.. 
Department  of  Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENliRAL 
MARKETING  OF  WOUND  CARE

SUPPLIES

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*  GIBBS  BROWN 
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0EI-03-94-O0791  OFFICE  OF  INSPECTOR  GENERAL 
The mission of the Office of Inspector General  (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department  of Health and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by four OIG operating components:  the Office of Audit Sefices,  the 
Office of Investigations, the Office of Civil Fraud and Adminsitrative Adjudicationand the 
Office of Evacuation and Inspections.  The OIG also informs the Secretary of HHS of program 
and management problems and recommends courses to correct them. 
OFFICE  OF AUDIT  SERVICES 
The OIGS Office of Audit Sefices  (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors  in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout  the Department. 
OFFICE  OF  INVESTIGATIONS 
The OIGS Office of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient  abuse in the Medicaid program. 
OFFICE  OF  EVALUATION  AND  INSPECHONS 
The OIGSOffice of Evaluation and Inspections (OEI) conducts short-term management  and 
program evaluations (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations contained in these inspection 
reports generate  rapid, accurate, and up-to-date information on the efficiency, vulnerability, 
and effectiveness of departmental  programs.  This report was prepared  in the Philadelphia 
Regional Office under the direction of Robert A. Vito, Regional Inspector General. 
PHILADELPHIA  REGIONAL STAFF  HEADQUARTERS STAFF 
Linda M. Ragone, Program Aizaijwt  Stuart R. Wright, Program Specialist

Robert A. Baiocco, Program Anaiyst  Barbara Tedesco, Technical  Support  Staff

Cynthia Hansford, Program Assistant  Brian P. Ritchie, Technical  Suppoti  Staff

Emily Tseng, Intern  Linda Moscoe, Technical  Support  Staff

Neil Montovani, Intern

Won Jong Oh, Intern

To obtain a copy of this repo~  please cdl the Philadelphia Regional OfKce at (800) 531-9562
 .. -
Department  of  Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
MARKETING  OF  WOUND  CARE

SUPPLIES

# SERVICEJ 
~+  Osq 
+  GIBBS  BROWN 
JUNE 
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: Inspector  General 
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0EI-03-94-O0791  EXECUTIVE  SUMMARY

PURPOSE 
This  report  describes  supplier  and  nursing  home  practices  that  can lead  to 
inappropriate  payments  for wound  care  supplies,  and  examines  issues concerning 
Medicare  beneficiaries  use of these  supplies. 
BACKGROUND 
Wound  care  supplies  are  protective  covers  or fillers  that  treat  openings  on the  body 
caused  by surgical  procedures,  wounds,  or ulcers.  The  Health  Care  Financing 
Administration  (HCFA)  reimburses  for wound  care  supplies  under  Medicare  Part  A 
through  its payments  to nursing  homes  and  home  health  agencies  and  Medicare  Part 
B through  its payment  to suppliers.  The  HCFA  broadened  its coverage  policy  on 
March  30, 1994, allowing  payment  for secondary  as well as primary  dressings  and 
including  wound  treatments  by non-physicians. 
The  HCFA  contracted  four  Durable  Medical  Equipment  Regional  Carriers 
(DMERCS)  starting  October  1993 to process  Part  B claims  for DME,  prosthetics, 
orthotics,  and  supplies  including  wound  care  supplies.  These  DMERCS  developed 
revisions  to their  guidelines  for wound  care  and  requested  comments  in January  1995. 
These  guidelines  clarify utilization  and  medical  necessity  issues.  The  effective  date  for 
implementing  the  revised  guidelines  is October  1, 1995. 
This  inspection  was conducted  as part  of Operation  Restore  Trust,  a pilot  program 
that  coordinates  Federal,  State,  and  local  anti-fraud  activity  in California,  Florida,  New 
York,  Illinois,  and  Texas.  The  program  will target  abuses  in home  health  agencies, 
nursing  facilities,  and  durable  medical  equipment,  including  wound  care  supplies. 
We  collected  data  from  both  nursing  homes  and  Medicare  beneficiaries  for  this  report. 
We  selected  a stratified  random  sample  of 420 nursing  homes  from  HCFAS  Online 
Survey  Certification  and  Reporting  system  and  a stratified  sample  of 469 beneficiaries 
who  received  Medicare-reimbursed  wound  care  supplies  between  June  1994 and 
February  1995. 
FINDINGS 
Musing homes  and physiciam detemine  which patients need supplies but som  suppliers 
determine the anumnt providld 
While  most  nursing  facilities  indicate  that  physicians  or nursing  staff initially  identify 
that  a patient  needs  wound  care  supplies,  in 23 percent  of nursing  homes  the  supplier 
representative  decides  the  number  of supplies  to be  delivered  in a given month. 
i 
  .-
Wound care supplies are fhquent~  provided in standurd kit form  to beneficiaries. 
More  than  half  of Medicare  wound  care  recipients  reported  they received  their

supplies  in kit form.  Similarly,  almost  half  (45 percent)  of nursing  homes  using

Medicare-reimbursed  wound  care  supplies  received  some  or all of these  supplies  in kit

form.  Under  the  new DMERC  medical  policy to be implemented  in October  of  1995,

supplies  provided  in these  standardized  kits would  not  be  covered.

Some supplierxprovidk inducements to musing homes and beneJiciwies. 
Thirteen  percent  of nursing  homes  have  been  offered  inducements  in exchange  for 
allowing  suppliers  to provide  wound  care  products  to patients  in their  facility. 
Information  from  nursing  homes  and  beneficiaries  indicates  that  some  suppliers  may 
be  routinely  waiving  the  Medicare  beneficiary  coinsurance,  a practice  that  violates  the 
Medicare  statutes. 
Benefkiaries  may not be receiving or using all of the wound care supplies reimbumd  by 
Medicare. 
Medicare  may be  reimbursing  for wound  care  supplies  that  are  not  needed  by 
beneficiaries  since  both  nursing  homes  and  beneficiaries  report  not  always using  all the 
supplies  they  receive.  In addition,  many  nursing  homes  have  no method  of ensuring 
that  supplies  are  used  by the  beneficiary  for which Medicare  was billed.  Medicare  and 
beneficiaries  may be  paying  for wound  care  supplies  that  are  not  used  specifically  by 
them. 
CONCLUSION 
The  information  in this report  is intended  to add  to the  body  of knowledge  being 
developed  concerning  the  use  of wound  care  supplies  for Medicare  beneficiaries.  It is 
being  issued  with  two other  reports  on this subject.  These  products  are  part  of a 
broader  strategic  effort  designed  to assess  payments  made  on behalf  of Medicare 
beneficiaries  in nursing  homes.  Information  from  previous  OIG  reports  coupled  with 
the  current  findings  on wound  care  provide  continued  support  for  the  effort  by HCFA 
to require  the  bundling  of semices  in nursing  homes.  This  solution  would  emphasize 
nursing  homes  responsibilities  for management  of patient  care  and  provide  incentives 
for the  appropriate  use  and  prudent  purchase  of supplies,  since  it would  be  nursing 
homes  and  not  suppliers  who would  receive  Medicare  reimbursement  for  these 
supplies. 
COMMENTS

We  solicited  and  received  comments  on our  draft  reports  from  HCFA  and  other 
concerned  organizations.  The  organizations  that  provided  us with  responses  were  the 
Health  Industry  Distributors  Association  (HIDA),  the  Health  Indust~  Manufacturers 
Association  (HIMA),  and  the  National  Association  for the  Support  of Long  Term 
ii  .-. 
Care  (NASL).  However,  I-HMA chose  not  to provide  specific  comments  on this 
report,  The  full text  of the  comments  from  HCFA  and  the  outside  organizations  can 
be  found  in a companion  report  entitled  Questionable  Medicare  Payments  for  Wound 
Care Supplies (OEI-03-94-00790). 
The  HCFA  agreed  with the  recommendations  in the  companion  report,  Questionable 
Medicare  Payments  for  Wound  Care  Supplies.  In addition,  HCFA  responded  that  they 
have  developed  a legislative  proposal  to require  bundling  of services,  including  wound 
care  supplies,  in Medicare  and  Medicaid  payments  to nursing  homes.  They  believe 
that  this may seine  as an incentive  for nursing  homes  to more  closely monitor  the  use 
of wound  care  supplies. 
The  outside  organizations  commented  that  they strongly  support  HCFAS  expansion  of 
the  national  coverage  policy for wound  care  supplies  and  that  no reduction  in the 
current  scope  of the  benefit  should  be  considered.  They  believe  that  the  DMERCS 
delay  in implementing  wound  care  policies  and  utilization  standards  after  HCFAS 
expansion  of the  policy was the  primary  factor  in creating  an environment  ripe  for 
potential  abusive  practices.  Both  HIDA  and  NASL  expressed  concerns  that  our 
wound  care  surveys were  misleading  and  biased  and  unlikely  to provide  meaningful 
data.  Nevertheless,  they both  stated  that  the  results  of the  surveys  show  that  the 
majority  of suppliers  and  facilities  act responsibly  in operating  their  businesses.  The 
HIDA  also responded  that  we incorrectly  implied  that  legitimate  market-driven 
supplier  services  were  inappropriate. 
While  we believe  the  initial  lack  of DMERC  policies  without  utilization  standards  for 
wound  care  supplies  played  a part  in allowing  abuses  to occur,  we do not  believe  it to 
be  the  entire  cause  of abusive  supplier  practices.  Even  without  specific  utilization 
standards,  suppliers  are  supposed  to be  able  to support  the  medical  necessity  of the 
wound  care  products  they deliver. 
In response  to HIDA  and  NASL  concerns  that  our  surveys for this report  were 
misleading  and  biased,  we believe  that  the  questions  in our  survey were  appropriate  in 
their  wording.  The  Medicare  beneficiary  survey was designed  to be  easily  understood 
and  completed  by the  sample  population.  We  do not  feel  the  questions  were 
misleading  to beneficiaries  nor  were  they  intentionally  designed  to solicit  biased  or 
untrue  information.  The  nursing  home  survey was designed  to obtain  comparable  data 
from  a large  number  of respondents  on a wide range  of issues  relating  to wound  care. 
In response  to HIDAs  concerns  that  we were  critical  of legitimate  services  that 
supplier  perform  on behalf  of their  customers,  we believe  that  we presented  the 
information  in a fair  manner  and  did not  draw  conclusions  that  could  not  be 
adequately  supported.  We  are  by no means  concluding  in this report  that  all suppliers 
are  involved  in questionable  practices.  In fact, we highlighted  in our  companion 
report  on  questionable  Medicare  payments  that  three-quarters  of the  excessive 
payments  we identified  in our  sample  were  made  to only 7 percent  of all suppliers  in 
the  sample.  However,  we do believe  that  some  of the  practices  reported  by nursing 
... 
111  .--
homes  and  beneficiaries  such as determining  the  number  of supplies  to be  delivered 
and  routinely  waiving  coinsurance  amounts  raise  concerns  about  the  legitimacy  of 
certain  semices  that  suppliers  provide. 
iv  .-
TABLE  OF  CONTENTS 
PAGE 
1 
EXE~  s~y  . . ... 
.1

