As a clinician, I hesitated to ask a certain question until enough clinical colleagues started asking the same question. The question started forming when suppliers and manufacturers began to share a list of products that were "Medicare Best Picks"—for consideration when performing client assessments.

It was pretty apparent to me that a best pick was more about margin than anything else. I fully support the need for consolidation and improved efficiencies in this industry, and I am sensitive to all the cuts that must be endured. However, I bring words of caution about how this is presented and how it is perceived by the clinical and funding communities.

Does a Medicare best pick indicate what is best for Medicare? Likely not, because Medicare reimburses for codes within a group based on clinical criteria and not specific brands. In actuality, a "best pick" could be perceived as the Medicare worst pick from the payor perspective, because one has to assume that the higher the margin, the lower the cost of production—and likely lower quality. It also could be perceived that the Medicare best pick could be the suppliers' inadvertent means of doing their own version of competitive bidding to the manufacturers. If this is the case, wouldn't Medicare be justified in implementing competitive bidding so they can also ensure the lowest cost product and savings within a code?

Does a Medicare best pick mean that the product listed is what is best for the end user? Are we reminding our clients/customers that they still have a choice? Also, keep in mind that patients are vulnerable people dealing with the overwhelming issue of their disability. These individuals put their needs in our hands as professionals, and they assume we are looking out for their best interests. Is the pick list going to dictate what products are most appropriate for that end user?

Does a Medicare best pick mean that this is the only brand Medicare will pay for? This is (somewhat) how it has been presented and interpreted by some of my clinical colleagues. We must continue to remind ourselves that Medicare pays for product codes, not brands.

There are certainly specific product groupings where a relative level of clinical equivalency exists across brands. However, when you get into complex situations requiring complex interventions, often a particular brand—and combinations thereof—needs to be specific to the needs of the end user. Does the pick list now dictate the product brand a clinician can recommend? Are suppliers and manufacturers consistently reminding the clinicians that they still have autonomy in their clinical decision-making, or is the pick list intended to dictate practice?

Mark R. Schmeler

If a Medicare best pick is truly all about margins, then why not just be forthcoming and call it what it is? The concept of pick lists (or procedures that are not money-losing propositions) has been around for decades. Since the onset of managed care and other cost-cutting strategies, practitioners and health care facilities have been challenged to continue to provide necessary services and become more efficient while maintaining standards of practice. I am sensitive to the situation we are in, but I hold suppliers to a high standard and respect them as health care professionals. As such, I am an advocate of moving them forward officially to this level.

Keep in mind that margins are certainly not within my area of expertise. I am a clinician and do not run a supply business. Suppliers have thrown out numbers as to the margins they need, and no supplier should be forced to lose money, which is not in anyone's best interest. But in most industries, margins can be somewhat justified and accounted for (except perhaps in the clothing or jewelry industries). Appreciate that they are more difficult to account for in the area of complex rehabilitation equipment, but a high margin needs to be justified.

Whether the equipment being prescribed is simple, complex, high cost, or low cost, the resources, including personnel time and other overhead, are somewhat relative. Whether a $2,000 or $20,000 piece of mobility assistive equipment is being prescribed, the supplier still has to spend time with the client, conduct a home assessment, and process paperwork. There certainly might be a little more time and work involved in a $20,000 device, but it is certainly not proportional to the margin that is needed.

The rationale I have heard is that profits made on the more expensive devices are needed to cost shift money loss on less expensive equipment. This is an area where we need to be careful. Cost shifting is a reality, but it is also a target that CMS keeps chasing.

We need to figure out better ways to be cost-effective and efficient without compromising patient care, which has always been a challenge in health care. And when we look at costs, it is not just the upfront costs of the equipment. We all know costs are related to a lot of other factors, including repair, dealing with unhappy customers, and being forthcoming with referral sources and payors.

Mark R. Schmeler, PhD, OTR/L, ATP, is a faculty member at the University of Pittsburgh in the Department of Rehabilitation Science and Technology, and has more than 15 years of clinical, teaching, and research experience. He practices in the Center for Assistive Technology at the University of Pittsburgh Medical Center. He is cochair of the International Seating Symposium, associate editor of RESNA's Assistive Technology Journal, and chair of its special interest group on wheeled mobility and seating. Schmeler can be reached at .