K0011 Roundup 2004

Power Struggle: Policy Possiblilities & Where Mobility Stands

When it comes to power wheelchair reimbursement, 2004 has not been for the faint of spirit. Of course, 2003 ended on a dark note, thanks to a CMS beneficiary eligibility "clarification" that neither clarified nor even maintained status quo. At Medtrade Spring in March, word filtered out that CMS had rescinded the clarification — but the attempt at assuring everyone that things were back to normal only underscored the current policy's efficiencies.

So 2004 has been a year of jam-packed Open Door Forums, confused suppliers and consumers pleading to retain their Medicare benefits. Heading into elections, where does the industry stand? We asked manufacturers for their opinions, and got an update on what's happening on the clinical level. And since audience participation is at the core of any successful effort, we include upcoming opportunities at Medtrade to get educated and get involved. Here's hoping 2005 will be a year of consumers getting access to the mobility products they need. — Ed.

Power Struggle: Policy Possibilities & Where Mobility Stands

Manufacturers have been on the front lines of CMS' current power mobility debate, most visibly over the question of how to determine if a Medicare beneficiary qualifies for power mobility.

CMS continues to examine its power policies, we asked power chair manufacturers how they think the battle is going.

Q: CMS has taken several steps recently to include the industry in fact-finding missions. Do you see these actions as positive? Negative? Neutral?

A: The efforts of CMS to include the industry when considering policy changes are positive for all parties: consumers, providers, manufacturers and CMS. By considering feedback and seeking information from industry and consumer representatives, CMS is demonstrating that it understands such communication is pivotal to assuring positive results when examining CMS policy and procedure. It is important for CMS to keep such issues public in order for them to make informed decisions. — Seth Johnson, Pride Mobility Products/Quantum Rehab

A: I see it as a part of law under BIPA that CMS take steps to include the public's input. I think the jury is still out on how much it will consider and implement. What will be interesting is once decisions are made, will it be another 10 years before they look at power wheelchairs again, or is the DME product permanently on their radar? — Darren Jernigan, Permobil

A: I think it's in general a positive; I don't think they're necessarily asking the right people, though. I think (CMS) should be going to more NRRTS members and NCART. Nobody's really sure who the "industry consultants" are, and it doesn't seem to be people who deliver rehab technology on a daily basis and have to live with the changes being implemented. — Mark Sullivan, Invacare Corp.

Q: Central to the power wheelchair question is the definition of "functional ambulation" vs. the current "bed or chair confined" restriction. How would you suggest that CMS define "functional ambulation"? Is functional ambulation the proper criterion to use to determine beneficiary eligibility?

A: I do think it's the right way. I think (CMS) can get the right information from clinicians. There are OTs, PTs and physical medicine specialists that assess people for their functional capabilities, and also for safety. Just because you can take four or five steps doesn't mean you can do it safely, or that you won't be wiped out for the rest of the day. I think we have to define things more by being able to do activities of daily living comfortably and safely. — Mark Sullivan, Invacare Corp.

A: Functional ambulation is so relative, but bed or chair confined limits many disabilities or diagnoses that would greatly benefit from assistive technology. Eligibility should be determined on a case-by-case basis. If technology will improve the activities of daily living and increase independence, the assistive technology should be funded. It is closely related to the current "in the home" interpretation. — Darren Jernigan, Permobil

A: The current definition of "bed or chair confined" to determine medical necessity is an outdated and highly restrictive policy that has generated additional problems due to inconsistencies in its interpretation. By considering "functional ambulation," CMS will take into account a patient's ability to perform his or her activities of daily living. The Pennsylvania Medicaid program defines "functional ambulation" as "the ability to walk so as to engage in day-to-day domestic, vocational and social activities. The assessment of functional ambulation requires an evaluation of whether a recipient is able to walk the distances necessary to complete the individual's activities of daily living, in each of the environments the individual would routinely encounter in the course of those activities. The individual must be able to walk the necessary distances safely, independently and in a reasonable period of time. The ability to functionally ambulate is specific to the setting or environment encountered, and an individual might reasonably be determined to have functional ambulation in some settings and not in others."

By using this or a similar definition, CMS would provide clarity as to when a patient would qualify for a wheelchair by considering the individual's specific conditions and needs. — Seth Johnson, Pride Mobility Products/Quantum Rehab

Q: Medicare's "in the home" policy has also been questioned. If Medicare were to remove the "in the home" requirement, what new policy should be used to describe what mobility equipment should be covered?

A: We are in the business of providing a means of independence, while Medicare's "in the home" policy puts limitations on that independence. My interpretation of a "home" is not just the building you live in, but also its surroundings. Medicare's "in the home" policy turns a "home" into a prison. — Rick Michael, Innovation in Motion

A: Now is a great time to push the issue. My definition of "home" is the United States. Seriously, it should not be about geography, but about not limiting an individual's independence. Using "in the home" as a policy is nothing more than segregating people with disabilities from society. Laws such as the ADA, Air Carriers Act, and the Olmstead decision were put in place to incorporate folks into society. The policy should reflect each individual's activities of daily living. — Darren Jernigan, Permobil

A: The home is much more than inside your four walls. It's your yard, your neighbors, the neighborhood. To tell someone with a disability that the only important things are within their four walls is just wrong. I think this can be described more so from a clinical evaluation. What are the things that people need to do on a daily basis? — Mark Sullivan, Invacare Corp.

Q: And where do scooters fit in?

