Home Health & Hospice Week

 GAO urges CMS to take a close look

One of the hardest bundling situations for home health agencies and suppliers to get used to under the prospective payment system concerned ostomy supplies.

"The whole thing makes very little sense," says Colin Cooke, a consultant for the United Ostomy Association. For example, under PPS bundling, a patient who is admitted to home care for a broken hip and who also happens to have an existing ostomy must obtain her ostomy supplies from the HHA for the duration of the episode.

"The ostomy isn't related to the reason for home health," Cooke protests, so why should the patient have to switch suppliers and possibly products? Chances are she's been managing her condition with ostomy supplies obtained from another supplier for years.

And most smart HHAs are now using a formulary for the supplies they furnish, including ostomy supplies. If a patient uses a brand of supplies that aren't on the HHA's formulary, she either has to switch types or pay for her usual supplies out of her own pocket.

"It's hard for the HHA to provide what every patient needs" due to the high cost of ostomy supplies, notes Linda Aukett, UOA's government relations chair. Under PPS, it makes financial sense for agencies to "turn a blind eye" to the supplies the patient has been using, she says, even if they have been recommended by ostomy specialists.

Members of UOA, which represents ostomy users, want all reimbursement of ostomy supplies to remain under Part B of Medicare, even if a patient is under a home health plan of care, Aukett says. Ostomy users and their advocates "have focused their energy on improving Part B payment," including coverage, billing codes and other areas.

Bundling ostomy supplies under home health PPS allows the Centers for Medicare & Medicaid Services to bypass all those improvements by giving HHAs financial incentives to limit patients' ostomy supply access with a formulary, she says.

HHAs and medical suppliers generally would be equally as happy to have ostomy supplies unbundled (see story, previous page).

And while the General Accounting Office hardly gives a resounding endorsement of unbundling in its recent report on home health medical supply costs, it does urge CMS to examine the issue closely for supplies related to chronic conditions. CMS "should gather and evaluate evidence on whether there have been systematic disruptions in care for some patients under PPS" when they have to switch supply types, the GAO recommends.

The watchdog agency notes that in CMS' comments on the report, it failed to mention this problem with supplies bundling. "It is important to explicitly consider this group of patients in designing analyses of the impact of the home health PPS and to consider changes to the payment to ameliorate any identified problems," the GAO stresses.

In wound and ostomy circles, it generally is believed that unbundling of ostomy supplies will occur before unbundling of wound care supplies, observes Patti Johnston, president of Positive Outcomes Inc. in The Woodlands, TX. That's because ostomy supplies are usually unrelated to the home health plan of care, and PPS rules force patients to change from their long-time supplies to new supplies mandated by an agency's formulary.

But former CMS official Bob Wardwell doesn't think providers should hold their breath for any unbundling of supplies. Wardwell, now with the Visiting Nurse Associations of America, says while at CMS he was a proponent of the idea because it would cost Medicare little money but would make both HHAs and beneficiaries happy. But CMS' top brass gave any unbundling proposal "a very chilly reception," Wardwell tells Eli.

Unbundling any items would work against the principle of the universal payment under PPS, and could set a dangerous precedent, CMS heads said, according to Wardwell. And if the change didn't save Medicare any money, there was no incentive to undertake it.