Although doctors don’t provide prosthetic care themselves, they suddenly find themselves at the center of a firestorm that’s threatening to reshape how people with limb loss/difference obtain a prosthetic limb from Medicare. Remarkably, none of them even understand that it’s happening. The story reads like the script for a health care-centric version of Thank You for Smoking, but it’s actually the true story of 21st century prosthetic care in the United States. Welcome to the future.
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Imagine trying to coordinate communications between an African tribesman, a Turkish housewife, an American factory worker, and a French novelist. (Or imagine the U.N. It’s basically the same thing.) Even if you could force them all to use the same tongue, getting them to understand each other would pose enormous challenges.
Though less extreme, the lexicons of different professions create similar obstacles to understanding. The specialized language of an MBA-trained CEO, for example, exists for the twin purposes of reminding the man who speaks it how marvelous and unique he is, while simultaneously signaling to the unfortunate who didn’t go through the rigorous three-step “Case Method” approach that a complex and vast body of knowledge exists beyond the edges of her understanding.
While specialized vernaculars are not entirely without value, they impair effective communication between people with different jobs. When I sit in business meetings, I experience this firsthand, both as listener and speaker. I stare at the spreadsheets on the screen behind our CFO, understanding every word that pours out of his mouth but never quite grasping the real meaning. On the other hand, when I pontificate about the vagaries of insurance law, health care reform, and reimbursement challenges, the people who devour spreadsheets and numbers suddenly find themselves sinking in a muddy slop, comprehending the words but struggling to understand what it is that I’m actually saying.
Similarly,while physicians and prosthetists both speak “medical”, the dialect unique to each confuses at least as much as it enlightens. The result is that both operate on their own specialized island, linked only by a small reef – the patient – that both happen to scuba dive near once or twice every 12-18 months. In the language of an MBA program, the MD and CP are “siloed” from each other. (The lexicon of business being offensive for the three-headed monster of (a) using the word “silo” to mean “separate”, (b) referencing farming to describe a business problem, and (c) making a noun a verb.)
But in the world of prosthetics, the linguistic differences only underscore a more fundamental chasm yawning between the amputee’s caregivers: those with the greatest prosthetic expertise – prosthetists – are entirely dependent on those with little to no knowledge – doctors – to deliver you an artificial limb. And that’s because, for reasons so old and complex that they’re now difficult to reconstruct, a prosthetist cannot submit a claim for a prosthesis without first getting a doctor’s prescription.
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In the past, a prosthetist’s simultaneous separation from and dependency on a doctor was more of an inconvenience than a barrier. Most physicians don’t question the requests for prescriptions sent to them by prosthetists, instead writing what’s asked for without truly understanding what it is beyond “an arm,” “a leg,” or some smaller part thereof. This isn’t doctors abdicating responsibility for what they should know. They’re simply deferring to subject matter experts – prosthetists – which, in the great scheme of U.S. health care, makes sense.
The biggest issue with this process is the amount of time it often takes to get the doctor’s script. Securing the prescription usually devolves into an elaborate game of phone tag that can go on for weeks. If a private citizen called another person as much as a prosthetist calls a doctor’s office, he’d get slapped with a restraining order for harassment. But this chronic inefficiency looks positively benign when compared to recent changes in Medicare policy that raise more complex and problematic issues for patients who require a prosthesis.
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Last fall, Medicare sent “Dear Physician” letters to doctors who prescribe prostheses to Medicare beneficiaries. On its face, the government’s guidance to physicians appeared reasonable. Specifically, Medicare reminded them that:
- in the event of an audit, a prosthetist’s records must be corroborated by the information in the doctor’s files;
- the physician should thoroughly document the patient’s functional capabilities;
- the doctor’s assessment generally should include the patient’s relevant history, symptoms limiting ambulation/dexterity, co-morbidities, assistive devices used by the patient, activities of daily living, a physical exam, and weight gain/loss, among other relevant data points.
