what if … you couldn’t get a prosthesis?

less is more 05.01.15

What if you lost your arm or leg and required a prosthesis? What if you had insurance when that happened? What if that insurance covered the cost of your amputation surgery? What if you left the hospital and looked forward to reclaiming your life with the help of a prosthesis? What if you visited a prosthetist 4-6 after becoming an amputee and were told that your insurance would cover only your initial prosthesis … or no prosthesis at all?

Several states – New York, Alaska, Nevada – either restrict prosthetic coverage to one prosthesis per limb per lifetime (NY) or don’t offer it at all (AK, NV) in plans available on their insurance exchanges. In this month’s Amp’d, The Amputee Mommy and I discuss the advocacy efforts underway in NY. We explain the underlying issues and what amputees can do to make their voices heard.

I was lucky enough to directly participate in some of those efforts in my capacity as President of the National Association for the Advancement of Orthotics and Prosthetics. (For more information about NAAOP generally and how to become a member/support the organization, please click on the link under the heading “Blogroll” on the upper left-hand portion of this webpage. NAAOP needs your support to engage in these kinds of efforts!) And, because like all advocacy efforts, things change fast, I’m happy to have a bit of an Amp’d spoiler alert.

The head of the New York State Senate’s Health Committee, Kemp Hannon, authored a letter just two days ago to the Executive Director of the New York health insurance exchange requesting that she eliminate the one prosthesis per limb per life restriction in that state’s benchmark plan. (When Peggy and I recorded our podcast, this had not yet happened. Click on the following link to read Senator Hannon’s letter: Hannon 1L4L Letter 04.28.15.) Special thanks to Senators John Bonacic, Andrew Lanza, Kenneth LaValle, Jack Martins, Mark Panepinto, and Michael Venditto as well, all of whom joined with Senator Hannon’s call for eliminating the one prosthesis per life restriction.

It’s an important step in the New York State advocacy effort, but it’s only the first step. We have just learned that the deadline for NY to make changes to the benchmark plan is only 30 days away, so much work remains to be done if we are to give NY amputees access to prosthetic devices in 2016.

If you haven’t already signed the petition requesting that NYS legislators take action regarding this issue, join the more-than 13,800 people who have already done so.

Access to qualified prosthetic care is a basic health care right for amputees. For many, it is the difference between living independently or requiring full-time assistance; between living an unhealthy, sedentary lifestyle or a healthy, active one; or between being forced to sit at home and depend on the government for support or rejoining the workforce.

In this month’s Amp’d, learn the dangers of taking this right for granted and how to make sure every amputee has the same opportunity to live a productive, active, healthy life.

P.S. The Amputee Mommy is getting in on the advocacy action as well, as she testifies in Washington D.C. today! Click here to read her pre-testimony post on the subject.

no such thing as deluxe

no such thing as deluxe 11.12.14

First, a belated thank you to those individuals who have served/are serving in the U.S. military. I’m lucky to have met many veterans who sacrificed their limbs in the line of duty and it’s an honor to know them and call them friends.

Second, I want to expand on one of my Random Thoughts from last week discussing the gap between how the media portrays “high-tech” prosthetic devices and the reality of the function they provide. Every day I read numerous articles trumpeting the amazing advances in prosthetic technology. Many of them go hand-in-hand with “feel good” stories about amputees overcoming their physical challenges. Invariably, these pieces include interviews with prosthetists who are understandably eager to emphasize the sophistication of the devices they fit, leading to virtually every piece including phrases like, “the first to fit the most technologically-advanced knee in the world.” (I’ve read phrases like that years after seeing the first article making that claim. It’s kind of depressing to see, actually, as it suggests the person making that claim either (a) has no idea that the device has been around and fit by others before, or (b) just doesn’t give a damn about the facts.) The patients, excited to receive these state-of-the-art components dutifully fan the flames, talking about how this prosthesis is the most amazing thing they’ve ever seen.

