AAHomecare CEO Tom Ryan in a screen capture from his subcommittee sppearance.
Tom Ryan, the president/CEO of the American Association for Homecare (AAHomecare), urged members of Congress to protect Medicare beneficiaries’ access to durable medical equipment (DME) during a three-hour meeting of the Energy and Commerce’s health subcommittee on Jan. 8.
About 30 members of Congress questioned Ryan and three other witnesses, including Connie Sullivan, president/CEO, National Home Infusion Association (NHIA).
Ryan had to cover a lot of ground. He was advocating for three durable medical equipment (DME) bills: H.R. 1703, the Choices for Increased Mobility Act to create a more accessible path for beneficiaries to upgrade to titanium or carbon fiber ultralightweight wheelchair frames; H.R. 2005, the DMEPOS [durable medical equipment, prosthetics, orthotics and supplies] Relief Act to improve reimbursement rates; and H.R. 2902, the Supplemental Oxygen Access Reform (SOAR) Act to create new reimbursement rates for supplemental and liquid oxygen.
But Ryan also underscored fundamental problems with the next round of Medicare’s competitive bidding program, as laid out in the home health final rule published in December.
Competitive bidding has already caused harm
In his opening statement, Ryan described the impact of past rounds of competitive bidding, including the loss of his own business.
“Before joining AAHomecare, I spent 25 years running a home medical equipment company in Long Island, New York,” he testified. “So I know firsthand how Medicare policy affects patients, families and the small businesses they serve.”
Ryan expressed concern over Centers for Medicare & Medicaid Services’ (CMS) plans to add ostomy and urological supplies to the competitive bidding category list, and also protested the addition of continuous glucose monitors.
“Despite clear Congressional intent that these items should not be included, CMS also plans to include new technology like continuous glucose monitors and change their payment category in a way that will sharply reduce reimbursement,” Ryan said. “This threatens beneficiary access and undermines innovation in diabetes care.
“Even more troubling, CMS intends to reduce the number of suppliers [in] these key product categories to fewer than 10 nationwide. This would devastate small businesses. It’ll destabilize the national home medical equipment infrastructure that patients rely on.”
Ryan told members of Congress that his own business didn’t survive competitive bidding’s earlier rounds years ago — and added that the program’s revival “will artificially drive payment rates to unsustainable levels, leaving too few suppliers to meet the needs of our Medicare beneficiaries.”
Competitive bidding has already thwarted product development, Ryan added. “We’ve seen that technology has really gone down over the years,” he said in response to a question from Rep. Diana Harshbarger, PharmD (R-Tenn.). “Patents have decreased significantly. So innovation has been problematic. Repairs have gone up significantly because the quality of the equipment is not the same.”
Protecting oxygen access with the SOAR Act
Ryan also explained to Harshbarger why protecting beneficiary access to liquid oxygen via the SOAR Act is crucial.
“These patients who are on high-flow oxygen need to have this technology,” he said. “It’s actually old technology: One cubic foot of liquid oxygen [expands] to 860 cubic feet of gaseous oxygen. So with a very small container [of liquid oxygen], you can have a much greater amount of [breathable] oxygen.”
Rep. Troy Balderson (R-Ohio) told Ryan, “I have heard from constituents and stakeholders alike that there’s often difficulty in finding an oxygen supplier that carries the equipment and supplies for liquid oxygen, particularly portable liquid oxygen. While patients may still be able to obtain different equipment, they’re often unable to leave their home except for a very limited period. Some do not have the appropriate equipment that would allow them to travel, even for something like a doctor’s visit.”
“You’re correct: The usage of liquid oxygen has gone down significantly over the years,” Ryan replied. “Portable liquid oxygen is down 77%. Stationary liquid oxygen is down 80%. And the reason for this is the reimbursement. The reimbursement of the competitive bidding program would not allow suppliers to provide liquid oxygen.”
Some patients have high-liter flow needs “that cannot be met with traditional portable oxygen concentrators,” Ryan added. “It couldn’t be met with the gaseous tanks.”
The SOAR Act “would take all oxygen out of competitive bidding,” Ryan said. “It could get more technology [into] the sector. And it would treat liquid oxygen differently. It would give it a much higher rate that would hopefully add to some expansion of the product category.”
Rep. Gabe Evans (R-Colo.), a non-committee member who helped introduce the SOAR Act and was waved on to speak at the Jan. 8 meeting, said, “We know how important supplemental oxygen is — liquid supplemental oxygen, at times, for people battling a variety of conditions. And I wrote down the number you just threw out: 860 times more oxygen in the liquid form in the same volume as you get in gaseous form. Can you describe the dilemma and the real human impacts that patients face when the existing system that we have with Medicare significantly limits access to liquid oxygen?”
“The reality is, looking at Medicare claims data, the decrease in both liquid portable oxygen and stationary portable oxygen has been significant,” Ryan answered. “It’s down 80%. So there again, there’s a subset of patients that require high-flow liquid oxygen, and essentially because of a poor reimbursement program, a failed competitive bid program, those patients no longer get that service.”