mC)DumON  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

~lNGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7


Nursing  home  and  supplier  control  over  provision  of supplies  . . . . . . , . . . . . . . . 
. . . . . .  8


Wound  care  tits  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . 9


upplieri  nducements.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10


Beneficiaries  notreceiting  or using all supplies  . . . . . . . . . . . . . . . . . . . . . . . . .

.  12

CONCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

APPENDI=

A-1

A  Nursing  FacilitY Suney  Instmment  and  Response  Rates  . . . . . . . . . . . . . . . .

B-1

B:  Beneficia~  Survey  Instrument  and  Response  Rates  . . . . . . . . . . . . . . . . . . . .
 INTRODUCTION 
PURPOSE 
This  report  describes  supplier  and  nursing  home  practices  that  can lead  to 
inappropriate  payments  for wound  care  supplies,  and  examines  issues  concerning 
Medicare  beneficiaries  use of these  supplies. 
BACKGROUND 
Wound  care  supplies  are  fillers  or protective  covers  that  treat  openings  on the  body 
caused  by surgical  procedures,  wounds,  or ulcers.  Wound  covers  are  flat  dressing 
pads.  Wound  fillers  are  dressings  placed  into  open  wounds  to eliminate  dead  space, 
absorb  exudate,  or maintain  a moist  wound  surface.  The  Health  Care  Financing 
Administration  (HCFA)  reimburses  for wound  care  supplies  under  the  Medicare  Part 
B programs  surgical  dressing  benefit.  The  coverage  policy for these  supplies  is found 
in section  2079 of the  Medicare  Carriers  Manual.  The  HCFA  contracts  four  Durable 
Medical  Equipment  Regional  Carriers  (DMERCS)  to process  durable  medical 
equipment  claims  including  wound  care  supplies.  The  DMERCS  issue  their  own 
guidelines  to  clarify their  coverage  policy. 
Medicare Part B Allowances for  Wound Care Supplies  1990-1994 
There  were  significant  changes  in wound  care  activity between  1990 and  1994. 
Medicare  Part  B allowances  were  as low as $50 million  in 1992, peaked  in  1993 at 
$132 million,  then  dropped  to $98 million  in 1994.  The  number  of beneficiaries  that 
annually  received  these  supplies  ranged  from  86,600 in 1993 to as high  as 273,300 in 
1991.  Allowances  per  beneficiary  varied  from  $199 in 1990 to $1,526 in 1993. 
Between  1993 and  1994 the  number  of Medicare  beneficiaries  that  received  wound 
care  supplies  increased  47 percent. 
In  1994, 61 percent  of the  average  allowance  per  beneficiary  was for  specialty 
dressings.  Medicare  fee  schedule  amounts  for specialty  dressings  are  as high  as $35 
for large  hydrogel  wound  covers.  Eleven  of the  specialty  wound  care  products  are 
reimbursed  by Medicare  at over  $10.  Prior  to  1992, Medicare  reimbursed  for wound 
care  supplies  primarily  in a single kit payment.  These  kits were  a compilation  of 
wound  care  supplies  and  were  reimbursed  at $8 each  in 1992.  Billing for  kits as one 
product  was  disallowed  in 1992.  However,  component  supplies  contained  in a kit can 
still be  billed  as individual  products.  As a result,  the  number  of billings  for wound 
care  supplies  has  increased  over  six times  from  13 million  in 1991 to  81 million  in 
1994.  The  table  on the  next  page  summarizes  surgical  dressing  activity  for  calendar 
years  1990 through  1994. 
1 
.  __.  -  ,-
Table  1. Wound  Care  Supply  Activity  1990-1994 
Allowances  $53 million  $87 million  $50 million  $132 million  $98 million 
Beneficiaries  266,400  273,300  117,300  86,600  127,300 
Per  Beneficiary  $199  $317  $423  $1,526  $769 
1  II 
No. of Supplies  NJA  13 million  45 million  69 million  81 million  ~ 
l%e HCFA  Broa&ns  its Coverage Poliqv for  Wound Care Supplies 
On March  30, 1994, HCFA  expanded  its coverage  policy for wound  care  supplies.

The  new policy provides  coverage  for primary  and  secondary  dressings  required  for

the  treatment  of a wound  caused  by, or treated  by, a surgical  procedure  that  has  been

performed  by a physician  or other  health  care  professional.  Primary  dressings  are

therapeutic  or protective  coverings  applied  directly  to wounds  or lesions  either  on the

skin or caused  by an opening  to the  skin.  These  include  alginate,  foam,  specialty

absorptive,  hydrogel,  hydrocolloid,  and  composite  dressings.  Transparent  film and

contact  layers  also  seine  as primary  dressings.  Secondary  dressings  serve  a therapeutic 
or protective  function  and  typically  are  needed  to secure  a primary  dressing.  Items 
such as adhesive  tape,  roll gauze,  and  bandages  are  examples  of secondary  dressings. 
l%e I?ior  Coverage Policy Wm More Restrictive 
The  HCFA  national  policy and  the  DMERCS  policies  prior  to March  30, 1994 were 
more  restrictive.  Stringent  requirements  were  placed  on the  type  of dressings,  length 
of treatment,  cause  of wound,  type  of provider,  and  medical  documentation.  The 
DMERCS  policy before  the  expansion  of the  national  policy  covered  only primary 
dressings  resulting  from  a surgical  procedure  for usually no more  than  2 weeks.  This 
policy stated  that  surgical dressings  for  closed  incisions  without  drainage  would  rarely 
be medically  necessary  for more  than  1 week and  when an ulcer,  traumatic  wound, 
or burn  has had  sharp  debridement,  it will be  considered  a surgical  wound  for no 
more  than  2 weeks  from  the  date  of debridement. 
Prior  to March  30, 1994, the  HCFA  national  policy would  allow dressings  to be 
covered  for treatment  of wounds  that  resulted  from  sharp  debndement  (e.g.,  scalpel, 
laser)  performed  only by physician.  The  DMERC  local  policies  stated  that  dressings 
for other  types  of debridement  (e.g., mechanical,  chemical,  autolytic)  were  not 
covered.  Wound  care  suppliers  were  required  by DMERCS  to submit  a certificate  of 
medical  necessity  to  document  the  need  for the  products.  After  the  policy  change  in 
March  1994, this was no longer  required.  The  table  on the  following  page  compares 
the wound  care  supply  policy before  and  after  March  30, 1994. 
.  . 
Table  2.  Comparison  of Wound  Care  Supply  Coverage  Policies 
IIOnly primary  dressings  Primary  and  secondary  dressings  I
, 
Time  limits  on medical  necessity  As long as medically  necessary 
Dressings  for sharp  debridement  only  Any type  of debridement 
Limited  to  physician  treatments  Physician  and  non-physician  treatments 
Certificate  of Medical  Necessity  Certificate  of Medical  Necessity 
required  not  required 
CarrierProce.rszkgof  Wound Care Supplies 
In June  1992, HCFA  issued  a final rule  designating  four  DMERCS  to process  all 
claims for durable  medical  equipment,  prosthetics,  orthotics,  and  supplies  including 
wound  care  supplies.  The  four  carriers  are  the  MetraHealth  Insurance  Company 
(DMERC  A), AdminaStar  Federal  (DMERC  B), Palmetto  Government  Benefits 
Administrators  (DMERC  C) and  Cigna  Healthcare  (DMERC  D).  In October  1993, 
HCFA  began  the  transition  to the  DMERC  processing  of wound  care  supply  claims. 
During  1994, 56 carriers  also processed  wound  care  claims  before  the  transition  to 
DMERCS  was complete.  During  the  transition,  these  carriers  did not  utilize  the 
DMERC  policies;  they  carriers  used  their  own local  policies  to process  claims. 
The DMERC3 Implement a Fee Schedule and Intmdke  New Codes 
Starting  in June  1994, reimbursements  for wound  care  supplies  were  based  on a fee 
schedule.  The  DMERCS  introduced  over  60 codes  for wound  care  products  to 
implement  the  fee  schedule.  Prior  to June,  less than  20 codes  were  used  to identify 
and  reimburse  wound  care  supplies.  The  DMERCS  granted  a grace  period  for  all but 
two old codes  submitted  through  October  1, 1994.  During  the  grace  period  the 
DMERC  would  crosswalk  the  old code  to the  appropriate  new code. 
The DMERG  Issue Dn@  Policy to Clar(ij Wound Care Coverage 
Each  DMERC,  working  with HCF~  developed  a policy to clari~  the  coverage  of the 
wound  care  benefit.  Included  in these  guidelines  are  definitive  utilization  and  medical 
necessity  parameters.  In addition,  modifiers  to the  codes  have  been  added  to identify 
the  number  of wound  sites being  treated.  In January  1995, the  DMERCS  solicited 
comments  on these  guidelines.  After  evaluating  the  comments,  the  DMERCS  issued  a 
revised  policy to be  effective  October  1, 1995. 
This change  was initiated  in part  as a response  to organizations  in the  wound  care 
community  that  expressed  the  need  for clarification.  For  example,  the  Health  kdustry 
3