Even though I work for a prosthetic component manufacturer and have been fortunate to wear virtually every “next great” product for lower extremity amputees over the last 17 years, I feel compelled to set the record straight: wearing a prosthesis never provides better function than a properly-working biological limb.* Consider the following examples.

Can you move from side to side? When I had both my legs, this movement occurred without thinking, whether I wanted to go left or right. But prosthetic knees only move in one plane – from flexion (as they bend) into extension (as they swing forward). That’s it.

Now imagine that you have to dodge an oncoming object. With a prosthetic knee you’re not completely prevented from moving laterally, but your ability to do so is massively compromised when compared to what you can do with a biological joint. For example, after losing my leg I once tried to play goalie during warmups while my soccer team comprised of 20-somethings peppered me with shots. One player sent an absolute rocket towards me that I simply couldn’t escape. If I had still had two legs, I would’ve either stepped out of the way or bent down to make the save. But with a prosthesis, I couldn’t do much of anything. The ball hit my prosthesis and rocketed about 30 yards away from the goal. I made the save but ended up on my face. This was wildly amusing to the team, which proceeded to start kicking balls at me as hard as they could to try to hit my prosthesis. Even I found this funny, and I excused myself from my goaltending duties, doubled over in laughter.

But here’s the point – the most sophisticated, expensive knee in the world will not function any differently in that situation than the cheapest, most rudimentary device. Since no prosthetic knee addresses lateral movement, they’re all equally lousy.

Or, as winter fast approaches, consider walking on slippery surfaces. Whether you’re an above-knee or below-knee amputee, you lack the tactile feedback from your foot that allows you to make split-second adjustments that keep you upright. You become aware of the fact that you’re slipping when your prosthetic foot is suddenly 6 inches away from where you planted it (and accelerating away from your body at a frightening rate). No microprocessor-controlled or motor-powered ankle-foot system can replicate the proprioceptive feedback provided by a biological foot.

At this point you might be asking yourself, “Why is Dave being so negative? Did prosthetic technology betray him? Did he have a falling out with his employer and this is his passive-aggressive way of working out his anger?” (Answers: I’m not. No. And NO!) The reason I get worked up about this is because the myth of space-age prosthetic technology ultimately ties back to how payers – particularly private insurance companies – view these devices. And that affects amputees’ access to them.

*   *   *

I’m thinking particularly about insurance policies that exclude “deluxe items,” an ambiguous term that insurers would say refers to components that provide benefits that aren’t essential to users. (I say it’s really code for “more money than we want to pay.”) Now think about how the narrative I described at the beginning of this post interacts with this kind of policy exclusion.

When manufacturers and prosthetists start trumpeting how component X samples force sensor feedback 20,000 times per second, or how component y employs complex gyroscopes to evaluate where it is relative to other parts of the patient’s body, insurers reply,

That’s a deluxe item. You don’t need those features to walk. Want proof? Amputees have been walking on hinged knees and wood feet for most of the last 100 years.

Similarly, when articles repeatedly quote patients talking about how they’re using the most sophisticated device ever made by man, it feeds into the deluxe/luxury exclusion argument.

Now I know that high-tech prostheses capture the public’s imagination. I know that news organizations want to focus on sexy soundbites that make people feel good both about modern medical devices and the people using them. But it’s a double-edged sword – this narrative overexaggerates the effectiveness of prosthetic components at the expense of a fair and balanced discussion of the facts.

Fact: the best prosthetic knee in the world doesn’t come close to replicating biological knee function in all planes. So that device – sophisticated as it is – isn’t deluxe when compared to a natural knee. It’s a pale imitation.

Fact: the best prosthetic foot in the world doesn’t come close to replicating the full range of ankle motion or foot functionality. Hell, it doesn’t even have functioning toes! It’s not deluxe when compared to a biological ankle-foot system.

I’m willing to bet there are tens of thousands of amputees today who are walking on components that underserve them because their insurers denied more appropriate devices on the ground that they were “deluxe.” Only by adding some nuance to the “most technologically-advanced” narrative will these people gain access to the devices they need.

