From: HME News

BALTIMORE—All is well. That was the word about Round 1 of competitive bidding from the Centers for Medicare and Medicaid Services at last week’s meeting of the Program Advisory and Oversight Committee.

After all, agency representatives said, of the 54,000 calls the 1-800 Medicare line has received about competitive bidding, only 43 were complaints.


“There seems to be a very large disconnect that CMS has no problems,” said Walt Gorski, vice president of government relations for the American Association for Homecare and a member of the PAOC. “We look at it as 54,000 people calling in to express concerns—and only in nine competitive bidding areas. Imagine what is going to happen as the realities of competitive bidding set in and there is a ten-fold expansion in the next round.”

Cara Bachenheimer, senior vice president of government relations for Invacare and a former PAOC member, said it was unclear what the 54,000 represented—all competitive bidding calls from the nine areas or other Medicare calls, as well?

She noted that the way CMS defined a “complaint” was also murky. “Their definition of … a ‘complaint’ is not the same as ours.”

According to AAHomecare, CMS classifies some contacts, which can include calls about difficulty finding a contract provider or switching to less expensive equipment, as “inquiries.”

In any case, Bachenheimer said, “[CMS’] mission is to prove to Congress that everything is great, everything is rosy; they paint this perfect picture. Why would they have to change anything?”

CMS created the PAOC, required under the Medicare Modernization Act, to give input on the implementation of competitive bidding. But committee members have often been vocal in their criticism of the agency program, saying that although the committee’s name indicates they have oversight powers, they don’t, and while they are to function in an advisory capacity, CMS seldom takes their advice.

The agency’s description of Round 1 as going fine was a typical example, attendees at the April 5 meeting said, and they weren’t buying it.

PAOC member Tom Milam, former COO of diabetic supply company AmMed Direct, disputed the evidence CMS used to support its “all is well” theory. In a presentation of results from real-time claims tracking, CMS charted users of oxygen, CPAPs and diabetic supplies, among others, and the percentage of whom, over four years, used the DME benefit, had been hospitalized, had an emergency room event and/or had died.

“By design, the numbers were flattened,” Milam said. In the oxygen group, for example, “the denominator that they were using was not the number of beneficiaries diagnosed,” he said. “I want to see what is happening to my current O2 users, my current CPAP users. This was misleading.”

Gorski pointed out that problems arising from lack of quality of care or equipment—increased emergency room visits, doctor visits and hospitalizations—may not develop immediately. It is “clearly too early to tell,” he said.

Added Bachenheimer, “You are not going to see these impacts for months and potentially years. That’s the kind of stuff you don’t capture immediately. It’s like you don’t see people going out of business right away; it’s going to be a slow bleed.”

While the agency did announce at the meeting that it would delay Round 2 by six months, Gorski said that was not enough time for the foundational changes in the program that need to be made. “For example,” he said, “if they wanted to address median pricing or calculation of the single-payment amount or capacity issues, those are things that would require CMS to open the rule.”

Generally, he said, it takes months for CMS to issue a proposed rule, allow for a 60- or 90-day comment period, publish the comments and then post the final rule. “The fastest this has occurred was with the physician fee schedule payment,” Gorski said. That came about in five months, what he called “breakneck speed” for CMS.

“When 95 percent of the people in the room suggest that the program needs to be changed, it is surprising that CMS remains steadfast in its Round 2,” he said.

Bachenheimer also said she saw no softening of CMS’ rigid stance on competitive bidding.

“I urge people not to read too much into the six-month delay,” she said. “CMS is still very adamant that the program is working smoothly in the initial nine bid areas; this does not signal anything from CMS that they are ready to make any meaningful changes to the bid program. Even with the revised timetable, there is no time for CMS to open up the bidding final rule and make substantive changes—which is a necessary step in the process if CMS were to really consider making any modifications.”

Even as CMS was painting its blissful picture of Round 1, PAOC members heard of one casualty: Miami provider Rob Brant told the committee he will be shuttering his 14-year-old business because of the effects of competitive bidding. (See “PAOC Speakers Give Different View of Competitive Bidding” in this issue.)

Brant’s comments, which drew applause, Milam said, underscored the deep fissures in the CMS project. Still, he said, he detected a “different tone” compared with previous PAOC meetings.

“CMS was quieter than in the past,” Milam said. “They actually said they wanted to hear what the PAOC thinks. In prior meetings, it was, ‘This is what is going on’ and ‘This is what we are getting ready to do.’ There was less of that.”

While CMS representatives did not respond to any comments, Milam said he hoped they were at least starting to hear the concerns about the national bidding program. “I would love to see … leadership at CMS say it is time to do it right,” he said. “We need to see a change here.”

That directive will only come from legislation, Bachenheimer said. “We know that no amount of pleading is going to make CMS change it on their own.”