Goodbye 2010

In my last blog, I talked about resolutions. I wasn't discussing resolutions for the DME industry, and did I hear about that!

An optimist stays up until midnight to see the new year in. A pessimist stays up to make sure the old year leaves. (Bill Vaughn)

Cheers to a new year and another chance for us to get it right. (Oprah Winfrey)

A new year is a new opportunity, I've been told by some of my readers. That's true. What I say in response is that a new day is a new opportunity; a new hour is a new opportunity. I suppose, though, that a new year is symbolic, so we'll greet the new year with suggestions for the industry as we drop-kick 2010 out the back door.

We will open the book. Its pages are blank. We are going to put words on them ourselves. The book is called Opportunity and its first chapter is New Year's Day. (Edith Lovejoy Pierce)

Suggesting Resolutions
It is only too easy to make suggestions and later try to escape the consequences of what we say. (Jawaharlal Nehru)

I think people hesitate to make strong suggestions because it puts them on the spot. Sometimes suggestions, if carried through, are good things. And sometimes, if suggestions are carried through and don't turn out well, things aren't so good; people today tend to like pointing the finger of blame too much. So most of us keep our heads down low and say as little as possible.

Unless, of course, we can give input and make suggestions anonymously. I (obviously) don't have a problem with that; sometimes anonymity creates an environment where freedom of expression can be fully enjoyed, which permits the airing of ideas that may be turned into constructive and productive actions.

Readers, you have a new year at hand, and it's a blank slate. 2011 is going to be what you make of it. I have one suggestion for all of you: Get off your a**** and make the changes most of you have been muttering about during 2010 (if not longer).

Paying Your Dues
One mail was about the dues structures of some of the industry organizations; specifically the ones that are based on a member's income. The author pointed out that it's no one's business what a company's income is, and asked if it really costs more for an organization to serve a larger entity than a smaller one.

My response: In this day and age it's extremely unlikely that it costs an entity like AAHomecare more to provide member services to a company like Lincare than, say, a small, mom-and-pop DME. When communications were sent out via fax (or mail), there were real costs involved in the sending. Today, with everything being sent out by email, costs are minimal. I think that basing dues on a company's income is an invasion of privacy as well as unfair, and this is a practice that should stop. Unless an organization can document that there are higher costs involved for serving larger members, this is a practice that should stop; dues structures, in these cases, should be reviewed and changed.

The Gift of Obscurity
Another reader told me that AMEPA needs to dissolve and fade into oblivion along with Rob Brant.

My response: Amen! As I've said in other blogs, my understanding is that AMEPA was formed to get rid of competitive bidding; AMEPA has failed to do this (not that it was ever likely to succeed, but that's another matter entirely). Rob Brant had delusions of adequacy when he decided that his group was the answer to the industry's problems. If we fast-forward a couple of years from the forming of AMEPA to today, we see Rob Brant involved with AAHomecare (another failure of an organization), apparently setting or deeply involved in formulating that association's (bad) policies, angling for an administrative delay to "fix" competitive bidding so it will actually work (at the literal expense of the round-two targets, who Brant says don't "need" a delay).

What a stupid idea.

Yes, AMEPA has launched its own "hotline" for problems relating to round one of competitive bidding, which is ridiculous (but typical). There should be one clearinghouse for issues, not three or more (AAHomecare, I'm talking to you as well).

AMEPA is almost as useful as AAHomecare is, and that's not saying much. An organization that accomplishes nothing deserves obscurity (I use that word as it means "the quality or condition of being unknown," not in any other definition or usage).

My own opinion is that Brant isn't going to go away because he likes the attention he gets from whatever it is he thinks he's doing (or wants you to think he's doing). He seems to have appointed himself as the spokesman and savior of the industry, and though that's clearly not reality, he imagines himself useful and important.

I know who you are, and I am not impressed. (Joan Jett)

The Politics of Staffing
Good help is really hard to find.

In a hierarchy, every employee tends to rise to his level of incompetence. (Dr. Laurence J. Peter)

If you're an employer, you want to hire an employee who'll do their job, not do your bidding. (Jeffrey Jones)

I've had several people tell me that Tyler Wilson and Walt Gorski should resign (or be fired) from AAHomecare and the association should hire people who have industry experience.

One reader told me that though Tyler Wilson had the mess to clean up that Kay Cox created, that mess was several years ago, and what has Wilson done for the industry lately?

Good question. It's normal to blame one's predecessor for the condition of an organization or business, but that wears pretty thin very fast. A rule of thumb for me is that if a successor can't show some real progress within a year, the successor was the wrong choice. Yes, a year goes by quickly. But a competent leader will rise to the occasion and take immediate and solid action to solve the problems that ail an organization. He or she might not always get it right, but time spent blaming a predecessor underscores the successor's lack of qualifications, professionalism, and drive.

I don't like or dislike Tyler Wilson and Walt Gorski. I have no personal feelings about either man. I know that Wilson was given a lot of benefit of the doubt the first couple of years of his tenure at AAHomecare because the truth is that Kay Cox did leave quite a mess. But that was then, and this is now, and the industry is no farther ahead.

I've heard many times that Wilson was the only person to apply for Cox's job. The AAHomecare board needed to replace Cox, but with only one person interested in the position, the board didn't have a lot of choice. They couldn't possibly keep Cox, so we ended up with Tyler Wilson, who brought Gorski in almost immediately.

I'm going to try to be fair here and point out that competitive bidding was already passed when Wilson came on the scene; MMA 2003 was a ball that Cox dropped, not Wilson. Since then he's had to try to stop the giant snowball as it rolls downhill toward him.

Since Wilson took the reins at AAHomecare, he's developed a staff that's heavy on the legislative side but the team he's built has failed to deliver results. Years later, we still have competitive bidding.

To add insult to injury, AAHomecare appears to have eliminated its professional education and events staff; that's a call only Wilson could have made, and the loss of Kim Kianka (who was with the association for many years) is as inexplicable as it is unacceptable. It makes no sense to replace Kianka with an administrative assistant, but that's what Wilson has done. No one will talk about what happened, but the loss of Kianka was a bad move. She functioned. The bloated legislative and communications staff does not (which is demonstrated by their collective lack of success). If Wilson was looking to save money (and I don't know that that was his motivation), he should have cut from those departments, not education.

If AAHomecare wasn't making enough money from their events, they should have lowered their prices and made them more affordable, which in turn would make them more attractive to potential attendees. Sometimes less is more.

The thing is that eliminating Wilson and some of his staff won't solve all of the problems that plague AAHomecare. Attention also needs to shift to the people on the AAHomecare board. Each year members are presented with a slate that the association wants to have voted in. What AAHomecare needs is to have real elections -- live elections -- where nominees from the floor can get in and shake things up. Control of AAHomecare needs to pass to new blood that's truly representative of the industry, not the same names shifting positions to stay in control. Don't believe me? Look at the too-familiar names on the AAHomecare board list.

I agree with my reader that changes need to be made at AAHomecare. Big ones.

The Merge Lane Begins Here
A reader suggested to me that AAHomecare, NAIMES, and CSI:HME should merge.

That's an interesting idea. But is it feasible?

I've never known AAHomecare to play well with others. That association insists it's the industry's "voice in Washington," and resists anything that it doesn't invent or initiate.

Nevermind that what AAHomecare has invented or initiated hasn't worked, of course.

I've preached about unity time and time again. I've had mails from readers who agree with me, but are reluctant to take a stand for fear of alienating or offending someone.

That makes sense; far better to end up losing your business because of competitive bidding than offending someone or making waves.

Some of the state leaders are guilty of towing the party line too. It's only appropriate to tow a party line if that line is working for you. If you're not happy with the status quo, and don't have the backbone to take a stand that will make some waves, then you deserve what you get.

It's really that simple.

In a perfect world, there would be one national organization that is responsive to the industry.

One reader said that a national association should submit policy decisions to the industry businesses for vote before acting on them. In this way organizations like AAHomecare wouldn't be able to move forward on the "administrative delay" idea to "fix" competitive bidding. Everyone that reader has spoken to is dead-set against that idea, but AAHomecare persists in moving on it.

When an organization that presumes to call itself the "voice of the industry in Washington" formulates a plan that the majority are against, then the organization needs to be responsive and drop the plan. Acting on it is senseless.

And it's not as though AAHomecare knows better; the association can't point to a record of successes and achievements to demonstrate that it knows what's good for the industry. The fact that "rival" organizations have sprung up in recent years should show AAHomecare that it isn't trusted or well-regarded in many quarters.

A merger wouldn't be a bad idea if done right. But why do I suspect that a merger from AAHomecare's point of view would mean AAHomecare "absorbing" NAIMES and CSI:HME, and making no real changes otherwise?