    .. 
. 
Distributors  Association  in cooperation  with the  National  Coalition  for Wound  Care, 
the  National  Association  of Retail  Druggists,  and  the  National  Association  for  the 
Support  of Long  Term  Care  developed  consensus  recommendations  for improving  the 
Medicare  wound  care  policy.  These  changes  were  recommended  prior  to the  release 
of the  proposed  changes  in January  1995. 
l%e General Accounting  ~ce  Discloses Wound Care Supply Abuses 
The  General  Accounting  Office  (GAO)  issued  a final  report,  Medicare  Excessive 
Payments  for  Medical  Supplies  Continue  Despile  Improvements  (HEHS-95-1 71), in 
August  1995 concerning  payment  controls  for Medicare  expenditures  of durable 
medical  equipment  with an emphasis  on wound  care  supplies.  The  GAO  found  a 
lack of system  wide  controls  which  led to abuse  in both  Part  A and  Part  B.  For 
example,  the  number  of dressings  billed  per  beneficiary  was nearly  three  times  higher 
under  29 new wound  care  codes.  They  attribute  this activity  to the  absence  of a 
clearly  defined  policy. 
Operation Restore  Tlust Tagets Heakh  Care Abuse  in Five Stat& 
Operation  Restore  Trust  is a health  care  anti-fraud  demonstration  project  developed 
within  the  U.S. Department  of Health  and  Human  Services  by the  Office  of Inspector 
General,  the  Health  Care  Financing  Administration,  and  the  Administration  on Aging. 
Its aim is to coordinate  Federal  and  State  resources  to attack  fraud  and  abuse  in 
home  health  agencies,  nursing  facilities,  and  durable  medical  equipment,  including 
wound  care  supplies.  The  projects  initial  focus will be  in California,  Florida,  New 
York,  Illinois,  and  Texas. 
METHODOLOGY 
For  the  purposes  of this report,  we collected  data  from  both  nursing  homes  and 
Medicare  beneficiaries. 
Numing Home  Sampk 
To determine  how  suppliers  market  wound  care  supplies  and  how nursing  homes 
handle  the  provision  of these  supplies,  we selected  a stratified  random  sample  of 420 
skilled nursing  facilities  and  nursing  homes  from  HCFAS Online  Survey  Certification 
and  Reporting  (OSCAR)  system.  The  system  contains  every  nursing  home  that  is 
certified  to receive  Medicare  or Medicaid  funds.  We  decided  to sample  nursing 
homes  from  the  OSCAR  system  that  had  a total  size of 60 beds  or more.  This  gave 
us a universe  of 12,878 nursing  homes  from  which we selected  our  sample. 
We  selected  a stratified  sample  so that  we could  provide  more  focused  information  on 
five States:  California,  Florida,  Illinois, New York,  and  Texas.  These  States  are 
currently  being  targeted  by Operation  Restore  Trust.  We  stratified  our  sample  into  six 
groups  including  the  five States  and  all other  remaining  states.  We  sampled  a total  of 
4  .-
420 nursing  homes;  the  number  of nursing  homes  from  each  stratum  is shown  in the 
table  below. 
Strata  Nursing  Home  Sample 
Universe 
California
 931  60 
Florida
 565  60 
Illinois
 700  60 
New York
 584  60 
Texas
 964  60 
Other  States
 9,134  120 
Total  12,878  420 
We  sent  identical  questionnaires  to the  administrators  of the  420 nursing  homes. 
Surveys were  returned  by 315 nursing  homes  giving us an overall  response  rate  of 75 
percent.  We  chose  to project  responses  only to the  responding  universe  and  not  to 
the  total  universe  of 12,878 nursing  homes.  Responses  from  the  315 nursing  homes 
were  weighted  by stratum  and  projected  only to the  responding  universe  of 9,770 
nursing  homes. 
In order  to accurately  project  responses  to the  total  universe,  we would  have  had  to 
perform  an  analysis  of non-respondents  to evaluate  the  characteristics  of nursing 
homes  who  chose  not  to respond.  Because  we knew very little  about  the  non-
responding  nursing  homes,  we decided  to use  the  more  conservative  responding 
universe.  The  survey  instrument,  nursing  home  responses,  and  an  accompanying 
explanation  of the  survey results  appear  in Appendix  A. 
Benej%iq  Samplk 
To  collect  information  from  Medicare  beneficiaries  who  used  wound  care  supplies,  we 
sampled  beneficiaries  for whom  Medicare  Part  B paid  at least  $20 for wound  care 
supplies  between  June  1994 and  February  1995.  We  selected  a stratified  random 
sample  drawn  from  the  National  Claims  History  1 percent  sample  file.  This  file 
includes  allowed  claims  paid  by Medicare  in 1994 and  the  early  part  of 1995.  As 
selection  criteria,  we used  85 billing codes  which  represent  the  types  of supplies  used 
by beneficiaries  requiring  wound  care  supplies. 
After  we removed  deceased  individuals  identified  through  information  in HCFAS 
Enrollment  Database,  we found  that  624 beneficiaries  met  our  selection  criteria  in the 
1 percent  sample  file. 
5
 .-
We  stratified  our  sample  into  the  following  two groups:  individuals  with  $1,000 or 
more  allowed  dollars  for wound  care  supplies  and  individuals  with $20 to $999 of 
allowed  dollars  for wound  care  supplies  between  June  1994 and  February  1995.  We 
sampled  469 beneficiaries;  the  number  of beneficiaries  from  each  stratum  is presented 
in the  table  below. 
Strata  Estimated  Universe  Sample 
Over  $1,000  16,900  169 
Under  $1,000  45,500  300 
Total  62,400  469 
We  mailed  questionnaires  to 469 beneficiaries  across  the  country,  we received  238 
responses  for  a response  rate  of 51 percent.  The  responses  from  these  beneficiaries 
were  weighted  by stratum  and  projected  to 31,871 beneficiaries  nationwide.  As was 
the  case  in the  nursing  home  sample,  we chose  to project  the  beneficiary  responses  to 
the  responding  universe  and  not  the  total  universe  of beneficiaries  (62,400)  receiving 
Medicare-reimbursed  supplies.  We  selected  the  more  conservative  approach,  since we 
did not  do an  analysis  of non-responses  and  therefore  could  not  determine  if there 
would  be  bias  among  that  group.  A sample  of the  suvey  instrument,  confidence 
intervals,  and  beneficiary  responses  appear  in Appendix  B. 
This  report  is one  of three  reports  concerning  Medicare  payments  for wound  care 
supplies.  A second  report,  Questionable  Medicare  Payments  for  Wound  Care  Supplies 
(OEI-03-94-00790),  identifies  questionable  billing  practices  for wound  care  suppliers 
under  Medicare  Part  B.  The  third  report,  Wound  Care  Supplies:  Operahon  Restore 
Trust  Data  (OEI-03-94-00792),  provides  more  detailed  billing  and  marketing 
information  on wound  care  supplies  in the  five Operation  Restore  States. 
This  inspection  was conducted  in accordance  with  the  Quali~  Standards  for  Inspections 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
6
 .. -
FINDINGS

