A Commentary, A Personal Viewpoint
For those doctors and clinicians that work with us closely you know our frustration with reimbursement. Especially frustrating is the coverage of TENS from CMS Medicare and Oregon Health Plan CCOs like Care Oregon. Workers Comp has joined the group of none or cheap payers too. Why? Because they can! Frankly you only survive in DME vending today if you have the political power to influence CMS and their regional so-called Medical Directors. Working with great local HMO/PPO organizations is a blessing and the only sanity in the system.
Many DME products have taken a sharp reimbursement haircut but nothing more dramatic than TENS. Although this might be the most over studied DME product in US history and most of those studies clearly show evidence that TENS works well in reducing pain. I have heard the science explained a couple ways, but one thing is for sure, the studies support TENS and outcomes are consistent. 10 years ago, there was a solid argument that reimbursement was too robust for a simple and aging technology. I agreed. And we know too well, abusers of the system that have billed unethically staining the reputation of great companies like EMPI. EMPI was closed over two years ago for violating CMS policy and years of unprofitability. The business model didn’t match the reimbursement sadly. CMS audited well beyond good intentions in this case, a common practice in the last administration.
But it is important to point out that CMS started the ball rolling by eliminating coverage for all lower back related diagnosis codes. More importantly their change in document procedure for reimbursement put a fork in it much more successfully. If you have a valid Dx code, covered by Medicare or a Medicare guideline policy you must tackle the gauntlet of paperwork and signatures. You need a RX for a “30-day trial” and very specific doctor chart notes recommending the TENS. 30 Days later to convert the transaction to a purchase or rental you need a special CMN form signed by the doctor after they have charted a follow up visit which seldom happens too. I must tell you from experience, ZERO percent of doctors will fill out the form because the questions are very confusing, and ZERO doctors will chart that the TENS is doing the intended job. And if we were successful in that juggernaut of communication, we would get a whopping $47. This is well below our cost for a high-quality FDA, FCC approved medical grade TENS with a good interface and recharging system. I refuse to sell a $20 import piece of garbage like the VA and Kaiser Permanente distribute to their patients.
Now let’s tackle the Oregon Health Authority. A monster sized state department with over 4300 employees running a $20 billion budget. Their CCOs recently stop paying us $59 for a TENS machine. They never paid us for supplies. I have several clients, one a very well know provider in the pediatric space, that finds TENS hugely successful treating pain for many chronic pediatric illnesses. They were shocked how easily pain drugs are covered and are flat out livid that TENS is no longer covered. One CCO case worker I know, who is frustrated with OHP, said they are claiming TENS is interventional and outcomes were not measurable? I asked her if she understand the concept of “self-fulfilling prophecy”? Yes, if you give out a cheap $20 TENS, use it improperly and do not send ongoing supplies for use the outcomes will most likely not be good. I know of many pediatric patients and parents that are so grateful for the relieve our high-quality units are providing. I have pain doctors and orthopedic surgeons that love the use of TENS.
Regarding workers comp coverage in Oregon and Washington. Good or fair in some cases, abusive in others. Sadly, our competitors stuck it to this group of providers for years and they are now paying us back in spades. But the short sightedness of SAIF and Washington’s Labor and Industry is increasing the overall cost of medicine and insurance. Yes, their mission to get even is fair and reasonable. Sorry the patients must suffer along the way.
We are not here to change medical philosophy, we know that. For example, we are not going to convince a young PT who just spent $200K on their DPT degree, who received very little modality training, that electrotherapy will help with pain, inflammation, circulation and sleep which leads to healing. We are at peace with their very good work. We have shifted most of our business and partnerships with doctors that now realize it is their job to address pain safely. We hear all about the war on opioids from the President all the way down to Kate Brown. But I call BS on these bureaucrats and politicians. We know our patients reduce drug use, sleep better, move more and heal faster when using TENS. I invite anyone to an intelligent debate on that subject. Did you know the average monthly supply of an opioid costs about 600 dollars?
We don’t need to compare apples and oranges to make intelligent choices. Join us in a smart and common-sense approach to medicine. Our philosophy is to put the patient first, treating each one with the care and respect we would expect for ourselves. Keep an open mind and advocate for the Right Thing!
Bill Booth, Managing Partner, MedStar NW