Mergers of equal partners are rare and difficult to carry out. (Juan Fernandez)

Come Together?
The theme for merging was carried over into Texas; I'm told that TAHCS and MESA should merge, with TAHCS dissolving after all is said and done.

I had to take some time to absorb this idea. On the surface, it's not an outrageous suggestion, but my initial thought was this:

MESA doesn't need TAHCS. No one needs TAHCS; it has nothing to offer.

The reader who made the MESA/TAHCS suggestion suggested the same for FAMES/FAHCS, but there isn't one good, credible organization between those two; the best thing that could happen to Florida is that a new, professionally run association should spring into being. And so I (regretfully) dismiss Florida.

I'm not a shy person, but I am a nosy one. So I sent a mail to MESA exec to see what her thoughts were about a merger with TAHCS.

She was cautious. She was diplomatic. I would be too if I had an email from a person who identifies himself/herself as an anonymous blogger who wants to ask a rather impertinent question (but nothing ventured, nothing gained, readers!). In a nutshell:

MESA would be pleased to honor the balances of paid TAHCS memberships, on a case-by-case basis, when TAHCS closes its doors. MESA always reserves the right to approve a company's application for membership, but recognizes that DME providers need the excellent representation and services that MESA offers.

I'm thinking that Barry Johnson and Dean Cheney need not apply. That wasn't said; it wasn't even hinted at. She was very tactful (more tactful than I would've been, I assure you). But if I put myself in her shoes, that's what I'd be thinking.

Tact is the ability to tell a man he has an open mind when he has a hole in his head. (Anonymous)

In the battle of existence, Talent is the punch; Tact is the clever footwork. (Wilson Mizner)

If I have any complaint about the tact shown here it's that the TAHCS people don't deserve it. But I'm not surprised that MESA has yet again out-classed TAHCS.

Should there be a merger between MESA and TAHCS? No. TAHCS just needs to go away and stay away (right away!).

What Are You Afraid Of?
I get a lot of offers from various organizations and individuals who offer me live seminars, webinars, and other "education" opportunities. How nice.

I resent it when I see something that looks good on paper, but the actual event was long on speculation and way too short on facts.

You know what I'm afraid of? Getting ripped off.

No one has all the answers. No one can tell you what your chances are of getting a contract in competitive bidding. And no one is yet in a position to offer you information that will give you and your company an "edge" in round two.

I could go on, but I'm sure you're getting my point.

Your state/regional associations (most of them, anyhow) produce events that offer you important, useful information presented by qualified speakers, and they deserve your support.

Too many others are hosting "road shows" and similar events that play on the fears of providers stuck in an uncertain industry and who are willing to pay for any answers they can get.

Before you give your money to an organization or individual to attend an event, do your homework. Look at the qualifications of the speaker (or speakers). Scrutinize the content; don't settle for generalities. If you know someone who's attended in another city, ask the attendee for feedback. Ask yourself if the session can offer you anything in the way of new information that will make it worth the price of admission.

But most important, don't let your fear of the future lead you to empty your wallet on seminars and other events from which you'll receive no benefit. Be careful; be choosy.

Help Yourself
And so 2010 draws to a close. Things must change for the industry in 2011. But things don't change unless we make them change. You're part of the solution; it's time to resolve to help yourself to a better future.

Resolutions and Revelations

It's quiet on the DME front right now; the Christmas/New Year season always means a lull in activity in most professions. Yes, we're still taking care of patients, but the politics are on hold, for now.

I am a firm believer in reflection. I know my merits and I know (all too well) my flaws. I'm not one of those people (one of those annoying, self-righteous, deluded people) who look only at the good points and ignore the bad points of my personality. There are days that I look in the mirror and like what I see, just as there are days I look in the mirror and don't like what I see.

I figure I'm doing well if I can stand myself at least half the time.

Millions of us have made or are making resolutions for the new year; a tiny fraction of us will actually keep those resolutions. I sometimes wonder if those of us who make resolutions do it because it's expected, but do so with the full knowledge that we're not going to keep them. I think we have good intentions, but making changes is hard.

A couple of years ago a friend of mine said that her resolution for the new year was to become a better person. I replied that I liked her fine as she was, and could she elaborate on what she means by "better," please?

bet·ter 1 (btr)
adj. Comparative of good.
1. Greater in excellence or higher in quality.
2. More useful, suitable, or desirable: found a better way to go; a suit with a better fit than that one.
3. More highly skilled or adept: I am better at math than English.
4. Greater or larger: argued for the better part of an hour.
5. More advantageous or favorable; improved: a better chance of success.
6. Healthier or more fit than before: The patient is better today.
adv. Comparative of well2.
1. In a more excellent way.
2.
a. To a greater extent or degree: better suited to the job; likes it better without sauce.
b. To greater advantage; preferably: a deed better left undone. See Usage Notes at best, have, rather.
3. More: It took me better than a year to recover.
n.
1. One that is greater in excellence or higher in quality.
2. A superior, as in standing, competence, or intelligence. Usually used in the plural: to learn from one's betters.
v. bet·tered, bet·ter·ing, bet·ters
v.tr.
1. To make better; improve: trying to better conditions in the prison; bettered myself by changing jobs. See Synonyms at improve.
2. To surpass or exceed.
v.intr.
To become better.

Better Off?
I'm all for improving a skill or a talent. If you're good at something, it can be very gratifying to become better at it. Or, conversely, if you're really bad at something, it can be quite rewarding to become better at what you're naturally bad at.

But my friend didn't mean she wanted to become better at any specific thing; she meant that she wanted to become a better person in general.

I suppose the goal has to be defined by the person setting the goal. My idea of being a "better" person is probably worlds apart from how another person would define it. The word "better" is subjective.

She explained that she wanted to be kinder. And she wanted to be more charitable.

Okay, I can grasp that. It usually costs nothing to be kind to another person, though I find it almost impossible to be "kind" to someone I dislike or who has been unkind to me. I'm sometimes just not good at letting bygones be bygones, and the truth of the matter is that sometimes pay-back is appropriate (and sometimes revenge just feels good).

Kindness, though, is a good thing. What concerned me was that she was going veer off into the path of righteous morality as dictated by someone (or someones) other than herself.

Correct morality can only be derived from what man is — not from what do-gooders and well-meaning aunt Nellies would like him to be. (Robert A. Heinlein)

Goodness alone is never enough. A hard, cold wisdom is required for goodness to accomplish good. Goodness without wisdom always accomplishes evil. (Robert A. Heinlein)

We've all heard about some of the famous rich who have decided to give away millions and millions for charitable reasons. I'm not opposed to being financially charitable, but if I'm going to give money or resources away, I'm going to do in a way that will help tackle the ills we have in this country, not in some remote village half a world away.

The thing about charity that bothers me is this: It's expected. The wealthy are often pressured by society (or by their more liberal wealthy peers) to be charitable. Whether wealth is inherited or earned makes no difference; the wealth belongs to the person who has it, and no person or society is entitled to dictate what one does with one's money.

Too often do-gooders want to do good with someone else's money.

Nothing of value is free. Even the breath of life is purchased at birth only through gasping effort and pain. (Robert A. Heinlein)

The problem with charity is that it rarely solves problems. And the people who receive it are rarely grateful (some tend to feel entitled to have what they're being given). I think that the Portuguese word for "thank you" ("obrigado" if you're male or "obrigada" if you're female) conveys the sense of obligation that our phrase does not. And obligation often does lead to resentment.

It's not a rare thing to bite the hand that feeds you. It's so common that we have a cliche about it.

Yet more and more often we have drummed into our heads that those who have have an obligation to those who have not.

Social responsibility above the level of family, or at most of tribe, requires imagination-- devotion, loyalty, all the higher virtues -- which a man must develop himself; if he has them forced down him, he will vomit them out. (Robert A. Heinlein)

Charity is not a debt one owes to one's fellow man. Though it may be a good thing to give help to those in need who are not related to the giver, no one should impose the obligation of charity on another. Giving should always come from a willing heart and be received by an appreciative heart.

My friend, however, is not wealthy, and has no money to give away. I could only conclude that she meant that she wanted to cultivate a kindly and lenient attitude toward people.

I'm an honest person, and so I told her that we have far too much lenience these days, thanks. The poison of lenience has created a society of lazy parents and ill-mannered children; lenience has led to more crime, less punishment, and a steady deterioration of the work ethic that built this country and made it great.

Not very charitable of me? White-washing something doesn't make it go away, and sugar-coating something doesn't make it more palatable in the long run.

I can hear some of my readers now: It's Christmas! How unkind and uncharitable can you be at such an important time of year for Christians?

My answer is simple. I am who I am every day of the year.

