Competitive Bidding Where are we Today? THE STATE

Competitive Bidding  Where are we Today? THE STATE

Competitive Bidding Where are we Today? THE STATE OF THE INDUSTRY John Gallagher The VGM Group 3 May 2005 First of all, much of todays presentation and related information may be found on DC Link...To get there, first go to And you are there! THE GOAL: EFFECTIVE LOBBYING GRASS ROOTS LOBBYING THE MOST EFFECTIVE

FORM OF LOBBYING WHY BECAUSE YOU & YOURS VOTE! YOU HAVE 15 MINUTES WITH YOUR CONGRESSMAN OR SENATOR --Before you sit down with your Senator or Congressman, Remember the SIX PPPPPPs Develop Triple Track approach to combating National Competitive Bidding: Legislative Develop a champion for the industry Grass-Roots Coordinate Grass-Roots activity at Provider Level Legal Develop Legal effort to delay and or defeat NCB The MMA of 2003 (*) HME Provisions

FEHBP Pricing Inhalation & Infusion Drugs CPI Freeze Competitive Bidding (*) On December 8, 2003, President George W. Bush signed into law the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003. THE 2003 MEDICARE BILL & THE HME INDUSTRY: FEHBP Industry analysts originally estimated that CMS would likely reduce reimbursement for stationary oxygen by about 11% on average and by 7% on average for portable oxygen.

On Wednesday (30 March) the DHHS Office of Inspector General released its revised report on Medicare fee schedule amounts for home oxygen for 2005. The report indicates that the stationary oxygen equipment "Percentage Difference Between Medicare and FEHB Weighted Mean" is 12.4% The report indicates that the portable home oxygen equipment "Percentage Difference Between Medicare and FEHB Weighted Mean" is 10.8%

CMS has notified providers that These fee schedule amounts will be implemented by the Medicare Contractors as soon as possible and by no later than April 8, 2005. THE 2003 MEDICARE BILL & THE HME INDUSTRY: FEHBP & Oxygen Note: The Morrison study, (AAHomecare) which used data from about 107 FEHBP plans, found virtually no difference between pricing for FEHBP fee-for-service plans and Medicare rates for home oxygen. E0431). And, the OIG study did not address the significant pricing, contracting, patient service and administrative differences between the Medicare program compared to FEHBP or Medicare + Choice plans. THE 2003 MEDICARE BILL & THE HME INDUSTRY:

ACTUAL 2005 REIMBURSEMENT CUTS Cuts vary widely by state; generally less than many industry observers had feared. diabetic test strips (A4253): 0 to 4 percent diabetic lancets (A4259): 0 to 5 percent semi-electric bed (E0260): 1.6 to 16 percent power pressure-reducing mattress (E0277): 0 to 7 percent nebulizers with compressor (E0570): 4 to 18.3 percent manual wheelchair (K0001): 0 to 2.5 percent

power wheelchair (K0011): 0 to 3.3 percent THE 2003 MEDICARE BILL & THE HME INDUSTRY: Example = FEHBP Cuts - State of VIRGINIA Actual Data HCPCS Code Item E1390, E4024, E4039 Stationary oxygen systems E0434, E0431 2005 Medicare Allowable

VIRGINIA 2004 Medicare Allowable VIRGINIA Reimbursement change (%) between 2004 & 2005 $194.48 $194.48 -0.0% Portable oxygen systems

$32.08 $35.97 -8.73% A4253 Blood glucose test or reagent strips, $36.54 $38.52 4.10%

A4259 Lancets, per box of 100 $12.06 $12.74 -5.33% E0260 Hospital bed, semi-electric, with mattress $1,404.60 $1,679.30

-16.35% E0277 Powered pressure-reducing air mattress $7,034.70 $7,593.60 -7.36% E0570 Nebulizer, with compressor

$161.10 $167.70 -3.94% K0001 Standard wheelchair $532.70 $546.20 2.47% K0011

Standard-weight frame motorized/power wheelchair with. $5,122.80 $5296.50 -3.28% THE 2003 MEDICARE BILL & THE HME INDUSTRY: Example = FEHBP Cuts - State of WEST VIRGINIA Actual Data HCPCS Code Item E1390, E4024,

E4039 Stationary oxygen systems E0434, E0431 2005 Medicare Allowable West Virginia 2004 Medicare Allowable West Virginia Reimbursement change (%) between

