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Ostomy Supplies: How You Can Help Your Patients Solve the Puzzle
When you fit your patient with a reliable ostomy appliance system, it is just the first step on the challenging supply pathway. Ostomy supplies are inextricably linked to costs and payer sources, and clinical education typically does not cover the information you need to navigate this process. The ideal situation would be for every patient with an ostomy to have coverage for a full range of product choices to suit their unique needs. This article attempts to fill in knowledge gaps and provide assistance to health care providers as they help their patients solve the ostomy supply puzzle.
BACKGROUND
The following list includes basic information about ostomy supplies and cost.
• Ostomy supplies are defined in Title XVIII, §1861 (s)(8) of the Social Security Act as prosthetic devices because they replace a body organ or organ function.1 Although the majority of ostomy appliances are disposable, they are covered because they are prosthetics.
• Ostomy supplies are extremely costly and not accessible in the customary retail manner. It is not unusual for the monthly bill for ostomy supplies to range from $500 to $2000.
• Generally, insurance will pay for supplies prescribed by authorized health care providers. Guidelines established by the Centers for Medicare & Medicaid Services for allowable amounts and product use have formed the standard that most insurance companies utilize. Requests for ostomy supplies that exceed the allowable amounts must be justified as medically necessary and require more steps for authorization.
• Ostomy supplies are available from large mail-order distributors and local durable medical equipment suppliers. Occasionally, you may find a small-town pharmacy that has a limited stock. Local durable medical equipment suppliers will order ostomy supplies but usually maintain a minimal product inventory because it is too costly to do otherwise.
Health care practitioners should know the answers to the following questions:
• How are ostomy supplies managed in your facility?
• Who should patients with an ostomy look to for assistance with supply issues?
• If the patient presents to the emergency department (ED) because they have no supplies, can the ED staff access the list of supplies and the distributor contact information in the electronic health record?
• Does the ED have a small cache of basic supplies, or does someone have to access central supply?
HOSPITAL PRACTICES FOR THE PATIENT WITH A NEW OSTOMY
Ideally, every patient who has had ostomy surgery will leave the hospital with a copy of their ostomy supply prescription and 5 pouching changes.2 In addition, these patients should be informed 1) of the contact information of the supply distributor and given detailed information of the supply ordering process, 2) that ostomy supplies cannot be obtained at the local drugstore, 3) that insurance companies pay for supplies based on allowable amounts from guidelines established by the Centers for Medicare & Medicaid Services, and 4) that they are not restricted to the products used by the hospital and are provided with names of additional manufacturers and resources. Patients should also be instructed to anticipate stoma size change and how to measure the stoma to accommodate the change.
When a patient is being discharged to their home, the health care provider should provide the prescription, which lists ostomy supplies, amounts, and manufacturer reference numbers, to a supply distributor approved by the patient’s payer source. If discharged home with home care, the home care agency should be provided with a prescription that lists ostomy supplies, amounts, and manufacturers’ references with the other discharge information.
When a patient is being transferred to a long-term acute care hospital, skilled nursing facility, or acute rehabilitation hospital, the receiving facility should be given a list of ostomy supplies, amounts, and manufacturers’ reference numbers in the initial transfer package.
Facilities that accept patients for care are responsible for providing the supplies once they assume care. Home care that is reimbursed by Medicare (A and B) has ostomy supply costs bundled into the payment for home care. Commercial insurance and managed care plans will outline their coverage in their home care contracts, so that home care may provide supplies in some instances and assist to obtain supplies in other circumstances. At discharge, both home care agencies and facilities have the responsibility of transitioning the supply provision to a supplier and reinforcing teaching so that patients fully understand how to order their own supplies.
Creating an ostomy supply list. Major manufacturers have catalogs both online and in print. United Ostomy Associations of America (UOAA) has a supply list form that can assist health care providers and be used as a patient teaching tool (Figure). Make sure that you give a copy to the patient.
SUPPLY ISSUES IN THE COMMUNITY
The transition from the health care facility to the community is often fraught with supply issues. Discharge from the hospital may take place after daytime business hours or on the eve of a weekend or holiday. The supplies may not have made it into the bags to take home or were left in the transport vehicle; sometimes the ostomy surgery is performed at a regional medical center and the lack of supplies is discovered 50 miles later. People very new to living with an ostomy may discard usable supplies because they cut them imperfectly or run through their limited supplies due to inexperienced application technique. Patients may have pouch leaking issues that went undetected in the hospital because they had limited output, which changed when patients resumed eating normally at home.
The above occurrences quickly translate to small-scale crises because they cannot be easily remedied and because, without the ostomy appliance, the only recourse is towels wrapped around the abdomen, which is a very undesirable outcome. Obvious solutions are to prepare for these possibilities by educating patients and their support system of possible mishaps and by ensuring that facility staff take extra care at all junctures of the discharge to make sure the supplies get out the door with the patient.
Post-acute provision of ostomy supplies. For a properly fitted ostomy pouching system, ostomy appliances are selected based on the type of ostomy, stoma shape and os placement, consistency of output, body habitus and abdominal contours, and any impairments the patient may have (eg, problems with eyesight or hand mobility). Post-acute facilities and home care agencies that accept patients with an ostomy are required to provide or assist the patient to obtain ostomy supplies. If the post-acute facility or home care agency does not use the same manufacturer as the acute care facility, they are expected to provide suitable equivalent products in a quantity similar to the approved allowable amounts. For the majority of patients, equivalent products that have been knowledgeably chosen and provided will be sufficient. For the patient with unique needs and a difficult pouching situation, poor communication of the needs and inadequate provision of products may result in peristomal skin damage and hospital readmission. For these patients, good communication is imperative among all facilities.