The origins of Christmas are easy to find for anyone willing to look. The true origin of Christmas is pagan; the holiday was a harvest festival that marked the winter solstice (the return of the sun—and honored Saturn, the god of sowing). Saturnalia was a rowdy time, much opposed by the more austere leaders among the still-minority Christian sect. Christmas developed as a means of replacing worship of the sun with worship of the Son.

Too many "Christians" become kind during major "religious" festivals, but fail to be so most of the year. I am who I am; I won't don a cloak of kindness, charity, and humility because of a holiday.

I know too many hypocrites, I suppose. I've met too many "Christians" who lie, cheat, steal, and who are judgmental, narrow-minded, and obnoxiously self-righteous. These people assume masks of religious kindness during Christmas and Easter, but are barely tolerable the other 363 days of the year.

I am free, no matter what rules surround me. If I find them tolerable, I tolerate them; if I find them too obnoxious, I break them. I am free because I know that I alone am morally responsible for everything I do. (Robert A. Heinlein)

One man's theology is another man's belly laugh. (Robert A. Heinlein)

I participate in Christmas; I buy presents and give them to family. What I don't do is infuse the holiday with any religious significance. I see and approach it as a commercial venture. If the gifts I give make the recipients happy, then that, for me, is the joy in the season.

When I think of the new year that's approaching, I hope that it will be better than the current year, and I know that I'll work toward realizing some of my goals. I'm too practical to make resolutions that I know I can't (or won't) keep; I'm not going to promise myself and others that I'm going to change certain aspects of my personality (and then fail to do it).

I am who I am. And though I may not be perfect, and though I know there's always room for improvement, I embrace who I am because there's no one else on earth like me.

And there's no one on earth like you. I encourage all of you to go into 2011 being who you are.

May you live as long as you wish and love as long as you live. (Robert A. Heinlein)

P.S. Many thanks to the reader for the links to the quotes in today's blog.

Education, Accountability, and Miracles

Today's offering is kind of a hodge-podge of topics, but with the common thread of DME, of course.

A Little Education Can Go a Long Way
There's a campaign on to educate referral sources about competitive bidding. One person with whom I correspond said that he (or she, but for the sake of expedience we'll assign male gender) supports a new effort to educate about reporting problems, not about how to make the program work.

He said that in response to some questions that I posed: "Wouldn't it be more productive for the industry's purposes to not educate referral sources? Wouldn't it hasten the collapse of the program if there was more confusion (and not less)?"

I suppose that my pen pal is right and I'm wrong; one of his concerns seems to be that he thinks the referral sources, if not taken by the collective hand and given a crash course in problem reporting, simply won't bother. I'm not sure that I agree with that; if the beneficiaries aren't being properly served by DMEs, beneficiaries are sure to complain loud and long. And, since physicians have more power and influence than the DME industry does, if they're having to deal with upset patients, wouldn't it stand to reason that they'd make their displeasure with the bid program very clear?

Chaos is the score upon which reality is written. (Henry Miller)

Chaos in the world brings uneasiness, but it also allows the opportunity for creativity and growth. (Tom Barrett)

Sometimes chaos is a good thing. Chaos is almost always viewed in a negative light, but it has its place and can be extremely useful.

Accountability
We throw this word around all the time, but do we really know what it means?

accountability noun \ə-ˌkau̇n-tə-ˈbi-lə-tē\

Obligation of an individual, firm, or institution to account for its activities, accept responsibility for them, and to disclose the results in a transparent manner.

This word came up when I was having a conversation about CMS and its contractors. Neither that agency nor its contractors seem to understand the concept of accountability.

In our recovery package we put new standards of accountability and transparency, which we hope will now apply. (Nancy Pelosi)

We've all heard about the way financial institutions found ways around stipulations in the bail-outs they received; I think we all know how much government-mandated accountability is worth because of the loopholes built into legislation.

Government agencies have far too little accountability. This is true of virtually every agency, but definitely so with CMS.

Public record requests are virtually useless, and any claims to transparency are almost always misleading. Why? Because our idiot legislators, when making and passing laws, provide so many exceptions that can be interpreted so many ways that they and government agencies can evade public scrutiny.

This is definitely true of CMS. That agency has refused to provide the financial requirements of the competitive bidding program on the grounds that it may be "harmful."

Harmful to whom? To the bid winners? To the companies that didn't win contracts? Or would that information be harmful to the agency?

I feel an independent accountability commission should audit all government services. (Imran Khan)

Independent commissions are as independent as they are objective, which means, when I say that, that independent commissions are neither. When a commission is created, the appointments reveal the partisanship of the commission right at the very beginning. I've seen so-called bipartisan commissions, and there is always an agenda being served.

Restoring responsibility and accountability is essential to the economic and fiscal health of our nation. (Carl Levin)

As long as the endless number of exceptions to accountability remain, there is almost no hope for restoration. What we actually need isn't restoration; what we need is reform. But not the way lawmakers reform, because they always do an awful job.

Sometimes the only way to fix something is to dismantle it. The responsible approach to that would be to determine the course of action, put the systems in place, and then shut down the old.

CMS doesn't need reformed, because you can't reform something that's so huge and so completely out of touch. Legislators talk about health care "reform," and promise more "oversight" of agencies and programs.

How much "oversight" do you supposed CMS actually receives? I'm guessing not much, if any at all.

When it comes to privacy and accountability, people always demand the former for themselves and the latter for everyone else. (David Brin)

I think that a private individual is entitled to privacy (the very privacy our government very steadily takes from us in the name of "security"). But when a private individual becomes a civil servant (I include all government employees in that category, including the President of this country), we the people are entitled to expect transparency and accountability.

Without the enormous list of exceptions that serve only to permit them to hide what suits them from scrutiny.

Perhaps nothing in our society is more needed for those in positions of authority than accountability. Too often those with authority are able (and willing) to surround themselves with people who support their decisions without question. (Anonymous)

A Crash Course in Civics
The government of the United States is not a democracy. It is a democratic republic.

A republic is a political unit governed by a charter, while a democracy is a government whose prevailing force is always that of the majority. Our political unit (our government) is governed by a charter, which is the Constitution.

I think the primary difficulty in defining these two words — democracy and republic — stems from the fact that many people consider them to be synonyms, which they most definitely are not.

A direct democracy is one which is ruled entirely and directly by the people; to decide on an issue, the question is put to the vote of the population and the majority of those votes determine the outcome. In a representative democracy, citizens elect people to represent their interests in the government, and these representatives determine how issues are decided.

But our system is governed by a charter, and so the most accurate way to describe our government is a democratic republic.

We the people don't have the voice, the power, or the freedoms that we're led to believe that we have. We are fed the lie that the United States of America is a democracy through our schools and the propaganda the government issues.

The next time a legislator tells you that we live in a democracy, one of the following two things is the truth:

1. The legislator is deliberately lying to you; or
2. The legislator is as ignorant as the majority of the citizens of this country.

When you pledge allegiance to the flag of the United States of America, you also pledge your allegiance "to the republic for which it stands."

You don't pledge to the democracy for which it stands.

The majority does not rule here. In theory, that can be a good thing, because then the rights of the minority aren't overlooked. This can also be a bad thing, because too often the rights and opinions of the majority are overlooked (or ignored) because special interests prevail.

Which also erodes (or virtually obliterates) accountability.

Acts of God
The answer to the accountability question is one of size. CMS is like the DOD i[t]s so big it takes too long to discover a problem and then an act of God to fix it.

That's a direct quote from one of my readers with whom I chat relatively regularly. I don't know who he or she is, and I don't care to know. What I do care about is that this is a person who often makes good points and who, so far, appears to have been candid with me.

And that one statement shows how very wrong our government has gone and how little control we have over it. When a government agency is that big and can operate so badly with no accountability, it's time to start over.

No More DME Supplier Numbers?

HME News reports that Senator Ron Wyden "blindsided" the industry by sending a letter to CMS that asks the agency to (temporarily) stop issuing supplier numbers to control fraud and abuse.

Interesting.

Expect the best, plan for the worst, and prepare to be surprised. (Denis Waitley)

The industry's response is typical; everyone's against it. The funny thing is that over the years, I've heard many people in the industry say that supplier numbers are too easy to obtain and that CMS should either stop issuing them or make them far harder to get.

Maybe it's okay for people in the industry to say it, but not okay for someone else who might be in a position to make it happen? Isn't that a bit hypocritical?

The article also charges CMS with incompetence because it can't control fraud and abuse.

Interesting.

That's like saying the police are incompetent because they can't prevent crime. No agency can predict intent. Even with accreditation requirements and surety bonds and supplier standards, CMS can't know that someone is intending to commit fraud. Does that make the agency incompetent? No.