2004 & 2005 $200.41 $228.80 -12.40% Portable oxygen systems $31.13 $31.13 -0.00% A4253

Blood glucose test or reagent strips, $36.94 $38.52 -4.10% A4259 Lancets, per box of 100 $11.48 $11.48 -0.00%

E0260 Hospital bed, semi-electric, with mattress $1,404.60 $1,627.60 -13.70% E0277 Powered pressure-reducing air mattress $7,034.70

$7,593.60 -7.36% E0570 Nebulizer, with compressor $161.00 $195.20 -17.52% K0001 Standard wheelchair

$532.70 $546.20 2.47% K0011 Standard-weight frame motorized/power wheelchair with. $5,117.40 $5,117.40 -0.00%

Surviving and Thriving with the newest Oxygen Reimbursement Cuts Use ABNs for newest technology and equipment upgrades Use financing to match reimbursement with payment Best Price at the best rate will allow you to maximize cash flow Every time you set up a new oxygen patient you know how much positive cash flow you have created Take advantage of quantity purchases and promotions to get the best possible purchase price Surviving and Thriving with the newest Oxygen Reimbursement Cuts Maximize efficiencies for certain patient populations that

are better handled with an outside source Utilize a patient follow-up program to increase quality of life and quality of life for oxygen patients Utilize compliance programs to ensure patients are compliant with their oxygen Select the best modality and the best products for individual patients One size equipment doesnt work for everyone Maximize positive cash flow by patient not by equipment In 2004 (108th Congress) Reps. David Hobson (R-Ohio) introduced a bill, H.R. 4491, to repeal cuts in Medicare reimbursement for these items. Co-sponsors: 117 VA = 4 0f 11 or 36% Rep. Goode, Boucher, Goodlatte, Davis & WV = 2 0f 3 or 66% Rep. Mollohan, Rahall. When congress adjourned sine die, all legislation that was

not brought to a vote dies in that Congress hence H.R. 4491 is dead AAHomecare, VGM, state/regional associations lobbied hard for this repeal: Comparisons between Medicare and FEHBP are inappropriate FEHBP plans serve younger, healthier populations and impose fewer administrative burdens on providers. H.R. 4491 was still a success Our industrys grassroots effort that pushed the bill forward developed a relationship with 117 members of Congress. In reality, the actual chances of HR 4491 coming to a vote were slim during an election year as well a lack of a companion bill in the Senate. Should a new bill be introduced in 2005, it is a good bet that a large majority of the original 117 co-sponsors will sign on again. A new bill will give us a chance to meet

with our elected officials once again to address the FEHBP cuts as well as NCB. This can only help our cause moving forward! Rep. Hobson: I am committed to making sure that seniors who depend on durable medical equipment will continue to have access to the equipment and services they rely upon so they can maintain the highest quality of life while staying in their homes. 109th Congress: New legislators include those from the healthcare ranks HME's own Representative Mike Ross (D-AR)

has been appointed to the House Energy and Commerce Committee. Contact Rep. Ross at [email protected], or at his Washington D.C. office (202.225.3772) and extend congratulations to him for landing this plum position. The HME industry finally has a friend on this very powerful House committee! Ross and his spouse own and operate an independent pharmacy/HME business Other 2005 Issues: Part B Drugs Infusion drugs frozen at 95% of AWP (in effect since October 1,2003) and then subject to competitive bidding starting in 2007. Inhalation drugs based on the ASP plus 6% for the drug. This amount would be updated quarterly. A $57 monthly dispensing fee for inhalation therapies applies for 2005. CMS also set a 90-day

fee of $80 in the fee schedule (*). (*) It is assumed that you will no longer be able to bill the $5.00 (E0590) dispensing fee per drug dispensed. Nebulizer Medications Transition On January 1, 2005, CMS transitioned to the ASP pricing model for nebulizer medications. This change in reimbursement methodology has caused much confusion within the small to medium size pharmacy providers of nebulizer medications. The appropriate drug mix for this type of patient must now change to provide results that are best for both the patient as well as for the provider. As a result of this transition to more brand drug usage, the smaller providers have found themselves in a difficult position as it relates to the usage of the Brand Drug Duoneb. Dey has a pricing structure for this product that is not beneficial to the small and medium size provider. We have made many attempts to work with Dey to solve this problem and have received Zero cooperation in doing so. Deys current price structure for Duoneb allows for a large discount to providers purchasing 100,000 vials per month. This would be 833 patient shipments every month. Dey offers as much as a 50% discount from what small providers pay for providers purchasing 500,000 or more vials per month. Previously, when utilizing their albuterol and Ipratropium generic products, small to medium size providers were within 5 cents of the same pricing offered to the largest providers. For Duoneb the difference is in excess of .40 cents per dose allowing the large providers to pocket an extra $50.00 per patient shipment.

