Business Lessons from Piracy

The world has demonized the image of the pirate but maybe we should learn a couple of lessons from those 'scurvy dogs.'

Pirates held the utmost contempt for anything that diluted the focus of the mission at hand. Pirates were focused on one thing and one thing only; bringing home treasure. Everything they did revolved around that one goal.

The pirate ship was run as a democracy with each member of the crew given a vote. The leader or captain was elected at the beginning of the voyage but didn't always come home commanding that same authority. If the crew was not satisfied with the results produced by the elected leader or had lost trust and confidence in the methods employed, a new leader could be elected. The deposed leader had the choice to walk away gracefully or fight the entire crew. Clearly, maintaining a good relationship with the crew and supporting them attaining their goals was not only a priority but also a survival technique.

Since booty was the goal, everything was built or designed to gather in that booty. Ships of that time were built to contain ballast in the hull that changed the characteristics of how the ship sailed. The ballast was usually composed of rocks or some other dead weight. While the ballast was important to sailing, it was less important than the booty. If the haul exceeded the weight capacity of the ship, the ballast was quickly traded to increase carrying capacity. In some extreme cases, a strategic decision was made to pitch cannons overboard to allow for more treasure. There were no sacred cows or cries of "but we always sail with dead weight in the hull." There was only focus on gathering treasure and getting it home no matter how creative the solution had to be.

Once the treasure was gathered in, the celebrations began. Guns were fired, mead was drunk, backs were slapped and cries of "Huzzah!" filled the air immediately after the work was done. In addition to their share of the treasure, pirates receive instant gratification and reward that binds the team together and creates legends that can be referred to as motivational stories for years to come.

You don't have to rape and pillage villages to be a corporate or an entrepreneurial pirate. You have to be focused, take care of your team, and celebrate every accomplishment.

Are you ready to wear an eye patch to your next business meeting?

Stable, Not Static [CELA]

Dynamic Seating to Improve Movement and Function Presenter:
Allen Siekman, Siekman Consulting

The pelvis was designed for standing and movement, it was not designed for sitting.

Dynamic Seating allows or enhances controlled natural movement patterns while providing stability.

Natural reaching patterns include pelvis and upper trunk movement. Restricting pelvic and trunk movement restricts functionality.

Standard shoulder harness usually does not allow torso movement, limits push range, strength, and reach for daily activities.

45 degree belts limit anterior tilt and limit range of motion. 60 to 70 degree belts allow for greater pelvis range of motion. 90 degree belts use the legs to hold the pelvis and allows increased pelvis range of motion. It is also possible to lean forward and do a pressure relief while using a 90 degree pelvic belt.

A leg harness (like the one from BodyPoint) allows pelvis and torso movement while holding the legs down and back.

A product like the HipGrip from BodyPoint is built to be a dynamic device that supports dynamic movement.

Although there are specialized options available, there is a lot of dynamic seating that can be done using traditional belts set up at the correct angles.

Image from: http://www.urz2.com/avivaw/images/drawing/pelvis_lateral.jpg

Powered Mobility Training for Children with Comples Needs [CELA]

Presenter:
Karen Kangas, OTR/L, Seating and Positioning Specialist in private practice, Shamokin, PA

Children are not small adults!
One of the reasons that children are not usually considered for powered mobility is because we view them within the paradigm of adults. Adults all ready know how to be mobile and move within space. Children may not have learned what it feels like to move in space they are still experiencing mobility.

For successful use of a powered mobility system, these three issues must be resolved:

1. Seating for task performance
2. Powerchair is programmed adequately
3. head first, hands free operation

Training should take place within the child's home or pre-school in an environment that is familiar.

We can not place adult standards of practice on children. Children will not demonstrate judgement or safety as these come with maturity and experience. The adults are responsible for these.

There is no doubt that independent mobility is critical for development, and that without it, delays in cognitive, emotional, social, and motor development are evident.

Image from: http://www.dragonmobility.com/as.php

Looking Back [CELA]

Lessons for the Future

Presenter:
Hymie Pogir, Vice President of Product Planning, National Seating and Mobility

This morning's session is a look back at the history of the rehab industry hoping to identify exactly where things went wrong and how to fix our future.