It's irresponsible to make such a charge; it smacks of passing the buck. The people who are ultimately responsible for fraud are the ones who deliberately engage in it. You disagree?

Is the victim of a robbery responsible because he has nice things? Of course not. That would be a ridiculous stand to take. But that appears to be the stand the industry is taking where CMS and the Medicare program is concerned.

The victims of the crime of fraud are the Medicare program and the tax-payers.

Cara Bachenheimer misses the point. She's quoted as saying in the article that "It's ridiculous. CMS has accreditation, and they are supposed to be going out and physically inspecting providers. Has CMS somehow said they are incapable of doing that? Because that is what the message is."

Unless Bachenheimer knows something that's not stated in the article, I don't see where a letter sent to CMS by a Senator sends a message that CMS has "somehow said" that they are incapable of doing "that" (whatever "that" is).

CMS didn't write that letter, folks. Though CMS is often the bad guy, let's blast the right party here, shall we? Let's not invent a "message" that doesn't exist.

Wayne Stanfield views the Senator's letter as "another example of being out of touch with Medicare and the whole DME benefit." Based on some of the letter's contents, that's a statement I can get behind, but only if he's talking about Senator Wyden and not CMS.

Things have changed since the 2007 OIG study that Wyden cites. AAHomecare's Walt Gorski is as guilty as Bachenheimer at missing the point, but he veers off in another direction: he splits hairs.

What's more, the letter includes a number of misleading statements. For example, Wyden states that nearly 100,000 HME providers now participate in the Medicare program. While Medicare recognizes that [there are] many active DMEPOS supplier numbers, only about 20,000 belong to HME providers. The rest belong to pharmacies, O&P companies and other kinds of providers, Gorski said.

Interesting. Here's the thing, Walt: Wyden's letter can say that there are one million HME providers participating in the Medicare program. If CMS knows better and acknowledges that, then what Wyden says can really do very little harm (if it can do any at all). Instead of nit-picking, AAHomecare, find a solution to the problems the industry is facing.

Oh, wait. AAHomecare can't; their bright idea is to ask for a round-one delay so the program can be tweaked enough to be successful. AAHomecare is the organization that's implied (if not said) that if that's done, the industry will accept competitive bidding.

There's probably a reason, AAHomecare, that you've had no luck in trying to contact Wyden to "discuss" the letter he wrote; it's because you have no influence and no credibility. You hold no cards.

Credibility is like virginity. Once you lose it, you can never get it back. (Anonymous)

At the end of the day, Walt Gorski, while CMS is trying to police a huge program, the suppliers currently in the system and those who want to join in the fun need to have more honest and more ethical intentions.

I want to see the critics of CMS do a better job at policing 20,000+ providers. It's all too easy to criticize what others do, even if you can't do the job yourself.

I know that I'm taking what will be an unpopular stand. I can live with that. For many years this industry has played the blame game, shoving all responsibility for fraud and abuse onto CMS, rather than ourselves. Oh sure, we acknowledge that there's been fraud, and we now pretend that, because of the new requirements, fraud is all but gone, and it's up to CMS to make the tiny bit left a thing of the past.

Fraud still exists. If anyone thought that supplier standards, surety bonds, and mandatory accreditation were going to cure fraud, then I've got a bridge to sell you.

A man is his own easiest dupe, for what he wishes to be true he generally believes to be true. (Demosthenes)

Credulity is belief in slight evidence, with no evidence, or against evidence. (Tryon Edwards)

fraud (frôd)
n.
1. A deception deliberately practiced in order to secure unfair or unlawful gain.
2. A piece of trickery; a trick.
3.
a. One that defrauds; a cheat.
b. One who assumes a false pose; an impostor.

The cure for fraud is simple. It's so simple, in fact, that it's almost silly. The cure for fraud is honesty. It's not the responsibility of CMS to "make" you honest; that's far beyond the agency's reach. The responsibility for honesty lies with every individual participating in the system.

Fraud is the ready minister of injustice. (Edmund Burke)

If there is injustice in the current system (and there is!) toward the providers who are honest and ethical, CMS is not to blame. And shame on anyone who says that the system "invited" fraud. It's a sad state of affairs when the people who are committing fraud aren't strung up; it does no credit to any honest person when he or she blames the system for being robbed.

It is easy to dodge our responsibilities, but we cannot dodge the consequences of dodging our responsibilities. (Josiah Charles Stamp)

When government accepts responsibility for people, then people no longer take responsibility for themselves. (George Pataki)

Has the agency done a good job dealing with the problem? I think they've been slow and heavy-handed. But most large government agencies are. Name one that's nimble. Go ahead, I'll wait right here.

I know that a very large portion of providers participating in the Medicare program today have never deliberately cheated the system. Yes, there have been billing errors that may have resulted in over-payments from Medicare, but things happen.

I also know that there are many out there participating in the Medicare program today who have knowingly and deliberately billed for items that their patients didn't need and never got (and for repairs not needed nor performed). I know that there are many out there participating in the Medicare program who have "padded" what they submit for reimbursement; an extra few dollars here and there that no one will miss, right?

Wrong. An extra few dollars here and there add up to millions in no time flat. Add that to the companies formed for the purpose of committing fraud, and the Medicare program bleeds money at an alarming rate.

I've complained along with most of the rest of you that CMS takes too long to catch someone who's committing fraud. Does an investigation really need to take a few years? Some seem to drag on forever! The thing is, though, that if due process isn't followed, the agency will be accused of railroading "innocent" providers; it's really a no-win situation if you think about it objectively.

Competitive bidding is a reaction (an extreme reaction) to providers choosing to rob the Medicare program. But it wouldn't have come about if the program hadn't been abused. The bid is going to eliminate suppliers. Thousands will end up closing their doors. When competitive bidding fails, the industry needs to have a viable plan ready to replace it. It isn't enough to tell legislators and CMS what we don't like, what we don't want, what isn't fair, and that the agency isn't doing enough. We need a Plan B that will render suggestions like the one Senator Wyden made pointless.

Welcome to the Grand Delusion

Delusions of grandeur make me feel a lot better about myself. (Lily Tomlin)

Leadership is a tricky thing. There are those who are natural leaders, those who are competent-if-uninspiring leaders, and then those who shouldn't be allowed out without keepers.

One of the wisest things a person can know about himself is what his limitations are. A lack of self-knowledge is a dangerous thing; this and an overinflated view of one's own importance can lead to delusions of adequacy (never mind grandeur for the moment).

The last couple of days have been very busy for me. I've been the recipient of a flurry of mails packed with information. Some of it I can verify (quite a bit of it, actually), and some of it I have to take on faith. What I do know is that the people who send information to me want it out there and are unable, for whatever reasons, to do it themselves. And so they send it to me.

And I give it to you.

I have no delusions of grandeur. I know my limitations. I don't presume to speak on behalf of anyone. I gather information, sort through it, form opinions, and blog. I leave it to my readers to decide if they agree with me; I leave it to my readers to decide if they're going to act on what I have to say. What I don't do (and won't do) is delude myself into thinking that I represent or speak for anyone else.

spokesman [ˈspəʊksmən], spokesperson [ˈspəʊksˌpɜːsən] feminine, spokeswoman [ˈspəʊksˌwʊmən]
n pl -men, -persons, -people, -women
a person authorized to speak on behalf of another person, group of people, or organization

The most important word in that definition is "authorized." Taken in context, it means "approved." So a spokesman is an individual who is approved to speak on behalf of another person, group of people, or organization.

One of the mails I received is a copy of an email alleged to have been written by Rob Brant. In it he states that "the round one suppliers would like a 6 month delay based on the following problems." I'll get to those specific problems in a moment; I'm going to discuss the obvious first.

I don't know how many of my readers are in a round-one bid area, but how many of you told Brant that you would like a six-month delay? And how many of you authorized Brant to be your spokesman?

I concede that Brant is a spokesman for AMEPA; it's his club, after all. AMEPA is a for-profit corporation, formed on March 28, 2008, and based in Miami (at the very same address as Brant's DME, City Medical Services). The first "benefit" of membership (read: giving AMEPA "dues" money), as stated on the AMEPA site, is "The Membership Fees support our national efforts for an adequate resolution of the DMEPOS Competitive Bidding Program."

At one time Brant's stated goal was to get rid of competitive bidding entirely. At the time he formed AMEPA, Brant said that he did so because no one was really doing enough to get rid of the program. More than two years later, AMEPA hasn't done enough either. In fact, Brant seems more interested in being a board member of AAHomecare than in his own organization. Why AAHomecare would embrace Brant is a mystery to me, though I've heard rumors that they did so to "control" him.

How's that going for you, AAHomecare?

So what, exactly, is an "adequate resolution" of the program? A six-month delay? To what end? Below are the contents of the Brant email with my comments in italics.

