With every new year come new possibilities, and 2024 seems especially full of promise for Complex Rehab Technology (CRT), which looks to build on a landmark Medicare funding win last year.

Still, the year will bring challenges as well, and plenty of unfinished business.

Funding for seat elevation gets underway

In May 2023, the formal Centers for Medicare & Medicaid Services (CMS) announcement of Medicare funding for power seat elevation systems was a watershed event. But that announcement was just the beginning, as industry stakeholders pondered how reimbursement would actually play out. In 2024, industry leaders will continue to press their case for further codes, notably for bariatric power wheelchairs.

That battle already is underway. In November, CMS issued details on seat elevation funding, a strategy that included eliminating the K0830 (Power wheelchair, Group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 lbs.) and K0831 (Power wheelchair, Group 2 standard, seat elevator, captain’s chair, patient weight capacity up to and including 300 lbs.) codes. CMS did not include a separate code or payment structure for bariatric power wheelchairs, designed for heavier body weights.

Then in a Nov. 30 coding meeting, the industry — represented by speakers Julie Piriano (Pride Mobility Products/Quantum Rehab), Bill Ammer (Ammer Consulting), Brad Peterson (Amylior), and Peter Thomas (ITEM Coalition/Powers Pyles Sutter & Verville) — responded by asking for a bariatric seat elevation code; asking CMS to delay eliminating the K0830 and K0831 codes; and asking CMS to view and fund seat elevation as a system in its own right, rather than as a seating add-on.

Because seat elevation coverage for Group 2 power chairs was a surprise — the industry hadn’t asked CMS for Group 2 coverage — industry presenters asked CMS to pause Group 2 funding decisions to give the industry time to collect relevant data.

This year, look for the industry to spend time educating CMS and other funding sources regarding the practical challenges of designing and manufacturing bariatric power chairs. Currently, CMS seems to think of bariatric wheelchairs simply as wheelchairs with higher weight capacities — which is largely true for standard equipment. But bariatric clients who use CRT often don’t carry their weight symmetrically — and thus require complex seating. Add seat elevation to that equation, with its changes in center of gravity and effects on stability, and the engineering becomes far more complicated.

Still pushing for standing consideration

In August 2022, when CMS opened the public comment period for Medicare seat elevation funding, the agency said, “The benefit category and coverage of standing systems will be considered at a later date.”

The industry requested Medicare coverage considerations for seat elevation and power standing in September 2020. But as 2024 begins, CMS still has not provided a timeline for standing consideration.

Clinically, the benefits of standing have long been recognized — and might be even more numerous than the benefits of seat elevation. A 2013 study published in Physiotherapy Canada — “The Impact of Supported Standing on Well-Being and Quality of Life” — noted the “measurable effects on different body functions and structures,” including bone density, cardiopulmonary function, range of motion, and hypertonicity. The study especially noted the effect a standing regimen can have on people with spinal cord injuries: Standing can decrease pressure injury risk and spasticity while facilitating the voiding of the bladder.

“Studies have reported that energy metabolism is doubled merely by standing instead of sitting, which is highly relevant to people who spend many hours a day sitting in a wheelchair,” the study added.

The industry that successfully demonstrated the value of seat elevation to CMS should find it even easier to prove the value of standing. In preparation of the coverage conversation that the industry hopes is coming up soon, the Clinician Task Force and RESNA released an updated position paper — “Position on the Application of Supported Standing Devices: Current State of the Literature” — in March.

The ongoing delay for standing could be related to ongoing seat elevation coverage conversations. Or maybe CMS simply wants to finalize seat elevation policy before tackling another coverage determination. Either way, the formal request for coverage determination was made more than three years ago. It’s time for an answer.

Making headway on CRT repairs

Admittedly, little about CRT is simple. And the current state of wheelchair repairs is complicated even by this industry’s standards. But this escalating problem must be high on the agenda for improvement in 2024.

Repair is a tangle of red tape and inefficiencies, balanced on a rickety foundation held together by outdated policies and Band-Aids. There’s too little funding for preventive maintenance, for example, and far too many prior authorization policies standing between wheelchair techs and the work they should be doing. (There are also too few wheelchair technicians and too few CRT suppliers offering service.)

A CRT provider’s office is the best place to do diagnostic and repair work, because that’s where the parts are (in an industry with many thousands of parts numbers). But consumers often can’t bring their broken wheelchairs in due to lack of transportation (and because a broken wheelchair equals a loss of mobility). So techs drive out to consumers’ homes, but often lack the parts to make the repair while on site. And also, they need prior authorization. Oh, and that driving-and-diagnostic time is often non-reimbursable, unlike the service calls that techs charge when coming over to fix a washing machine or air conditioner.

The current state of repairs does not have an easy answer. Frustrated, immobile consumers are increasingly sharing their feelings with mainstream media, whose stories nearly always paint the industry as the villains.

