good job often have to make many tweaks and visits to make sure that wheelchair adjustments are perfect. So the cost for some of these items are not just the direct cost of the technology, but also the cost of the installation, adjustments, and upkeep. The other issue is that if the market doesn’t seem large enough (not enough people use the technology or are able to access it due to lack of insurance), the technology goes away. These are real threats that we have seen occur before. If you have ever had a feature on your power wheelchair that you found no longer existed when you went to order your new chair several years later, you have seen this phenomenon first-hand.
So - what’s happening now and why is this issue popping up?
In 2008, this issue was raised. The disability community united and became very vocal and – as a result – the Medicare Improvement for Patients & Providers Act (MIPPA) specifically excluded complex rehab technology from CMS’s Medicare competitive bidding program (in which the DME provider who can provide the service at the cheapest rate gets your business, irregardless of their expertise, proximity to you, or customer service). We thought the issue was resolved.
Well… CMS found a loophole.
Rather than subjecting CRT to competitive bidding, per se. What they are planning to do is simply apply the ‘competitive bidding rates’ to the CRT items. This will substantially reduce what insurance pays for these features to DME providers meaning that consumer (YOUR) costs will be driven up and eventually providers will no longer be able to provide such tailorized equipment as demand goes down and certain types of technology could be discontinued. It’s a slippery slope that we don’t want to travel down.
H.R. 3229 and S. 2196 are short and sweet bills. 2 pages each, in fact. They simply work to close the loophole and implement the spirit of MIPPA’s exclusion of CRT from the CMS Medicare Competitive Bidding Program.
CMS does impact private insurance availability. Because if CMS makes cuts, so does everyone, and the incentive for the technology manufacturing is lost. Help us protect your technology access – by closing this loophole.