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HME Past, Present and Future: State of the Industry/Benchmarking Update/Round 2021 and Beyond

From the Desk of Mark Higley

January 2021


Introduction.............................................................................. 3 State of the Industry Update................................................... 4 Overall Demand for Products and Services............................. 6 The COVID-19 Effect and Competitive Bidding...................... 8 The Bid Bond Issue................................................................. 13 The Proposed Rule.................................................................. 14 Geographic Payment Amounts.......................................... 15 Review the Proposed Rule and Submit Comments............ 16 VGM/HME News Benchmarking Survey................................ 17 HME Benchmarking Toolkit................................................ 18

HME Past, Present, and Future



I was honored to present at the 2020 HME News Business Summit Sept. 15–17, held, due to COVID-19, in a first-time “virtual” format. My session, “The 14th Annual HME News/VGM Group Financial Benchmarking Survey,” included a series of data, trends, and analysis as to the state of the industry from 2010 to the present, as well as financial and operational highlights from supplier submissions applicable to their 2019 results. One hundred and twenty-five unique HME suppliers responded to the survey request. These entities ranged from smaller, single-location operations to major regional players. We compiled the raw data in a (de-identified) Excel spreadsheet, created a summary PDF “visual” file of the responses, and, in many instances, tracked trend lines from 2010 to 2019 via a PowerPoint slide presentation. Note: You can access this presentation, along with the other 2020 sessions, at hmesummit.com. This report summarizes that presentation, and I encourage readers to contact me with specific questions or requests for additional information/clarification at any time.

Mark J. Higley, MBA Vice President, Regulatory Affairs, VGM Government Relations Mark.Higley@vgm.com 319-504-9515

HME Past, Present, and Future


State of the Industry Update Consolidation continues its decade-long trend, resulting in fewer but larger players in our industry. And, competitive bidding and other negative market forces have directly or indirectly resulted in almost 3,500 HME locations closing since 2010.



In 2010, 11,677 traditional HME locations maintained active Medicare operations. At the beginning of 2020, there were 8,289.

Many of you are aware that VGM has obtained from the Pricing, Data Analysis, and Coding (PDAC) [via a Freedom of Information Act (FOIA) request] an annual report of all active Provider Transaction Access Numbers (PTANs) within the scope of the DMEPOS industry. There exists more than 100 “supplier types” whose numbers of locations approaches 100,000 (pharmacy locations, for example, encompass almost half of these). But DMEPOS suppliers are arrayed into certain “primary supplier types,” which include medical supplies and equipment, oxygen, and orthotic/prosthetic/pedorthic services. The 10year trend of active locations for each may be found here. In 2010, 11,677 traditional HME locations maintained active Medicare operations. At the beginning of 2020, there were 8,289. Interestingly, in our Sept. 8, 2020, report, that number increased to 8,730, an addition of 441 locations and, effectively, the first increase in a decade. This took us somewhat by surprise— acquisition/consolidation does not necessarily “add” to the number of new locations, and the demand for DMEPOS, while steady (detail to follow), did not suggest numbers to this degree.

HME Past, Present, and Future

To which there may be what I will dub a potential for “the pandemic effect.” You are likely aware that during the public health emergency, CMS relaxed the requirements to enroll as a DME supplier. You could enroll without a background check, fingerprints, application fee, or accreditation. These waivers are still in effect [the public health emergency (PHE) has been formally extended for an additional 90 days]. However, once CMS lifts the restrictions, these new suppliers will have a certain period of time in which they will be required to meet all the standards. Accordingly, VGM will then access another report to attempt to analyze the effect, if any.


A state-by-state data analysis indicates a 5,000+ decrease in locations over the past decade, or more than 40%.


In any case, there are additional data sources indicating the size of our industry. Somewhat simply stated, if you count only suppliers (of all types) that are actively being reimbursed, and for common HME products (e.g., CPAP, walkers, oxygen, beds, etc.), the decrease in locations is actually larger. We created a state-by-state data analysis, which indicates a 5,000+ decrease in locations over the past decade, or more than 40%. And lastly, if you monitor unique tax IDs (that is multi-location operations are measured as “one” and not by PTAN count), the 2010 data indicated 9,769 entities; the 2020 number was 6,152, or a reduction of 37%.


State of the Industry Update continued...