NURSING HOMES  AND  PHYSICIANS DETERMINE  WHICH  PATIENTS NEED 
SUPPLIES  BUT  SOME  SUPPLIERS  DETERMINE  THE  AMOUNT  PROVIDED. 
Nursing  home  responses  indicate  that  they  and  not  suppliers  are  responsible  for 
determining  if a patient  needs  wound  care  supplies.  More  than  two-thirds  of nursing 
homes  report  that  nurses  initially identify  a patients  need  for wound  care  supplies. 
Thirty-five  percent  indicate  that  physicians  also provide  the  initial  identification. 
However,  in some  nursing  homes,  suppliers  are  determining  the  amount  of supplies 
ordered  for patients.  While  most  nursing  facilities  indicate  that  physicians  or nursing 
staff initially  identify  that  a patient  needs  wound  care  supplies,  in 23 percent  of 
nursing  homes  the  supplier  representative  decides  the  number  of supplies  to be 
delivered  in a given  month. 
Suppliers  have  also  attempted  to determine  which nursing  home  patients  need  wound 
care  supplies.  Almost  one-third  (32 percent)  of nursing  homes  had  suppliers  attempt 
to determine  which  Medicare-eligible  patients  qualified  for wound  care  supplies. 
Wound  care  suppliers  have  requested  to review  medical  records  in 17 percent  of 
nursing  homes.  These  homes  report  that  the  reason  suppliers  give for review  records 
is to determine  the  eligibility  of patients,  view the  physician  orders,  record  treatment 
progression,  and  to gather  supporting  documentation  for billing  purposes.  In addition 
to reviewing  patient  medical  records,  suppliers  have  suggested  to  17 percent  of nursing 
homes  how medical  records  should  be  documented  to support  the  need  for  wound 
care  supplies. 
More  than  any  other  method,  nursing  homes  become  aware  of new wound  care 
products  through  supplier  representatives.  Sixty-seven  percent  of nursing  homes 
receive  their  information  about  advances  in wound  care  treatment  from  supplier 
representatives.  Forty-five  percent  of nursing  home  also have  received  information 
from  training  sessions  or conferences  offered  by wound  care  suppliers.  Nursing  home 
staff also become  aware  of new products  through  medical  literature  and  training 
provided  by local  medical  and  nursing  associations.  Additional  avenues  for  education 
identified  by nursing  homes  include  corporate  training  staffs,  enterostomal  therapist 
consultants,  and  word  of mouth  among  nursing  home  colleagues. 
Seventy  percent  of nursing  homes  have  had  suppliers  offer  training  to their  staff 
concerning  the  treatment  and  care  of wounds.  Suppliers  have  provided  wound  care 
specialists  or specialty  nurses  in more  than  one  third  of nursing  homes  (36 percent)  to 
assist nursing  home  staff  in patient  care  or in developing  a treatment  plans.  These 
specialists  have  been  provided  to nearly  half  of all nursing  h~mes  (47 percent)  which 
use Medicare-reimbursed  supplies.  .-
Thenursing  homes  offered  mixed  review  of thehelpfu]ness  of supplier  assistance  and

training.  One  nursing  home  responded  that  the  nurse  consultants  sent  to review

wounds  in the  facility have  no more  additional  training  than  staff  nurses  already

employed  by home.  Another  nursing  home  said that  after  a doctor  recommended

using a particular  wound  care  supplier  for his patient,  it was the  supplier

representative  and  not  a nurse  that  came  in to see  the  patient.  This  particular  nursing

home  refused  to provide  the  representative  with  access  to the  patient  since he was

not  a medical  person.  However,  a third  nursing  home  reported  that  their  supplier

has been  very  helpful  when  called  upon  for a challenging  skin\wound  care  situation.

WOUPJD  CARE  SUPPLIES  ARE  FREQUENTLY  PRO~ED  ~  STAND~

KH FORM  TO  BENEFICLMUES.

More  than  half  of Medicare  wound  care  recipients  reported  they  received  their

supplies  in kit form.  Similarly,  almost  half  (45 percent)  of nursing  homes  using

Medicare-reimbursed  wound  care  supplies  received  some  or all of these  supplies  in kit

form.

Under  the  new  DMERC  medical  policy to be implemented  in October  of 1995,

individual  supplies  provided  in these  standardized  kits would  not  be  covered.  The

policy states  that  surgical  dressings  must  be  tailored  to the  specific  needs  of an

individual  patient.  The  policy goes on to say that  this cannot  be  accomplished  when

dressings  are  provided  as kits or trays  containing  fixed quantities  and/or  multiple  types

of dressings.

The  DMERC  policy  defines  a surgical  dressing  kit as a non-individualized,

standardized  packaging  containing  repetitive  quantities  of dressings  not  related  to the

individual  medical  needs  of a beneficiary,  or whose  contents  have  not  each  been

prescribed  for  the  care  of the  specific wounds  of that  beneficiary,  or that  contain

materials  in addition  to surgical  dressings.

Many  of the  kits  received  by the  nursing  homes  in our  survey would  not  be  covered  if

one  applies  the  DMERC  definition  of non-individualized,  standard  surgical  dressing  or

wound  care  kit.  Almost  one  quarter  (24 percent)  of nursing  homes  reported  that  the

same  basic  wound  care  kit is provided  to every Medicare  beneficiary  requiring  wound

care  supplies  in their  facilities.  Only  16 percent  of nursing  homes  have  asked  a

supplier  to make  changes  to their  standard  kits.

Many  of the  wound  care  kits received  by nursing  homes  also  contain  many  materials  in

addition  to the  surgical  dressings  that  Medicare  covers.  Thereby,  these  kits would  also

be  excluded  from  coverage  based  on the  new DhlERC  policy.  When  asked  to provide

the  contents  of a typical  wound  care  kit, the  items  most  frequently  cited  by nursing

homes  are  listed  in the  table  on the  top  of the  next page.  The  only items  in the  table

that  are  covered  by Medicare  under  the wound  care  benefits  are  gauze,  tape,  and

ABD  pads  (an  absorptive  specialty  dressing).
 1
ITEMS  MOST  FREQUENTLY  INCLUDED 
IN  WOUND  CARE  KITS 
Suppliers have provided musing homes with mideading informatiim in regards to wound 
care E& 
Eleven  percent  of nursing  homes  have  been  incorrectly  told  by suppliers  that  Medicare

requires  the  use  of kits when  treating  a wound.  Wound  care  suppliers  in  12 percent  of

nursing  homes  have  also suggested  that  a standard  number  of wound  care  kits should

be  used  per  day on patients.  Eleven  percent  of nursing  homes  have  also been

erroneously  informed  that  Medicare  will cover  routine  items  such  as saline  solution  if

gauze  or specialty  dressings  are  purchased.  Medicare  does  not  consider  saline  solution

a covered  item  when  used  for the  purposes  of moistening  dressings  or irrigating  a

wound.

SOME  SUPPLIERS  PROVIDE  INDUCEMENTS  TO  NURSING  HOMES  AND

BENEFICIARIES.

Thirteen  percent  of nursing  homes  have  been  offered  inducements  in exchange  for

allowing  suppliers  to provide  wound  care  products  to patients  in their  facility.

Seventeen  percent  of nursing  homes  with Medicare-reimbursed  products  have  been

offered  these  inducements.  The  inducements  range  from  free  trial  products  to

cameras,  blenders,  and  diamond  rings.

Suppliers  may not  be  following  Medicare  regulations  with regards  to beneficiary

coinsurance.  Information  from  nursing  homes  and  beneficiaries  indicates  that

suppliers  may not  be  billing beneficiaries  for the  coinsurance  amount.  Beneficiaries

are  required  to pay  (unless  there  is financial  hardship)  a 20 percent  portion  of the

costs of their  wound  care  supplies.  However,  27 percent  of beneficiaries  (9,263)  did

not  pay coinsurance  for their  wound  care  supplies  nor  did  they  have  some  other  form

of insurance  which  would  have  paid  the  coinsurance  amount.  In addition,  28 percent

of nursing  homes  have  been  told by suppliers  that  wound  care  supplies  will be

provided  to Medicare  beneficiaries  at no cost to the  patient.  One  nursing  home  stated
 . . 
that  suppliers  main  selling  point  is it wont cost your  facility,  or your  residents

anything  and  well handle  all the  paperwork.

The  OIG  has  in the  past  taken  the  position  that  routine  waiver  of Part  B copayments

may be  prohibited  under  fraud  and  abuse  laws.  First,  routine  waiver  may  constitute  a

violation  of the  Medicare  and  Medicaid  Anti-Kickback  provision,  42 U.S.C.  s  1320a-

7b(b),  if the  purpose  of the  routine  waiver  is to induce  Medicare  or Medicaid  business.

Second,  a providers  routine  waiver  of a beneficiarys  obligation  to pay  may  result  in

the  filing of a Medicare  or Medicaid  claim  that  is false  in that  it misrepresents  the

actual  amount  charged  for the  item  or sefice.  Anti-kickback  violations  and  false

claim  may be  actionable  under  criminal,  civil, and  administrative  authorities.

Some  suppliers  appear  to specialize  in the  Medicare  market.  One-fifth  (20 percent)

of nursing  homes  report  that  their  suppliers  provide  wound  care  products  only to the

Medicare  eligible  patients  in their  facility.  In addition,  31 percent  of nursing  homes

have  had  suppliers  attempt  to determine  which patients  in their  facility  qualify  for

Medicare  reimbursement.

BENEFICIARIES  MAY  NOT  BE  RECEIVING  OR  USING  ALL  OF  THE

WO~  CARE  SUPPLIES  REIMBURSED  BY MEDICARE.

Medicare  may be  reimbursing  for wound  care  supplies  that  are  not  needed  by

beneficiaries.  Eleven  percent  of beneficiaries  reported  they  used  either  none  or only

some  of the  wound  care  supplies  they received.  Fifteen  percent  of nursing  homes

report  that  they  do not  typically  use  all of the  supplies  in wound  care  kits.  The  items

most  frequently  cited  as not  being  used  are  gauze,  ABD  pads,  and  tape.  These  are

also the  only items  in a standard  kit for which  Medicare  pays.

More  than  one-quarter  of beneficiaries  (28 percent)  reported  they  used  wound  care

supplies  on wounds  other  than  those  resulting  from  surgery  on pressure  ulcers.  Some

of these  beneficiaries  used  these  wound  care  supplies  for colostomies  and  catheters

where  in certain  instances  gauze  is covered  by Medicare.  However,  other  beneficiaries

used  wound  care  supplies  for tracheotomies  and  feeding  tubes.  These  supplies  may be

more  appropriately  covered  under  Medicares  tracheotomy  or enteral  nutrition

benefits  than  the  surgical  dressing  or wound  care  benefit.  Beneficiaries  also  reported

using wound  care  supplies  for skin tears  and  abrasions  which  should  not  be  covered

under  the  Medicare  wound  care  benefit.

