This week we launch The Editor’s Notebook, a new E-Source segment in which one of HHP’s editors briefly comments on a topic of current interest. Because our editors immerse themselves every day in the business, politics, and science of product design, disability and rehabilitation, they are well-positioned to add their voices and informed commentary to ongoing debates about health care as they affect providers, patients, and equipment manufacturers.
The Editor’s Notebook won’t necessarily appear every week, but you can look for it when important issues arise that are of broad concern to the DME, disability and rehabilitation communities. We welcome your responses to The Editor’s Notebook and may publish selected comments that encourage the exchange of ideas within the DME community.
This week, HHPmanaging editor Jeffrey Green looks at the evolution of the DME industry since Medicare’s enactment in 1965. He suggests that the public’s perception of DMEs as an ambiguous combination of health-care professional and merchant may help explain why the industry was ignored for so long by the surrounding culture’s preoccupation with official certification and is only now being hit by accreditation requirements.
We live in a certification culture. People aren’t allowed to provide skilled personal services of any significance without first getting permission from an official authorizing body. Everyone from people who cut hair, give massages, and provide physical therapy to those who cook professionally, give tattoos, do nails, offer psychotherapy, or even baby-sit is required to obtain an officially sanctioned organization’s seal of approval.
From this perspective, it’s actually surprising that medical-equipment providers escaped the licensure frenzy of the last three decades. After all, when they fit people for power chairs, help patients select the best hospital bed for their condition, or assess patients’ needs for the best support surfaces, DMEs are offering health-care counsel.
So, why aren’t DMEs already certified as a matter of course?
At least part of the answer lies in their hybrid nature. Are they merchants or health care professionals? If merchants, licensing is irrelevant. If health care professionals, licensing is a no-brainer. The answer wasn’t clear, but the ambiguity didn’t strike anyone as a problem. Anyway, the perception of DMEs as equipment dealers, not unlike sellers of refrigerators or vacuum-cleaners, was pervasive, so life went on.
Meanwhile, the Congress enacted Medicare in 1965. The program’s spending began accelerating, as did the sophistication, variety, complexity, and cost of home health technologies and the expertise necessary to provide and support them. As concern about Medicare outlays turned into an open fear that the country may not be able to afford them, regulators began looking for ways to rein-in spending, minimize waste and abuse, and institutionalize accountability.
Regulators’ attention turned back to the equipment providers who bill Medicare for billions every year. Their lack of formal accreditation, thought to be a marker of professionalism and quality, became a target. Suddenly, though, thousands of people who devoted their adult professional lives to serving the elderly and frail of their communities sense that they are under attack, that their businesses and livelihoods are at risk.
While it’s hard to argue against accreditation, it is deeply unfair to implement it in a way that turns life upside down for this country’s independent providers who have consistently and conscientiously served their communities for years. Accreditors and consultants sigh and explain that DMEs knew this was coming and that they should have been ready.
In an ideal world, sure.
In an ideal world, though, DMEs don’t work 18-hour days and still have trouble fitting in everything that absolutely, positively has to be done. They don’t have trouble keeping good employees or face hurricane seasons for which they have to prepare their DME clients in case another Katrina hits Gulf Coast communities filled with the elderly and disabled. They don’t have to choose between reading a 400-page regulation and repairing wheelchairs or following up on the oxygen equipment and hospital beds they delivered yesterday.
Culture is very powerful. The independent-DME culture is dominated by people who have been doing an outstanding job, often at great personal sacrifice, for decades. Now, they feel insulted and mistrusted. And it’s not because Medicare wants them to be accountable. It’s because of Medicare’s assumption that an entire industry hard-working, caring people — not technocrats with MBAs and large staffs just waiting to create, analyze, and update spreadsheets and forms can put its culture aside virtually overnight to jump through expensive hoops while still keeping their businesses going and their patients cared for.
As if that’s not enough, every independent provider knows that even if they cross every t and dot every last i, they still may not be in business a year from now if they fail to come out on top in the competitive bidding that follows accreditation.
So, no, the problem isn’t that providers want to blow off accreditation. The problem is that, despite the fact that DME accounts for only about 2 percent of Medicare outlays, CMS is penalizing DMEs for not being crazy about throwing their culture out the window and adopting an entirely new way of operating — in just weeks. And, if they don’t fall into line, it’s all over.