Yes, we’ve seen huge advances in prosthetic technology, particularly over the last 12 years. Yes, prosthetic components do a better job of replicating their biological counterparts today than they ever have before. But let’s keep things in perspective. Until a prosthesis allows an amputee to do everything she did in exactly the same way she did it before, there’s no such thing as a deluxe prosthetic component.

 

*For the sake of simplicity, I’m carving out individuals who have severe impairments in their biological limb(s) who opt for amputation. For these people, amputation actually can improve both their function and quality of life.

please sir, may I have another?

 

please sir, may i have another 6.3.14On May 28, Medicare published a new rule that would require your prosthetist to submit virtually all prosthetic claims for prior authorization. What is that? Why is Medicare proposing this change in policy? What effect will it have on you? We discuss each of these questions in this week’s (longer-than-normal but important) post.

what is prior authorization?

Prior authorization requires you to seek approval from the payer before you can deliver the item. While common among private payers, which usually require prior authorization in order to confirm what exactly this plan out of the 40 offered by this insurer covers, traditional fee-for-service Medicare – a payment system with the exact same coverage for every beneficiary –  has never required it.

In 2014, FFS Medicare, which has always operated under a “deliver and bill” methodology, will provide coverage to 70% of all Medicare beneficiaries. In this system, your prosthetist obtains a prescription from your physician, fabricates your prosthesis and then delivers it to you. After delivery, she submits the claim to Medicare for payment.

why is Medicare proposing this change in policy?

Unlike prior authorization in the private pay world, Medicare’s proposed rule isn’t really about confirming what Medicare covers. Rather, the proposed rule is intended to establish whether the actual claim materials satisfy Medicare’s requirements. Medicare’s logic is simple: (a) its data suggests that its paying for lower limb prosthetic claims that lack required documentation, (b) the current “deliver and bill” FFS system doesn’t allow it to review claim documentation beforehand, preventing it from addressing these inappropriate payments, so (c) “We believe a prior authorization process would ensure beneficiaries receive medically necessary care while minimizing the risk of improper payments and therefore protecting [sic] the Medicare Trust Fund.” While this appears to make sense at first glance, a deeper look at the issue indicates the data on which Medicare bases this proposal aren’t as clear-cut as it maintains.

Just to cite one example out of may possibilities, Medicare contends that 66% of all DMEPOS claims (more on that acronym in the next sentence) failed to meet its coverage requirements. The 66% figure applies to all DMEPOS – durable medical equipment, prosthetics, orthotics and supplies. DME and supplies are things like crutches, canes, wheelchairs, mattresses, and diabetic test strips – devices delivered to Medicare beneficiaries in much larger numbers than prostheses. Because the annual report relied upon by Medicare for this statistic contains no data breaking down prosthetic-specific error rates, it’s hard to know whether improper payments for prosthetics were anywhere near as high as those for DME and supplies.

It’s unlikely that potential data deficiencies like this will derail the push for prior authorization. But when Medicare proposes changes that could have a significant impact on amputees, you would hope that the foundation upon which the proposed rule is built would be rock solid. It’s not entirely clear that that’s the case here.

what effect will it have on you?

From the amputee perspective, it’s hard to find something positive in the proposed rule. The best way to illustrate this is with a hypothetical patient.

Jane is a new amputee who lost her right leg below the knee at age 65 to dysvascular disease. It has been 45 days since her amputation and she has been limited to a wheelchair since the surgery. Her prosthetist has already assembled the necessary paperwork to file her claim and determined that she is ready for delivery of her first prosthesis. Under the current system, the prosthetist obtains a prescription from the physician, documents Jane’s medical need for a below-knee prosthesis, orders the appropriate components, and delivers it to her as soon as he can schedule her for fitting. He then bills Medicare.

Current State Outcome: Jane has her prosthesis on Day 45 and the prosthetist is responsible for ensuring that Medicare pays him.

