Medicare TEP Policy Hurts Providers, Patients SLPs lose money when providing tracheoesophageal prostheses to Medicare patients, so some no longer offer the devices. Data and advocacy may increase reimbursement—and access to services. Policy Analysis
Free
Policy Analysis  |   September 01, 2014
Medicare TEP Policy Hurts Providers, Patients
Author Notes
  • Meryl Kaufman, MEd, CCC-SLP, BCS-S, is a clinician at the Emory University Department of Otolaryngology, Head and Neck Surgery. She is a board member of the Head and Neck Cancer Alliance and an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders; and 13, Swallowing and Swallowing Disorders. Meryl.Kaufman@emoryhealthcare.org
    Meryl Kaufman, MEd, CCC-SLP, BCS-S, is a clinician at the Emory University Department of Otolaryngology, Head and Neck Surgery. She is a board member of the Head and Neck Cancer Alliance and an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders; and 13, Swallowing and Swallowing Disorders. Meryl.Kaufman@emoryhealthcare.org×
  • Jeff Searl, PhD, CCC-SLP, is an associate professor in the Department of Hearing and Speech at the University of Kansas Medical Center. jsearl@kumc.edu
    Jeff Searl, PhD, CCC-SLP, is an associate professor in the Department of Hearing and Speech at the University of Kansas Medical Center. jsearl@kumc.edu×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   September 01, 2014
Medicare TEP Policy Hurts Providers, Patients
The ASHA Leader, September 2014, Vol. 19, 30. doi:10.1044/leader.PA2.19092014.30
The ASHA Leader, September 2014, Vol. 19, 30. doi:10.1044/leader.PA2.19092014.30
If a medication costs a pharmacy $10, but laws require the pharmacy to sell the medication for $5, would the pharmacy carry that medication?
Most probably would not, and consumers who need that medication—because it’s the only treatment for their condition—would have a hard time locating it, especially because they are prohibited from ordering it directly.
This scenario is exactly what many laryngectomy patients have faced since a Medicare rule took effect in 2010.
Laryngectomy patients often use a tracheoesophageal voice prosthesis to produce sound. There are two types of TEPs: indwelling, which must be inserted by a health care professional, and non-indwelling, which can be placed by the patient. Both types must be replaced periodically.
Prior to 2010, Medicare patients who use an indwelling prosthesis could order the TEP directly from the distributor, receive Medicare reimbursement that totaled about half of the cost, and pay the difference out of pocket.
In 2010, Medicare determined that reimbursing patients for indwelling TEPs is inconsistent with Medicare law and stopped doing so. Instead, the professional who places an indwelling TEP must order the device on the patient’s behalf (although patients may order them without reimbursement). With this change, SLPs who order prostheses for a patient take a financial hit: Medicare reimburses the device at less than half its actual cost, and prohibits health care providers from collecting the difference from the patient.
This change applies only to indwelling prostheses.
Based on the average cost of an indwelling TEP and current Medicare reimbursement rates, an SLP who provides one Medicare indwelling TEP per week loses about $7,000 per year. Many facilities have much higher distribution and incur much larger losses.
Patients are feeling the effects of this policy:
  • Facilities lose money every time they purchase an indwelling TEP for a Medicare patient, so some providers are discontinuing TEP services.

  • The majority of facilities that do offer TEPs can’t—because of the cost—keep a large stock of brands and sizes in stock. A Medicare patient who needs an indwelling device replaced must wait until the facility orders and receives a new one. The only alternative is to pay out-of-pocket to purchase the device directly from the manufacturer.

  • Because they would have to pay out of pocket, patients are not likely to buy extra back-up devices—as they did before 2010—to have for emergencies.

When patients have to wait to replace a TEP because of access issues or delivery waits, the results can be a leaking prosthesis, aspiration pneumonia, temporary loss of speech or permanent loss of the insertion puncture tract.
ASHA and other organizations, including the International Association of Laryngectomees, took immediate advocacy action following the 2010 rule change, but the Centers for Medicare and Medicaid Services failed to respond. In subsequent discussions, CSM officials agreed to review the reimbursement rate using “inherent reasonableness” authority, but only if data are provided that reflect the impact on patient access, quality or supplier participation.
When sufficient data and patient experience evidence are available, ASHA will request to meet with CMS staff about increasing the TEP reimbursement rate to one that is commensurate with the market. To participate in collection of data and patient experience evidence, contact Lisa Satterfield, ASHA director of health care regulatory advocacy, at lsatterfield@asha.org, or either co-author.
0 Comments
Submit a Comment
Submit A Comment
Name
Comment Title
Comment


This feature is available to Subscribers Only
Sign In or Create an Account ×
FROM THIS ISSUE
September 2014
Volume 19, Issue 9