The Mail
Here is the argument to the Obama administration, or Congress to delay Round One from beginning on January 1, 2011. The Round One suppliers would like a 6 month delay based on the following problems:

I've had comments from round-one suppliers who don't want a six-month delay, which contradicts Brant's claims that they want one.

1) CMS delayed the release of the bid winners by 2 months. The names were supposed to be released in September and they were finally released in November, intentionally after the General Election, when it was too late for Congress to act.

There was indeed a delay in releasing the names of the winners, but it's quite a stretch to attribute that delay as being one engineered to be too late for Congress to act. Congress has had two years in which to "act." Would announcing the contract winners prior to elections have mattered? Would that have prompted Congress to take action? Would it have inspired a Senator to introduce a companion bill for H.R. 3790? No. And here's the thing: the elections are over, but the same people are still in Congress, until January, and could still act.

2) CMS sent information promoting the program to beneficiaries, but did not send a list of bid winners to beneficiaries. Beneficiaries, physicians, case managers, and hospital discharge planners have been directed to find providers thru the medicare.gov website which is confusing and misleading. Many beneficiaries, in need of Home Medical Equipment do not have access to the internet and neither do their part-time caregivers.

There are many beneficiaries who are quite internet savvy. Those who are not can call 1-800-MEDICARE to find out which suppliers are Medicare contract suppliers as an alternative to going online. This alternative is also in CMS literature sent to beneficiaries. Telling a half-truth erodes credibility. Is this the best Brant can offer?

3) 258 legislators understood that this program is not really Competitive Bidding because it is a bid without any financial accountability. Additionally no real bidding program would allow out of area, inexperienced, and financially bankrupt companies to win bids and set prices, only to walk away from the program or sell their companies/bid contracts.

258 legislators might have agreed to support H.R. 3790, but without Senate support, the House support is, in a word, worthless. As for what a "real" bidding program would or would not allow, how is Brant qualified to make such a statement?

4) Due to CMS’ political maneuvering, the industry did not have the opportunity to raise arguments of 166 top auction experts/Economists and the problems of out of area, inexperienced and financially bankrupt and insolvent bid winners to the 111th Congress. The results will be a lack of compliance by patients, more work for case managers, longer hospital stays, more bankruptcies, more unemployment and loss of local access to beneficiaries.

The industry has had more than two years to point out the flaws of the program. The economists/experts released their collective opinion in September. Is Brant saying that between then and now the industry didn't have time to tell legislators about it? What does Brant want to do, retool the bid so that it actually succeeds? That's a great idea. Let's have some experts tell them how to do the bid right so that it actually works.

We need it to fail.

5) At this point we would not ask to delay Round 2. We could Delay Round 1 without delaying the January 2013 start and the bulk of Medicare’s proposed savings of Round 2. Besides, Medicare claims that the program is perfect “as is” and they do not anticipate any changes to Round 2. Just because Round 1 is delayed 6 months, does not mean that Round 2 should be delayed at all.

No delay to round two? Why not? Is it because Brant doesn't own a DME in a round-two area? What kind of logic is being used here? This begs for explanation, and those who are facing round two should be up in arms over this.

Even using the most exaggerated savings (created by out of area, inexperienced and financially bankrupt and insolvent bid winners), the CBO claims the DMEPOS Bidding Program will save $20 Billion over 10 years. The bulk of that savings will come from 91 MSA’s in Round 2, including the largest areas: New York City, Los Angeles, Chicago, Philadelphia, Atlanta, etc.

The savings were based on projected reimbursement savings, not by the bid winners.

Using basic math (which I am sure does not apply here) $20 billion over 10 years = $2 billion per year.

No, really? Did you figure that out with or without a calculator?

The 9 Round One MSA’s roughly consists of 9% of the proposed savings. Nine percent of $2 billion = $180 million.

Half a year of that proposed savings = $90 million. I do not remember if the CBO calculated an additional compounded savings, three years after the Round One and Round Two are rebid. If that is the case, the savings for 6 months would likely be much less than $90 million.

If you base your premise on something you believe to be flawed, then your premise is flawed.

If the industry had time, an argument could be made that $90 million is not a large sum of money to delay a program which will certainly cause so many problems. However with only a few weeks left, a change in Congress, and the House and Senate leaders general feeling about our industry, we will likely have to offer a budget neutral proposal to delay the program. Below are a few option ideas.

How much more time do you need? Many years have passed since the industry started arguing against competitive bidding. What do you honestly think can be accomplished in a six-month delay?

OPTION 1:

An offset by taking future CPI-U cuts nationwide, that we will never see anyway, and that the industry will not really feel?

The industry feels every single cut.

OPTION 2:

Perhaps a nationwide cut of 0.5% or 1% to delay the program 6 months

It's extremely dangerous to imply that the industry can swallow more reimbursement cuts. And who authorized Brant to make that kind of an offer?

OPTION 3:

Perhaps an immediate cut to the Round One MSA’s of 2.5% in addition to a national cut of 0.5%. This solution may have a better appeal to the national community of HME providers. Although the additional cut to Round One would likely be more symbolic, than a necessary pay-for mechanism.

So Brant wants round-two DMEs to help pay for a delay from which they won't benefit? "Just because Round 1 is delayed 6 months, does not mean that Round 2 should be delayed at all." Yet Brant wants them to foot the bill? I can't imagine how the "national community of HME providers" would support that, and they shouldn't.

OPTION 4:

A combination of OPTION 1, OPTION 2, or OPTION 3

OPTION 5: NONE OF THE ABOVE!

My source told me that a supplier commented thus: Brandt (sic) is trying to protect individual suppliers (i.e., himself) rather than looking at the big picture. If the email and the plan therein does, in fact, belong to Brant, I will say that I think that his company's preservation is a motivating factor in his approach (though let's not forget that he's got a bid contract in his pocket, and so has a better chance at survival than most). Is it the only motivating factor? I don't think so. I think that Brant is having delusions of adequacy, and that somewhere along the way he started believing his own press (generated by shameless self-promotion, not based on actual accomplishment). I've stung him on several occasions for being very late to the fight-competitive-bidding party, and rightly so.

A better-late-than-never mindset may be applicable to parties, but it's not applicable to something this important.

If Brant is driving AAHomecare's activity and strategy these days, each and every one of you needs to think long and hard about whether or not you authorize them separately or them collectively to be your spokesman. You have to decide whether or not you agree with the message they're sending and the deals they're attempting to make. Everything they say and do has the potential to have a profound effect on you and your business.

You have the right to decide who speaks for you, and you have the right to have input on the message your spokesperson sends. In the end, the person who represents you works for you, and your interests must be served.

You also have the right to make it clear who does not speak for you. If an organization approaches government agencies and legislators with a plan you don't support, tell the government agencies and legislators that you disagree.

Silence implies consent.

You have other options out there. AAHomecare isn't the only game in town. I haven't seen much out of VGM on the six-month delay plan, so I can't tell you whether they support it or not. Another option for providers is NAIMES. If you're looking for an organization to get behind, ask them what their positions are. Ask them what their plans are.

Competitive bidding needs to fail, not be delayed while it's improved. If that means that round one must go forward as is, that also means that failure is more imminent. Am I comfortable with sacrificing some people in the round-one areas? No. But I'm far less comfortable asking for a delay to help CMS make improvements to a program that will ensure its success.

The truth is that failure will save the industry.

Collective Effort Minus One
Coming together is a beginning. Keeping together is progress. Working together is success. (Henry Ford)

There's a site out there that almost all industry organizations are urging round-one providers to use to report bidding-related problems:

www.competitivebiddingconcerns.com

There is a notable exception, however, and that is AAHomecare.

Show me an elitist, and I'll show you a loser. (Tom Clancy)

AAHomecare is using its own site to gather information on bidding-related problems. There is a time and place for establishing an independent identity, but it isn't now and it isn't there.

He who stands aloof runs the risk of believing himself better than others and misusing his critique of society as an ideology for his private interest. (Theodor Adorno)

Most providers, if they're going to report problems, aren't going to do the same reporting in two different places. It's time for AAHomecare to learn to play well with others and pool all knowledge in one convenient place.

The foolish and the dead alone never change their opinions. (James Russell Lowell)

Now is not the time for a stiff-necked, aloof stance. AAHomecare can only improve its declining position by openly cooperating with others; it needs to really listen to the industry, regroup, and come up with a plan that people will want to get behind.

An association with no members isn't an association for very long.

To most of us the future seems unsure. But then it always has been; and we who have seen great changes must have great hopes. (John Masefield)

I think if everyone can get behind the failure of round one, the industry will win in the end. But we have to support failure together.