Now assume exactly the same clinical facts but with Medicare’s proposed prior authorization rule in place. On day 45 Jane’s prosthetist has all the necessary paperwork but isn’t delivering anything. Instead, he’s submitting that paperwork to Medicare for review. Let’s further assume that everything goes perfectly – they get prior approval on Day 55 and Jane receives her prosthesis 5 days later when her prosthetist can first fit her in his schedule. Jane’s absolute best-case scenario is that she sits in a wheelchair until 60 days after her amputation instead of 45.

Whether there’s a material long-term clinical impact on Jane due to an extra 15 days in a wheelchair isn’t exactly clear. We’d probably all agree it would be better for Jane to be in her prosthesis on Day 45 as opposed to Day 60. But under this system, that isn’t possible.

Best-Case Prior Authorization Scenario Outcome: Jane has her prosthesis on Day 60.

Now let’s walk through a more pessimistic – and, based on how Medicare’s contractors have reviewed prosthetic claims over the last 24 months – realistic fact pattern. Jane’s prosthetist submits the prior authorization request on Day 45. On Day 55, he receives notice from Medicare that it has denied his request for prior authorization, saying (a) without a great deal of specificity, the physician’s notes fail to satisfy Medicare’s coverage criteria and (b) he has failed to demonstrate the medical necessity of the prosthetic components prescribed for Jane.

The prosthetist contacts the doctor and gets what he believes to be additional appropriate documentation. He also updates his notes to further justify the components recommended and prescribed for Jane. He submits those for prior authorization on Day 60. Medicare responds on Day 80, informing him that it is still denying authorization because (a) the doctor’s notes don’t specifically state that Jane is “motivated to ambulate” and (b) Jane doesn’t have the functional “potential” to effectively use the components.

The prosthetist resubmits the authorization request a second time, now including a new physician note with the “motivation to ambulate” language included, new physical therapy notes addressing Jane’s functional potential and his own new records. It takes him a bit of time to assemble all this new information, as Jane needs to see the physician and PT, so he sends in the new paperwork on Day 95. On Day 115, Medicare finally approves the claim, and Jane receives her prosthesis on Day 120.

Here, it’s pretty clear that spending an extra 2 months in a wheelchair while Medicare screens paperwork will have both short-term and potential long-term effects on Jane’s rehabilitation. She now hasn’t been upright in 4 full months. She may well have developed a contracture in her knee joint. Her cardiovascular capability has degraded severely. Her sound leg’s muscle tone has also decreased. The chances of Jane becoming the kind of walker that her prosthetist originally envisioned are substantially lower. If she does get back to that level, it’ll take a lot longer. If she doesn’t, we can expect a greater number of physical and mental health issues to affect her in the coming months and years than she would have had otherwise.

Real Word Prior Authorization Scenario Outcome: Jane has her prosthesis on Day 120.

One other point on prior authorization: the system takes the authority for deciding what components are best suited for each individual patient out of the hands of the amputee’s health care team and gives it to claims processors. While Medicare officials might dispute this contention, compared to the current system it’s not even an arguable point.

Today, only the prosthetist and physician decide and document a course of treatment and a specific kind of prosthesis for each patient. The patient receives that prosthesis and the prosthetist must justify what she already delivered. But in a prior authorization world, if claims handlers don’t believe that the items prescribed for the patient are appropriate, they can effectively prevent the patient from receiving them in a timely fashion or, in a worst case scenario, at all. Prosthetists, faced with potentially lengthy delays and a patient who needs prosthetic care more and more with each passing day, may be forced to choose the path of least resistance. They may start putting Medicare patients in less appropriate components to get the prior approval, to provide the patient something.

Whatever the flaws of the current “deliver and bill” model, it has two strengths that prior authorization cannot replicate: (1) the health care team – the group with the best insight into the amputee’s clinical needs – has more control over what the patient gets, and (2) it allows amputees to receive more timely care.

conclusion

For all the horror stories about (a) national government programs generally and (b) health care specifically, I’ve always taken a  positive view of how fee-for-service Medicare treats people with limb loss. I’ve stated multiple times over the last decade that if I could choose any insurance for my prosthetic needs, Medicare would be close to the top of my list.