To solve this problem and better even the playing field, we are suggesting that instead of switching patients to Duoneb, your pharmacy should consider using one vial of Xopenex and one vial of ipratropium (where necessary). This will offer you patients the benefits of Xopenex with equal benefit of albuterol but with only half the active ingredients of albuterol. This benefit also reduces the side effects of normal albuterol by as much as half. This is a true benefit to the physicians and patients. Sepracor has over 1,500 detail representatives ready to work with you and inform physicians of your choice to offer their product. It is like adding sales reps to your company for free. When you compare the profitability, you will also find that you will make a substantially higher profit that when using Duoneb. We offer this solution to our VGM Members. Other HME Provisions of MMA (none positive) CPI Freeze 5 year freeze in the CPI update for DME and off-the-shelf orthotics in those areas where competitive bidding is not being phased in, in 2007 and 2008.

COMPETITIVE BIDDING COMPETITIVE ACQUISITION AUTHORITY: Section 302 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173) authorizes the Secretary to utilize our competitive acquisition authority, as outlined in the U.S. Code Section 1847(a). Section 302(b)(1) of the Medicare Modernization Act, requires Medicare to replace the current durable medical equipment (DME) payment methodology for certain items with a competitive acquisition process to improve the effectiveness of its methodology for setting DME payment amounts. This new bidding process will establish payment amounts for certain durable medical equipment, enteral nutrition, and off?the?shelf orthotics. Competitive bidding provides a way to harness marketplace dynamics to create incentives for suppliers to provide quality items and services in an efficient manner and at reasonable cost. The Medicare DME Competitive Bidding Program has five objectives: 1.

To operationalize competitive bidding for DME and to use this to determine appropriate prices for categories of DME covered by Medicare Part B; 2. To protect beneficiary access to quality DME throughout the program; 3. To reduce the amount Medicare pays for DMEPOS and bring the reimbursement amount more in line with that of a competitive market; 4. To limit the burden on beneficiaries by reducing their out-of-pocket expenses; and 5.

To mitigate proliferation of use of certain items of DMEPOS by contracting with suppliers who engage in a business model that is beneficial for the program and for Medicare beneficiaries. In the coming months CMS will be publishing more information and resources Competitive Bidding Commences in the 10 of the largest MSAs in 2007; followed by the next 80 largest MSAs in 2009. After 2009, (the DHHS) Secretary has authority to apply Competitive Bidding prices nationally. Note: CMS is interpreting Sec. 302 of the MMA to read ten of THE largest MSA with population of 1million or more. Competitive Bidding The Largest MSAs 1. Los AngelesLong Beach, CA

2. New York, NY 3. Chicago, IL PMSA 4. Philadelphia, PANJ 5. Washington, DC/MDVA/WV 6. Detroit, MI 7. Houston, TX 8. Atlanta, GA 9. Dallas, TX 10. Boston, MANH COMPETIVE BIDDING FACTS Total amounts paid under the contract (including costs associated with administration of the contract) be lower than the total amounts that would otherwise be paid Requires re-bid of contracts ** NOT TO EXCEED** every 3 years Allows limitation of number of contractors in a

competitive acquisition area to the number necessary to meet product demand Requires the award of contracts to multiple entities in each area for an item or service. Requires that entity to meet quality and financial standards. Requires studies to determine whether suppliers under competitive bidding influence physician prescribing practices based on profitability of products. Requires report to Congress annually on the competitive acquisition program. Each report shall include information on cost savings, reductions in beneficiary cost sharing, access to and quality of items, and beneficiary satisfaction. Requires GAO to submit report to Congress on the impact of Competitive Bidding on manufacturers and