A call for educating people on exactly what we do. We shouldn't be the "wheelchair providers." We should be viewed as the people that are product experts, help people get jobs, provide functionality, help sick children.

Is the NRRTS Code of Ethics inconvenient or is it only being used when it is convenient? If adherence is inconvenient, we should change the code. If the changes are inappropriate, insist on adherence to the Code AS IS.

Mass marketing has made a positive impact on the industry. There is very little if any stigma to the usage of a powerchair. Mass marketing has expanded the market and increased the knowledge of the consumers. What should set rehab dealers apart from mass marketers is the process that the company uses.

As an industry, we do not unite together to fight the problems that come from payors and legislation. There is no unified organization, there is only a series of small and larger businesses that have to aggresively take a stand to save the industry.

All politics is local. We can not rely on someone else to do the work. We need to do the work and we need to involve the consumers. Consumer's stories are worth much more than the impact we can make on lawmakers.

Doing More With Less Part 2 [CELA]

Doing more with less - Making appropriate seating and wheeled mobility clinical decisions in the face of funding cuts - part 2 - Power Wheelchairs and Seating

Panelists:
Mike Babinec, OTR/L, ABDA, Product Manger: Power Wheelchair Electronics, Invacare Corporation
Julie Piriano, PT, ATP, Director, Rehab Industry Affairs, Quantum Rehab
Ann Eubank, OTR/L, Director of Education, Permobil
Moderated by:
Joni McGhee, OTR, Clinical Coordinator, TIRR/Memorial Hermann


Julie Piriano started off by explaining the role of the "SPARC" principle at Quantum. Singularity of Parts and "first time quality" in supply chain and manufacturing practices have provided cost savings that have been passed on to the dealers. Quantum understands that the more successful a company becomes the more risk they take on with repairs. By providing equipment that is tested and has a high quality, there will be fewer failures and less money lost on repairs.

Mike Babinec opened up stating that the manufacturers need to get the education out into the field about the coding process and why equipment has certain codes. We need to educate consumers because they are the people that have the most potential to make changes on Capitol hill. We need to educate our therapists more so that they understand better how to justify power equipment as well as so they understand the pressures that the dealers are working under.

Ann Eubank talked about limiting choice. Is there an ethical dilemma when we limit choice based on reimbursement. We should offer all alternatives to customers regardless of their insurance reimbursement possibilities. Offering the best alternative, even if it is not financially provided by their payor, is empowering. Only offering alternatives available based on funding is oppressive. We should be advocates for each customer based on their actual needs.

Develop and forge a relationship with local and statewide disability groups. Explaining why changes happen, what the issues are the industry faces, and what the issues are that the consumers will face will help build that relationship while educating them at the same time.

Teach consumers how to find their congressman and advocate for themselves.

The question then becomes how to help consumers overcome their fears and be able to advocate for themselves.

Ann Eubank made us aware of a new advocacy group called Users First Alliance. The alliance is focused on helping people with disabilities gain access to the seating and mobility equipment that they need and deserve. They also give a unified voice to the fragmented demographics of the disability community.

Educate the customer on all of their options and provide the optimal solution for them. Discuss funding last after they are sold on the solutions and on the benefits that the solutions will provide their daily lives. When the discussion turns to money, they are more likely to write a check for upgrades or non-reimbursable items if they see them as a whole package of care.

OR. . .

Discuss funding up front. By knowing the insurance company information, you can have the discussion with the client about what the needs are, what the solution HAS to be as well as what the solution CAN be. Once the options are available the consumer, provider, and therapist can make more informed decisions.

Doing More With Less [CELA]

Doing more with less - Making appropriate seating and wheeled mobility clinical decisions in the face of funding cuts - part 1 - Manual Wheelchairs and seating

Panelists:
Foster Davis, Freedom Designs
Tom Whelan, Global Vice-President, Seating, Sunrise Medical
Tina Roesler, MSPT, ABDA, Director of Sales & Education, TiLite

Moderated by:
Joni McGhee, OTR, Clinical Coordinator, TIRR/Memorial Hermann

A discussion panel focused on how to provide the right equipment with fewer dollars and shrinking funding sources.

