The Energy and Commerce’s health subcommittee hearing on Jan. 8, billed as a meeting to discuss legislation “to support patient access to Medicare services,” unsurprisingly included some partisan comments, such as the length of time that had passed since its last meeting on Sept. 18.
But the bottom line was this: The nearly 30 members of Congress who spoke during the three-hour meeting were concerned about how well Medicare is serving its beneficiaries, and how access to durable medical equipment (DME) and services is key to Medicare achieving that primary goal.
The main DME-related bills on the agenda were H.R. 1703, the Choices for Increased Mobility Act to create a more accessible path for beneficiaries to pay out of pocket to upgrade to titanium or carbon fiber frames for their ultralightweight wheelchairs; H.R. 2005, the DMEPOS [durable medical equipment, prosthetics, orthotics and supplies] Relief Act that would improve reimbursement rates; and H.R. 2172, the Preserving Patient Access to Home Infusion Act to reform Medicare coverage of home infusion.
Here are my biggest three takeaways from the meeting that featured testimony from Tom Ryan, president/CEO, American Association for Homecare (AAHomecare) and Connie Sullivan, president/CEO, National Home Infusion Association (NHIA).
Medicare policies and proposed policies are hurting rural beneficiaries
Rural access came up time and time again, starting with committee Chairman Rep. Morgan Griffith, R-Va., who noted that while his district “is considered very rural by many metrics,” as part of the Medicare’s DME competitive bidding program, “CMS [Centers for Medicare & Medicaid Services] determined that a good portion of my district is non-rural. I’m looking at the map here of what’s considered non-rural. I can’t figure it out.”
“A lot of people can’t figure that out,” Ryan agreed, explaining that Medicare used ZIP codes to determine what areas of the country would be competitively bid and which would be non-bid, non-rural areas.
“So your district probably has a lot of these non-bid, non-rural areas,” Ryan added. “H.R. 2005 would help with that. The SOAR Act would help with that because you get increased reimbursement for those product categories if that in fact comes into place. But that is a common question — people are questioning CMS’s methodology on that ZIP code application, and it is just one of the flaws of the program.”
Rep. Diana Harshbarger, PharmD (R-Tenn.), brought up rural beneficiaries requiring home infusion services. “For many patients, especially in rural areas, home infusion can improve outcomes and quality of life while avoiding unnecessary trips to the hospitals or extended facility stays,” Harshbarger said.
She introduced a letter from a constituent who needs infusion treatments, but as a Medicare beneficiary, would need to travel to a medical facility to get them — “several hours through the mountains,” as Sullivan pointed out, “in inclement weather to reach an infusion center, which is a very difficult thing for a lot of patients to do, particularly our seniors and those with disabilities.”
“I represent a large rural area of Southern California where many patients have to travel up to an hour or more to receive medical treatment,” said Rep. Raul Ruiz, M.D., M.P.P., M.P.H. (D-Calif.), a cosponsor of H.R. 2172. “And like many underserved communities, transportation and geographic distance are considerable barriers, including the lack of nursing facilities in these communities. If a patient has to travel back and forth to a facility every day or every week for IV therapy, that barrier can be the deciding factor that pushes a patient into a nursing home or leads them not to receive care at all. But receiving treatment in their own home is a game changer.”
Current Medicare bills are ‘common sense’
Rep. John Joyce, M.D. (R-Pa.) called H.R. 1703 “common-sense legislation, and it would give greater access to Medicare beneficiaries to titanium and to carbon fiber wheelchairs.
“There is one key word in this legislation, and that is ‘choice,’” Joyce continued. “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.”
Under questioning from Joyce, Ryan noted that other insurers allow this kind of upgrade process. “The patient, if they have the means to at least pay the upgrade amount, [it] makes perfect sense,” Ryan said. ”And that is the way it had been in Medicare previously. But through sub-regulation, they made a change, and it’s no longer in effect.”
Sullivan referred to the Preserving Patient Access to Home Infusion Act as common sense as well. “This bill matters because Medicare still does not have a complete home infusion benefit, and this bill addresses a real access problem for America’s seniors and people with disabilities,” she said. “Without home infusion access, seniors must travel back and forth to facilities or extend their hospital stay to receive these necessary and often life-saving treatments.”