Estimated Number of Traditional Medicare DMEPOS Unique Supplier Companies by State DATE TOTAL STATE



9,769 11/10


8,837 7/13


7,158 7/17


6,469 4/18

Difference Between 6,152 11/10 and 04/20 4/20 4/20

5,976 4/19

































































































HME Past, Present, and Future


Overall Demand for Products and Services While there seems to be a plethora of independent (but pricey) market research services attempting to analyze the DMEPOS market spend and growth trends, I prefer to monitor the regular updates of CMS’ estimates of national health expenditures (NHE). On a macro basis, national health spending is projected to grow at an average annual rate of 5.4% for 2019–28 and to reach $6.2 trillion by 2028. Because national health expenditures are projected to grow 1.1 percentage points faster than gross domestic product per year on average over 2019–28, the health share of the economy is projected to rise from 17.7% in 2018 to 19.7% in 2028. Among major payers, Medicare is expected to experience the fastest spending growth (7.6% per year over 2019– 28), largely as a result of having the highest projected enrollment growth.

HME Past, Present, and Future


National health spending is projected to grow at an average annual rate of 5.4% for 2019–28 and to reach $6.2 trillion by 2028.


Citing “Table 15” of the NHE link above, DMEPOS spending is projected to total $62 billion this year, representing a 6.35% increase from 2019. The government’s estimate for the next decade hovers around high 5% to low 6% per annum. Medicare increases are, comparatively—and perhaps not unexpectedly— less than the growth rate of private health insurances and Medicaid. The average per capita DME spend in the U.S. is estimated at $187 this year, increasing to $280 in 2028. There is much more detail available via the NHE tables, and I urge readers to review.


Overall Demand for Products and Services continued...


Long-term demand will remain strong—but the industry is (obviously) subject to the COVID-19 effect.


I mentioned above the possibility of a “pandemic effect” relative to the number of DMEPOS suppliers. As the NHE estimates were updated March 8, 2020, there certainly exists the possibility of a decrease in 2020 (and 2021) spending amounts for the same reason. Overall, market demographics and chronic conditions will remain key leading indicators— and the long-term demand will remain strong—but the industry is (obviously) subject to the COVID-19 effect.

HME Past, Present, and Future


The COVID-19 Effect and Competitive Bidding This is a big unknown as to accurate forecasting for industry results in 2020. Stakeholders report concern for DMEPOS suppliers (albeit less for those with a large percentage of revenue in respiratory products) who are dependent on certain elective procedures requiring DME. And a recent report/analysis on home health visits from VGM CEO Mike Mallaro suggests many patients, even with referrals, are not following up with their post-acute care—whether it be home health, pharmacy, or acquiring DME—up to 46%. We will closely monitor the data as it becomes available. Additionally, on Oct. 27, CMS announced an update to the Round 2021 Competitive Bidding Program. The notice revealed that only two of the categories will move forward on schedule: knee and back orthotic braces [noninvasive ventilation (NIV) was already out due to CMS’ decision on COVID-19]. This means that 13 categories will not move forward in Round 2021. In conjunction with this announcement, there was also a CMS release relative to a new proposed rule (CMS-1738-P), which, among other things, potentially affects reimbursement for competitively bid product category items on or after April 1, 2021, or “the date immediately following the duration of the emergency period” or, put more simply, when HHS declares the public health emergency over, whichever is later.

CMS competed 16 product categories in 130 competitive bid areas for Round 2021 of DMEPOS, reviewing 49,000 bids. As noted, noninvasive ventilators were removed in April 2020 in response to COVID-19, leaving 15 product categories. Thirteen of the product categories had been bid during previous rounds while off-the-shelf (OTS) back and knee braces were competed for the first time. CMS has decided NOT to award competitive bidding contracts for any of the 13 product categories that were previously competed because “the payment amounts did not achieve expected savings.” Contract offers have been made in 127 competitive bidding areas (CBAs) for the OTS back and knee braces. Winning bidders had to respond to contract offers by Nov. 10, 2020. The memo did not include information on when competitive bidding will go back into effect for the product areas left out of round 2021. However, I believe that unless legislative changes occur, the next competition will have an effectivity date of Jan. 1, 2024. CMS stated it had heard from a range of stakeholders requesting that the agency delay or cancel the Round 2021 program due to the ongoing COVID-19 PHE. Apparently, CMS considered that feedback and, as noted above, is not awarding competitive bidding contracts for the 13 product categories “because the payment amounts did not achieve expected savings.”