suppliers by January 1,2009. PROTECTION OF SMALL SUPPLIERS In developing procedures relating to bids and the awarding of contracts under this section, the Secretary shall take appropriate steps to ensure that small suppliers of items and services have an opportunity to be considered for participation in the program under this section. Other MMA Regulatory Issues Requires establishment and implementation of quality standards and accreditation requirements. One year after the quality standards are developed, DHHS is required to designate and approve one or more independent accreditation organizations. Quality standards as applied by accrediting

organizations must be met in order to receive or retain a supplier number. Mandatory Accreditation Many providers we surveyed comment that accreditation had a positive impact on their business, and others said they would investigate accreditation as a way to improve their companies. However, the majority of providers remain unaccredited (estimated at about 60%). About one fourth of unaccredited providers are considering accreditation in 2004. REPORT ON IMPACT OF FEHBP CUTS ON COMPETITIVE BIDDING SAVINGS Summarized from report written by economist Dr. Kenneth Brown, Ph.D. Allowed Charges

Under Demonstration (Modified) Allowed Charges in Absence of Demonstration (Modified) Polk County, Florida $21,315,740 $26,184,833 San Antonio, Texas $14,786,802

$18,731,722 $36,102,542 $44,916,555 Grand Total Actual Administrative Expenses Actual Savings to Medicare Pro-forma Allowed Charges in Absence of Demonstration - After FEHBP Polk County, Florida $21,315,740

$23,564,225 San Antonio, Texas $14,786,802 $16,807,336 $36,102,542 $40,371,561 Actual Administrative Expenses Actual Cost to Medicare $4,869,093 $3,944,920

% Differential 18.6% 21.1% $8,814,013 19.6% -$4,800,000 -54.5% $4,014,013 Allowed Charges Under Demonstration

Grand Total Differential Differential $2,248,485 $2,020,534 8.9% % Differential 9.5% 12.0% $4,269,019 10.6%

-$4,800,000 -112.4% -1.3% -$530,981 Program Advisory and Oversight Committee (PAOC) Overview In order to allow the industry to have input on the DME provisions of the MMA (e.g., FEHBP cuts, competitive bidding, mandatory accreditation), CMS formed the PAOC. Equipment manufacturers (e.g., Sunrise, Invacare and Pride Mobility), three state Medicaid programs, two national provider associations, national and independent

HME dealers, independent pharmacies, accrediting bodies, manufacturers that sell directly to patients and advocacy groups make up PAOC. The committee is charged with assisting CMS in the development of a national competitive bidding program. PAOC MEETING SUMMARIES INITIAL MEETING OCTOBER 6, 2004 Review of the competitive bidding demonstration projects Quality Standards

Scored savings from NCB Items of concern following the meeting Savings in light of the FEHBP cuts What standards do winning bidders have to meet Dealers allowed to form networks to bid Cost shifting

SECOND MEETING DECEMBER 6 & 7, 2004 Review of existing DME competitive bidding programs VA Utah O2 Minnesota Wheelchair Possible program design Bidding Cycles MSA selection Possible Phase-in process MSAs Equipment/ HCPCS codes THIRD MEETING FEBRUARY 28, MARCH 1 & 2, 2005 Timetable for NCB process Summer 2005 Publish regulations for NCB Fall 2005 Review comments Spring 2006 Finalize proposed regulations and move them thru Congress

Fall 2006 Begin Implementation process January 2007 Implement in 10 large MSAs All decisions are preliminary until the final regulations are published. PAOC will have an open door forum after the preliminary regulations are made public. Progress on issues raised in previous PAOC meetings CMS has been given more money to study the impact on small businesses CMS allocated more time and money to development of quality standards Coding changes and improvements CMS was told that the Congressional Budget Office factored in the FEHBP cuts and CPI freeze when they scored the NCB savings?

