HME News

JAN 2018

HME News is the monthly business newspaper for home medical equipment providers. This controlled circulation publication reaches 17,100 home medical equipment services providers, including traditional HME dealers & suppliers, hospital- and pharmacy-o

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Rx and Specialty Providers 18 www. HME n E w S .co M / january 2018 / HME n E w S WASHINGTON – Three senators have introduced a bill that would, they say, establish a clear medical guideline for non-invasive ventila- tors, the VGM Group reports. S. 2175, the "Beneficiary Respiratory Equipment Access and Transparency to Home Ventilator Care" or the BREATH Act of 2017, would also pave the way for pro- viders to receive a possible increase in reim- bursement for non-invasive vents, pending any decreases in utilization. Sens. Bill Cassidy, R-La., Charles Grassley, Vent bill back in play R-Iowa, and Joe Manchin, D-W.Va., intro- duced the bill on Nov. 30. Cassidy and Grassley also introduced a similar bill last year, in response to sweeping changes that CMS has made to non-inva- sive vents, including reducing the number of codes for the product category from five to two, and reducing reimbursement by about 33%. A companion bill in the House of Repre- sentatives will be introduced soon, headed up by Rep. Larry Bucshon, R-Ind. hme the deal as a way to increase access for consumers and create a more personalized healthcare experience. CVS currently has more than 9,700 phar- macy locations and 1,100 MinuteClinic walk-in clinics. "The bottom line is they are just monop- olizing the whole industry and making it worse for everybody in the end," said one pharmacist who didn't want to be quoted for fear of reprisal from the PBM. "In any other industry, they'd be up in arms." Community pharmacies already strug- gle under CVS's PBM and others. The three largest—CareMark, ExpressScripts and OptumRx—control nearly 80% of pharmacy benefits in the U.S., according to the National Association of Community and state Medicaid programs about how they plan to implement the provision. The Cures Act was signed into law nearly a year ago, on Dec. 13. While the spreadsheet gives stakehold- ers some new information, they're still waiting for CMS to issue a letter to the state Medicaid programs with additional guidance, particularly on reimbursement. "Which Medicare rates?" asked Seth Johnson, senior vice president of govern- ment affairs for Pride Mobility Products. "They're saying bid rates, but if you look at any number of states, there are multiple bid rates. Which ones are they going to use?" Williard had heard the letter might be issued before a State Operational and Tech- nical Assistance conference call on Dec. 7, but that didn't happen. "The letter has been sitting at the Office of Management and Budget for approval for about two months now," she said. Stakeholders on a national and state level have been educating Medicaid pro- grams that the provision doesn't necessar- ily mean they have to set their reimburse- 47,000 claims from the ALJ so far," said van Halem, president of the van Halem Group. "The numbers from September show a decline in ALJ cases pending, and the QIC demo is a testament to that." While the QIC struggled to get provid- ers to participate in the demo initially, that was an education issue more than any- thing else, says Andrea Stark. hme MEDICAID CUTS c o n t i n u e d f r o m pa g e 1 ment at Medicare reimbursement. They have succeeded in getting some programs to hold off from making any changes pend- ing additional guidance, but things are down to the wire. "The states have to ensure access to care, so they have the right to set rates to what- ever they need to," Williard said. "It just impacts the overall federal match." And therein lies the rub: State Medicaid programs can decide to set reimbursement at higher than the Medicare reimburse- ment, but they'll have to make up for the reduced contribution from Medicare. "That's why we're concerned they'll just go and change their rates to Medicare rates just to comply and be done with it, instead of doing their due diligence," Williard said. "I don't think most will do that, but it's a concern." Stakeholders believe states whose Med- icaid programs are largely administrated by managed care organizations may be exempt from the provision, which would help. "Until that's actually verified, though, I'm not going to breathe a sigh of relief," said Rose Schafhauser, who leads a number of state HME associations. hme Pharmacists. "I got locked out two months ago from a PBM that told my clients they could no longer shop with me," said Nelson. "I have lost 40% of my patients because I have been beaten up by the bigger stores that own PBMs." The deal, which still needs approval from federal regulators, comes in the wake of reports that Amazon has filed applica- tions for pharmacy licenses in more than a dozen states. "Health care is being commoditized," said a pharmacy manager who didn't want to be quoted. "It's like we are just heading into price conscious-only shopping where we don't care about anything else. That's scary." hme million in the quarter. Going for ward, InfuSystem is reviewing existing customers and lines of business, and plans to pursue new opportunities in its infusion products and pain management businesses, says Lehman. "I am pleased we continue to win new business and grow our market share in a responsible way," he said. The third quarter was the first full quarter under an executive manage- ment reorganization in May that cre- ated a temporary "Office of the Presi- dent" led by Lehman, and consisting of two directors and three senior manage- ment team members. "We are happy with how the office is working as demonstrated by improve- ments in our financial results," said Lehman. "Our initial plan was to oper- ate under this structure through the end of the year, but no decision has been made." hme CVS - AETNA DEAL CASTS SHADOW c o n t i n u e d f r o m pa g e 1 INFUS y STEM c o n t i n u e d f r o m pa g e 1 7 BID RELIEF c o n t i n u e d f r o m pa g e 3 PHONE DEMO c o n t i n u e d f r o m pa g e 3 PROSTHETICS c o n t i n u e d f r o m pa g e 1 7 Additionally, in 2015, the four DME MACs released draft local coverage determina- tions for lower limb prosthetics that would severely limit access to K3 and K4 devices. CMS needs to overhaul its policies to better reflect technological advances. Even MPKs have been around for nearly 20 years, says Oros. "The current operating environment for coverage is outdated and needs to change," he said. hme in six weeks. "We continue to talk to our champions, Rep. Cathy McMorris Rodgers, and Sen. John Thune," said Jay Witter, vice president of government relations for AAHomecare. "They are working with the committees on ways of getting this fixed. They clearly under- stand the timing of this issue." AAHomecare also continues to release tools that stakeholders can use to gather support for bid relief, most recently a white paper, "Why Urban Areas Must Help Stop Drastic Cuts to DME Items in Rural & Non- Bid Areas." The paper outlines several key ways in which urban areas will benefit from the bill, even though it's focus in non-bid areas. "There's been some questions about how this helps bid areas," said Ryan. "This explains that. I keep talking about the domi- no effect of managed care plans using unsus- tainable bid rates and taking a deduction off of that for all areas. We're doing everything we can to see if there's an opportunity to get it passed, but (if we don't), the bill will roll right into next year." hme NOW SERVICING THE ENTIRE U.S.A. VALUE ANALYSIS FREE NOW SERVICING THE ENTIRE U.S.A. 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