HME Past, Present, and Future


The COVID-19 Effect and Competitive Bidding continued...

When we consider the past and details of the (then) new auction methods, this “did not achieve expected savings” statement is disturbing. It is well known that the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires Medicare to replace the current fee schedule payment methodology for selected DMEPOS items with a competitive bid process. In early March, the CMS announced plans to consolidate the CBAs included in the Round 2 Re-compete and Round 1 2017 DMEPOS CBP into a single round of competition named “Round 2021.” Key Changes for “Round 2021” • Use of the “clearing price” to set rates: The single payment amount (SPA) for a lead item will be equal to the maximum bid submitted for that item by bidders whose lead-item bids for the product category are equal to or below the pivotal bid for that product category in a CBA. • Lead-item pricing: To allow for the use of what is essentially a “clearing price” methodology, suppliers will submit a single bid for a lead item in the product category. The SPA will be calculated for that lead item in the CBA based on the highest amount bid within the winning bids. The SPAs for non-lead items will be based on the relative difference in the fee schedule amounts for the lead and non-lead items. • Bid surety bonds: Bidders must obtain a $50,000 bid surety bond for each CBA for which they submit a bid. • Use of SPAs to set rates in non-CBAs: CMS also uses the SPAs to set the rates in nonCBAs that are not rural but will set the rural non-CBA rates at what is essentially the SPA plus 10% in rural areas. This means the bids HME Past, Present, and Future

for CBAs will have a direct impact on the rates in non-CBAs. • Bid limits substantially raised: Auction experts and economists recognized that a continual reduction in the “bid limit” (the amount of which suppliers must bid below) would eventually lead to unsustainable SPAs as each round of bidding effectively lowered the payments and set the new bid limits for future rounds. Accordingly, Round 2021 bid limits were set at 2015 non-adjusted (before competitive bidding fee schedule) rates, plus an allowance for inflation to the bidding period. By way of example, a month of rental oxygen (E1390) bid limit was increased from approximately $70 to almost $190. The majority of other categories saw similar increases. In addition, to help suppliers get up to speed, a group of industry leaders collaborated to launch an online educational resource: www.dmecbpeducation.com. The website—the product of a collaboration between the American Association for Homecare (AAHomecare), the Council for Quality Respiratory Care, the Healthcare Nutrition Council, and VGM Group—served as a complementary resource to the Competitive Bidding Implementation Contractor (CBIC) website. Suppliers and prospective bidders nationwide could use the website’s powerful calculators to estimate how lead item pricing may impact costs and compare them to an approximation of how the SPAs compare to the then current 2019 Medicare rates. The calculator also showed how a bid would affect the rates in non-CBAs if it became the SPA. Moreover, the website served as a platform for webinars and events intended to educate prospective bidders about the CBP in the lead-up to the bidding round.


The COVID-19 Effect and Competitive Bidding continued...

Taking all of these changes into account—a much higher “starting point,” a maximum bid “clearing price,” and a rather substantial barrier to prevent unqualified bidders from entering the auction via a $50,000 bid bond for each market—industry stakeholders anticipated higher new payment amounts. It is also inconceivable that CMS’ own analysts did not expect an increase, as the new methodologies were designed to prevent patient access issues and ensure quality services from DME suppliers. Hence, the decision to remove the previously bid product categories due to “lack of savings” was perplexing; the new system was designed to ensure sustainable rates. There was a mixed reaction among industry stakeholders. Some publicly traded companies

opined the three-year hiatus from contracting added stability to the overall market (and the respective stock prices reflected that interpretation). Others, anticipating improved SPAs and a more qualified array of supplier contractors, effectively “cried foul” to the actions. In any case, CMS did move forward with the bracing categories and made offers in 127 (out of 130) CBAs. The release included that Medicare expects to save $600 million for the program and beneficiaries over the three-year Round 2021 contract performance period. CMS has released the new SPAs and has sent contract offers to bidders for the OTS back braces and OTS knee braces product categories. The number of offers (and locations) by CBA, may be found here.

