After more than 40 years in the medical care/equipment field—35 of them as the founder and president of Electro-Med Systems in Louisville, Ky—James “Jim” Tittle knows the business. The now 68-year-old was an art major in college, a paratrooper with the Army Rangers, and a barnstormer at county fairs. Tittle decided to “get a real job” in 1964 and answered an ad for a hospital equipment salesman. He eventually started his own business in 1970 specializing in surgical equipment.
While recuperating from injuries suffered in a 1977 automobile accident, Tittle took stock of his business, and realized he could not match the volume of sales done by his bigger competitors. Around that time, he found out about transcutaneous electrical nerve stimulation (TENS) units, which back then sold for $600 to $700. “I thought if you could rent these things to make sure that they actually worked, and then, if they didn’t, you could refurbish them somehow, that would be the way to go.” Tittle never looked back, and has helped thousands of TENS patients.
Dealer/Provider: What are the primary electrotherapy modalities?
Tittle: TENS, an alternating current; high-volt galvanic stimulation (HVG), which is a direct current; and neuromuscular electrical stimulation (NMES), which is manufactured with pretty much the same pulse wave as a TENS unit, but has a much deeper pulse—each pulse will stay on the skin longer so it penetrates a little more and stimulates the nerve points to activate muscles.
I do a lot of work right now with muscle stimulation on the limbs of children who have cerebral palsy. We have had some real good success with that. There is another modality called interferential, where you put more than one electrode on, and then cross them, and where they cross, one channel interferes with the other one and you get one really deep penetration. The deeper you can get that electrical current to that nerve, the better off you are.
There is also microcurrent, a subsensory current that works at the cellular level. There has been research that shows it is pretty good for some forms of healing. With most of the others, the only healing you get is the increased circulation in the area you are stimulating—and good circulation is always going to help healing.
Dealer/Provider: In your experience with TENS/electromedical devices, what has been the most significant technical advancement?
Tittle: The miniaturization and the ability to do more adjustments with the same piece of equipment. The first TENS units that came out in the late 1970s were like the early portable cassette players. As the electronics and research with microchips started moving more and more forward, the manufacturers started making them smaller and smaller. By doing that, they were less cumbersome, and also able to produce a cleaner transmission of the electrical impulses. Additional whistles and bells included adjusting the length of each pulsation and its frequency per second.
Dealer/Provider: Was there ever a “golden age” of electromedical reimbursement? How would you characterize the current state of reimbursement?
Tittle: The golden age of reimbursement was when we first came out with the devices in the late ’70s/early ’80s. Insurance companies did not know that much about them yet. We got the early approval from Medicare. By getting that, all the other insurance companies had to fall in line or lose out, so they started giving approval. As most things happen, there were some greedy people in the medical field who would go to retirement areas, door-to-door, telling older people they knew would be on Medicare that their doctor had prescribed this piece of equipment for pain control. They would give them a little sales pitch, and then bill Medicare. They made millions of dollars, but Medicare started doing some investigation, and several people went to jail for that. And that gave us a really black eye for a while.
Insurance companies are intensely looking at their bottom line now. Whereas we used to get $70 a month rental for a TENS, Medicare now approves something like $25. The only good thing about reimbursement now is that the cost of the TENS unit has come down.
Dealer/Provider: Has it become harder for a smaller business like yours to survive in this industry, especially with reimbursement being so poor?
Tittle: If you do enough volume, it is not hard to survive. A lot of the money is made in the accessories, in the electrodes. I have experienced a lot of ups and downs, as far as reimbursement. The insurance companies really nickel and dime now. It takes me 2 or 3 months of rentals just to get the equipment paid for. The whole secret is that you have to know what to buy and what to pay for it. I have had thousands of TENS patients, and I still do fairly well. The business has completely gone through a change.
Dealer/Provider: Among HME providers, what is the biggest misconception about the electromedical business?
Tittle: That you just take a TENS unit, hand it out, and that’s it. You have to know your product. Most of the HMEs, the bigger ones especially, have people who I would refer to as order-takers who know nothing about the equipment. You need to know your product to make recommendations.
Dealer/Provider: What tips would you offer to someone trying to succeed in the electrotherapy business?
Tittle: Become familiar with the equipment you want to carry. Become almost an expert in it by talking to people like me. Be financially ready. If you are going to rent equipment, you should have enough finance to do at least 90 days before you get any meaningful returns. That is just a rule of thumb. Don’t look to be taking any money out of your profits for at least 90 days. You have to go into it well financed. You can’t go into any kind of business in the medical field underfinanced anymore because you will lose business.
Find a core group of doctors—go to some of the pain clinics, orthopedic doctors, neurosurgeons, general practice doctors—and show them what you’ve got. You must be confident with it, and they will use you. Two key areas are a good doctor’s office, and a good doctor’s office that has a physical therapy clinic—or a chain of physical therapy clinics.