Tom Whelan started off explaining the need for education of our referral sources, payors, and our customers. We need to educate all parties on the need for the right equipment

Tina Roesler opened her remarks with a call for better collaboration. She noted that we need to go back to the model of the RTS/ATP working in collaboration with a therapist to come to a decision on the best outcomes for the customer. She stated that many RTS's are providing services to consumers for free that a therapist can bill for and may be more appropriate for a therapist to provide.

Foster Davis begins with advocating the development of a state organization of suppliers that can band together to work with each state legislature to develop the Medicaid program. The association in Texas has been able to work with the state in development of new programs to strengthen the Medicaid standards of care for the customers. This also allows the industry to impact the development of the laws rather than react to the laws.

The first question from the audience is in regards to the new Medicaid program cuts proposed in Georgia and how to build a relationship similar to Texas.
Time and relationship building are very important in building that relationship. It was also suggested from the audience that we should share our equipment costs as well as time and labor involved in providing the equipment for a consumer. Texas legislators have begun to understand the costs of doing business and are more sympathetic to the dealers now that they have a working relationship with the dealers in the state.

One of the keys to building that relationship is to show how you can save the state money. You may have to reduce spending or utilization on items like diapers (as was done in Texas) to a reasonable level in order to build trust and confidence when other items need to have the allowable raised.

NCART is building a repository for Medicaid information for all states across the country. There is a News, Toolbox, and Medicaid by State section of the website.

A call for uniformity in discount pricing. Since some payor contracts are based on discounts received by manufacturers, some providers have asked their manufacturers to reduce their primary discount and increase their secondary discount so that they can receive a higher reimbursement from the payor. If there is a standard discount for all rehab products (suggested 40%) and then negotiate secondard discounts based on purchase volume, credit terms, etc.

Doing more with less can not always mean going back to the manufacturers for discounts to get more money. We need to educate our therapists and payors on what our actual costs are to make the business argument to maintain or increase reimbursement. We need to show that rehab does not have the same cost structure as DME but is closer to the overhead cost structure of O&P.

Does providing products based on reimbursement, keeping the suppliers and manufacturers in business, and taking a stand on maintaining profit negatively impact the end user? At what point do we stop providing "appropriate" equipment and start providing "OK" equipment?

Image provided from: http://api.ning.com/files/8DI5WcJFfBFz9bITKl7sxWmPAxsZreeBOyf7qJtJijiy7CbIMk6m4Xf3dKnAfsLftCgnduYND9G-8PeZACABCUhciY5p-g4H/consensus.jpg

Saying No [CELA]

A survival skill for complex rehab providers and therapists

Presenter: Gerry Dickerson, CRTS, Director of Rehab Technology, Medstar, Inc.

Different Types of No in the Rehab industry:

Corporate No (or not saying no). This is when saying no is out of your hands based on business decisions, practices, or insurance contracts.

• Managed Care contracts
• Making it up in volume
• Leveraging Complex Rehab (Loss leader to get a contract for different business)

Saying No in this instance may be out of your hands based on existing practices but it is also important to have the ability to say no in the future based on opportunities that arise. The caution here is to not use rehab business as a loss leader for gaining other business. This hurts the industry as a whole as well as hurting the consumer by reducing access to needed equipment as reimbursements are continually lowered.

Point of Service No (including items that aren't fundable)

• "Can you just grow my chair. . . "
• "It's just a simple repair. . . "
• Giving a product or service away for free
• Formularies

Our job is ". . .Providing the best available product match based on clinical indicators allowed under the payer source." Our job is not to give stuff away for free. Free service, upgrades, and products set unrealistic expectations with the therapists and the consumers.

New York state Medicaid Myth:
Gerry shared his experience with providing a TiLite K0009 Wheelchair in New York City to a customer with Medicaid. In New York, a provider can set up a private pay agreement with a consumer IF:

• both parties have agreed PRIOR to the rendering of the service that the enrolee is being seen as a private-pay patient
• signed consent
• NEVER bill Medicaid for that particular piece of equipment

The message is that we need to stop assuming that we can't bill a Medicaid beneficiary cash for items. We need to investigate the rules and laws that govern the benefit and take full advantage of all options available state to state.

Pushing Back
Just because you hear no from a payor source does not mean that the equipment can not be provided. Push back to the funding source and exhaust all avenues. Investigate alternate options. Don't forget cash. Use video to prove the medical necessity of the equipment needed by your clinic.

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