Unfortunately, I’m hard-pressed to see how this proposed rule helps amputees, and that’s because it’s really not about helping amputees: as Medicare freely acknowledges, it’s about preventing improper payments. Medicare may accomplish that goal, but there’s really no way to do it in a prior authorization system without putting amputees in a worse position than they are today.

Medicare is taking public comments on the proposed rule between now and July 28, 2014.

If you wish to submit comments so that amputees’ voices are heard in this debate, you can click here to submit electronically. When you get to the webpage, cut and paste the following reference into the large “Search” box in the center of the page: “CMS-2014-0070-0001”. This will lead you to a citation of the proposed rule. To comment, just click on the “Comment Now!” blue button to the right side of the citation.  Alternatively, written/typed comments can be submitted by regular mail to Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–6050–P, P.O. Box 8013, Baltimore, MD 21244–8013. 

what if … you could win an insurance appeal? (part 2)

less is more 02.25.14

What if all the action-packed excellence of a podcast giving you useful tips and tricks for winning appeals – all while relating amusing stories to make the experience actually enjoyable – couldn’t be contained within a single podcast? What if Part 2 were even better than Part 1?

If either of those things were true, then you should listen to Part 2 of Amp’d’s ongoing series about how to beat insurance companies at their own game. Click here to listen!

what if … you could win an insurance appeal?

less is more 02.18.14

What if your insurance company denied your claim for a new prosthesis? What if that happened and you happened to co-host a podcast about issues facing amputees? What if the denied claim discussed in this podcast included a request from the insurance company that was so inappropriate that even I was taken aback?

Well, with that background in place, this podcast is a must-listen for everyone. In the first of a multi-part series, the Amputee Mommy and I discuss her recent claim denial and strategies for overcoming it. Click here, and enjoy!

what if … you were a letter and a number?

less is more 10.15.13

And what if this letter and number gave you access to certain types of prosthetic components but not others? What if Medicare and private insurance refused to pay any claim that didn’t include the letter and number on the claim form?

What if you disagreed with the letter and number assigned to you by your prosthetist and doctor?

What if you could take certain steps to help make sure that your prosthetist and doctor assigned you the right letter and number? So that you could get the most clinically-appropriate prosthesis given your individual needs?

In the October edition of Amp’d, The Amputee Mommy and I cover the important and slightly bizarre world of “K Levels,” which describe every lower limb amputee’s current or potential ability to walk. We explain how current trends within both Medicare and private insurers have made K level documentation the center of a war between prosthetists and payers, and how you can avoid getting stuck in the middle. So click here to immerse yourself in a painful but necessary discussion … K?

the cost conundrum

05.14.13 the cost conundrum

“I’ve been an AK for 23 years and can only wish that my prosthetic allowed me to be as active as I was prior to losing my limb. It is nowhere near as good as the real deal, and I have [a] $100,000 leg. No kidding. That’s what was billed to my insurance company.”

Cheryl, less is more reader, commenting on “the disconnect

“[A]mputees [ ]would be a lot better served with better products for far lower prices. … [The prosthetic hands I happily use] cost $400 to $700 bucks[.] That concept has certainly not been understood by manufacturers and as long as that is not the case I see no reason why insurances are [not] guilty of [ ] paying for shamelessly overpriced gadgets[.]”

Wolf, less is more reader, commenting on “the disconnect

While the term “prosthetic costs” means different things to the different players in the U.S. health care system, few would describe these devices as “cheap.” Insurance companies pay thousands of dollars even for low-end prostheses, while technologically advanced ones cost tens of thousands, with some breaking the $100,000 barrier.

Why do prosthetics cost so much? It’s a fair question.