Bid solicitation process Step 1 Evaluate the Basic eligibility requirements Valid NSC number No current CMS sanctions Valid state or local licenses ( if applicable) Step 2 Calculate the composite bid Individual items? Product categories? Bid solicitation (continued) Step 3 Array the bids lowest to highest Step 4 Evaluate Quality Step 5 Evaluate financial capabilities of bidders Bid solicitation (continued)

Step 6 Calculate market and supplier capacities Step 7 Select Pivotal Bid Everyone at or below the pivotal bid is selected as a winner if they meet all other requirements Options being considered for selecting number of winners Pick enough winners so all estimated demand is met Base bid on the median rate Pre-select the number of winning bidders and take the lowest rates Base the bid on a target composite bid i.e. Give the bid to anyone who bids 20% off Determining Payment amounts

Bid individual HCPCS codes and set rates on each Bid a group of codes and award the lowest total rate Principles of Bidding Principle 1 Bidders at or below the pivotal bid are selected as winners Principle 2 All winning supplies will be paid the same price for each item Principle 3 - Winning suppliers will have to receive at least as much for an item as they bid Rural Area and Low Population

Density Exemption Authority Area Phase-in; 10 MSAs in 2007 80 MSAs by 2009 2010 - ? Proposed Approach to Accreditation During Summer 2005, RTI will conduct focus groups in 3 4 sites across the US yielding responses from 40 1000 small suppliers. First Focus group was at MedTrade West Potential market areas: Atlanta, Cleveland, Denver, Chicago, Minneapolis, Raleigh / Durham, NC CMS Announces More Focus Groups for Small HME Providers

on "Competitive Bidding" and Seeks Email Feedback The Centers for Medicare and Medicaid Services (CMS) has announced focus groups in Dallas and Chicago for small home medical equipment (HME) providers to help CMS evaluate the effect of quality standards, accreditation, and the selection process under "competitive bidding." By small, CMS means providers that have gross annual revenues of $3 million or less and/or 10 or fewer full-time equivalents. Both accredited and non-accredited providers are welcome. In a statement, CMS says it is particularly interested in providers with $1.5 million or

less in revenues to "assist CMS in considering alternatives for the protection" of small HME providers. CMS plans two focus groups in Dallas, TX on Wednesday, May 4 and two in Chicago, IL on Thursday, May 5. To register for one of the focus groups, please contact [email protected] by Wednesday, April 27th. CMS asks that you rank your location and time preferences and provide the following information: Name of Business Mailing Address Phone Number Estimated gross revenue (2004) Is your business accredited? (Y/N) If yes, by whom?

Number of FTE's (full time equivalents) Primary product categories offered by your business (e.g. oxygen, mobility aids, etc.) CMS says, "Space is limited to 16 participants per session and registration is on a firstcome basis. However, RTI may modify participants to allow participation from the various regions. Input from the various areas is very important. Among those selected to participate, only one participant per company will be allowed." The statement notes that, "If you do not receive a confirmatory email by the end of the day on Friday, April 29th, you have not been selected to participate in this round of focus groups." However, CMS says those not attending the focus groups can provide feedback on these issues via email by sending comments to [email protected] To get full details, see the CMS announcement at: Size of Competitive Acquisition Areas May expand the size of areas for 2007 & 2009 to

include areas adjoining the MSA if it is determined they are highly competitive or are high utilization areas. May carve out areas within an MSA if they are not considered competitive Nationwide Areas may be considered Items that can be provided via mail order. Quality Standards MMA Section 302 . The Secretary shall establish and implement quality standards for suppliers of items and services described .. To be applied by recognized independent accreditation organizations.. This applies to; 1. Furnish any such item or service

And 2. Receive or retain a provider or supplier number Quality Standards Domains Organization Structure Financial Management Human Resources Patient/Client Management Assessment and Evaluation of Quality Facility and Patient Environment and Safety Management Ethics/Rights Information Management (Patient Records,etc.) Accreditation Accrediting bodies Rational for Accreditation MMA Section 302 The Secretary shall designate and approve one or more

independent accreditation organizations Small Business Companies are considered small by: SBA & NAICS if they do less than $6 million in annual sales CMS if they employ 10 or > people Based on these criteria 60% of DMEPOS suppliers qualify as small businesses KEEP IN MIND MMA 2003 does allow for the exclusion of some products and geographical areas. CMS is looking closely at the VA and some Medicaid programs for implementing this program. Even through it was pointed out in a very clear terms that these programs operated very differently than Medicare. In fact, a CMS representative alluded to the fact that Medicare is using HME Competitive Bidding

to see if there are other areas for competitive acquisition of health care. Summary: Your message to Congress and federal regulators is simple: Homecare provides high-value, high-quality care at a low cost. We are the solution not the problem. Homecare is the answer to the health care crisis because it delivers tremendous value for Americans' health care dollars. GRASS-ROOTS EFFORT You Can Do In Your Home District Advocacy Tips Providers from the home district of a member of Congress

have much more clout than people from outside that district. You represent an important service and important business that contributes to the well being of the district, in terms of jobs and the economy as well as health care. When you meet with or contact your member of Congress by fax, put a human face on the issue. Describe how the issue would affect people in the district. Encourage your employees to be politically active on issues that affect this industry. Advocacy Tips Become a valued resource to members of Congress and their staff on homecare issues so you are the local expert on these issues. Utilize HCVA (, AAHomecare ( and VGMs DC Link ( for details about homecare legislation and regulatory issues.

