The Nashville area’s health care ecosystem generates about $100 billion in annual revenues from just about all corners of the industry. The complex rehabilitation technology space isn’t one that catches a lot of the spotlight, but several of its key players are based in Middle Tennessee. They’re growing, too, and pushing for a helping hand from the insurance industry to fulfill what they see as their market potential.

Home to HCA Healthcare and other hospital players as well as surgery center operators and senior care providers, the Nashville area presents a wealth of marketing opportunities for CRT companies as the U.S. population’s average lifespan continues to climb and produces a robust pipeline of potential clients with ailments that necessitate equipment such as power wheelchairs. Those products are far more than just wheelchairs with motors: Contemporary models are smart chairs that not only move at variable speeds but also rotate nimbly, elevate and lower the seats and connect to features for OnStar-like alerts so that chair producers can send out technicians to assess the product or help users take advantage of the chairs’ features.

Among the local CRT players is Swedish global producer Permobil, which has had its headquarters for North and South America in Lebanon since 2000. The two other big names are National Seating & Mobility, or NSM, and Numotion. Both companies are headquartered in Williamson County and owned by large private equity firms — NSM by Cinven since 2019 and Numotion by AEA Investors, which bought a majority stake in 2018 — and market and distribute equipment and related technologies. (Numotion also sells urological supplies and speech-related solutions.) NSM runs 180 locations throughout North America — it first expanded into Canada nearly three years ago — while Numotion has about 150 stores in the United States and works with more than 260,000 clients.

All three companies have been acquiring of peers in recent years. In addition to buying small retail operations as NSM has been doing, Numotion in July acquired Ohio-based SpinLife.Com, an e-commerce firm that markets durable medical equipment for disabled and elderly consumers. The deal added 80,000 annual customers to Numotion’s client base. Around the same time, Permobil executed a different strategy by acquiring Progeo, an Italian manual wheelchair manufacturer.

Affordability is critical to the CRT sector because part of the draw of power wheelchairs and other products is that they can help lower expensive emergency room and inpatient care episodes. Yet, despite their market’s long-term promise and their own financial muscle, CRT companies are still looking to make a bigger mark.

“There’s a lot of conversation in the world today about social justice and minorities, but by and large, the disabled community has not had a unified, big voice,” says Isaac Rodriguez, senior vice president of strategic development at NSM. “And the last time they had a huge win was when they had the ADA pass, and that was George Bush I.”

Part of the value proposition of today’s more finely engineered CRT products is that they help relieve pressure and joint pain and can ward off the development of pressure ulcers. Better seating and positioning can also make patients less susceptible to falling, which often leads to hospital or nursing home stays.

“That can lead to significant health care costs,” says Numotion CEO Mike Swinford, whose organization scored a 100 on the 2021 Disability Equality Index developed by the Disability:IN nonprofit.

Looking to further help improve the cost-benefit dynamic — and thus get more insurers on board — is Nashville startup Luci, which has developed a novel power wheelchair attachment system that amalgamates camera, radar and ultrasonic data sets to create a 360-degree view. The company’s work earned it a spot on Time magazine’s Best Inventions of 2020 and its system already is part of Numotion’s inventory and in the pilot phase at NSM.

“We are partnering with the manufacturers, but we are bringing a new level of connectivity and product intelligence that has never existed in the mobility space,” Luci CEO Barry Dean says.

All about the data

To help make the case for CRT products, NSM also is running a research and development operation, chiefly by collaborating with multiple organizations including the University of Pittsburgh on functional mobility assessments. Those survey patients on targeted data points that correlate with noticeable benefits (or the lack thereof) to determine if and how CRT products are improving pain, daily routine and other issues.

The goal is to show that patients are experiencing fewer falls or are able to work more and in other ways have a better quality of life. That data can then help validate the companies’ claims to insurers. Rodriguez says carriers still disagree over whether technical features such as seat elevators on power wheelchairs — which let users reach things in higher places with less risk or be better seen between cars in parking lots or while crossing streets — should be covered. The goal is to have the data serve as lobbying ammunition for NSM and its peers with legislators.

“There’s technology that has come out that, up until this point, insurances and Medicare say, ‘We think that’s a convenience item,’” Rodriguez says. “We’re getting very close on seat-elevate.”

The connected chair is a similar example of advancements CRT producers feel insurers should cover. But there’s been little to suggest that will happen soon.

“Quite honestly, the CRT industry has been fighting reimbursement reductions,” Rodriguez says. “We’re telling insurances, ‘You can’t keep cutting us.’ One of the biggest wins that we would have would be the seat elevator coverage. That would be a pretty significant win.”

Part of insurers’ reticence stems from having been burned in the past by fraud and abuse. In 2007, the Inspector General’s Office at the U.S. Department of Health and Human Services resolutely determined that Medicare power wheelchair claims did not meet documentation requirements, citing “numerous instances of fraud and abuse” and “growth in Medicare power wheelchair expenditures.” By 2018, the same concerns still appeared prevalent when a federal jury convicted a Jackson, Tennessee, couple and their son of health care fraud for misrepresenting coverage options of power wheelchairs and forging documents to qualify buyers of units produced by Jackson-based Jaspan Medical Systems.

Swinford views Numotion’s acquisition of SpinLife as a means to secure a significant number of consumers who can afford the company’s products with or without insurance coverage.

“Payors have evolved and recognize that CRT is a critical part of medically necessary care, meaning it is essential to protecting and improving the health status of a patient,” Swinford tells the Post. “We work closely with health plans and most now understand why CRT is so important. However, customers still face challenges with documentation requirements, inconsistent denials and differing requirements among payers.”

Luci’s Dean says the status quo of sorts between manufacturers and insurers “has led to a stagnation of innovation.” But Dean is optimistic insurers can still be coaxed into supporting products in this space.

“We’ve had seven state Medicaid programs fund Luci, as well as one large private insurer, using a ‘miscellaneous’ code,” he says. “It’s still a long road to having our own code but we feel like payors are rapidly understanding” the value of Luci.

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