Funding Concerns Ahead
- By Laurie Watanabe
- Nov 01, 2010
Wheelchair cushions and other accessories face a special and additional funding challenge that’s tied to how this technology category is defined and described by the Centers for Medicare & Medicaid Services. In a Mobility Management interview, Dave McCausland, senior VP of planning and government affairs for The ROHO Group, detailed the difficulties that can result from this current method of categorization. Among other questions, we asked whether establishing a separate benefit category for complex rehab technology would help to sort out the access question to cushions and accessories.
McCausland answered: “The problem you’ve got with seating is: It comes down to how much of seating is rehab. One of the primary coverage criteria for seating is wound care. A large percentage of the wheelchair cushions that are provided aren’t provided with high-end complex power wheelchairs. They’re provided with standard manual wheelchairs.
“Do the people with high-end complex power needs need a high-end cushion? Yes, they absolutely do, because they’re probably the most at risk. But over 80 percent of your wound care patients meet one criterion and one criterion only: They’re over the age of 65. So a lot of your seating patients aren’t going to fit that rehab profile. That’s the challenge with the separate benefit: How do you juggle those items that are absolutely needed by the high-end rehab people, however, they’re also very needed by the non-rehab people, i.e., wound care people. That’s the struggle in seating that we’re going to deal with. I don’t think you have that struggle when you deal with seating relative to positioning, especially very complex positioning.
“Back in the early 2000s, when they published the proposed medical policy for seating, a lot of people wrote in an argument that said when you’re talking about skin-integrity seating, you shouldn’t have that adjective of ‘wheelchair’ on it. Because you don’t care whether (the client) is sitting in a wheelchair or sitting in a day chair or in a gerichair or frankly sitting at home in her La-Z-Boy. If she’s at risk for skin breakdown, she needs to be protected. Two of the most important areas if you’re at risk for skin breakdown is your toilet and your tub. So that argument, that seating is only eligible for a benefit when it’s affixed to a wheelchair — we all argued that that should not be the case.
“The response back from the medical directors stated that they disagreed with our comment. The reason they disagreed is they said in order to have a benefit through Medicare Part B, a product either has to be classified as DME or it has to be an accessory to DME. And they said they felt that seat cushions inherently would not meet the five-year lifespan requirement to be defined as DME. Therefore the only way they could affix a benefit to seating was to attach it to a piece of DME as an accessory, in this case a wheelchair. So this has nothing to do with medical necessity. They made a statement that cushions don’t meet the DME requirement for a five-year life, therefore we’re going to make a requirement and add this adjective of ‘wheelchair’ in there, because that’s the only way we can come up with a benefit.”
We also asked about the ongoing concern about competitive bidding for wheelchair cushions that are tied to wheelchairs that are included in the bid program. McCausland answered: “The other thing that becomes problematic with seating is that in order to bid something, you have to have a really distinct, homogenous group of products. If I say, ‘Picture in your mind a semi-electric hospital bed with a mattress and siderails,’ I’ll bet you can come up with an image in your head. But if I say, ‘Picture an adjustable skin-protection and positioning cushion,’ a layman can’t come up with a picture. If you actually go to the PDAC Web site and look up those codes that those products are tied to, there’s over a thousand different items: manufacturer, make, model, size, shape, materials. It’s a cornucopia of products that fall under one code. I like to use the analogy that bidding seating is like saying, ‘I want you to bid for a vehicle with four wheels and a motor.’ I can bid anything from an ATV to a Humvee. Ultimately, the provider is going to be bidding on the products that cost them the least to obtain, whereas in these categories when you’re dealing with wound care, that’s not even remotely close to addressing the individual’s needs. I’d love to say a ROHO’s the right cushion every time, but I know that’s not true. Ultimately, I want the patient to have access to the products they need, not to the lowest-cost product.
“What’s really frustrating with woundcare seating is that wound-care seating is designed to reduce the incidence and the prevalence of wounds. We’re talking products that Medicare pays approximately $300 for. The average cost to heal a wound can be up to $70,000, one wound. And that’s not even factoring in time off work, the negative impact on the quality of life, plus the fact that you have a large minority that might end up having additional complications, including death. So if seating reduces one out of 100 wounds, you’ve already saved money based on the cost it takes to treat the wounds. And yet, what we’re focusing on — my dad would say we’re being penny wise and dollar foolish.”
This article originally appeared in the November 2010 issue of Mobility Management.
Laurie Watanabe is the editor of Mobility Management. She can be reached at email@example.com.