A more accurate perspective is that repair policy fails in many different ways for many different reasons. The ultimate resolution will therefore require collaboration and cooperation from many different stakeholders.

That much is obvious. The question is which part of the tangle — which knot, which snarl — stakeholders should attack first. Manufacturers have been called upon to extend warranties and build more durable wheelchairs — but that also requires funding sources to pay more for higher-quality materials and engineering. Preventive maintenance sounds good, but providers can’t find, hire, and train more techs until funding sources pay to maintain equipment.

And then there’s the question of where all those additional techs will come from.

Finding the next great generation

A significant percentage of today’s seating and wheeled mobility professionals are eyeing retirement. While every industry must ponder its next generation, this question is especially urgent for CRT, given the older-than-average age of ATPs in the field.

The industry’s small size and specific focus means seating professionals largely arrive here via one of two paths. First: They followed a family member or close friend into the industry, or they arrived while searching for technology for a loved one with disabilities.

Second: They arrived serendipitously, via a general job posting or a woefully abbreviated but intriguing “wheelchair unit” in OT or PT school. They stumbled upon CRT and fell in love, which is crucial for career longevity, as CRT is too emotionally, mentally, and physically difficult unless your heart is truly in it.

So CRT is challenged to create a more reliable, concrete career path for future ATPs. For example, the University of Pittsburgh now offers a Master’s degree in Rehabilitation Technology.

But how will the industry find its next generation of wheelchair technicians, some of whom become ATPs?

In my time covering the motorcycle industry, I learned about schools such as the Motorcycle Mechanics Institute, supported by the industry and tasked with developing the next generation of techs. There are similar schools for automotive and marine mechanics.

While the powersports industry is much larger than CRT, I love the idea of training up our own techs — determining the abilities and personalities that would be the best fit for seating work, recruiting excellent candidates, and building them up through hands-on education using actual power and manual wheelchairs.

Rather than waiting and hoping for the right techs to find us, it would be great if we could create better ways to find them.

A bill to expand freedom of choice — for some riders

The Choices for Increased Mobility Act of 2023, H.R. 5371, would provide a more feasible way for Medicare beneficiaries to pay out of pocket to upgrade their ultralightweight wheelchair frames from aluminum to carbon fiber or titanium.

Currently, beneficiaries who want a carbon fiber or titanium frame must pay for the entire ultralightweight wheelchair up front, then wait for partial Medicare reimbursement. H.R. 5371 would allow them to pay just for the upgrade, and that difference in pricing would likely put an upgraded frame within reach for more riders.

The amended version of the bill (updated while in the Energy & Commerce Committee) calls on CMS to create a HCPCS code specifically for carbon fiber and titanium frames.

H.R. 5371 has limitations. It divides riders into haves and the have-nots, with the benefits of carbon fiber or titanium available to those who can afford it. Shouldn’t the benefits of vibration dampening, greater strength, greater durability, etc., be available to everyone who qualifies for this medically necessary mobility?

Yes, of course. But H.R. 5371 is a starting point. It’s a bill that expands consumer freedom of choice and the right of riders to advocate for the best possible outcomes.

May this bill not only become law in 2024, but be a bridge to greater freedom of choice for all consumers.

Does CRT’s future include January in Vegas?

Finally, since it’s January, it’s time for my annual existential crisis: Whether I should be attending and covering CES (formerly the Consumer Electronics Show), the king of electronics events in Las Vegas.

Heading to Vegas for a show expected to draw 130,000 attendees, according to the Associated Press, sounds… yeah. But the Associated Press is covering this event. That’s how impactful CES is, with exhibitors including Amazon, Google, Honda, Mercedes, and L’Oreal (who is showcasing its HAPTA hand-held computerized makeup applicator, “designed for those with hand-motion disorders, arthritis, Huntington’s disease, and following stroke-related motion challenges”).

I’ve heard from CRT industry members who’ve walked CES and remarked about how CRT and other technologies are converging. This year’s categories for CES exhibitors include Smart Home, AI/Robotics, Vehicle Tech & Advanced Mobility (which includes Personal Mobility), Digital Health, Metaverse (including wearables) and Accessibility. I see crossover among those categories and Complex Rehab Technology such as wheelchair sensors, power wheelchair and power-assist electronics, exoskeletons, smart home functions and accessibility, connected chair functions, and home accessibility.

While much of the time CRT is an extremely specialized niche of assistive technology and healthcare, there’s every indication that our orbits grow nearer and nearer those of other industries — many of which could bring greater resources and scalability.

I’m personally offended every time I hear an entrepreneur from outside the industry proclaim, “Wheelchair design hasn’t changed in a hundred years, and I’m swooping in to save the day!” What an ignorant, inaccurate, insulting thing to say. But does every industry need regular infusions of fresh ideas and perspectives? Yes.

So maybe my future — our future — will include CES. I really don’t want to go to Vegas in January. And yet, I do.

Image: istockphoto/Bitter