A: Currently, individuals eligible for Medicare reimbursement are most often directed to power chairs as the primary mobility solution. While we agree there is a legitimate need for power chairs, the design and function of POV/scooters are clearly different and should be recognized? how ironic that POV/scooters have always offered more mobility and are less expensive than power chairs, but have always been harder to get under Medicare. [We suggest] individual needs along with home evaluations be determined, and that lower-cost alternatives be given equal or priority consideration for providing the best solution based on those findings and Medicare costs. — Al Thieme, Amigo Mobility

Q&A: How Clinicians Will Impact the Power Benefit

On June 14, CMS held an Open Door Forum to ask what clinical factors should determine a beneficiary's eligibility for a manual wheelchair, power wheelchair or scooter.

CMS' Rich Lawlor said previous Forums had shown "the need for some distinct working areas in order to reach our ultimate goal of making the wheelchair benefit a lot more accessible, understandable and useful." Therefore, the June 14 meeting "was to focus directly and primarily on the criteria that would be needed to allow someone to get the power-operated wheelchair, regular wheelchair or power-operated vehicles covered under our program from a clinical perspective? We want to get as much input [as possible] about what diagnostically, clinically [should be] related to a patient's need for a wheelchair and how we should format that for your use in the Medicare program."

Dr. Barbara Crane is a member of a clinical coalition working to provide just such input to CMS. Here, Dr. Crane shares the coalition's objectives, where they stand in the process, and her hopes for the future (at press time, the September 1 date was upcoming).

MM: Take us through your background and how you came to work on this.

Dr. Barbara Crane: I'm a physical therapist doing rehabilitation and specializing in wheelchairs and seating for about the last 10 years. I've been a physical therapist for 15 years. I returned to school in 2000; I went back to the University of Pittsburgh and got my Ph.D. in rehabilitation science. I completed that last year.

This opportunity came about because of a stakeholders' meeting, and the coalition was formed because of CMS' overly conservative interpretation of the coverage guidelines, especially for motorized wheelchairs and the whole definition of bed or chair confined. When the coalition came together, determination was made that a clinical expert task force would really be important, to get together experienced clinicians from around the country to provide guidance to the CMS interagency workgroup, or to try to actually petition for new coverage policy on power chairs.

MM: How important is it for people involved in the coalition to be clinicians who work in this specialty?

Dr. Crane: We felt that was very critical. So there were 30 clinicians from various areas of the country who are all specialists in wheelchairs and seating, and who all either work in private practice or in clinical settings in that capacity. (Dr.) Laura Cohen and myself agreed to co-chair this clinical task force to pull together all of the experts, come to a consensus on these issues, and generate information to help guide the CMS interagency work group, because there were things that they asked for input on. One was a better definition of functional ambulation. So we've been trying to respond to the issues that they requested input on, and also to consider other issues in terms of service delivery and getting people the appropriate equipment.

[CMS] is concerned about several things, including fraud, which we recognize does need to be managed. But there's also an issue of wasted resources if people are not getting appropriate equipment. We're trying to provide what we feel is "best practice" in this area — what should be involved in evaluating people and what level of equipment really is appropriate.

MM: What is your timeline?

Dr. Crane: [CMS is] operating on a very aggressive timeframe, and they've already started work, I believe. But we are hoping to deliver to them, before September 1, some initial documentation in these areas: the definition of functional ambulation; a document that would spell out what's involved in a wheelchair evaluation; and a preliminary coverage policy that takes the general pattern used in lower-limb prosthetics in terms of describing functional categories. And we've said that if they have particular information they would like us to research, we would be happy to try to do that. We want to try to work with them as much as possible. We want to be responsive to information that they're specifically requesting in terms of clinical guidance documents. After we deliver the preliminary information, we will be monitoring drafts that [CMS release], and they have already said they will release a couple of policy drafts for public comment.

MM: Will you be addressing the "in the home" equipment restriction?

Dr. Crane: We have not specifically been addressing that because that is one issue that the ITEM coalition was focusing on. We have not said "in the home" or "out of the home" in our clinical practice documentation. We've been saying, "If you have a person who looks like this, this is the appropriate level of equipment." We have talked about different environments, in terms of whether they're accommodated or non-accommodated, meaning ADA accessible — indoor and smooth, level-surface outdoor environments, or more difficult, usually outdoor terrains.

MM: It sounds as if you're approaching this from a daily-living standpoint, not just indoors vs. outdoors.

Dr. Crane: Yes. It depends on the individual, but it could include family care roles, work roles — whatever that person's typical activities are, that's what we want to try to meet the needs of.

MM: This sounds like a policy in very real-life, understandable language.

Dr. Crane: We hope to have it [described in terms of] "this is what the person does every day, so this is the mobility that's required to do those activities." There are several members in the [interagency workgroup] that have admitted they don't have experience in this area, so they would like some education. We're putting together a telemedicine type of evaluation that they can watch from a distance. Several members of the interagency task force have agreed to observe [wheelchair] evaluations, via a telemedicine relay, at the University of Pittsburgh. [Members of the workgroup] said, "We don't even know what goes on in a seating clinic; can you explain?" So they'll observe an evaluation and see how they do figure out what equipment is appropriate for the person.

MM: Are you working with mobility providers and rehab technology suppliers on this?

Dr. Crane: There are a couple of rehab technology suppliers involved — certified ATS's. Many of them also have clinical backgrounds: folks like [NRRTS president] Dan Lipka, for example, who is an occupational therapist who happens to be working for an RTS right now; and [National Seating & Mobility's] Simon Margolis, who has a long clinical background in orthotics. We do have a few of those folks because we wanted their very important input. As expert clinicians, we feel it very appropriate to provide CMS with how these clinical decisions are made and what processes should occur in a best-practices situation. I'm not sure how this is all going to work, but we'll be responding to drafts as they come out, and as a clinical group, we expect to work over the next year and a half to two years on these issues.

This article originally appeared in the October 2004 issue of Mobility Management.

In Support of Upper-Extremity Positioning