CONTACT YOUR LOCAL ELECTED OFFICIAL Before you make the call, familiarize yourself with the issue and write down the points you want to cover visit and click on DC Link for additional support material. While at D.C. LINK get the telephone number and address for your elected officials. When you call or go by the district office - Always identify yourself as a CONSTITUENT Ask to set up an appointment with your elected official in their office or at you store. Offer your location as the best option. Set the Agenda. Let the Staff member know what you will cover Go to D.C. Link and click on VIRGINIA Web Site: E-mail: Contact Via

'Write Your Rep.' Danville Phone: (434) 792-1280 Fax: (434) 797-5942 Address: 437 Main St. Danville, VA 24541 Farmville Phone: (434) 392-8331 Fax: (434) 392-6448 Address: 103 South Main St. Farmville, VA 23901 Rocky Mount Phone: (540) 484-1254 Fax: (540) 484-1459 Address:

70 East Court St., #215 Rocky Mount, VA 24151 Rep. Virgil Goode (R) 5th District 4th Term = Appropriations Committee Washington Office: 1520 Longworth House Office Building Washington, D.C. 205154605 Phone: (202) 225-4711 Fax: (202) 225-5681 Main District Office: 104 South 1st St. Charlottesville, VA

22902 Phone: (434) 295-6372 Fax: (434) 295-6059 Go in person to your local Congressional district office Introduce yourself to the local Congressional district office staff MEETING WITH YOUR LOCAL ELECTED OFFICIAL KEY MEMBERS OF THE HCAV CONGRESSIONAL DELEGATION SENATE:

Senator George Allen (R-VA) Small Business & Entrepreneurship Senator John Warner (R-VA) Chairmen Armed Services Senator Robert Byrd (D-WV) Ranking Member Appropriations Senator John Rockefeller (D-WV) FINANCE HOUSE: * Rep. Jo Ann Davis (R-VA, 1st Dist) Armed Services Rep. Thelma Drake (R-VA, 2nd Dist) NEW MEMBER * th Rep. Virgil Goode (R-VA, 5 Dist) Appropriations * Rep. Bob Goodlatte (R-VA, 6th Dist) Chair - Ag Rep. Eric Cantor (R-VA, 7 th Dist) Ways & Means (Whip) * Rep. Rick Boucher (D-VA, 9th Dist) Energy & Comm

* Rep. Alan Mollohan (D-WV, 1st Dist) Appropriations * Rep. Nick Rahall (D-WV, 3rd Dist) Resource (Rnk Mem.) = Signed as co-sponsor to HR 4491 YOU HAVE 15 MINUTES WITH YOUR CONGRESSMAN OR SENATOR --- WHAT DO YOU DO NOW? 1. TELL ME WHAT YOUR GOING TO TELL ME 2. TELL ME tell your story - promote the beneficiary

3. TELL ME WHAT YOU TOLD ME 4. CLOSE BY ASKING FOR SOMETHING THE ASK FOR WITH YOUR MEMBER OF CONGRESS 1. In light of the FEHBP cuts that are going into place January 1, 2005, we request that the CBO re-score the competitive bidding demonstration project estimated savings. 2.

