Changes to competitive bidding process
September 8, 2011
Donald M. Berwick, MD, MPH
Centers for Medicare and Medicaid Services
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, DC 20515
The Independence Through Enhancement of Medicare and Medicaid ("ITEM") Coalition writes to express our thoughts and concerns on Medicare's competitive bidding program for durable medical equipment, prosthetics, orthotics, and supplies. Over the past few years, the ITEM Coalition, which is a consumer-led coalition of 75 disability-related organizations with the goal of improving access to assistive devices for people with disabilities and chronic conditions of all ages, has expressed our members' concerns with and hopes for the program, and we appreciate the CMS staff who have worked with us during that time.
We applaud the agency's decision to exempt off-the-shelf orthotics from Round Two of the DMEPOS competitive bidding program.
Orthotics and prosthetics are clinically-based, complex services that are customized to each individual's needs. This customization involves a wide variety and configuration of components to achieve maximal function for the patient, who benefits greatly from the clinical and device expertise that orthotic and prosthetic suppliers provide. The ITEM Coalition, therefore, believes that competitive bidding does not lend itself well to orthotic and prosthetic patient care. While there are steps that CMS could take to reduce fraud and abuse and improve quality in the Medicare orthotic and prosthetic benefit category, we are grateful to CMS for not exposing orthotic and prosthetic patients to competitive acquisition.
We remain disappointed, however, that CMS plans to bid specialized wheelchair seating cushions in Round Two of the program.
The ITEM Coalition has invested significant time and attention to making the case to key CMS officials that competitive bidding of specialized wheelchair seating cushions for long-term users of mobility devices is not in the interests of Medicare patients, and not in the overall interests of the program. Long-term users of wheelchairs receive immense benefit from customized seating cushions by preserving their skin integrity. We fear that including specialized seating cushions in the program -- especially with so many different kinds of cushions being described by so few HCPCS codes -- will result in less suppliers providing the more specialized and expensive items to beneficiaries.
Because only four HCPCS codes are used to describe a wide variety of seating cushions, more complex seating cushions used to address the risk of skin breakdown are coded in much the same manner as much less sophisticated and less costly cushions. This discrepancy within the coding system, combined with significant pressure on reimbursement levels for suppliers, can result in fewer contract suppliers willing to stock the more specialized seating options, to the detriment of patient care. It would only take a small number of skin ulcers in patients to nullify any cost savings CMS expects from competitively bidding these items.
An appropriate wheelchair cushion that ensures a proper fit between the long-term wheelchair user and the wheelchair itself is critical to skin integrity and the long term health and function of the patient. Because receiving the proper seating cushion is integral to the beneficiaries' health and can prevent very costly and debilitating secondary conditions, we request that CMS reconsider bidding these items in Round Two. Short of an exemption, the ITEM Coalition requests the agency to use its discretion to modify the HCPCS codes applicable to such cushions to ensure that CMS bids similar, high-end products against each other, rather than lumping all seating cushions into a small number of HCPCS codes.
The ITEM Coalition is also concerned with a new category identified for the upcoming bidding process in Round Two, that of "Standard (Power and Manual) Wheelchairs, Scooters, and Related Accessories."
This product category combines the bidding for power and manual wheelchairs in a manner that will likely cause confusion and create unintended consequences when bidding commences. The ITEM Coalition requests CMS to bid power and manual wheelchairs separately as these wheelchairs are often provided by different suppliers to very different patient populations.
Similarly, CMS should bid high strength lightweight and ultra lightweight manual wheelchairs separately from other manual wheelchairs, as their technology has advanced to make them distinct from most manual chairs and are particularly effective for people with long-term mobility needs. In fact, CMS should revisit the manual wheelchair category and update the HCPCS coding assigned to these products in order to better define the products available and their differences from each other. Bidding these subcategories separately will help ensure fair and appropriate comparisons in products under the program and will reduce the likelihood that patient choice and quality will suffer.
In addition, this category contains a number of specialized and individually configured devices and accessories, such as specialized wheelchair seating cushions, that should be exempted from competitive bidding in the same way that complex rehabilitation wheelchairs were exempted by Congress under Round One. Any wheelchair accessory that modifies an exempt complex rehabilitation wheelchair should also be exempt so as not to burden beneficiaries by requiring them to visit multiple suppliers to obtain appropriate technology.
The ITEM Coalition has a strong interest in ensuring that competitive bidding works for beneficiaries with disabilities and chronic conditions. The program can only work for those with long-term and chronic device needs if beneficiaries retain sufficient choice of devices that are designed to meet their individual needs. In addition, the program must ensure that suppliers are committed to providing quality services to beneficiaries living with disabilities and chronic conditions.
As always, we appreciate your attention to our concerns. If you have any questions or would like to further discuss these issues, please contact Peter Thomas, ITEM Coalition Counsel, at 202-872-6730, or any of the Steering Committee members listed below. Thank you.