Many  musinghorns  have rw method  of ensuring that supplies are used by the benejkimy 
for which M&&are  was billed 
The  majority  of nursing  homes  indicated  that  they do not  have  tracking  mechanisms  to 
ensure  that  supplies  are  used  only by the  specific  beneficiary  for which  Medicare  was 
billed.  In almost  half  of all nursing  homes  using Medicare-reimbursed  supplies  (46 
percent),  these  supplies  are  not  identified  or marked  for use by specific  patients  when 
delivered.  After  receiving  wound  care  supplies,  67 percent  of nursing  homes  take 
10
 .. -. 
these  supplies  and  store  them  in a general  supply  room.  However,  several  of these 
nursing  homes  report  that  if the  supply  is sent  for  a specific  beneficiary  they  will store 
them  by the  patient  name  in the  supply  room. 
Medicare  and  beneficiaries  may be paying  for wound  care  supplies  that  are  not  used 
specifically  by them.  More  than  one-quarter  of nursing  homes  using  Medicare-
reimbursed  supplies  (26 percent)  reported  that  unused  or excess  supplies  are  stored 
and  used  for  all patients  in the  facility.  Another  8 percent  of nursing  homes  reported 
receiving  wound  care  products  from  suppliers  that  they  did not  order. 
11
 .-
CONCLUSION

The  information  in this report  is intended  to add  to the  body  of knowledge  being 
developed  concerning  the  use of wound  care  supplies  for Medicare  beneficiaries.  It is 
being  issued  with  two other  reports  on this subject.  The  first report,  Questionable 
Medicare  Payment  for  Wound  Care  Supplies,  describes  trends  in utilization  before  and 
after  the  expansion  of Medicare  coverage  policy for wound  care  supplies.  The  second 
report,  Wound  Care  Supplies:  Operation  Restore  Trust  States,  provides  more  specific 
utilization  and  supplier  marketing  information  for California,  New York,  Illinois,  Texas 
and  Florida. 
These  products  are  part  of a broader  strategic  effort  designed  to assess  payments 
made  on behalf  of Medicare  beneficiaries  in nursing  homes.  We  have  previously 
reported  on the  use  of incontinence  supplies  in nursing  homes,  nonprofessional 
services  in nursing  homes,  and  the  range  of semices  and  supplies  provided  to 
Medicare  beneficiaries  in skilled  nursing  facilities. 
Information  from  these  reports  coupled  with the  current  findings  on wound  care 
provide  continued  support  for the  effort  by HCFA  to require  the  bundling  of services 
in nursing  homes.  This  solution  would  emphasize  nursing  homes  responsibilities  for 
management  of patient  care  and  provide  incentives  for the  appropriate  use  and 
prudent  purchase  of supplies,  since it would  be  nursing  homes  and  not  suppliers  who 
would  receive  Medicare  reimbursement  for these  supplies. 
AGENCY  AND  OUTSIDE  ORGANIZATIONS  COMMENTS 
We  solicited  and  received  comments  on our  draft  reports  from  HCFA  and  other 
concerned  organizations.  The  organizations  that  provided  us with  responses  were  the 
Health  Industry  Distributors  Association  (HIDA),  the  Health  Industry  Manufacturers 
Association  (HIMA),  and  the  National  Association  for the  Support  of Long  Term 
Care  (NASL).  However,  HIMA  chose  not  to provide  specific  comments  on  this 
report.  The  full text  of the  comments  from  HCFA  and  the  outside  organizations  can 
be found  in a companion  report  entitled  Questionable  Medicare  .Payrnents for  Wound 
Care  Supplies  (OEI-03-94-00790).  A summary  of the  comments  and  our  response 
follows. 
HCFA  cO17U?WltS 
The  HCFA  agreed  with  the  recommendations  in the  companion  report,  Questionable 
Medicare  Payments  for  Wound  Care  Supplies.  In addition,  HCFA  responded  that  they 
have  developed  a legislative  proposal  to require  bundling  of services,  including  wound 
care  supplies,  in Medicare  and  Medicaid  payments  to nursing  homes.  They  believe 
that  thfi may serve  as an incentive  for nursing  homes  to more  closely monitor  the  use 
of wound  care  supplies.  The  HCFA  also provided  us with  a technical  comment 
12
 concerning  the  need  to emphasize  the  difference  between  national  and  regional 
coverage  polices  on wound  care  supplies. 
Outw&  OganLzations  Comments 
The  organizations  commented  that  they  strongly  support  HCFAS  expansion  of the

national  coverage  policy for wound  care  supplies  and  that  no reduction  in the  current

scope  of the  benefit  should  be  considered.  They  believe  that  the  DMERCS  delay  in

implementing  wound  care  policies  and  utilization  standards  after  HCFAS  expansion  of

the  policy was the  primary  factor  in creating  an environment  ripe  for  potential  abusive

practices.  While  the  organizations  support  the  need  for implementing  DMERC

medical  policies  for wound  care  supplies  that  reflect  current  clinical  practice,  they  also

believe  that  some  of the  utilization  standards  in the  DMERC  policy to be

implemented  on  October  1, 1995 are  incorrect  and  need  to be  resolved  before

implementation  occurs.  The  NASL  and  HIMA  also stated  that  the  DMERC  policy

prior  to March  30, 1994 that  we discuss in the  background  section  of our  report  was

never  fully implemented.

Both  HIDA  and  NASL  expressed  concerns  that  our wound  care  surveys  were

misleading  and  biased  and  unlikely  to provide  meaningful  data.  Nevertheless,  they

both  stated  that  the  results  of the  sumeys  show that  the  majority  of suppliers  and

facilities  act  responsibly  in operating  their  businesses.

The  HIDA  responded  that  we incorrectly  implied  that  legitimate  market-driven

supplier  services  were  inappropriate.  They  reported  that  they  provide  critical

functions  which  hold  down  or eliminate  costs the  nursing  facility would  othenvise

incur.  These  services  include  billing/collection  activities,  bar  code  technology  for  order

processing  and  handling  of supplies,  delivery/transportation/inventory  management

activities,  and  value  added  services  such as training  on product  availability  an

appropriateness  of clinical  objectives.

OIG  RESPONSE

While  we believe  the  initial  lack of DMERC  policies  without  utilization  standards  for

wound  care  supplies  played  a part  in allowing  abuses  to occur,  we do not  believe  it to

be the  entire  cause  of abusive  supplier  practices.  Even  without  specific  utilization

standards,  suppliers  are  supposed  to be  able  to support  the  medical  necessity  of the

wound  care  products  they  deliver.  Some  of the  examples  of questionable  billings  that

we encountered  in our  questionable  Medicare  payments  report  were  not  mere

misunderstandings  of medical  policies  for wound  care.  For  example,  when  suppliers

are  billing for  amounts  large  enough  to purchase  12.5 miles  of tape  or 5 gallons  of

hydrogel  wound  filler  in a 6-month  period  this would  fall out  of even  the  most

generous  clinical  guidelines.

We have  made  changes  in the  report  to reflect  the  comments  that  HCFA  made  about

clarifying the  difference  between  national  and  local  policies.  We  have  also  added

13  .-
additional  language  in the  report  to emphasize  that  during  the  phase-in  of the

DMERCS,  the  previous  carriers  were  still processing  claims using their  own policies.

In response  to HIDA  and  NASL  concerns  that  our surveys for this report  were

misleading  and  biased,  we believe  that  the  questions  in our  survey were  appropriate  in

their  wording.  The  Medicare  beneficiary  survey was designed  to be  easily  understood

and  completed  by the  sample  population.  We  do not  feel  the  questions  were

misleading  to beneficiaries  nor  were  they intentionally  designed  to solicit biased  or

untrue  information.

The  nursing  home  survey was designed  to obtain  comparable  data  from  a large

number  of respondents  on a wide  range  of issues relating  to wound  care.  We  realize

that  some  of these  issues  are  complex  and  nursing  homes  may have  felt  the  need  to

provide  more  detailed  responses.  Therefore,  each  facility had  the  option  to complete

the  Additional  Comments  section  of the  questionnaire  if they  felt  additional

information  was warranted.  Many  did use this option  and  also provided  additional

information  directly  underneath  many  of the  questions.  This information  was included

in our  analysis  of the  data  provided  by the  surveys.  In addition,  each  nursing  home

was afforded  the  opportunity  to call our toll-free  number  if they  had  concerns  or

needed  clarification  about  the  survey  questions.

In response  to HIDAs  concerns  that  we were  critical  of legitimate  services  that

supplier  perform  on behalf  of their  customers,  we believe  that  we presented  the

information  in a fair manner  and  did not  draw conclusions  that  could  not  be

adequately  supported.  For  many  of the  sen-ices  that  HIDA  reported  suppliers  provide

to nursing  homes,  we did not  collect  information  from  nursing  homes  that  would

enable  us to evaluate  these  semices.  We  did, however,  report  that  suppliers  provide

training  and  technical  assistance  to nursing  home  staff.  Information  on the  helpfulness

of this assistance  is outlined  in our  report  and  includes  both  favorable  and  unfavorable

comments  by nursing  home  staff.

We are  by no means  concluding  in this report  that  all suppliers  are  involved  in

questionable  practices.  In fact, we highlighted  in our  companion  report  on

questionable  Medicare  payments  that  three-quarters  of the  excessive  payments  we

identified  in our  sample  were  made  to only 7 percent  of all suppliers  in the  sample.