Are You Being Served?

ser·vice [ súrvəss ]

1. work done for somebody else: work done by somebody for somebody else as a job, duty, punishment, or favor
2. helpful action: an action done to help somebody or as a favor to somebody
3. work for customers: work done for the customers of a store, restaurant, hotel, or similar establishment, often with regard to whether it pleases them or not

My last blog seems to have touched a nerve. Industry organizations and trade associations are all about service. They produce no tangible goods. The worth of an industry organization can be measured in the quality of service it gives to its members.

Controversy is only dreaded by the advocates of error. (Benjamin Rush)

A lot of what I say about the DME industry, its individual advocates, and its service organizations is controversial. I don't fear controversy, because I see it as a productive tool of change. I despise political correctness, because I view that as verbal tyranny. I've had people tell me that though they agree with something I've said, they're not going to do so publicly, lest they hurt or offend someone.

What's wrong with that? A lot. These people, instead of speaking their minds, are cowed into silently maintaining the status quo, even though they disagree with it.

Even if their silence hurts them in the long run.

Freedom of expression was granted to each American citizen by the founders of this country. That our society has become one where only a few have the guts to express themselves, often at great cost to others, is one of the saddest statements I can make.

Things won't change, readers, if you don't make them change. I've said it before and I'll say it again: You can say what's on your mind and be polite about it (if the situation warrants that kind of thoughtfulness). But you should never, ever, be afraid to say what you think because you fear being talked about or unpopular or because you fear reprisal.

Both pass quickly. Ask the Dixie Chicks, or anyone else who's been through a scandal. If they survived it, so will you. If things are a bit unpleasant for a while, hold your head up and be proud that you took steps toward effecting change. And don't for a minute allow anyone to make you think that you're in the wrong if you're a lone dissenting voice. If "they" are so right, why are things so wrong?

The first duty of a wise advocate is to convince his opponents that he understands their arguments, and sympathizes with their just feelings. (Samuel Taylor Coleridge)

The DME industry is packed with advocates. The problem is that some of them serve everyone badly (AAHomecare), and some of them clearly seem serve only their own interests (AMEPA, FAHCS and TAHCS).

No man should advocate a course in private that he's ashamed to admit in public. (George McGovern)

I got mail about my last blog, and in it a reader told me that AAHomecare's plan to seek an administrative delay to "adjust" competitive bidding was formulated and sprung on the state/regional associations with no consultation and no warning. I'm told that the plan was a "board action," and the states were asked to either agree with it or not agree with it (and if they didn't agree, they were asked for an alternative "practical" solution).

I've done some digging, and I've found that several of the state associations disagreed with AAHomecare; I'm told that at least one of them called for new staff at AAHomecare.

We need to find the courage to say NO to the things and people that are not serving us if we want to rediscover ourselves and live our lives with authenticity. (Barbara De Angelis)

AAHomecare's membership has been in steady decline for a decade. Though they claim to have a membership of 3,000 locations in all 50 states, I'm wondering how many actual members they have, and whether or not AAHomecare has many small, independent providers.

A leader is one who knows the way, goes the way, and shows the way. (John C. Maxwell)

I'm not saying that AAHomecare is alone in the failure to prevent and then to repeal competitive bidding. But though the industry gets a lot (too much) of hot air and posturing from AMEPA and their FAHCS/TAHCS off-shoots, AAHomecare is the organization that tells the DMEs that it is their "voice in Washington." AAHomecare tells its members that it is seen in Washington as the "credible representative of HME."

If this is the case, and I doubt it is, this is bad news for the industry. Why? Because the association wants an "administrative" delay so the program can be tweaked (again) and brought into line with what some economists had to say, which will then result in the industry accepting the program.

It is a bad plan that admits of no modification. (Publilius Syrus)

The current AAHomecare plan isn't a modification, it's pretty much a re-run. Did the first delay do any good? No. During that time, there was at least an effort to repeal competitive bidding. Now the goal is to change it so it's more palatable.

That's not much of a goal.

He that will not apply new remedies must expect new evils; for time is the greatest innovator. (Francis Bacon)

A new remedy isn't a drastically watered-down goal that amounts to giving up.

In times of rapid change, experience could be your worst enemy. (J. Paul Getty)

Despite the anger and disagreement of so many in the industry, AAHomecare appears to be moving ahead with its plan. I can only conclude that the association's board and its staff think that they know better than anyone else. History has not proven them right.

The worst things in history have happened when people stop thinking for themselves, especially when they allow themselves to be influenced by negative people. That’s what gives rise to dictators. Avoid that at all costs. Stop it first on a personal level, and you will have contributed to world sanity as well as your own. (Donald Trump)

Though I'm not addressing world sanity, I do think that the most important part of that quote is the importance of thinking for ourselves. If our "experts" aren't doing the job we pay them to do, it might be time to ask ourselves if they really know what they're doing and if they really know more than we do.

Don't be buffaloed by experts and elites. Elites can become so inbred that they produce haemophiliacs who bleed to death as soon as they are nicked by the real world. (Colin Powell)

Experts often possess more data than judgment. (Colin Powell)

If you disagree with AAHomecare's intentions, and are not willing to accept an adjusted competitive bidding program, now is the time for you to make it clear to CMS and to legislators that AAHomecare does not represent and does not speak for you.

The sad truth here is that it's extremely unlikely that round one can be stopped. That's another battle lost. But the war isn't over. It's time to regroup and to come up with plans (viable plans!) that don't include giving up the fight. Somewhere out there is someone who can step up and lead (not you, Rob Brant).

The vision must be followed by the venture. It is not enough to stare up the steps - we must step up the stairs. (Vance Havner)

Don't follow a bad plan blindly. Make sure you're being served.

Strategic Thinking

Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat. (Sun Tzu)

The Agony of Defeat
DME has had, in the battle against competitive bidding, several tactics, but no real strategy. Strategy requires a game plan with a cohesive team, and DME lacks a cohesive team.

I've heard over and over again that the national organizations talk to each other and "strategize" together, but I'm guessing that there's some selective hearing going on, considering how often they all contradict each other.

I've heard some rumblings, straight out of Medtrade, that make me pause. I'm pretty sure that some of these things aren't supposed to be common knowledge yet, but gentlemen (I use that term loosely in this case), if you don't want something known, don't discuss it on the show floor (I'm talking to you, Rob Brant).

I got an angry mail from one of my faithful readers telling me that AAHomecare has a new "strategy." The association is going to push for another delay so competitive bidding can be "fixed."

My source overheard Brant discussing this with another, unidentified person who appeared to be dissatisfied with this new delay tactic.

However beautiful the strategy, you should occasionally look at the results. (Winston Churchill)

The industry has already squandered a two-year delay during which nothing of any real value was accomplished. I guess the obvious questions are these: Will the industry ever think the competitive bidding process is right, and will the industry be reconciled to competitive bidding once it's fixed (again)?

What rocket scientist came up with this stupid idea?

I can hear the justifications now: If the industry can get a delay (another delay), that will give more time to repeal competitive bidding while CMS is forced to "fix" the process (again).

Did that "strategy" work during the last two years? No. So how are the "leaders" going to make that work for the industry now?

You have to be fast on your feet and adaptive or else a strategy is useless. (Charles de Gaulle)

The ability to adapt and maneuver quickly is crucial. As I've said again and again, the "leaders" in the industry embody the definition of insanity: doing the same things over and over again and expecting different results.

The delay tactic is doing the same thing over again, but expecting (or touting their delusional belief that they'll be able to achieve) different results.

A leader needs enough understanding to fashion an intelligent strategy. (John Kotter)

Is this the best that the national organizations can come up with?

I'm pluralizing organization because I'm assuming that, because they say they all "strategize" together, that they're in agreement on this redundant (and wasteful) tactic. If any of them wants to disown this plan, they can feel free to let me know and I'll be sure to pass it on here.

Tactics mean doing what you can with what you have. (Saul Alinsky)

The problem with doing what you can with what you have is that the DME industry doesn't really have anything. If it did, would it be where it is?

Think I'm wrong?

We all knew competitive bidding was coming when CMS did those two demonstrations; it was only a matter of time. MMA 2003 wasn't exactly a surprise, and though some people in the industry lobbied hard against it (except the Rob Brants of this world), deflection wasn't possible.

From the passage of MMA 2003 through the original round one of competitive bidding (enter Brant and his ilk after he/they didn't get contracts), five years of lobbying and trying to "educate" legislators did no real good. Yes, there were a couple of bills introduced. But what good did they do? None.

Just as H.R. 3790 will go the same way as other bills (which means it's a goner), the only thing the industry managed to do was get a delay, attached to the doc fix, that would "fix" what was (allegedly) wrong with the bidding process. In the meantime, the industry would use that time to get competitive bidding repealed.

