Editor's Note

Cushion Funding Logic: Beam Me Up!

• By Laurie Watanabe
• Oct 01, 2010

I don’t attend Star Trek conventions, but I’ve always had a little crush on Mr. Spock. I admire not only his renowned intelligence, but of course his finely honed sense of logic. If I had to hurtle through galaxies and confront ornery blue-skinned critters with antennae on their heads, I’d want Spock on my side.

In working on this issue, and specifically on our Living Well with Spinal Cord Injury special (starting on page 15), I found myself fervently and repeatedly wishing that a little more Spock-style logic could be put into play — particularly in regard to cushion funding.

The back-story: an interview with Dave McCausland, The ROHO Group’s senior VP of planning & government affairs, that highlighted the complete lack of logic behind wheelchair seat cushion funding these days.

Cushion funding has always been shrouded in mystery for me. If I can understand how a cushion costing several hundreds of dollars can prevent pressure sores that cost many tens of thousands of dollars to treat, why aren’t payors jumping at the chance to be proactive? (Dave explained that the cost of a cushion and the cost of pressure wound-related surgery/hospitalization come from different Medicare “buckets,” and that could make it more difficult for the DMEPOS bucket to appreciate that its expenditure just saved the hospitalization bucket a bunch of money.)

But what really confounded me is what Dave discusses in our cushion story that starts on page 24.

Here’s the gist: Increasingly, the allowables for cushions (and other “accessories” as well) aren’t being based on the costs of research & development, materials, manufacturing or provider training and follow-up. Instead, funding is based on location — as in “Where is the cushion going to be placed — on a power chair or manual chair?” and “Where does the beneficiary live — in or out of a competitive bidding area?”

And this strikes me as illogical, not to mention potentially dangerous to the client.

As Dave pointed out, thanks to Medicare’s competitive bidding rules, there are multiple sets of allowables for a single cushion because Medicare is determining prices based on whether the cushion will be used, for instance, on an ultralightweight manual chair or a power chair. If it’s the latter, Medicare also needs to know what kind of power chair it is, complex rehab or consumer, because that will make a difference, too. As will the beneficiary’s actual neighborhood.

None of which, by the way, is related to the actual cushion itself — its materials, its design, its size or clinical applications, and the expertise required of the professionals who recommend it, sell it, size it or teach clients how to use and care for it.

And that’s why I’m having a Spock-like disconnect of Andorian-Empire proportions.

This is medical technology we’re talking about. Cushions and other assistive technology undergo extensive examinations for performance, safety and — depending on the particular product — clinical applications. Lengthy and formal lists of diagnoses, as well as detailed patient histories and measurements, are used to determine which types of cushions — skin-protection, positioning, adjustable, etc. — make the best medical sense.

Foam, gel, air cells and honeycomb don’t automatically become less expensive just because they’re going to be used in Riverside, Calif., rather than Los Angeles. And I can’t believe that Medicare wants providers in those areas to be less educated on the technology and clinical indications, or to provide lessthorough training to beneficiaries living there. And yet, beneficiary access to these products seems to be coming down to location, location, location. Worse yet, Dave indicates that Medicaid programs are taking cues from 2008 and 2010 round 1 prices to potentially rewrite their own fee schedules.

Logic dictates other payors could do the same thing.

Where is a Vulcan genius when you really need him?

This article originally appeared in the October 2010 issue of Mobility Management.