However,  we do believe  that  some  of the  practices  reported  by nursing  homes  and

beneficiaries  such  as determining  the  number  of supplies  to be  delivered  and  routinely

waiving coinsurance  amounts  raise  concerns  about  the  legitimacy  of certain  services

that  suppliers  provide.

We believe  the  data  we received  from  the  surveys was meaningful  and  presented  a

broad  picture  of supplier  and  nursing  home  practices  with regards  to wound  care

supplies,  and  provided  useful  information  on Medicare  beneficiaries  use  of these

supplies.

14
 .. 
.
APPENDIX  A

NURSING  FACILITY  SURVEY  INSTRUMENT  AND  RESPONSE  RATES 
Each  nursing  home  in our  sample  was asked  to complete  a 48 question  survey.  The 
questions  for the  survey were  developed  by reviewing  information  on wound  care 
supplies  produced  by HCF~  the  Durable  Medical  Equipment  Regional  Carriers, 
wound  care  suppliers,  and  professional  organizations. 
For  most  questions,  we report  the  percentage  of nursing  home  responses  to the 
question  and  the  projected  number  of responses.  The  percentages  have  been  rounded 
to the  nearest  whole  number  and  therefore  will not  always add  up to  exactly  100 
percent.  The  projected  numbers  have  been  rounded  and  will therefore  not  always add 
up  to exactly  9,770 nursing  homes.  In addition,  for several  questions  respondents 
selected  more  than  one  answer.  These  questions  are  identified  by an  asterisk  in the 
sample  survey  instrument  that  follows. 
We  also report  the  semi-width  for each  of the  response  percentages  at the  95 percent 
confidence  level.  The  semi-width  is the  standard  error  of the  projection  multiplied  by 
1.96.  The  semi-width  added  or subtracted  to the  percentage  provides  a 95 percent 
confidence  interval.  The  range  of the  95 percent  confidence  interval  is presented  in 
the  table  following  each  question. 
In the  several  questions  where  respondents  were  asked  to provide  numerical  data 
(e.g., number  of beds  or percentage  of patients  receiving  wound  care  supplies),  an 
average  number  or percentage  is provided.  For  questions  where  we requested  textual 
responses,  a percentage  of respondents  who provided  written  responses  is given. 
In addition,  when  written  responses  were  furnished,  these  questions  were  analyzed  for 
content  and  used  in the  report.  However,  due  to the  length  of the  responses,  they  are 
not  presented  in this Appendix. 
There  are  instances  in the  report  where  information  from  a subset  of nursing  homes 
which  used  Medicare-reimbursed  wound  care  supplies  for patients  is presented.  These 
data  were  developed  by evaluating  responses  from just  the  55 percent  of nursing 
homes  (5,379 projected  number  of facilities)  who answered  yes to question  six of the 
survey- are  any of the  surgical  dressings  or wound  care  supplies  used  for  patients  in 
your  nursing  facility billed  to Medicare  Part  B. 
A-1
 2.  How  manybeds does your  nursing  facility contain? 
Number  of Beds  137.1  *11.9 
3.  How many patients  are currently  residing  in your  facility? 
Number  of Patients  111.6  ~8.3 
4.  What  percentage  of your  population  is eligible  for Medicare  Part  B Coverage? 
Percent  Eligible  for Medicare  Part  B Coverage  84.3  *4.O 
5.	 What  percentage  of your  current  patient  population  receive  surgical  dressings  or wound  care 
supplies  (e.g. gauze, hydrogel  or alginate  dressings,  wound  pouches)? 
Percent  of Patients  Reeeiving  Wound  Care Supplies  10  +1.8 
6.	 Are  any of the surgical  dressings  or wound  care supplies  used for patients  in your  nursing 
facility billed  to Medicare  Part  B? 
Yes  55  *7.5  5380 
No  40  *7.4  3917 
No Response  5  *3.4  474 
A-3
 ,.. 
7.	 Does your  nursing  facility directly  bill Medicare  Part  B for wound  care supplies  or do you have 
at least  one  external  supplier  who bills Medicare  Part  B directly  for these  supplies? 
1
Rrcent.age  1  95%(btikdence  projected Nutdw 
Response  Inteffaf  of Nursing Homti 
3005 
31  *7. 1 
Nursing  Facility  is sole supplier 
45  *7.5  4371 
At least one externalsupplier 
19  *5.9  1862 
Other (pleasespecify) 
5  *3.2  532 
No Response 
8.  Do you have a wound  care supplier  that  provides  wound  care products  only to the 
Medicare-eligible  patients  in your  facility? 
Percentage  95,v. Confidence  projected NUOIbfZ 
Response  IttK?@@I  of Nursing IWIW 
20  *5.8  1944 
Yes 
77  *6.2  7491 
No 
3  *2.7  335 
No Response 
9.  How did your  facility become  aware of the suppliers  you use? 
PercentageR  95 %Confidence  Projected Number 
Response  Internal  ~bNtming Homes 
18  *6.1  1723 
Through  supplier  advertisements 
*4.O  651 
7 
Through  supplier  direct  mail 
marketing 
63  *7.1  6182 
Throughsupplier 
representative/salespersonvisit 
36  *7.3  3511 
Other (pleasespecify) 
7  *3.3  718 
No Response 
ysome respondents 
%morethartorteanswerwasselectedb
A-4
 Useof WoundCareSupplies 
10.  Who  initially  identifies  that  a patient  has a need for wound  care supplies? 
Family  Physician  35  *7.2  3393 
I I  1 
Medical  Director  of Nursing  8  *4.2  808 
Facility 
1

Supplier  Representative  1  *1.6  134 
I  1  I  I 
Director  of Nursing  27  *6.6  2662   
1  1  r 
Nurse/Nursing  Facility  I  66  I  *7.O  I  6457  II 
Attendant  I  I  I  II 
Wound  Care  Specialist  5  ~2.8  487 
Contracted  by Nursing  Facility 
Other  (please  specify)  13  *4.8  1247  II 
I  I  I 
No Response  0.2  +0.3  16 
I 
more  than  one answer was selected  by some respondents 
11.  Who  decides  what specific supplies  will be ordered  for the patient? 
Family  Physician  61  k7.3  5975 
1  I  I 
Medical  Director  of Nursing  12  *5.O  1157 
Facility 
) 
Supplier  Representative  2  *2.2  236 
,  1  I 
Director  of Nursing  25  k6.2  2479 
I  i 
Nurse/Nursing  Facility  36  k7.3  3543 
Attendant 
Wound  Care  Specialist  12  *4.9  1158 
Contracted  by Nursing  Facility 
Inventoxy  Supervisor  3  *2.7  333 
Other  (please  speci@)  18  *5.8  1726 
I 
1  1 
No Response  1  *1.5  92 
more  than  one  answer was selected  by some respondents 
A-5
 . . 
12.  How are the wound  care supplies  initially  ordered? 
Response  I%rcentage  95 %I0n Ctoemnfaidi en~  Pofr oNjeucrtseidn gI THuomrnb=e r 
80  ~6.O  7802 
Nursing  facility contacts  supplier 
6  *3.5  599 
Supplier  is told of need when 
supplier  representative  or 
delivery  person  visits 
4  +2.7  359 
Supplier  suggests wound  care 
supplies  would  be appropriate 
for certain  patients 
15  *5.6  1504 
Other  (please  specify) 
2  *2.2  222 
NO Response 
y some respondents 
* more  than  one answer was selected  b
do you use Medicare-reimbursed  wound  care supplies  on 
13.	 At which  stages of a pressure  ulcer, 
patients? 
Percentage>  95 % Confidence  Projected Number 
Respome  Interval  Of  Nursing Wmm$ 
9  ~4.6  892 
Stage  I 
27  *6.9  2683 
Stage  II 
62  *7.3  6039 
Stage  111 
48  &7.5  4644 
Stage IV 
20  *6.O  1937 
Other  (please  specify) 
10  *4.5  978 
No Response 
y some respondents 
* more  than  one  answer was selected  b
SuuulierMarketinl!Practices 
14.	 Have supplier  representatives  ever tried  to market  their  wound  care products  directly  to 
patients? 
9S ~  Confidence  Pmjectecf Nunti 
Permntage 
Response  Interval  of pliursipgHOOlm 
6  *3.4  541 
Yes 
94  *3.4  9192 
No 
+0.4  37 
No Response  0.4 
A-6  15.	 Have supplier  representatives  ever helped  you determine  which  patients  in your  facility qualify 
for Medicare  reimbursement  of wound  care supplies? 
IIYes  I  31  I  *7.O  I  2992  II 
I 
68  I  *7.1  I  6677  II 
No Response  1  +1.6  102 
16.	 Have supplier  representatives  ever attempted  to help you determine  which  Medicare-eligible 
patients  in your  facility need various  wound  care supplies? 
Yes  32  *7.2  3152 
No  67  *7.3  6517 
No Response  1  *1.6  102 
17.	 Have  supplier  representatives  ever attempted  to help you determine  if patients  not  eligible  for 
Medicare  need various  wound  care supplies? 
Yes  23  *6.5  2252 
No  75  *6.7  7331 
No Response  2  k2.2  187 
II 
18.	 Have you ever been  offered  inducements  by suppliers  such as free products  to allow  them  to 
provide  wound  care supplies  to your  patients? 
Yes  13  *5.1  1316 
1 
No  85  *5.3  8314 
\  I  I 
No Response  1  *1.6  141 
If yes, please  describe  the nature  of such inducements. 
Provided  Information  91 
Did Not  Provide  Information  9 
A-7  19.	 Has a supplier  ever provided  you with the necessary  prescription  forms  to be filled out  by 
facilitys physician  or the patients  family physician? 
Rqwmse  Percentage  [ 95 % Cotildence  Projected Number 
Interval  of Nursing Homes 
[ 
Yes  10  *4. 1  950 
No  89  *4.4  8685 
No Response  1  *1.6  135 
20.	 Has a supplier  ever filled out  the prescription  form and presented  it to you for the  physicians 
signature? 
Yes  7  *3.7  688  I
, 
II I 
No  91  *4.1  8907 
I 
I  I 
No Response  2  *1.7  176 
21.	 Does  the supplier  representative  decide  the number  of supplies  to be delivered  in a given 
month? 
22.  Have you ever been  told by a supplier  that  Medicare  requires  the  use of certain  types of 
Yes  ]81  *4.O  I  796 
No  90  *4.5  8791 
,  I 
No Response  2  *2.2  184 
A-8
 ,-
23.	 Have you ever been  told  by a supplier  that  Medicare  requires  the  use of wound  care ~  on 
Medicare  beneficiaries? 
Response  Fercentsge  95 % Confidence  Projected Number 
Intervsl  of Nursing Homes 
Yes  11  *4.9  1069 
No  88  *5.1  8568 
No Response  1  *1.6  134 
24.	 Has a supplier  ever told you that wound  care supplies  will be provided  to Medicare 
beneficiaries  at no cost to the patient? 
Yes  28  *6.9  2741 
I 1 
No  70  *7.O  6794 
I I 
No Response  2  *2.2  236 
25.  Is the  same basic wound  care kit provided  to every Medicare  beneficiary  in your  nursing  home? 
IIYes  I  24  I  *6,5  I  2393  II 
No  56  *7.5  5489 
No Response  19  ~6.O  1888 
26.	 Has a supplier  ever suggested  that  a standard  number  of wound  care  trays or kits per  day (e.g. 
three  per  day) should  be used? 
Response  Fercentage  95% Confidence  Projected Number 
IIIteNat  . of Nursing Homes 
Yes  12  *4.9  1173 
No  84  *5.4  8249 
No Response  4  *2.7  349 
A-9
 .-
27.  Have you ever been  told by a supplier  that  Medicare  will cover  routine  supplies  such as saline 
solution  if gauze or specialty  dressings  are purchased? 
I 
Response  Percentage  9596 Confidence  Projected Number 
Intezw  of Nursing I-Iomea 
Yes  11  *4.7  1037 
No  86  *5.3  8421 
No Response  3  *2.7  312 
28.  Do your  suppliers  routinely  waive the 20 percent  copayment  required  of Medicare 
beneficiaries? 
Reqxxtse  Percentage   95 % Contidewe  Projected Number 
Interval  of Nursing HouIes 
Yes  3  *2.3  279 
No  32  *7. 1  3127 
Do Not  KItOW  56  *7.5  5466 
No Response  9  *4. 1  899 
29.  Has a supplier  ever provided  a wound  care specialist  or specialty  nurse  to assist you in patient 
care or in developing  a treatment  plan? 
Response  Per+zrkage  .95 ~  Confidence  ~ Projected Number 
Interval  , of Nursing Homes 
Yes  36  *7.3  3519 
No  62  57.3  6075 
No Response  2  *1.7  177 
30.  Has a supplier  ever offered  training  to your staff concerning  the  treatment  and  care of wounds? 
Yes  70  *6.8  6856 
> 
No  28  *6.6  2693 
No Response  2  *2.2  222 
A-10