Sound familiar?

Here's the irony, readers: Everyone in the original round one would have been better off financially if the delay to "fix" it hadn't been done. Reimbursements on the items were higher then than now; the delay actually hurt the people in the first MSAs far more than it helped.

Don't believe me? Check the reimbursements, then and now, for yourself.

So if you're in a round-one area and have "won" contracts, be sure to thank AAHomecare, the yahoos at AMEPA, and anyone else who participated in thinking up that delay tactic that ended up harming your bottom line.

Does this industry really need that kind of help? No. I shouldn't have to point that out to you, but sometimes it's hard to see the forest for the trees, isn't it?

People make bad decisions when they're in panic mode. The delay tactic was a bad decision. I'm sure it sounded good at the time to people in the original round one who didn't get contracts, but it would appear that no one was looking down the road.

Leadership has been defined as the ability to hide your panic from others. (Anonymous)

If you're going to panic, panic constructively. (Anonymous)

When the industry panicked, it didn't do so constructively, and the proof is in the results we have two years after the delay.

Degrees of Defeat
Different people will look at the situation in different ways. I see defeat, because the DME industry basically has no other cards to play. It has never gained the foothold it's so desperately needed in D.C., despite the money thrown at lobbyists and (ineffective) national organizations.

If you can accept losing, you can't win. (Vince Lombardi)

And if you don't have a solid strategy supported by logical and effective tactics, you can't win. You can quote me on that.

Victory has a thousand fathers, but defeat is an orphan. (John F. Kennedy)

Not this time, John. The fathers of the defeat that this industry has experienced are readily identifiable. Because you can't expect to experience victory if you have a flawed plan and no tools.

I really thought we'd win that. (Adolph Hitler)

I'm not going to bother with all those quotes that talk about defeat building character, or defeat being stimulating, or defeat being temporary, because I think they're all crap. Defeat isn't inspiring. Defeat hurts, especially when there's so much at stake. Defeat isn't opportunity. For most people, defeat is the end of the road.

Be careful that victories do not carry the seed of future defeats. (Ralph W. Sockman)

I think Ralph is talking about the delay of the original round one.

Does the industry need to continue to fight? Of course it does. But are the right people giving you the right tactics? What are the results showing you?

There are no bad regiments, there are only bad officers. (Field Marshall Lord Slim)

If you stand up and be counted, from time to time you may get yourself knocked down. But remember this: A man flattened by an opponent can get up again. A man flattened by conformity stays down for good. (Thomas J. Watson, Jr.)

The significant problems we face cannot be solved at the same level of thinking we were at when we created them. (Albert Einstein)

The way forward may not be clear right now, but the thing the DME industry must discard is what's already been done and not worked. You can quote me on that, too.

The Show Must Go On

This week is the Medtrade show in Atlanta. And I'm not there.

The only consolation I can find in your immediate presence is your ultimate absence. (Shelagh Delaney)

I used to go to Medtrade. At first I would attend some of the educational sessions, walk the floor, see and be seen, and go to the parties. As the years passed, I'd walk the floor, see and be seen, and go to the parties. The last time I went to Medtrade I walked the floor not caring if I was seen or who I saw, and then go to the parties.

And though I could write off the trip as a business expense, I decide that it was a costly investment to make considering the lack of return.

My own fault? To a degree, yes. I suppose that a show like Medtrade is what you make of it. But Medtrade got smaller and smaller, and the content of some of the education sessions got less relevant and less timely.

Part of the reason for the "slip" in content quality is, I think, technology. State and regional associations used to have to fax information to members, and because sending faxes involved long-distance phone charges, information sent out to members was somewhat measured.

Along came E-mail, and associations got more technologically savvy, which resulted in information being sent to members more frequently, in more detail, and at very little cost.

It's also far less expensive for me to attend my association's events than it is to attend a show like Medtrade. My association offers me excellent speakers, relevant topics, and timely information at a good price.

Why pay more?

Medtrade is a great place for DME providers to look at and compare products, and they might get some bargains from vendors along the way.

Man is an animal that makes bargains: no other animal does this - no dog exchanges bones with another. (Adam Smith)

Even the trade show portion of Medtrade was rapidly shrinking during the many years that I attended. Fewer and fewer vendors were willing (or able) to spend the money on exhibiting at the show; there was little or no return on the investment. And that I can well understand.

More and more DMEs are needing to find less expensive equipment, especially those in the first round of competitive bidding.

There are very honest people who do not think that they have had a bargain unless they have cheated a merchant. (Anatole France)

At the bid reimbursement rates, the manufacturers and distributors are probably going to end up feeling like they've been cheated if they have to cut their rates to move their equipment. The thing is that there are costs associated with manufacturing and distributing, and a company is in business to make money, not give their merchandise away.

But providers are also in business to make money, and with reimbursements slashed, they can't afford what they were once able to buy. It's a real conundrum.

To Go or Not To Go?
I did consider going this year. I'd been told that at last year's show, and at Medtrade Spring, the state associations were finally given space at the event (free of charge!), and this is a good thing. Most of the state or regional associations (with a few sadly obvious exceptions) are the workhorses of the industry, and they deserve the recognition and the break.

I'm a bit puzzled, though, about why some of the associations attend the Medtrades that they do. I'll explain:

NCAMES and VADMEC were at Medtrade Spring this year; they're also at the Atlanta show now. I can understand being in Atlanta, but I'm mystified about those two east-coast organizations being at the Vegas show.

Medtrade Spring is a smaller event, and I can't imagine that the NCAMES and VADMEC members (and potential members) go to Vegas in droves. Unless east-coast associations (we'll throw NEMED and FAMES into the mix too) are signing up bunches of members in Vegas, I don't understand why they're paying money to be there.

I know people who attended Medtrade Spring this year, and I know that FAMES was very loosely represented there (and by loosely I mean an unmanned table in the association area; tossing some literature on the table and being gone 90% of the time isn't exactly representing the organization or being available to existing and potential members). Funny thing is that FAMES has no table in the association area of the Atlanta show. It seems to me that the Atlanta Medtrade is far more relevant to that organization than the Vegas event could ever be.

MAMES, MESA, and other associations central in the country attending both makes more sense, though I suspect that there are greater gains for those organizations in Atlanta than in Vegas.

As for CAMPS, I'm just not sure how profitable it is for a California association to be at an Atlanta show, but they're there.

And where is OAMES?

The thing that I can say, even if I don't understand why some of them go where they go, is that the representatives of NCAMES and VADMEC (Beth Bowen), NEMED (Karyn Estrella), MAMES (Rose Schafhauser), and MESA (Elizabeth Moran) actively connect with their members.

And maybe that's the point of them attending both Medtrade events. I'm looking at it from a financial perspective.

I don't think going to the events is about ego, because none of the Executive Directors, with the exception of one, highlights himself or herself on their respective web sites or in other promotional literature that I've ever seen (the exception being FAMES where, if you click on "about us" you get a personal bio, complete with mention of that E.D.'s consulting firm, but no information about FAMES, which is what I'd expect and hope to find; even AMEPA, FAHCS and TAHCS don't do that).

Okay, the PAMS site has a blurb about John Shirvinsky, but as side-bar, not as the the sum and total. That's appropriate, and the blurb is very well done.

Don't get excited, AMEPA, FAHCS and TAHCS. I haven't changed my opinion of you, and I'm not softening up. I'd expect class-less, personal self-promotion from your bunch; I'm merely disappointed to see something like that from an organization that should know better.

Anyhow, back to the point: It's not about them, the individuals; it's about them as representatives of and advocates for their members. That's my guess. Maybe they see their participation in both Medtrades as a worthwhile investment from an interaction point of view.

But I'm a dollars-and-cents person, and if I'm going to spend my time and money on an industry event, I'm going to invest in my state (or regional) association's production. They need the money and I'm going to see more of a return both in the long and short runs. Am I telling you, dear reader, to not attend Medtrade? No. It's up to you to determine how your own interests are best served, and if the Medtrades work for you, then that's where you should go.

Just don't forget how hard your associations work (most of them, anyhow); please support them.

Speaking of Shows ...
Are you paying attention to what's going on in D.C. after elections? So far we still have the same squabbling and the same power-plays; I don't think legislators got the message sent to them by the angry electorate.

Are you surprised by that? I'm not.

For those of you who live in districts sending new faces to Washington, make plans to open dialogues and get to know them and their staffs. Tell them about what you do and how it benefits the beneficiary community. Don't wait to begin your efforts; do it now. Get the jump on CMS by educating them; start a proactive and productive conversation instead of the rushed, angry, and reactive relationships the DME community is typically forced to have.

Arm them at the beginning with your side of the story. It may help down the road when the industry needs it.