People with LL/D generally expect their doctor’s medical records to contain this information. (An apparently debatable assumption, as we’ll see a bit later.) The Big Problem comes out of left field:
“Note that when physicians are unable to provide the requested documentation to the [prosthetists], the [prosthetists] receive denials for the items billed which could result in your patient being financially responsible for all or part of the charges for the items/services received.” [Emphasis added]
If Medicare’s financial incentives aligned in a logical way, its reminder to physicians would have an immediate and positive impact. Your doctor’s records would suddenly overflow with salient information relating to your prosthetic needs, and Medicare would process your prosthetic claim with nary a second thought. But physicians are nothing more than an administrative cog in the claims process. The only thing they do is author a prescription. The denial of your prosthetic claim has absolutely no financial impact on physicians. They don’t get paid for the prosthesis – your prosthetist does. Medicare has replaced a logical heuristic – doctors deferring to prosthetists’ because they’re … well, trained in prosthetics – with a new paradigm that (1) forces physicians to invest exponentially more time and effort documenting their patients’ condition, but (2) lacks any enforcement mechanism, since the physician doesn’t get punished in any way for failing to do what Medicare now requires. This leaves you and your prosthetist in a difficult position. Assume that your prosthetist has compiled an exhaustive account of everything that has gone on in your life for the last decade. She has detailed patient notes painstakingly describing every visit you’ve ever made to her. Her request for your new prosthesis includes not only a complete social and physical history, but 17 studies, neatly indexed with exhibit tabs A-Q, all of which show with compelling clarity why each element of the requested prosthesis will uniquely benefit you. Based on this wall of evidence, your doctor writes the prescription. Medicare receives the claim, and asks your prosthetist for a copy of the doctor’s records to confirm that what she’s saying about you is true. The doctor sends over your patient file, and the only entry for the last 12 months is the prescription he just wrote at your prosthetist’s request. Medicare will deny your claim. Your prosthetist will not get paid by Medicare. And as the Dear Physician letter so nicely points out, you may now face unexpected financial exposure as a result.
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It’s not a coincidence that the Dear Physician letters came out at the same time as a report from the Office of the Inspector General, the branch of Health and Human Services responsible for fraud and abuse investigations. In that report, which examined lower limb prosthetic claims, OIG announced a troubling statistic: based on its review of 2009 data, Medicare paid $61 million in claims where the prescribing physician hadn’t seen the patient in the previous five years.
To put this in perspective, Medicare’s total spend on lower limb prosthetics in 2009 was $655 million. So 9.3% of the total amount spent by Medicare that year purportedly involved claims where the prescribing physician had no record of seeing or treating the patient in the 60 months before the 2009 script. OIG concluded that this “raises questions about whether the physician ever evaluated the beneficiary and whether these devices were medically necessary.”
Based upon this finding, OIG recommended and CMS agreed to institute a “face-to-face” requirement between the patient and the prescribing doctor. The thinking was that by mandating this visit, Medicare would take an affirmative, preemptive step against fraud and abuse. The only way to obtain all the information required by the Dear Physician letters? A face-to-face visit.
If you step into the shoes of a Medicare official after reading the OIG report, you can’t simply dismiss the Dear Physician letters as fundamentally illogical or motivated by ill intent.* And that’s one of the sad ironies here: while Medicare beneficiaries get sucked into this claims-related quicksand, the position of every party to the claim transaction – the doctors who write the prescriptions while deferring to the prosthetists’ expertise, the prosthetists who complain that they can’t control what doctors choose to put in their records, the patients who assume that their doctors and prosthetists have files that complement each other, and Medicare officials who interpret data suggesting that nearly a tenth of its lower limb prosthetic spend involves doctors who barely know their own patients – is entirely understandable and even logical.
But the fact that everyone’s motivation is pure doesn’t help the person with LL/D who needs a prosthesis from Medicare. As a practice manager for a high-quality facility told me just last week, “we sent a patient to his doctor with a copy of the ‘Dear Physician’ letter so that the doctor could make sure his records contained the appropriate information. The doctor said to the patient, ‘Are you kidding me?’, and just sent the patient back to us.”