  . . 
31.	 How does your  staff become  aware of new wound  care  products  that  might  benefit  your 
patients? 
Response  Percentage  957. InCtoernvfaidl ence  Pofr oNjeucrtseidn gN Humombeers  
67  *6.9  6561 
Through  supplier  representatives 
45  *7.5  4383 
Traininfj/Conferen@s  offered  by 
suppliers 
62  *7.4  6016 
Medical  journalsfliterature 
48  *7.5  4661 
Training  provided  by 
medical/nursing  associations 
23  *6.4  2250 
Other  (please  specify) 
1  *0.6  80 
No Response 
y some respondents 
* more  than  one  answer was selected  b
32.  Have supplier  representatives  ever requested  to review patient  medical  records? 
Percentage  95 9ZZC@uliden~ Projecied Numb 
Response  Interval  ..  of Numbg:Hcmes 
19  *6.O  1878 
Yes 
80  *6.O  7818 
No 
1  *0.6  75 
No  Response 
If yes,  for  what  reason? 
I  Ekmettiage 
Rqcm$e 
95 
Provided  Information 
5 
Did Not  Provide  Information 
33.	 Have supplier  representatives  ever suggested  how medical  records  should  be documented  to 
support  the  need  for wound  care supplies? 
A-n 
.  34.  How  many different  suppliers  provide  you with wound  care supplies  for your  patients? 
Number  of Suppliers  1.7  *0.2 
) 
35.	 Please  list the  names,  addresses,  and phone  numbers  of the suppliers  who provide  your  facility 
with  the  majority  of wound  care supplies  for your  patients? 
IIProvided  Information
 76  I 
Did Not  Provide  Information
 24 
36.  Are wound  care  supplies  marketed  to you in kits or as bulk supplies? 
Both  Kits  and  Bulk Supplies
 35  *7.3  3394 
Wound  Care Kits
 10  *3.9  947 
Bulk Supplies
 37  *7.4  3697 
Other  (please  specify)
 9  *4.5  902 
No Response
 9  *4.O  831 
37.  Are wound  care  supplies  shipped  to you in kit or bulk  form? 
Both  Kits and  Bulk  Supplies  28  *6.9  2774 
I  , 
Wound  Care  Kits  8  *3.6  777 
Bulk  Supplies  45  k7.5  4437 
1 
Other  (please  specify)  8  *4.2  786 
1 
No Response  10  *4.3  996 
A-12
 . 
38.	 When  delivered  by the supplier,  are wound  care kits or supplies  marked  or  identified  as being 
intended  solely for a particular  patient? 
IIYes  36  *7.3  3564 
, 1 I  I 
No  53  *7.5  5201  I 
I i  I 
1 
No Response  10  *4.3  1006 
39.  If suppliers  market  or ship wound  care kits to your  facility, what  suppIies  are  typically 
contained  in a kit? 
1!  I 
Provided  Information  78
1 
Did Not  Provide  Information  22 
I 
40.  If suppliers  market  or ship wound  care kits to your  facility, do you typically use all of the 
supplies  within  those  kits? 
1 
Res~nse  Percentage  95 % Confidence  !-Projected Nu&ber 
InttxVd  . ofl!hu,-sing~,cimes 
Yes  32  *7.O  3140 
No  15  *5.4  1481 
No Response  53  *7.5  5150 
If no, what  supplies  are typically not  used? 
1Pr1ovided  Information 45 
I I 
Did Not  Provide  Information  55 
II 
41.	 Have you ever asked  a supplier  to make equipment  changes,  such as removal  or addition  of 
products,  in their  standard  wound  care kit? 
Yes  16  *5.7  1536 
No  57  *7.5  5571 
No Response  27  *6.7  2663 
A-13  .. . 
If yes, what  changes  did you request? 
11 
Provided  Information  91
I 1 
Did Not  Provide  Information  9 
II 
If yes, did the supplier  make  the changes? 
Yes  14  *5.4  1334 
No  3  *2.6  276 
No Response  84  *5.8  8145 
42.	 Do suppliers  provide  you with all the necessary wound  care supplies  for each patient  once  a 
month? 
Yes  40  *7.4  3868 
No  37  *7.3  3622 
No Response  23  *6.4  2280 
If no, how are supplies  provided  by the supplier? 
Provided  Information  73 
Did Not  Provide  Information  27 
43.  How are wound  care supplies  stored  in your  nursing  facility? 
!1 I  I 
Stored  by individual  patient  !  27  *6.8  2651  II
IIassignment  in supply room 
1  I  1 
IIStored  in general  supply room  67  *7. 1  6563 
1 
I II 
Stored  by the  patients  bedside  2  *2.2  181 
,  \ 
I 
Other  (please  specifi)  11  *4.7  1049 
I 
No Response  5  *3. 1  513 
more  than  one  answer was selected  by some  respondents 
A-14  .-
44.  What  happens  to unused  or excess supplies? 
Returned  to supplier  32  k7. 1  3082 
Stored  for future  use by specific  !  24  k6.6  2326 
patient 
Stored  and  used as needed  for  33  *7.O  3257 
all patients 
Other  (please  specify)  13  *4.9  1284 
No Response  10  *4.3  974 
I 
I 
more  than  one  answer was selectel  by some respondents 
45.  Have you ever received  wound  care supplies  that  were not  ordered? 
46.	 Do you know  if Medicare  limits the maximum  amount  of wound  care suppIies  allowable  for 
payment  each month  per patient? 
Yes  19  *6.2  1875 
No  71  *6.9  6957 
No Response  10  *4.3  938 
If yes, please  describe  the  limits. 
IIProvided  Information  51 
1 
Did Not  Provide  Information  49 
A-15

