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                                   those changes have a relevant, possibly observable impact on the population of intended users that we identified when we designed that product, and I’ve designed this product to address a need that’s
not addressed by the products that are currently coded — then I should be able to get a unique code for that.
“With many technologies the patient-specific outcome is observable; [the product] meets the medical or functional need, or it doesn’t. If I can demonstrate, through observation of the product or scientific evidence of the product — maybe case studies where clinicians have trialed products with patients or followed patient outcomes for an appropriate period of
time or done comparative effectiveness studies to see which products answered the patient’s identified medical and functional needs — and I can demonstrate that the products are different and have a different outcome, I should be able to obtain a unique HCPCS code to ensure access, so that the payors can create coverage policies around these products and the population of people they serve.”
What today’s CRT users don’t need,
Stanley said, is just more of the same tech- nology for years to come.
“There are already tons of products that fit the codes,” she said. “The only advantage that a manufacturer can really bring is if they can innovate to meet unmet medical needs. But if you’re going to shove [an innovative new product] into the existing code with the same existing allowable, [manufacturers] have zero incentive to be innovative. And they can’t build innovative technology when there is an artificial allowable constraint.”
Reimbursement is also a problem for CRT providers who, by nature of the consumers they work with, deal almost entirely with higher-end technology.
“There is an assumption made by some at CMS,” Stanley said, “that if all the prod- ucts are in the same code and we’ve got this allowable, sometimes a supplier is going to make a decent allowable, sometimes they’re going to lose money. Hopefully, at the end of the day, it comes out equal.
“The problem with that theory is suppliers that are providing the stan- dard product are not typically the same suppliers who are doing the majority
of the CRT. So the supplier who does complex rehab all day long never sells enough of the product that he makes margin on to make up for the products he loses money on. So he’s losing money almost every single time.”
Many Stakeholders, One Goal
If there’s a bright spot in the ongoing challenge of adjustable seat cushion codes, it’s this: Aligning the HCPCS codes with function and outcomes would benefit all involved parties.
“All stakeholders win in a scenario where HCPCS codes are established based on technological and functional differences and their benefits to consumers, and then
payment and coverage are all associated with that properly,” Stanley pointed out. “The payor is paying for what the consumer is receiving. Consumers are getting what they need. And you’ve even promoted the economic side of it: Manufacturers are going to develop innovative products that meet unmet medical needs.”
For that to happen, Stanley believes that a product’s functions and features need to be part of the code that’s being created.
“The model needs to change, with technological differences and the func- tionality and features [becoming] the basis for coding,” she said. “For headrests alone, you could easily have five or six different codes that would represent the array of headrest technology. You could go through each of the HCPCS codes and clearly identify features and functions: What are those technological differences that are relevant, and why are they rele- vant, and who are they relevant for?
“If that were the basis of the HCPCS code set, you would see a very different outcome for every single stakeholder, including payors. Then if they decide to competitively bid the standard technology, at least everybody is bidding on the same features and functions. It may not be
the exact same cushion, but at least the minimal standards are consistent, and you don’t have a whole array of product that exceeds the minimum requirements, but nobody can obtain it because of the cost.”
In that model, products within a code would all have comparable features and functions to serve a common patient population. Manufacturers could choose to differentiate their products in other ways, such as by improving aesthetics.
“If I want to add features that make
it preferable to a consumer, but aren’t a medical necessity — if I make mine weigh five ounces less, or I paint it some new funky color of pink — that’s something
that becomes patient choice and becomes a manufacturer’s prerogative, and we compete in those different ways,” Stanley said. “But when it comes to medical necessity, patients shouldn’t have to pay out of pocket. That should be something covered by their insurer, whoever their insurer is.” m
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MOBILITY MANAGEMENT | JANUARY 2019 19
When it comes to medical necessity, consumers shouldn’t have to pay out of pocket — Rita Stanley
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