*   *   *

the component-part manufacturer

Companies like the one I work for invent (or buy from others), fabricate, and sell a wide range of components, ranging from prosthetic hips, knees and feet for people with lower extremity limb loss to prosthetic fingers, hands and arms for upper extremity amputees. They also make liners, adaptors and pyramids that prosthetists use to assemble the finished prosthesis.

If you ask a component-part manufacturer about the cost of its devices, you’ll get a detailed lesson in the product development and manufacturing process. What starts as a concept “drawn” into a computer eventually makes its way to the marketplace, typically over the course of 18-24 months, and in the case of more complex technologies – think myoelectric, microprocessor, and motor-powered devices – two to three times longer than that.

The manufacturer then has to take into account the costs of manufacturing and assembling these products once they’re market-ready. You have the expense of the raw materials used in the device; the costs of purchasing certain sub-elements – particularly in the case of more sophisticated technology – from other manufacturers; and the expense of operating the factory where a team of people and costly machines make the item.

Next, you have the development of marketing and educational materials, as well as the fixed costs of a sales force that provides both information and support to providers actually fitting the device. Finally, you have the costs associated with maintaining and supporting the product post-launch. This provides a high-level snapshot overview of the expenses associated with a product, and it doesn’t even take into account a myriad of other expenses I’ve left out for the sake of simplicity (e.g., legal/regulatory expenses, etc.)

While you may say this model supports bloat and expense, no viable alternative to it has come to the fore. The Open Prosthetics Project – an open source approach to prosthetic solutions – has close to 600 members, but hasn’t disrupted the traditional approach yet.

the prosthetist

Prosthetists buy most of their prosthetic parts from component-parts manufacturers. In addition, they have to purchase plastics and other materials to custom-fabricate the prosthetic socket that’s fit to the patient’s residual limb.

In addition, prosthetists do not get paid on a “per visit” basis. Payors only reimburse them for delivering a device, an amount that implicitly includes both the time the prosthetist spent fabricating and assembling the prosthesis, and the time associated with all necessary follow-up treatment and training.

So when you talk about prosthetic costs with a prosthetist, he’ll typically take into account the following: (1) all of the costs associated with buying components, plus (2) all of the costs of the raw materials that he crafts into a socket, plus (3) the cost of his time to make the prosthesis, plus (4) the estimated future cost of seeing you multiple times after delivery to both adjust the prosthesis and, if necessary, train you to use it effectively.

the payor

All payors, whether governmental or private, think of prosthetic costs as the amounts billed to them by prosthetists. And payors – especially private insurance companies – have increasingly shifted health care costs towards consumers over the last 8-10 years.

While the stated goal of cost shifting is to encourage patients to make economically-intelligent health care decisions, most data suggest that the primary effect is to discourage patients from seeking any health care at all, which may lead to higher health costs when they finally do seek treatment. Secondarily, cost shifting results in lower expenditures and higher profitability for payors, while purportedly helping employers keep insurance premiums from spiraling out of control.

the patient

That leaves us with the people who need prosthetic care and who increasingly shoulder a higher share of the prosthetic cost burden. We want the prosthesis that’s most comfortable and that gives us the greatest possible mobility. Over the last decade, our wants have often led us to more complex (read: expensive) prosthetic solutions. We wear a prosthesis that brings us closer to a four-limbed individual’s functional level, but it comes at a higher cost, both in terms of raw dollars and the amounts that we’re asked to spend in the form of copays and deductibles.

*   *   *

“[Y]ou act as if prosthetic prices were ‘as is.’”

Wolf, less is more reader, commenting on “the disconnect

The question of whether the economics of this system make sense or treat people with limb loss fairly doesn’t have an easy answer. Like it or not, in the U.S. right now prosthetic prices are ‘as is.’ While alternatives may theoretically exist, implementing them might come with other costs, such as discouraging innovation or encouraging the use of less expensive and less functional materials.

I’m employed by a component-parts manufacturer today. I worked for and co-owned a prosthetic facility before that. I’ve been an amputee since 1996. And I represented payors in the early part of my professional life.

The only thing I know for sure is that there are no easy answers to the cost conundrum.