In order to bid something under NCB, a dealer needs to know what standards will apply if they are a winning bidder. It does not appear that the MMA gives CMS enough time to address the standards issue. What would be required to move the Standards and Accreditation criteria forward on the fast track? 3. For CMS to move forward with NCB, there needs to be a provision where groups of companies can go together under one umbrella to bid, i.e. a network (RTI has referred to this as a Alliance in their presentation). One concern is that the organization functioning as the network administrator must be allowed to get a Medicare Provider number. CMS needs to addres this possibility, and be prepared to facture the networks or alliance in to the NCB planning process. 4. Several members of the PAOC board asked that CMS / RTI conduct a study of the effect of Re-admission rates of patients who where involved in the Demonstration

Projects conducted in Polk Co., FL and San Antonio, TX. Is CMS following up on this request to see if there was indeed a cost shift in the demonstration projects? 5. Demand CMS complete all five Demonstration Projects mandated by the BBA97. VGM ACTION PLAN 1. Develop Action Plan to have CMS or Congress request CBO to "RESCORE" NCB factoring the FEHBP cuts - are there any true savings (Dr. Brown's study on Polk Co. and San Antonio, TX). 2. Determine what is the "COST" of implementing NCB and overlaying that with the information in # 1. What % "SAVINGS" remain under NCB? (Have Dr. Brown develop cost overlay study. Combine with study on FEHBP cut impact on Savings) 3. Determining if there truly was a "COST SHIFT" during the demonstration projects of patients from DME to Hospital Care. What is that cost? And, can we get the numbers (perhaps a Dr. Brown number crunch with Mark H. help ** Look at Average Admissions of people from Home Care to Hospital care). Develop

natural allies from NE Governors and other States to question the idea of "Cost Shifting" to State Medicare budgets under NCB. 4. Request Senator Grassley, Congressman Nussle and others direct the HHS Sec. to conduct the three Demonstration Projects that where never completed during BBA-97 (Large, Under Served and Rural MSA's), thereby delay implementation of NCB until this Demonstration Projects validate the concept of NCB. Determine the legislative mechanism to delay NCB, while not change the MMA law? 5. Contact polling firm to conduct survey of Residents (beneficiaries) in large Metro / MSA areas (NY, NJ). Look for issues of access to quality of care and concern over loss of current provider. 6. Develop Triple Track approach to combating National Competitive Bidding: Legislative Develop a champion for the industry Grass-Roots Coordinate Grass-Roots activity a provider level Legal Develop Legal effort to delay and or defeat NCB

COPD CAUCUS Urge Members of Congress to Join the Congressional COPD Caucus The bipartisan Congressional Chronic Obstructive Pulmonary Disease (COPD) Caucus was formed by Senator Michael Crapo (R-ID) who chairs the Caucus with Senator Blanche Lincoln (D-AR), Rep. Cliff Stearns (R-FL) and Rep. John Lewis (D-GA). COPD is a growing healthcare crisis that afflicts more than 14 million Americans and costs $18 billion in direct medical expenses annually. The Caucus will focus on a vast coalition of patient/homecare associations and physicians to both educate Members of Congress on COPD as well as advocate public policies to strengthen and encourage early detection and prevention. Additional members of the Caucus include Sen. Thad Cochran (R-MS), Sen. Richard Durban (D-IL), Sen. Rick Santorum (R-PA), Rep. Tammy Baldwin (D-WI), Rep. Duke Cunningham (R-CA), Rep. Jim Gerlach (R-PA), Rep. J.D. Hayworth (R-AZ), Rep. Raul Grijalva (D-AZ), Rep. James Langevin (D-RI), Rep. Zoe Lofgren (D-CA), Rep. Karen McCarthy (D-MO), Rep. Thaddeus McCotter (R-MI), Rep. Marty Meehan (D-MA), Rep. Victor Synder (D-AR), Rep. Ed Towns (D-NY), and Rep. Chris Van Hollen (D-MD).

What does the future hold for DME? Of course those of us who have been in the business for a long time understand that we are the favorite whipping boy of the politicians and that we have to adapt to this along with fighting it. We have learned and prospered. In the 80s, the industry encountered Medicare reimbursement changes from pure rental, to purchase, to OBRA and the six-point plan. The 90s brought the BBA of 1997. Each of these drastic changes was hailed as the death of our industry. And, as you know, each time that death was prematurely reported and each attack was followed by growth and continued earned prosperity for most providers. Jim Walsh Council - VGM Ms. Wheelchair America 2005 = Ms. Juliette Rizzo Ms Maryland Congratulations VIRGINIA for MWVA & MWA Runner Up Dr. PAM CLARK

WEST VIRGINIA did not hold a 2003 or 2004 Ms. Wheelchair Pageant Thank You For Opportunity to Speak to HCAV! Presented by John E. Gallagher The VGM Group [email protected]

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