Dropping the Pilot

I've run across several articles and blogs that discuss the possibility of Texas withdrawing their Medicaid program.

Sixty percent of Texas Medicaid is funded by federal funds. Even with the funding the program receives from the federal government, the Texas Medicaid program is a huge expense for the state.

I suppose this is true for most states.

Medicaid programs do good things for people in dire need. There are well over three million children enrolled in the Texas Medicaid program, as well as adults with disabilities and what one blog referred to as "impoverished" Texans.

The Helpless
I'm sympathetic toward very ill children who need care that their families simply can't afford. I can't imagine being in that position (as either parent or ill child), but it's good that a program is available that will help fund the care of a child in need. I don't begrudge them assistance.

It is hardly possible to build anything if frustration, bitterness and a mood of helplessness prevail. (Lech Walesa)

The Hopeless
There are also adults with disabilities who cannot work, and so need assistance with medical issues. Are there some with legitimate, debilitating illnesses that make these unfortunates seek assistance from state programs? Without a doubt.

But then there are those who are perfectly capable of some form of work, and some form of productive activity, but who play the "illness card" that enables them to receive benefits -- both medical and income -- for little or no effort. It's their "disabilities," you see.

I personally have known several people who fall into that category. I don't know them for long, because I resent parasites.

Sure I am a freeloader but my morals permit that. (Anonymous)

From Each According to His Ability ...
To each according to his need. This is an appalling philosophy. I remember talking to someone several years ago who was adamant that the legend of Robin Hood was one of the worst and most irresponsible crimes perpetrated by humanity on humanity.

She maintained that it was an abomination to encourage the mindset that taking from the productive "rich" to give to the undeserving (and useless) poor was moral and right. She wasn't wealthy; she worked for a living, and wasn't looking for or expecting hand-outs. But she did resent that some of the taxes she paid went toward the upkeep of society parasites.

Yes, she was one of those who adamantly supported welfare turning into workfare, and drastically limiting the free ride too many get.

I was, at the time, surprised; I thought, at the time, that she was being a bit cold. But as the years have passed, more and more people are getting an entitlement mentality, and I now see what she was saying. I also find that I agree.

The welfare of each is bound up in the welfare of all. (Helen Keller)

Why does society today perpetuate the myth that we are all our brothers' keepers? Why are those who work obligated to fund the lives of those who don't? I don't mind that some of the taxes I pay help those who are in legitimate need, but just because someone is "impoverished," doesn't mean they should be entitled to a free ride at my expense.

There are millions and millions who work, contributing to society and taxes, and they don't have health insurance because they can't afford it. Do they get state benefits? No. They don't qualify because they're too wealthy.

Huh?

Let me get this straight: The productive members of society can't benefit from what they pay in by getting assistance from the state? How is that right?

Aliens Among Us
One blog had a comment from someone who said that it's okay for Texas to drop Medicaid because of all the illegals in it.

Illegal is anything that is against the law including drug trafficking, smuggling, terrorism or crossing the border into a country. Undocumented is anything that can no longer be verified including unemployed American workers who no longer qualify for unemployment benefits and are no longer counted in statistics. What a sorry nation we are becoming when we allow corporate political correctness to pervade our daily speech. Illegal means illegal. (Peter Romanenko)

I'm a curious person, so I checked to see if Texas Medicaid has any citizenship requirements, and it does. There is, however, an exception. A pregnant illegal can get medical coverage through the Medicaid program. So Texas citizens are footing the bill for illegals to have children in the state.

Illegal means illegal. Pregnant illegals need to be sent back to their home countries, not permitted to leech from a system into which they do not and are not likely to ever pay.

True charity is the desire to be useful to others without thought of recompense. (Emanuel Swedenborg)

I'm not opposed to being charitable. But what I am opposed to is having my pocket picked by lazy, useless people.

Charity is injurious unless it helps the recipient to become independent of it. (John D. Rockefeller)

Exactly, John. The government "support" programs today don't encourage the recipients to become independent of them; they only encourage the vast majority participating to work the system as long as they can.

Capital punishment is as fundamentally wrong as a cure for crime as charity is wrong as a cure for poverty. (Henry Ford)

I disagree with Henry Ford on his capital punishment stance, but agree absolutely that charity is wrong as a cure for poverty. The more people get for free, the more they want (and the more they think they're entitled to have). Welfare, disability compensation, and Medicaid are charity.

Government Wants Poor People to Die
That's a ridiculous statement, but bleeding-heart liberals say things like that when entitlement programs are threatened.

I've often wondered how much of their own time and money liberals donate to their causes; it's more advantageous for their purposes to have the tax-payers fund their generosity. In their minds, society owes the poor (and the lazy), and society should give 'til it hurts.

Ladies and gentlemen of the liberal persuasion, I have news for you: It hurts. In fact, it's been hurting for quite a while now. And I, for one, have had enough of throwing money at people who make no effort to help themselves.

Tightening Up In Texas
The Texas legislators who want to bid farewell to the Medicaid program know that they'll have to find an alternative that will continue to address the needs of the truly needy.

Texas won't be dropping the pilot by dropping out of Medicaid, if that's what they end up doing. What Texas would accomplish is escaping the too-broad and too-expensive federal guidelines and requirements of a program that's too easy to milk.

In participating in the Medicaid program, and receiving federal funds for that program, Texas is obligated to play by federal rules, which are so loose that the state pays out more than it should. Texas has to offer Medicaid entitlement programs (and dollars) to individuals they might, if they had the power, (correctly) reject.

My main concern is what such a move would do to the DME industry. And this is something that suppliers in Texas need to think about as they keep an eye on the future of Texas Medicaid.

The Winner Is: No one!

Always mystify, mislead and surprise the enemy if possible. (Thomas J. Jackson)

That quote seems to be the philosophy of CMS. DME is the enemy, and the agency seems to take great delight in mystifying, misleading, and surprising the industry.

Eighty percent of all surprises are unpleasant. This includes bills, estimates, unkept promises, firings, birthday parties, and pregnancies. (William Marstellar)

I'm going to add legislation and anything CMS does to the unpleasant surprises that appear in the quote above. The agency has a gift for springing news on the industry very late in the day. Because they do that so often, I think it's safe to say that even the village idiot knows that they do it on purpose.

Americans of all ages deserve quality end-of-life medical care. (Bill Nelson)

Nice one, Mr. Nelson, but who defines quality?

In politics people give you what they think you deserve and deny you what they think you want. (C. Northcote Parkinson)

This explains healthcare reform and CMS's approach to the DME industry.

So we know now who the bid winners are for the re-do of round-one. Is anyone surprised by the results? I'm not. I expected to see many of the company names that appear on the lists.

Oh, I raised my eyebrows when I saw that Rob Brant's company and Barry Johnson's company got contracts; so much for principles, huh? I suppose it's all well and good to be philosophically opposed to competitive bidding, but it's okay to embrace and participate in the process because one has to to feed one's family (or something along those lines).

It may be that because they're so publicly "passionate" about their anti-competitive bidding stance, I naturally assumed that they'd not want to participate in a program that would destroy the businesses of so many of their friends and supporters (well, okay, the few that they actually have; it's not like I'm talking about a crowd here).

It's easy to be against something when you're shut out; Rob Brant's company failed to get a contract in the original round one, and so he suddenly (and very belatedly) became an ardent industry activist.

There's nothing like being left out in the cold to get you moving, right? I'll be interested to see what happens going forward. Wont you, dear reader?

We must not tolerate oppressive government or industrial oligarchy in the form of monopolies and cartels. (Henry A. Wallace)

I suppose the argument could be made that, because there are many "winners" in the round-one MSAs, the government hasn't created monopolies. The companies that got contracts will still have to compete with each other for new referrals and for beneficiaries.

America is at that awkward stage; it's too late to work within the system, but too early to shoot the bastards. (Claire Wolfe)

Even though there will have to be competition among those left standing, the sad truth is that too many of those who didn't "win" contracts are going to suffer. And there's no solution in sight; 3790 is dying a quiet death, there's still no one willing to introduce a companion bill in the Senate, and by the time the industry rallies again, competitive bidding will have been implemented and Congress will adopt a wait-and-see attitude.

And some of the current crop of "winners" won't make it either. The reimbursements are so low that some companies won't be able to manage. Which means the provider gene pool will shrink even more.

What's the answer? There isn't one, at the moment. But while all this is going on, the industry needs to take note of and document every single failure of the competitive bidding program to use as ammunition against CMS and to use as justification (and inspiration) to make legislators do something about the bid.

I know I'll be keeping an eye on things, but that can't come as any real surprise, right?

And just when you thought you were the coolest person in the room, I walked in. (Unknown)