Prevention is the best solution to post-acute dilemmas. Post-acute facilities and home care agencies can learn what products are used by the referring facilities in their area. Contacting the regional manufacturer’s representative is a resource that often is overlooked but can result in acquiring product information, catalogs, and in-service instructions on product use. This resource can make establishing an ostomy supply stock much easier. Too often facilities and agencies do not design a cohesive collection of ostomy supplies and rely on leftover products. A well-designed supply stock and instruction in product use will result in decreased waste of products and wiser utilization of staff time.
Nonmedical switching issues. An example of nonmedical switching occurs when distributors of ostomy supplies change ostomy products that they distribute, often without consultation with the patient or medical professional. This practice suits business needs rather than patient needs. A company may, of course, make business decisions related to its circumstances, but unannounced changes by nonmedical staff are irresponsible. The consequence of this practice is that many patients may not be able to obtain their prescribed prosthetic devices and are unable to manage their ostomy effectively. Patients need to be informed in advance of a change so they have the opportunity to determine if an equivalent product is appropriate, consult with medical professionals for assistance, or determine if they need to change suppliers. If patients are switched to a product that fails to maintain system integrity, they may need a clinical consultation for instruction on the new product, assistance justifying the previous product, or identifying a new product.
Denial of supplies. Denial of supplies by the payer source is different from nonmedical switching. An appeals process accompanies any payer source denial (due process) and is the key to resolving the issue. Consultation with a clinician knowledgeable about ostomies for review of the denial prior to the appeal may help identify the problem and provide a solution (eg, a non-sting wipe may be reimbursed but a non-sting wand may not, or a specific manufacturer’s non-sting product may be denied but a generic non-sting product may be approved). Patients need to be educated that denial letters must include instructions about the right to appeal and that an appeal is the next step. The patient can also contact the insurance company’s customer service department for assistance with the appeal process. The patient should be prepared to explain the specific circumstances that necessitate the denied product (eg, the barrier ring is needed because it absorbs moisture and provides convexity to redirect output caused by an oddly situated os).
Copays. Another category of supply issues occurs when the high cost of ostomy supplies translates to patient copays. A copay of 20% on a supply bill of $1500 can result in a budget-busting expense. The challenge of finding less-expensive supplies is often overwhelming to a patient with a new ostomy. A clinician review of supplies with the patient can clarify what is needed on a monthly basis and what can be ordered less frequently and also can determine the most cost-efficient way to create convexity. Patients with high copays need to obtain cost estimates for their supply list from suppliers accepted by their insurance so they can make the most frugal choice.
Deductibles. Patients with high deductibles can shop from a larger range of suppliers, including low-cost options and charity sources. These options were discussed in a previous “Upfront With Ostomies” column.3
There is variance in the coverage of ostomy supplies by managed care insurance plans; some plans pay 100%, and some require a 20% copay or other copay amounts. A solution for people with managed care providers (Medicare, Medicaid, and Affordable Care Act) may be found by researching plans and changing at the annual open enrollment or special enrollment periods to a plan that offers better supply coverage.
Patients without insurance. Despite recent changes and efforts made to obtain insurance coverage for everyone, a population exists that has no coverage. Some large hospital systems have developed systems for subsidized/discount ostomy (and wound care) supplies through the hospital pharmacy for at-risk populations. This is often dependent on hospital funding resources for the indigent population. This resource possibility is worth exploring for patient eligibility. Some major ostomy supply manufacturers have programs to assist the uninsured. Local ostomy support groups may maintain supply closets of donated products and can be found through UOAA resource lists (ostomy.org). The larger charity thrift stores in some locations offer ostomy supplies, and there are also low-cost ostomy supply programs.3
CONCLUSION
Ostomy education is not something that is a one-time exercise and completed in the hospital; it extends to all levels of health care. It is comprehensive and includes teaching about supply provision. Ostomy health care professionals who understand the supply process and common supply problems will hold the keys to solving the puzzle of ostomy supplies. They can anticipate supply issues, offer guidance to prevent problems, and recognize when their clinical intervention will make a difference.
Susan Mueller is the co-chair of the United Ostomy Associations of America’s (UOAA) Advocacy Committee. Inquiries can be made to: advocacy@ostomy.org. Information in this article was provided by UOAA. UOAA does not endorse particular products, manufacturers, providers, or other sellers of ostomy products. This column was not subject to the Wound Management & Prevention peer-review process.
1. Social Security Administration. Compilation of the Social Security Laws: Part E–Miscellaneous Provisions. Social Security Administration. Accessed February 8, 2021. https://www.ssa.gov/OP_Home/ssact/title18/1861.htm
2. Prinz A, Colwell J, Cross H, Mantel J, Perkins J, Walker C. Discharge planning for a patient with a new ostomy: best practice for clinicians. J Wound Ostomy Continence Nurs. 2015;42(1):79–82. doi:10.1097/WON.0000000000000094
3. Prinz A. Ostomy supply heroes: how financial distress after ostomy surgery inspired four ostomates to create low-cost ostomy supply programs. 2020;66(6):14–15.