Contract Offers by Compettiive Bidding Area and Product Category PRODUCT CATEGORIES COMPETITIVE BIDDING AREA

Off-The-Shelf Back Braces

Off-The-Shelf Knee Braces



















Aiken & Edgefield Counties, SC

Akron, OH

Albany-Schenectady-Troy, NY

HME Past, Present, and Future

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The COVID-19 Effect and Competitive Bidding continued...

You may find the new SPAs on the CBIC website, dmecompetitivebid.com. Click on Round 2021 and then “Single Payment Amounts.”

One interesting anomaly I noticed was the extremely large variances in the OTS bracing SPAs among the CBAs. As noted above, the “clearing price” methodology allowed all bidders to receive the maximum bid. Somewhat simply stated, the bids are arrayed from the lowest acceptable amount and continue upward, taking into account the estimated demand in units for one year (each supplier was required to submit the number of braces the company was willing to offer) until the supply equaled the expected demand. If there were relatively low amounts of units offered by each supplier, that clearing price could near the bid limit—that is, the current fee schedule and the amount of which suppliers must bid below. Conversely, if suppliers offered a large amount of units, the results could be that only a few suppliers could fulfill the demand, and, depending on the “highest price” offered, result in a very low SPA. HME Past, Present, and Future

This occurred. Here is an interesting graphic:

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The COVID-19 Effect and Competitive Bidding continued...

Thus, for the same brace, the reimbursement (SPA) differs up to $900. This has never occurred before; in previous rounds for common DME such as oxygen, CPAP, and hospital beds, the variance among the 130 CBAs was frequently only a few percentage points. This is an issue which we will continue to monitor in future rounds. These new payment amounts and contracts went into effect on Jan. 1, 2021. Winning bidders for the OTS back and knee brace product categories have received Round 2021 contract offers in Connexion, the DMEPOS CBP’s secure portals. Winning bidders had to respond to the contract offers before Nov. 10, 2020.

HME Past, Present, and Future

The initial array of contract acceptances will be included for a short period on the CBIC website; when the program begins, current contractors may be monitored by accessing the Medicare supplier directory and entering the permanent ZIP code of the beneficiary (this is the ZIP code to which the social security payment is on file). This search feature is updated frequently; there may be additional contractors serving the CBA as some entities are removed and others are added (e.g., erroneously disqualified but reinstated, small suppliers added after the SPAs have been calculated to allow for certain 30% small supplier participation goals, etc.).

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The Bid Bond Issue As most are aware, Round 2021 required suppliers to acquire one $50,000 bid surety bond per CBA (not per product category). The bid bond “liability” (that is, the $50,000 per CBA) would not exist if no contract offer was made in the CBA or, if the supplier did opt to contract, it would expire 90 days after the contract was executed. Suppliers that were offered contracts for the OTS bracing had the option to decline the offer if their bid was higher than the “median bid” for all suppliers within the CBA for the category. The concept of “median bid” may be confusing, as Round 2021 incorporated a “clearing price” bid versus the previous rounds’ median bid. While the median bid for Round 2021 OTS bracing did not set the SPA, it was nevertheless monitored for purposes of enforcing the bid bond. Let me offer an example/visual. I will use a faux “widget” that had a bid limit of $100. The lowest bid that was accepted by the CBIC was $50. The clearing price (where the number of suppliers’ offers in units met the expected demand) was $76.50. As previously noted, all suppliers would be reimbursed at the new SPA of $76.50. But nevertheless, there had to be a “middle bidder” among those offered a contract:

Thus, if a supplier bid above that median dollar amount, they could decline the contract. If not, they must accept the contract. In the case of the brace contract offerings, the supplier could see in Connexion whether or not they bid above the median. Which leads us to a most common question: “I only bid in the 13 product categories that were removed. Can I get a bid bond refund?” The quick answer is no. The premium was “earned” upon their payment and the initial credit check required by the surety entity. The statute is clear in that “if no contract was offered” the liability ceases; this does NOT imply that the bidding supplier is entitled to a refund (as no contract was offered). HME Past, Present, and Future

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The Proposed Rule The legislation provided suppliers in designated rural areas with a fee schedule that was a 50/50 blend of the rates before competitive bidding and of the then-applicable adjusted rates due to competitive bidding. CMS-1738-P states:

Note: A complete summary via the CMS Newsroom may be found here. In short, the Oct. 27 proposal is intended to establish payment methods for these items effective on or after April 1, 2021, or the end of the PHE, whichever is later. But let’s begin with the current environment, of which you are likely aware: As required by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, CMS had adjusted the fee schedule amounts for items and services furnished in rural and non-contiguous, non-competitive bidding areas based on a 50/50 blend of adjusted and unadjusted rates for the remainder of the COVID-19 public health emergency. CMS also provided higher payments for certain DME items and services furnished in non-rural, non-competitive bidding areas by a 75/25 blend, with dates of service on or after March 6, 2020, through the remainder of the COVID-19 public health emergency. As noted, the COVID-19 PHE resulted in legislative action that, among other things, was directed to allow DMEPOS suppliers with relatively better reimbursement from Medicare. HME Past, Present, and Future

Under the proposal, CMS would continue paying suppliers higher rates for furnishing items and services in rural and noncontiguous areas (this is Alaska and Hawaii except for Honolulu) as compared to items and services furnished in other areas, informed by stakeholder input indicating higher costs in these areas, greater travel distances and costs in certain non-CBAs compared to CBAs, the unique logistical challenges and costs of furnishing items to beneficiaries in the non-contiguous areas, significantly lower volume of items furnished in these areas versus CBAs, and concerns about financial incentives for suppliers in surrounding urban areas to continue including outlying rural areas in their service areas. Previous feedback from industry stakeholders expressed concern regarding beneficiary access to items and services furnished in rural and remote areas. …(W)e are proposing to continue paying the 50/50 blended rates in rural contiguous areas, but are proposing that the 50/50 blend will no longer be a transition rule under §414.210(g)(9), and will instead be the fee schedule adjustment methodology for items and services furnished in these areas under §414.210(g)(2) unless revised in future rulemaking. We are proposing that the fee schedule amounts for items and services furnished in rural contiguous areas on or after April 1, 2021, or the date immediately following | 14

The Proposed Rule continued... the duration of the emergency period… whichever is later, be adjusted so that they are equal to a blend of 50 percent of 110 percent of the national average price for the item or service and 50 percent of the fee schedule amount for the area in effect on December 31, 2015, increased for each subsequent year beginning in 2016 by the annual update factors specified in sections 1834(a)(14). What does this mean?



CMS-1738-P means rural areas and non-contiguous Alaska/Hawaii keep the 50/50 blend.

It means rural areas and non-contiguous Alaska/ Hawaii keep the 50/50 blend. The “transition” (temporary) blend was set to expire on April 1 or the end of the PHE, but this proposal makes it permanent—unless changed by future rulemaking. What about “non-rural” areas that are cities and large towns but not large enough to be competitively bid? Prior to the CARES Act, they were reimbursed at a regional rate, or RSPA, which stands for “regional single payment amounts.” Effectively, these areas were reimbursed for items at approximately the same rate as the larger CBAs within their region. However, Congress did approve a better benefit—that is, 75% of the RSPA and 25% of the much higher non-competitive bidding rate. These amounts continue today and will continue until April 2021, or until the PHE is declared over.

HME Past, Present, and Future

However, this proposed rule does not allow for a continuation of this 75/25 blend at this time. It reads: …(F)or items and services furnished on or after April 1, 2021, or the date immediately following the duration of the emergency period whichever is later, in all other nonrural non-CBAs within the contiguous United States, we are proposing that the fee schedule amounts be equal to 100 percent of the adjusted payment amount established under §414.210(g)(1)(iv). This means these non-rural and non-bid areas revert to the lower-reimbursed RSPA amounts. Geographic Payment Amounts CMS established eight geographic regions and eight RSPAs. CMS calculates the RSPA for each region using the unweighted average of the SPAs for a DMEPOS item from all CBAs that are fully or partially located in that region, regardless of population. CMS averages the RSPAs, weighted by the number of states in that region, to calculate a national average RSPA. Here is a visual of the 130 CBAs (the red “footprint” includes all the counties within the CBA):

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The Proposed Rule continued... The “regions” mirror the current regions used for unemployment analysis by the BEA:

What about these CBAs? What will suppliers be paid for the next three years? The proposal includes: For items that were included in Round 2021 but have essentially been removed from Round 2021 of the CBP, we are considering whether to simply extend application of the current fee schedule adjustment rules… until new SPAs are calculated for the items once competitive bidding of the items has been resumed. Effectively, the current reimbursement amounts in the 130 CBAs would remain the same until a new bidding program came into effect.