.  .. . 
47.  Do you have written  or  verbal  agreements  with  your  wound  care  suppliers? 
Response  Percentage  95 %I nCteornvfaidl:e nce  POf roNjeucrtseidn gN HUo@mJeWs  
25  *6.6  2430 
Yes  (written) 
6  *3.2  587 
Yes  (verbal) 
58 k7.4  5710 
No 
11  *4.7  1044 
No  Response 
If yes, please  describe  the nature  of such agreements. 
-1
Fercent~~e 
Response 
68 
Provided  Information 
32 
Did  Not  Provide  Information 
48.  Have you ever complained  to Medicare  or other  authorities  about  the  marketing  or business 
practices  of any wound  care suppliers? 
If yes, what  was the nature  of these  practices? 
Percentage 
Response 
90 
Provided  Information 
10  I
Did  Not  Provide  Information 
Thank you for completing thti survey, If you have additional comments or would like to answer any of the 
questionsmorefully,please usethenextpagemarkedAdditional Commentsfor thispurpose.  Pleasereturn 
thesurveyin theself-addresse4postage-paidenvelopeweincludedinourmailingtoyou orfix  the SUYWY 
and any additional information to us at (215) 596-6987. 
A-16
 APPENDIX  B

BENEFICL%RY  SURVEY  INSTRUMENT  AND  RESPONSE  RATES 
Medicare  beneficiaries  in our  sample  were  asked  to complete  a 19 question  survey. 
The  answers  to these  questions  provided  information  on the  beneficiaries  type  of 
wound,  the  treatment  of the  wound,  and  the  use of Medicare-reimbursed  wound  care 
supplies. 
For  the  questions,  we report  the  percentage  of beneficiary  responses  to the  question 
and  the  projected  number  of responses.  The  percentages  have  been  rounded  to the 
nearest  whole  number  and  therefore  will not  always add  up  to  exactly  100 percent. 
The  projected  numbers  have  been  rounded  and will therefore  not  always  add  up  to 
exactly  31,871 beneficiaries. 
We  also  report  the  semi-width  for each  of the  response  percentages  at  the  95 percent 
confidence  level.  The  semi-width  is the  standard  error  of the  projection  multiplied  by 
1.96.  The  semi-width  added  or subtracted  to the  percentage  provides  a 95 percent 
confidence  interval.  The  range  of the  95 percent  confidence  interval  is presented  in 
the  table  following  each  question. 
The  sample  survey  instrument  with results  begins  on the  next  page. 
B-1

_  MEDICARE  BENEFICIARY  SURVEY  FOR  SURGICAL  DRESSINGS 
Our  records  show  that  between  _  and  _  Medicare  paid  $  for surgical 
dressing/wound  care  supplies  on your  behalf.  Surgical  dressing  and  wound  care 
supplies  are  used  for wounds  such as surgical  incisions  and  bed  sores/pressure  ulcers. 
Surgical  dressings  and  wound  care  supplies  include  gauze,  tape,  wound  pouches, 
specialty  dressings,  and  other  products. 
Please  answer  the  following  questions.  If you have  any problems  or questions,  please 
call Linda  Ragone  at  1-800-531-9562. 
1.	 Did you receive  surgical  dressingshvound  care supplies  during  the time  period  mentioned 
above? 
I 
Yes  93  *3.4  29,543 
I 
No  2  *2.O  742 
!1  1 I  I 
Do  Not  KXIOW  4  *2.6  1,338
1 I I  I 
No Response  1  *1.1  248 
II 
2.  Did  a doctor  tell you to get these  supplies? 
Yes  77  *5.4  24,686 
No  11  *4. 1  3,467 
Do Not  KIIOW  10  *3.8  3,173 
No Response  2  kL7  545 
3.  Did the  supplies  come  packaged  in a plastic tray or kit? 
Reapcxke  Percentage  95 %Crmfidentx  Pmjec$Ed Number 
M3rvat  of Beneficiaries 
Yes  54  *6.4  17,205 
No  20  *5.2  6,285 
Do Not  KIIOW  25  *5.5  7,837 
No Response  2  *1.7  545 
B-2
 4.  Were  there  any types of supplies  that you received  that  you did not  need  for your  wound? 
No  79  *5.2  25,025 
, 
I  11 
Do Not  ~OW  16  *4.6  4,960 
No Response  2  *1.7  597 
5.  What  portion  of the supplies  that  you reeeived  did you actually  use? 
Respcmw  Percentage  95 % Qmfikkrwe  Projected  Number 
Interval  of. Bessefkiarks 
All  72  *5.7  23,093 
Some  8  *3.5  2,628 
None  3  k2.o  845 
Do Not  KllOW  15  *4.5  4,660 
Not  Answered  2  *1.8  645 
6.  Were  you a resident  of a nursing  home  during  the  time  period  mentioned  above? 
Response  Pmx!ntage  95. % Con fidtxstx  lkojecced  Number 
Interval  0113enefidarie$ 
Yes  41  *6.O  12,961 
No  58  *6.O  18,513 
Do Not  KXIOW  1  *1.3  297 
No Response  0.3  +0.6  100 
7.  Were  you receiving  services from a home  health  agency (such as a visiting  nurse)  during  the 
time  period  mentioned  above? 
Yes  38  *6.3  12,183 
No  59  *6.4  18,695 
IIDo  Not  KllOW  1  *1.4  397 
1 
No Response  2  *1.7  597 
B-3
 . . 
8.  What  type of wound  did you have that  required  these  supplies? 
Response  Percentage  95 % Gmfidence  Projected  Number 
Interval  of 13enefkiaries 
Wound  From  Surgery  30  *5.9  9,410 
Bed Sore/Pressure  Ulcer  43  ~6.O  13,755 
None  1  *1.6  445 
Do Not  KItOW  3  *2.4  1,038 
Other  (specify)  28  *5.8  8,965 
No Response  4  *2.7  1,387 
9.  How many  different  wound  areas  required  treatment  with  these  supplies? 
Number  of Areas  1.6  *O.18 
10.  On what  area(s)  of the body was your wound(s) 
Chest/Stomach
 19  k5. 1  5,940 
Back/Buttocks
 24  *5.2  7,750 
Leg
 27  *5.7  8,620 
Foot
 32  *5.9  10,220 
Arm/Hand
 8  *3.3  2,635 
None
 1  *1.6  445 
Do  Not  KIIOW  3  *2. 1  842 
Other  (speci&)  17  *4.8  5,505 
No Response  3  *2.2  942 
I 
more  than  one  answer was selected  by some respondents 
B-4
 ..-
11.  Who decided  what  kind of dressing  or wound  treatment  supplies  you would  need? 
12.  How many times  per dayhveek was the dressing  changed? 
Number  of Changes  per Week  8.8  +0.98 
II 
13.  Who  changed  the dressings  on your wound(s)? 
Home  Health/Visiting  Nurse  30  *5.9  9,658 
I 
Physician  7  *3.3  2,232 
Nursing  Home  Staff  33  *5.7  10,382 
! 
Wound  Care  Product  Supplier  0.3  *0.6  100 
Relative/Friend  19  *5.1  6,092 
Myself  20  +5.2  6,530 
Do Not  WOW  3  *2.2  942 
I 
Other  (speeify)  8  *3.6  2,625 
I 
No Response  2  *1.9  693 
more  than  one  answer was selected  by some respondents 
B-5
 . . 
2 
14.  For  how long a period  of time  did you use the supplies  (please  answer  in days, for example, 
months  would  be 60 days)? 
Average  % % Confidence 
Response 
Interval 
147.9  *32.7 
Number  of Days 
15.  Did you receive  supplies  after your wound  was healed? 
Percentage  95 % Confidence  prajected  Numbfl 
Response  IntervaI  of Bene@* 
6  +3.0  1,883 
Yes 
71  *5.9  22,506 
No 
10  ~3.8  3,125 
DO Not  KnOw 
14  *4.5  4,357 
No Response 
16.  Did you pay coinsuranu  for the surgical  dressingshound  care supplies  reeeived  during  the 
time  period  mentioned  above?  (Coinsuranm  is the 20 percent  of the bill or Medicare  allowed 
amount  that  you pay the supplier.) 
Percentage  9S % Confidena  I?mjee[ed Number 
m.qxmse  Intervai  of Benefieiarki 
32  +6.0  10,155 
Yes 
48  *6.4  15,270 
No  I  11 
16  *4.6  5,012 
DO  Not  KxIOw 
5  *2.7  _1,. 4.-3.5 
No  Response  II
did  you  have  any  other  insurance  which  would  have 
17.  If you  answered  no  to  previous  question, 
paid  the  coinsuranm  for  you? 
Percentage  957.  Confiden@  Proj-ed  Number 
Response  IntetWd  of Ben&iciaxieS 
37  ~8.4  6,292 
Yes 
56  *8.7  9,623 
No 
8  24.5  1,290 
DO  Not  KtlOw 
B-6
 18.  Who  filled out  this survey? 
Reapottae  Percentage  95 % Cmfidtvme  Projected Number 
rmcNaf  of Btmeficiariea 
I Filled  It Out  Myself  40  *6.3  12,776 
Someone  Filled  It Out  For  Me  58  ~6.3  18,401 
No Response  2  *1.9  693 
19.  If someone  filled out  the survey for you, who are they? 
Response  Percxwlge  95 % CMidence  Projected  Number 
Mervaf  of Beneficiadea 
Relative
 38  *6.2  12,148 
Nursing  Home  Employee
 10  *3.7  3,228 
Friend
 3  *2.2  942 
Home  Health  Nurse  or Aide
 33  *2.4  1,090 
Other  (specify)
 7  *3.3  2,180 
No Response
 39  *6.3  12,283 
Thank  you for completing  this survey.  If you have additional  comments,  please  write  them  under 
Additional  Comments.  Please  return  the survey in the self-address@postage-paidenvelopewe 
includedin our mailingto you. 
ADDITIONALCOMMENTS: 
B-7