Sullivan then provided a common example of how Medicare’s current home infusion policy hurts both beneficiaries and itself: “A patient develops a serious infection due to an injury and is hospitalized. After a few days of IV antibiotics, the patient stabilizes and is ready to be discharged, but must finish the 14-day course of daily IV antibiotics to ensure the infection doesn’t recur.
“If this patient has commercial insurance, they would most likely be discharged to home because it is a safe, effective way to finish therapy using the least intensive medical resources. For Medicare beneficiaries, discharge to home, especially for IV antibiotics, is more difficult because the Medicare structure does not support the home-based model.”
The results: Patients need to make daily trips to hospitals or enter long-term care until the therapy ends. “This challenge is especially notable in rural communities, where the closest facility that can perform infusions may be hours away,” Sullivan noted. She called the home infusion act “a common-sense solution that strengthens access for Medicare beneficiaries, supports rural and underserved communities and avoids unnecessary facility-based care.”
Common sense was also the theme of questioning posed by Rep. Jay Obernolte (R-Calif.), who told Ryan, “I was really interested in the part of your testimony when you said the reimbursement rates for liquid oxygen are far below supplier costs.”
Ryan explained that liquid oxygen “is one of the most expensive product categories due to the nature of FDA [U.S. Food & Drug Administration] overnight and the infrastructure that the company must build to provide liquid oxygen. Back before competitive bidding, Medicare would pay per pound for liquid oxygen.” Patients, Ryan added, “could ambulate, get out and about. You could fill from your liquid canister, a portable canister and go out and about. You didn’t have to be limited by the number of hours or limited hours in a gaseous oxygen tank.
“Technology has evolved, so you do have things like portable oxygen concentrators (POC), where you can get lower flow oxygen from a portable concentrated device that provides a battery, and the battery is your lifeblood. ‘Do I have enough batteries to make sure I can go out and about and get my chores done?’ But there is a subset of patients who require a higher liter flow. And that higher liter flow in today’s technology is not able to be accomplished with a POC. It can be accomplished with a gaseous tank, but [with] the amount of oxygen that you would need to use, that gaseous tank would empty out every 30 minutes.”
The room seemed ready for change
“Well, I think sometimes we forget as we negotiate these reimbursement rates that the end goal is not just greater efficiencies for the taxpayer,” Obernolte said in replying to Ryan. “We’re trying to strike this balance between providing world-class health care with positive health care outcomes at the lowest cost to taxpayers. And achieving that balance can be tricky, but that’s why all of you being here today is so important.”
And that was the overall tone of the meeting: In trying to protect its trust fund, Medicare has swung far away from its primary responsibility. Rep. Kat Cammack (R-Fla.) noted, “We’re looking at several proposals that all point to the same reality. Medicare is struggling to keep pace with how care is delivered for people who live with chronic conditions and disabilities.”
Cammack asked Ryan to repeat a statistic — that 37% of DMEPOS providers have gone out of business since 2013 — “because I want the folks at home to really understand. That is a staggering number. Folks at home, people in underserved communities and rural communities, they need to understand that consolidation and services are going away. I think they’re living it every day, but people in America need to understand that this is at a tipping point.”
“For millions of our seniors, access to Medicare services is only as good as the payment policies behind them,” said Rep. Nick Langworthy (R-N.Y.). “When those policies fail to keep pace with modern care delivery, patients feel it first, through delayed services, fewer provider options, and reduced access to care in their communities. Across the country, providers are telling us the same thing. Outdated reimbursement rules and rigid payment schedules are making it harder to deliver care where patients need it the most, which is at home, close to family, and outside of institutional settings.”
“I’ve had family members rely on supplemental oxygen, and representing a state like Colorado, where we have high altitude, we know that many of our constituents also rely on supplemental oxygen,” said Rep. Gabe Evans (R-Colo.), a non-committee member who helped introduce the SOAR Act and was waved on to speak at the meeting. “House Republicans have been laser focused on affordability this Congress, but affordability goes hand in hand with accessibility, which is the centerpiece of the SOAR Act.”
“For many seniors and individuals with complex needs, the goal is not a cure,” Cammack pointed out. “It is a maintaining of their independence, whether it’s staying at home and avoiding unnecessary trips to the hospital or ending up in a nursing facility. Home-based services play a critical role in making that possible. We continue to hear from providers and patients that outdated payment structures and rigid policies are limiting access to care that is often safer and more cost-effective when delivered in the home.”
