By any definition, the complex rehab technology (CRT) industry is still very young and truly born out of need. To a large extent, what is now available through manufacturers had some seed in garages or warehouses, or were built by rehab engineers desperate to develop solutions in order to increase function and independence for people with disabilities. In many situations it was in fact the person in need or their families that forced the innovation.
Over the years, technology advanced, and the need to understand how to apply it evolved. Clinicians and suppliers worked together in a team approach to match technology to medical and functional needs and to ensure that the myriad components were compatible, appropriate and met the identified needs of their mutual client. The number of therapists, suppliers and manufacturers who received tremendous personal satisfaction from seeing the impact of technology solutions on individual lives gradually increased.
It is difficult to adequately convey the thrill of watching someone regain function and independence. I remember seeing a young woman who had spent over 10 years in a heavy stainless-steel wheelchair receive her first ultralightweight wheelchair. One push of the wheels that had been set up to maximize her ability to self-propel allowed her to travel the entire length of the large room we were in. In her steel wheelchair she could only move a few feet with each push. This meant more than distance to this young woman. It meant she wouldn’t go home totally exhausted at the end of each day. It meant, among other things, that she would have the energy at the end of her workday for other important activities.
With all the growth in CRT came a need for education, certification and operational standards. People involved in the service/delivery process for this technology started to specialize in the field of wheeled mobility and seating. By the ‘70s the Rehabilitation Engineering Society of North America (RESNA) was blazing the trail for CRT. By the early ‘90s, the National Registry of Rehabilitation Technology Suppliers (NRRTS) was formed by a group of rehab suppliers who, in their words, were “committed to raising the standards of the profession, and ensuring consumers receive quality, cost-eff ective, individualized and function-enhancing equipment.” To this end, a code of ethics and standards of practice were established, as well as mandatory annual continuing education so registrants maintain appropriate skills and current knowledge in the field of rehabilitation technology.
Unfortunately, as everyone was working hard to professionalize and advance this new profession, no efforts were made to segregate these professionals or the technology from a funding perspective. As suppliers and providers were growing in their understanding of how to apply the technology to improve people’s lives, the funding world was evolving, too. What few people understood was that the funding changes would ultimately threaten access to the technology advances that many people were benefiting from and dependent upon.
After more than a decade of funding cuts, coverage changes, inadequate coding and convoluted documentation requirements, stakeholders have realized that the current system is significantly based on least costly alternative, not best clinical outcome. Even though Medicare can no longer down-code based on least costly alternative, the effect is the same. In an attempt to avoid a race to the bottom from a technological perspective and to protect access to the most appropriate technology for people with disabilities, stakeholders recognized that a clean slate is the only way to correct the years of complex twists and downward spirals. Systematically revising coding, coverage, payment and documentation policies inside a segregated benefit category designed to meet the needs of people with disabilities is the only meaningful solution. It is also the only way to promote ongoing innovation. Incremental fixes to a flawed foundation will not resolve the issues.
The industry is harrowingly close to being pushed backwards regarding technology. With the complex rehab manual wheelchair defined as ultralightweight adult manual wheelchair and the adjustable wheelchair cushions included in round 2 of competitive bidding, Medicare beneficiaries with disabilities in the next 91 metropolitan statistical areas are at high risk of receiving fewer features and options and lower-performing devices than they would have before competitive bidding. They are also at risk of receiving this complex technology from a supplier that has very little if any experience with this level of technology. In the end, even if the person receives the right wheelchair, the odds of it being set up to maximize the user’s function are dramatically reduced, especially if the supplier does not have the proper skills, knowledge and experience.
People with disabilities have worked too hard to regain function and independence to lose it because policy makers lack adequate understanding regarding the technology. A separate Medicare benefit category is necessary to wipe the slate clean and begin to build appropriate policies to protect adequate access to complex rehab technology. Looking back, possibly this strategy should have been implemented years ago. Hopefully efforts to obtain a separate benefit category will pay off just in time and will provide much needed stability.
Reimbursement stability will allow all stakeholders to focus on the most important thing — ensuring the best clinical outcome for each person. With proper coding, coverage and payment, innovation is once again unleashed and can thrive once again.
Rita Hostak, VP of government relations at Sunrise Medical, is a member
of MM’s editorial advisory board.