Ryan, who has worked as a respiratory therapist, also praised H.R. 2902’s goal of supporting that profession. “The SOAR Act provides a payment structure to get paid for respiratory therapy,” he noted. “Compressing prices has taken the service model and changed it severely. It’s taken [away] the opportunity to have a respiratory therapist that could go into the home and do the proper services. The SOAR Act could bring that back.”
“Thank you for that,” Evans said. “A big part of that is making sure that these programs work, making sure that the money goes where it’s supposed to while also rooting out the fraud, waste and abuse. I’m just struck by that ‘860’ number that you threw out there. People that need this high-flow oxygen — sometimes there’s really only one answer to that, and that’s liquid oxygen.”
Improving DMEPOS reimbursement
Ryan also spoke on the urgency of passing H.R. 2005, which he described as “relief for non-bid, non-rural areas.”
He added in his opening remarks, “Since 2016, CMS has applied competitive bidding rates [to these areas] that never participated in competitive bidding. These cuts often were more than 50%. They’ve been devastating. Congress has repeatedly stepped in with temporary relief, most recently through the 2022 omnibus bill. But that relief expired at the end of 2023. As a result, suppliers in these areas are again facing cuts of more than 30%.
“H.R. 2005 restores a 75/25 blended rate for non-bid, non-rural areas. This is essential to maintaining access to home medical equipment and preventing further supplier choices. And we look forward to working with the committee to update the timeliness as this bill advances.”
Among the committee members speaking on behalf of H.R. 2005 was Rep. Mariannette Miller-Meeks, M.D. (R-Iowa), who introduced the bill.
“As a physician and nurse, I have seen firsthand how critical, timely access to oxygen equipment, mobility devices, and home medical supplies are to keep patients healthy and out of hospitals,” Miller-Meeks said. “When access to these services is disrupted, patient outcomes suffer, and costs to the health care system increase. Particularly, small independent providers and those serving rural communities are under growing financial pressure due to inflation, workforce shortages, supply chain disruptions, and Medicare reimbursement rates that have not kept pace with real-world costs.
“In many cases, suppliers are being forced to limit services or exit the Medicare program altogether, leaving beneficiaries with fewer options and longer wait times.”
Miller-Meeks said the bill “provides targeted temporary payment relief to stabilize the supplier market and preserve beneficiary access without undermining program integrity or patient protection. The goal is simple: To ensure seniors and individuals with disabilities can continue receiving the equipment and supplies they need, where and when they need them.”
Miller-Meeks then asked Ryan how current reimbursement rates are impacting providers, especially small independents and providers serving rural areas.
“When those rates cuts came into effect again, we did a survey around the country of our membership,” Ryan said. “And some of the key findings: 65% of the companies reduced the amount or type of products they offered, 46% reduced their service areas, 53% laid off staff, 35% used personal savings to maintain that business.
“So the non-bid, non-rural areas of the country — [providers] woke up overnight and got a significant decrease, a 30% decrease without getting an increase in market share.”
Rep. Kat Cammack (R-Fla.) asked what access issues Ryan expected to see if DME suppliers “further consolidate or just leave the program.”
“We’re losing suppliers,” Ryan answered. “We believe 37% of the industry has gone out of business.” Making the 75/25 blended rate permanent “would certainly be a help when it comes to making sure we’re getting the proper care and technology and outcomes that these patients deserve.”
Greater access to ultralightweight upgrades
Ryan also urged support for H.R. 1703, which “addresses a 2016 policy that effectively eliminated beneficiaries’ ability to upgrade to titanium or carbon fiber wheelchairs unless they paid the full cost out of pocket. This is contrary to long-standing Medicare policy that has severely restricted access to these lighter, more durable chairs. The bill restores the ability for the beneficiary to pay the difference for the upgraded materials without adding any cost to Medicare.”
Rep. John Joyce, M.D. (R-Pa.), who introduced the bill, described it as “common-sense legislation” and emphasized the importance of beneficiaries being able to decide what works best for them.
“There is one key word in this legislation, and that is ‘choice,’” Joyce said. “This bill allows Medicare patients the opportunity to decide whether a titanium or a carbon fiber wheelchair is the right choice for them. And if it is, then patients with Medicare B have the ability to pay out of pocket for wheelchair upgrades if they so choose.”
Ryan noted that Medicare previously did offer the upgrade option to beneficiaries, but no longer does.
“You bring out a great point,” Joyce said. “That is previously what Medicare patients had the capabilities of having, to have a lightweight wheelchair. And this legislation once again will provide that for the patients. I urge all of my colleagues to support this common sense, zero-cost measure, which passed unanimously out of this committee last Congress, so that it may be signed into law.”
In a bulletin sent to stakeholders on Jan. 8 after the subcommittee meeting, AAHomecare said, “A key theme throughout the hearing was that Medicare payment policy doesn’t just set prices; it undermines whether patients can get the care they need, especially in rural communities and for people with complex chronic needs.
“Members of the House Energy and Commerce health subcommittee repeatedly emphasized Ryan’s remarks on data showing that 37% of suppliers have gone out of business since 2013 due to competitive bidding — an alarming trend that illustrates the program’s growing impact on access to DME services and equipment.”
