Don’t Let Medicare Undermine Life-Saving Surgery – Inside Sources

Every surgeon makes a promise to patients. We cannot always promise a cure or that complications will not happen. However, we can promise to: one, do everything in our power to achieve the best possible outcome; and two, work to find them the resources they need to recover and return to a healthy life.

A new Medicare policy is making me wonder whether I can still make that second promise to patients undergoing ostomy surgery.

I regularly care for patients with colorectal cancer, traumatic injuries and inflammatory bowel disease. For many, an ostomy — a surgically created opening that allows waste to leave the body into a pouch — is a life-saving or lifestyle-saving operation. About 1 million Americans live with an ostomy.

Surgery is only the beginning. Successful recovery depends on the ostomy supplies that patients use afterward. Patients must have reliable access to pouching systems, skin barriers, and adhesives that fit their bodies and work for their daily lives.

Those supplies are not interchangeable. They are highly individualized medical prosthetics that patients often spend weeks — or months — working with clinicians and medical equipment providers to get right.

When patients find the right fit, they return to work. They care for their families. They travel. They regain the independence that surgery was meant to restore.

When they do not, the consequences are painful, frustrating and often costly. More than one-third of ostomy patients experience skin complications within three months of surgery. A poorly fitting pouch can allow waste to sit against the skin, causing painful irritation, breakdown and infection. It can also leak or come off entirely — disrupting daily life and making it difficult to leave home. These issues can also lead to emergency room visits and hospitalizations.

Unfortunately, the federal government is moving forward with a competitive bidding program that could make these issues far more common.

Patients typically try multiple ostomy care products before finding the combination that works for them. Even then, their needs can evolve as they recover from surgery or their bodies change. That is why surgeons view ostomy supplies as essential medical prosthetics that must be tailored to each patient.

Instead of ensuring patients receive the products that work best for them, this new program could force them to rely on whatever products a contracted supplier happens to carry.

Medicare uses competitive bidding to lower what it pays for certain medical equipment by having suppliers compete for Medicare contracts. For the first time, ostomy suppliers will participate.

Rather than dividing the country into smaller regional markets, Medicare has created a single nationwide competitive bidding area covering every state, territory and the District of Columbia. Suppliers awarded contracts will serve Medicare beneficiaries across that entire area.

Meeting those nationwide requirements may be feasible for large companies, but community-based suppliers could struggle to compete, leaving patients with fewer choices and less support.

What’s especially troubling is that such a sweeping policy — one that could determine patient success after a critical operation — is based on essentially no relevant evidence.

In its more than 700-page final rule, the Centers for Medicare & Medicaid Service offers just one ostomy-specific example. Medicare allowed charges for billing code A4407, a type of convex ostomy barrier, increased from $13 million in 2003 to $37.4 million in 2022. CMS cites that growth as part of its rationale for including ostomy supplies in competitive bidding.

However, increased spending alone doesn’t demonstrate waste or over-utilization.

After adjusting for inflation, $13 million in 2003 is $20 million in 2022, accounting for much of the apparent increase. And greater use of convex barriers does not suggest inappropriate care. Many patients require specialized products because of their anatomy. Patients are also living longer after illnesses and injuries that once proved fatal, and advances in care have allowed us to treat increasingly complex cases.

In other words, growth in the use of these products reflects advances in medicine and changing patient needs — not evidence of a broken ostomy supply market.

Medicare argues that the new rule will still protect patients because it allows clinicians to prescribe a particular brand when medically necessary. That safeguard sounds reassuring. However, it also exposes the fundamental mismatch between competitive bidding and ostomy care.

When CMS created this safeguard, it said prescribing a particular brand would rarely be necessary because products within the same billing code perform the same therapeutic function.

That’s not the case in ostomy care. Two products may serve the same general function and still perform very differently on an individual patient’s body. The shape of a barrier, its flexibility, convexity and adhesive properties can all determine whether a patient maintains a seal or develops leakage and injury.

If patients can’t get products that fit them properly, they may be forced to use products that don’t work as well while they look for an alternative. Any savings achieved by paying less for ostomy supplies could easily be offset by higher spending on wound care and treatment for preventable complications. A procurement system that lowers supply costs while increasing the overall cost of patient care is not a success.

I frequently raise these concerns with lawmakers and Medicare officials. Everyone I speak with recognizes what is at stake.

Members of Congress are drafting bipartisan legislation to postpone the competitive bidding program for urology and ostomy products for five years, giving policymakers, clinicians and patient advocates time to assess its effect on patient access. Congress should introduce and pass that legislation without delay.

Regardless of what happens, I will keep knocking on doors and coming up with creative solutions to ensure that every patient who grants me the privilege to participate in their care has the best life possible after surgery.