Competing for care

View larger image Sandi Waugerman is aided recently by Angie Fishel, a registered respiratory therapist and director of Valley Home Care, at Waugerman's home in Winchester. Waugerman suffers from amyotrophic lateral sclerosis, commonly known as Lou Gherig's Disease. Dennis Grundman/Daily View larger image Fishel and June Weatherholtz, a licensed practical nurse and home health care provider, visit with Waugerman at her home. Dennis Grundman/Daily

Change in Medicare equipment policy could affect patients, vendors

By James Heffernan - jheffnernan@nvdaily.com

WINCHESTER -- Sandi Waugerman's home is a modest three-bedroom ranch in a quiet, older neighborhood, with a shade tree in the front yard and a nameplate next to the front door. The inside is neat and tidy, but also warm and welcoming. Antiques and trinkets line the walls and family portraits are on every tabletop and screen saver.

Waugerman, an engaging woman with snow-white hair and eyes full of hope, is propped up in a recliner in front of her computer, a familiar perch from which she can keep in touch with friends and family, check her Facebook page and continue work on her book about living with amyotrophic lateral sclerosis.

The 56-year-old was diagnosed with ALS, more commonly known as "Lou Gherig's Disease," in 1993. The condition, which slowly kills the nerve cells in the brain and spinal cord that control voluntary muscle movement, has left her with no mobility except in her neck, jaw and feet. She can't speak or swallow and requires a suction tube to capture any oral secretions.

A purse-sized ventilator on the corner table is attached to her trachea, pushing air into her lungs at regular intervals and helping control her breathing.

The portable, state-of-the-art device, which arrived last December courtesy of Valley Home Care, was a "beautiful Christmas present," her longtime nurse, June Weatherholtz, says -- small enough to travel with her outside in the yard on occasion or even to Wal-Mart or Kohl's to shop.

"When Sandi first came home, she wasn't ventilator-dependent," says Angela Fishel, a respiratory therapist and director of Valley Home Care, a division of Winchester-based Valley Health. "Now, at this stage, she needs a ventilator round the clock."

Valley Home Care also provides Waugerman with oxygen, a hospital bed, seat lifts, a wheelchair and other items that allow her to be cared for at home. Fishel or a member of her team visits at least once a month to make sure the equipment is working properly and are on call 24 hours a day in case there's a problem.

Asked what she would do if she were to lose the service, Waugerman focuses her gaze on a block of letters on the computer screen in front of her. A laser scanner attached to her glasses tracks her right eye's movement and the words slowly begin to appear.

"I ... would ... have ... to ... go ... to ... a ... nursing ... home," she says.

Her mind is sharp, but the software isn't keeping up, and she is growing frustrated. Weatherholtz holds up a card with letters that Waugerman can point to with her toes to finish her thought.

"I ... would ... want ... to ... be ... disconn ..."

"No, dear, let's not go there," Weatherholtz says.

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As a Medicare patient, Waugerman could soon be forced to use a different home medical equipment supplier, one chosen by the federal government in a competitive bidding process. Worse, she may lose the ventilator she has come to depend on, as those providers who win bids would likely face reduced reimbursement rates and there would be little financial incentive for manufacturers to develop new technologies.

The Medicare Modernization Act of 2003 requires Medicare to replace the current home medical equipment payment system with a selective contracting process. Any provider not awarded a contract would be prohibited from providing home medical equipment or services to Medicare patients for a three-year period.

A pilot program was rolled out in the 10 largest metro areas in the country in 2008, with mostly disastrous results -- patients forced to go to multiple providers for their equipment and service, increased hospital stays, large national companies attempting to serve an unfamiliar territory, and so-called "desperation bidding" from providers faced with the threat of losing their business if they aren't awarded a contract.

The program was scheduled to be extended to an additional 70 metro areas, but Congress issued a stay in the summer of 2008 to try to correct some of its flaws. However, advocates say the Center for Medicare Services has since turned a deaf ear to proposed reforms.

"Sadly, the program today is unchanged," said Shawn Steffey, owner of RCA Home Medical, a small Winchester-based provider that opened in 2000 and competes with Valley Home Care for a 15-county territory in Virginia and West Virginia.

As it stands, the two companies must submit bids next year as part of the larger Baltimore-Washington metro area. The new system would take effect in January 2013.

Both Steffey and Fishel are concerned that quality and service will be compromised under a competitive bidding system. The few home health care providers that survive would face severe budget constraints, they say, and the first thing that would be cut is service.

"Neither of us will win bids in every category," Steffey says.

"Our patients know us. They trust us," Fishel says. "Where are they going to go?"

Most likely they will wait until they have to go to the emergency room, she says, shifting the costs from Medicare Part B to the more expensive Part A.

Home health care providers can care for a patient for a full year for less than what it costs to keep that person in a hospital for half a day, Steffey says.

Competitive bidding is actually anti-competitive, he adds, reducing the number of market competitors and potentially putting many small providers like his out of business.

"I'm afraid we'll realize a lot of this after it's too late," he says.

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Waugerman is a fighter.

"I haven't let ALS stop me from doing the things I believe in," she says.

Waugerman is a member of the ALS Guardian Angel foundation, a support group for those suffering with the disease.

"I just encourage them to fight a little more," she says.

Her tireless advocacy has earned her friends and visitors from as far away as England.

Family support is also key, she says. Waugerman has two sisters in Front Royal, as well as two sons, two stepchildren, and five grandchildren who visit her regularly.

After eight years of caring for Waugerman in her home, Weatherholtz and Fishel are part of the family as well.

"They're wonderful," she says.

Fishel and Steffey have become fighters, too, attending hearings on Capitol Hill and drumming up support for legislation introduced by Rep. Kendrick Meek, D-Fla., to end competitive bidding for home medical equipment. They recently convinced 10th District Rep. Frank Wolf to sign on as a co-sponsor and asked that senators support a companion bill to H.R. 3790.

"We continue to fight and stay very active," Fishel says.

They encourage anyone who is concerned about competitive bidding of home medical equipment to contact their representatives in Congress or call the U.S. Capitol switchboard at 202-224-3121.