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All of this activity is occurring at the same time that Medicare has significantly stepped up its auditing of prosthetic claims. Using a variety of government contractors, some of whom are paid a percentage of the money they recover from prosthetists, anecdotal evidence suggests that Medicare has not only recovered large sums of money for inappropriate claims, but has also scared some prosthetists away from delivering certain kinds of technologies out of fear that the codes associated with those devices will trigger an audit. This may be particularly true of claims for more expensive prosthetics.
This new level of claims scrutiny combined with the increased physician documentation requirements presents unique business challenges for prosthetists. Driving physician compliance with the detailed elements of the Dear Physician letters may prove difficult or even impossible if the prosthetist doesn’t have a meaningful relationship with the doctor in the first place. Nor can the prosthetist pay doctors to comply or offer them some other incentive to do so, as the federal Anti-Kickback Law prohibits them from giving physicians anything of value.
In addition, those prosthetists who change their prescribing patterns in an effort to skirt the quicksand may fall victim to three perils. First, no matter what device they deliver to a patient, the doctor’s records still need to contain the corroborating documentation in order for Medicare to approve the claim. So turning away from medically necessary but more expensive devices doesn’t safeguard against either claim denials or the resulting financial losses and/or cost-shifting to the patient that may ensue.
Second, prosthetists who decide not to deliver certain types of components to avoid audits are arguably failing to fully understand how the auditing entities function. The published list of auditing triggers does not include a particular code or group of codes associated with high-cost devices, but rather, focuses on documentation of the patient’s actual and potential functional level. The issue isn’t what device the prosthetist chooses; it’s which patient the prosthetist chooses to put it on.
Lastly, even if steering away from high cost devices did help prevent prosthetists from getting targeted by auditors, it doesn’t prevent them from losing patients to more aggressive competitors. In a patient culture that’s increasingly characterized by unlimited access to information about products, the vacuum created when one prosthetist stops delivering certain kinds of prosthetic solutions will be filled by another who recognizes that the audit risk is worth the opportunity to capture new patients from the competition quickly. This is particularly true if that prosthetist has a sophisticated billing department and a strong relationship with her prescribing physicians that permits her to drive compliance with the Dear Physician letters.
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While prosthetists grapple with these issues, Medicare beneficiaries remain in an unenviable position. Many prosthetic companies seek to ease the “insurance burden” on their patients by having a team of in-house claims experts focus on those issues. This allows their patients to focus exclusively on achieving the best possible physical outcome while putting reimbursement questions in the hands of others. But the Dear Physician letters now force Medicare patients to directly solve their insurance problems, regardless of the prosthetist’s historical philosophy about patient involvement.
The Medicare beneficiary who in the past could simply rely on her physician to provide a prescription sight unseen today needs to visit that doctor in person, Dear Physician letter in hand. She – either alone or in conjunction with her prosthetist – needs to explain to the doctor the significance of that letter, the need for the documentation it lists, and the ramifications (both clinical and financial) to the patient if the doctor’s records lack that information.
If the patient’s doctor shows any unwillingness or inability to comply with the guidelines in the Dear Physician letters, the patient now needs to find another physician who will and can do so. This requires a significant investment of time and effort where none was previously required.
Finally, the most insidious effect of Medicare’s Dear Physician approach is that it implicitly encourages beneficiaries to ask themselves whether their prosthetists are recommending a particular device because it’s truly the best thing for them, or because it’s the one least likely to be disruptive to the prosthetist’s business. The patient will never be able to get a clear answer to that question, and the likely outcome will only be increased distrust between both the Medicare beneficiary and the professional providing her prosthetic care.
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Prosthetists want to provide the best possible prosthesis for their patients. The doctors treating those same individuals want them to succeed. People with LL/D ask only for the best possible prosthetic solutions to address their unique clinical needs. And payers like Medicare want to make sure that access to prosthetics is balanced against the reality that unscrupulous people abuse the system.
Everyone’s right. So why does the current state of things feel so wrong?
* The leading organizations in prosthetics, however, have questioned the foundation on which some of OIG’s conclusions are based. The letter sent by The O&P Alliance to OIG can be read on the industry’s leading news website, oandp.org, here.