Dealer/Provider: What common errors should providers avoid?
Tittle: Giving the wrong kind of equipment and not really knowing that much about the patient. Not coordinating with the physical therapist or doctor’s office about what patients exactly need is also a common error. Providers also forget to assure patients that this will help them, and if they have any questions, to call the provider.
Dealer/Provider: Can you offer a specific example of a business challenge you overcame?
Tittle: The biggest challenge was years ago when a TENS company that was owned by a major manufacturer sued that manufacturer and won a lot of money from that lawsuit. The major manufacturer paid somebody to do research to prove that TENS didn’t work because they were noticing that a lot of their in-hospital and postoperative pain medications just were not being ordered. They hired people, and those findings about TENS units not being effective were published in a major medical journal. Of course, the insurance companies jumped all over that. But the researchers did not do any of the right protocols for using TENS, and the doctors who were knowledgeable about TENS came out in support of the TENS units. It took us a while to come back from that, but the proof is in the user.
Dealer/Provider: How do you market to referrals?
Tittle: Generally, the best place to go is to the physical therapy clinics that use electrotherapy. They use electromodalities every day. When I first started in this business, there were no freestanding physical therapy clinics. Now you go in there, do an in-service, and show them what is the best kind of equipment. The doctor is also an important part, but a doctor sends a referral to a physical therapist and tells them what the diagnosis is, and tells them to evaluate and treat the patient any way they can—unless they specifically put down what to do. So it is the physical therapists who tell the doctors what they want to use to treat patients.
Dealer/Provider: In your many years in the electrotherapy business, what has surprised you the most?
Tittle: The biggest surprise is that these things really work, and they work a lot better than most people think they do. The reason I have been able to do this for so long is that I have confidence in the modalities. I know that what I have will work.
| Provider Perspectives Q: How do you market to Veterans Administration hospitals?
Mike Elcott, general manager at Strata Therapies, Birming-ham, Ala, responds: I find key decision makers in areas such as purchasing/prosthetics, rehabilitation, pain management, orthopedics, and occupational therapy. I meet these contacts and analyze their needs and current practices relative to electromedical stimulation. Inevitably, most have not heard of the major brands and are excited about their prospects. I ask if they have specific patients that might benefit from these modalities that address depression, insomnia, anxiety, and pain. I follow-up with each department in writing, phone calls, and in person.
Q: What are the problems associated with marketing to VA Hospitals?
Elcott: Funding and budgets for each department are set yearly and allocated prior to year-end funding in the September and October time frame. Often National contracts require the facility to purchase from a national vendor for certain products. We are on contract with the VA Hospital system as a medical dealer, but may not have the specific national contract for a specific device. This is often overcome by meeting with decision makers in purchasing who actually approve each departmental request for medical devices, cuts the purchase order, and pays us with a VA credit card. Setting our company apart through service (in-home), marketing a unique product within the nationally contracted product group, and providing better pricing to the facility often allows the purchasing agent to buy through us even if we do not have the national contract for a specific product group—such as electromedical stimulators.
Q: What is the best way to describe and market electromedical products to potential referral sources?
Ronald C. Lefkowitz, Core Medical Consulting, Agoura, Calif, responds: My previous experience as a financial planner has taught me that you need to be more than a vendor of services to your clients. You must be an active partner and consultant and provide your referral clients with a way to improve outcomes and generate additional revenues. Electromedical products are best described as an adjunct to physical therapy and treatment. These products are an adjunctive tool for conditions such as pain, edema, and neuromuscular reeducation. Their clinical value is substantial—allowing practitioners to get better outcomes in a shorter period of time. This is important in today’s health care environment since insurance restrictions limit the number of visits between the patients and therapists. Therefore, today we may have half the clinical contact time to attain the same outcome. In marketing electromedical products, we must convey to potential referral sources that we bring value-added services to their practice. We not only provide DME, but we also have the ability to assist with determining the goals and objectives with their practice. In a market where reimbursement is declining, we need to demonstrate areas in which we can save clinics money (electrodes and supplies) and offer suggestions that may increase their reimbursement or authorizations. An area of potential increased revenue is patient home use of these modalities. In most instances, the physical therapist is using modalities in their clinic on a regular basis. They have an understanding of electrotherapy in general and use it within their practice. It stands to reason that if the clinician uses the modality in their facility, then they must believe in it as being efficacious. Our job is to be able to make the nexus and obtain agreement that if it works in the clinics then it should also be effective at home. Therefore, we look to providing electrotherapy modalities for their patients to use at home. Another important marketing component is providing independent advice and services free of company bias. Being independent allows us to educate the clinicians and help them achieve their desired objectives The best way to introduce new products is during an in-service (everyone likes a free lunch). |
Danielle Cohen is associate editor of Dealer/Provider.
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