CMS adjusts fee schedules for states in different regions of the country based on previous competitive bidding round pricing in these “regions.” The regional prices are limited by a national ceiling (110% of the average of regional prices) and floor (90% of the average of regional prices). For example, Colorado non-bid areas will be reimbursed at the weighted average of not only the CBAs within the state, (Denver and Colorado Springs) but also the other CBAs in the Rocky Mountain region, such as Boise and Salt Lake City.

Review the Proposed Rule and Submit Comments CMS published a formal notice in the Federal Register, which included the offering of public comments and a deadline for submission. I urge all stakeholders to review the actual documents and proposed rule if you have accessed this information prior to the deadline of Jan. 3, 2021. Submitting Comments on the Proposed Rule Electronically: Go to www.regulations.gov and follow the “Submit a comment” instructions. By regular mail: Send comments to Centers for Medicare & Medicaid Services Department of Health and Human Services, Attention: CMS1738-P, P.O. Box 8013, Baltimore, MD 212448010.

HME Past, Present, and Future

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VGM/HME News Benchmarking Survey This was the 14th annual update for the survey. While the number of participants (sample size) is not extremely large at 125 this year, the year-over-year data allows a respectable trend assessment for analysis. While the details of the survey are beyond the scope/word limit of this summary (and I urge readers to go to hmesummit.com for a recording; a “toolkit” with the raw data and a comparator feature will be available shortly), I’d like to share some of the key takeaways: • Almost 60% of the respondents indicated they were “full line HMEs,” with a slight increase in hospital-owned or -operated facilities. Rehab technology unique tax IDs continued to decrease, likely reflecting the continued consolidation/acquisition efforts of two large national entities.

• With a choice of “decline, stay steady, increase 1–10%, 11–20%, or over 20%,” the total collectible HME revenues for 2019 had 40% of the respondents decline or stay steady, 60% increased—14% more than 20%. • Traditional Medicare remains the largest payer, albeit the percentage of overall revenues continues to decline. When the survey began, Medicare FFS approached 50% of revenue; this year the figure was 29%. As expected (citing the increase in Medicare Part C Advantage Plans throughout the country), Managed Medicare grew, as did private health insurance.

• The proportion of rentals to sales continues to trend downward. A decade ago, respondents maintained an average “60% rental, 40% sales” mix; those numbers have exactly reversed to a 40/60 basis. • Operating profit before interest and depreciation (EBITDA) rose to an average of 14%. From a decade low of 9% in 2013, EBITDA has remained relatively steady over the past five years. • Almost half of the respondents reported operating from a single location. The industry remains in a mode of “one” (as it has throughout the history of the survey) but the amount of 5+ locations has been steadily increasing. With the advent of continued acquisition and private equity funding, expect this trend to continue. HME Past, Present, and Future

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VGM/HME News Benchmarking Survey • Of the 125 respondents, respiratory product sales/rentals make up 50% of overall revenues (oxygen at 17%, sleep at 28%, ventilation at 5%). Supplies and retail sales continue an upward trend.

Accordingly, across product lines it suggests manufacturers and distributors have reasonably held prices in line to reflect the 2019 reimbursement levels. (As noted, we will closely monitor the 2020 acquisition trends due to the pandemic.)

• Sleep remains “king;” 58% reported the category as the largest increase year over year.

There are literally 50 more survey questions with accompanying data points and trend lines. Again, I urge readers to access the actual report and comparator toolkit.

• When asked “did your unit cost of comparable HME equipment (for rental & sales) purchased by product increase, decrease, or stay the same,” the responses were: » Oxygen 34/13/53 » Sleep 24/28/48 » Beds/wheelchairs 36/16/48 » Supplies 40/13/47 » Power mobility 34/14/52 » Complex rehab 32/9/59



Stay the Same

100 53














34 20


14 40




Power Mobility

Complex Rehab




Beds/ Wheelchairs

HME Past, Present, and Future


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HME Past, Present & Future: State of the Industry / Benchmarking Update / Round 2021 & Beyond