a two-fer

This week started normally. Peggy and I recorded our “standard” weekly podcast, which focused on explaining the alphabet soup of organizations whose work directly and indirectly affects people with limb loss/difference. These include entities that certify the prosthetists who treat us, accredit the facilities in which we receive that care, and devote significant time to prosthetic research and legislative initiatives.

Straightforward, right?

Then, late Monday afternoon, House Republicans released The American Health Care Act, the first step in following through on their promise to “repeal and replace” The Affordable Care Act. We read through the 120+ pages and recorded a new “special alert” podcast Tuesday evening that went live immediately afterwards. In it, we explained what The American Health Care Act would do and how it would directly affect people with limb loss/difference. We also issued a new call-out to our amp’d Activists to again reach out to their legislators to express their thoughts about this new proposal and created updated model letters for amputees and their relatives/friends to personalize and send to their Congressional representatives.

Both podcasts address issues of importance to amputees. If you’re not already subscribed to our iTunes or other podcast feeds, you can visit www.ampdpod.com to listen to them and download our Podcast Summaries. (We’ve now embedded podcast players into the site so you can listen to us without having to leave ampdpod.com.) And whether you’re an amputee yourself or a family member/friend of one, please visit the Current Issues section of our website to directly engage with your elected officials. Your voices matter. A lot. So speak.

how to speak to politicians effectively

Last week in our amp’d podcast, Peggy and I issued a call to action to the amputee community and its family/friends. We asked you to reach out to federal legislators to ensure that two key protections provided by the current health care law – (1) classification of prosthetics as Essential Health Benefits, which prevents insurers from placing annual or lifetime caps on prosthetics, and (2) prohibitions on pre-existing condition exclusions – do not get repealed as part of the heated and quickly-evolving healthcare debate on Capitol Hill. As part of that effort, we created a new “Amputee Activism” section of our website, along with a tool designed to help you develop your skills as an amp’d activist.

In our newest podcast, we now walk through that tool step-by-step, showing you how to professionally and powerfully speak to your Representative and Senators about these two important issues. The debate in Congress is happening right now! If you wait to make your voice heard, it may be too late. So check out the latest amp’d, learn how to become an effective activist for the entire limb loss/difference community, and reach out to your elected officials immediately to ensure that they #DontExcludeAmputees.

 

early adoptors (at amputees’ expense)

early adopters (at amputees' expense)

The importance of the proposed changes to lower limb prosthetic clinical care, coverage, and coding by Medicare’s contractors has dominated the last few posts I’ve written and will do so again today. We need to turn to the more insidious – though, sadly, entirely expected – implications of the draft Local Coverage Determination.

Yesterday, I received a link to United Healthcare’s medical policy update bulletin (the no-initial-caps styling of the document belying its significance), 36 pages of scintillating minutiae about pending changes to the company’s medical policies. Medical policies, the name notwithstanding, set forth an insurance company’s coverage position for a variety of different treatments. Every major private insurer has a medical policy (or clinical policy, as some prefer to call them) describing what it covers and does not cover when it comes to lower-limb prosthetic devices. 

Page 27 of the United Healthcare bulletin is where we run into trouble:

Added coverage guidelines for vacuum pumps for residual limb volume management and moisture evacuation systems among amputees (HCPCS codes L5781 and L5782) to indicate:

The use of vacuum pumps for residual limb volume management and moisture evacuation systems among amputees is unproven and not medically necessary due to insufficient clinical evidence of safety and/or efficacy in published peer reviewed medical literature[.] (emphasis added)

United Healthcare states that this change will go into effect in just over 3 weeks, on October 1st. 

If elevated vacuum had just come to market without research proving its efficacy, if United Healthcare had reached this decision based on its own thorough review of the applicable literature, and if these components were not medically necessary, this “evidence-based” conclusion might not be so offensive. Unfortunately, none of those things are true. The only reason that United Healthcare has made this change to its coverage guidelines is because Medicare’s contractors have provided it the cover to do so without fear of reprisal.

Why do I say that? Because before the Medicare contractors’ publication of the draft Local Coverage Determination, United Healthcare covered elevated vacuum. However, once the draft proposal found its way into the public eye – including its unsupported conclusions about elevated vacuum – UHC adjusted its coverage policy to make it consistent with the draft document. 

Let’s review the timeline here: July 16 – Medicare contractors publish draft proposal; September 8 – United Healthcare publishes updated coverage guidelines; October 1 – new UHC guidelines go into effect. Total time from Medicare’s proposed changes to private payer implementation? Seventy-five days. I would hazard a guess that there are some private insurance claims for lower limb prostheses that have been stuck in prior authorization longer than that.

I’d like to tell you that this is an unanticipated, unforeseen consequence of Medicare’s draft proposal. Unfortunately, it is not.

In my August 31st post, I included a link to the formal comments I submitted to Medicare’s contractors regarding the proposed changes. In that document, I said the following:

[G]iven the fact that every proposed change related to coding in the Draft LCD has the effect of decreasing overall reimbursement for lower limb prostheses, private payers have a huge financial incentive to follow Medicare’s lead in this instance. There is no economic argument – literally none – in favor of not adopting the provisions of the LCD if you operate a private insurance company.

Thus, to act as if changes to the current LCD will somehow remain cordoned off from the broader private insurance market would be naïve, in direct conflict with historical precedent, and economically inconsistent with private payers’ short-term interests. The draft LCD does not potentially affect just amputees covered by the Medicare program; it will directly affect virtually all amputees in the United States. For people like me who depend on a prosthesis every second of every day to navigate the world, the stakes here could not be higher.

I also discussed this exact issue – elevated vacuum – in my comments:

[T]he DME MACs take the position that there is “insufficient published clinical evidence” in support of elevated vacuum suction systems, rendering them medically unnecessary.[ ] First, that is simply untrue. Plenty of peer-reviewed, published research exists supporting the efficacy of elevated vacuum. Second, the DME MACs have chosen to reach this new conclusion more than a decade after Medicare’s HCPCS Coding Workgroup created the codes describing elevated vacuum. Tens of thousands of Medicare amputees have received these devices since these codes went into effect. They have used them to control the volume of their residual limbs, to remove excess moisture, and to assist in wound healing. 

The most bizarre element of this decision is that more evidence supporting the use of elevated vacuum exists today than existed in 2003. To deny amputees the right (1) to continue to use what they have consistently and successfully used for more than a decade, and (2) to access this type of technology at all moving forward, even when clinically appropriate, defies easy explanation. This is especially true in light of the fact that the DME MACs have failed to cite any clinical evidence in support of their conclusion.

With every passing day, the draft LCD’s continued existence puts amputees insured by private insurance companies in the crosshairs, increasing the likelihood that the devices they have worn and depended on for years will suddenly be stripped away from them in the future. This is exactly why the draft policy should be rescinded immediately, not just placed “on hold” while Medicare’s contractors try to amend it.

While I’m not prone to hyperbole, I can’t overstate the significance of what’s transpiring here. Since 2003, Medicare’s contractors have approved tens of thousands of elevated vacuum devices for lower-extremity amputees because they deemed these components medically necessary. The contractors have cited to nothing – NOTHING – in their bibliography that supports the “no evidence of efficacy” conclusion regarding elevated vacuum systems. But this draft document, with all of its undisputed deficiencies, has provided United Healthcare the ammunition it needs to now erase from coverage a proven, medically-necessary solution that premium-paying lower limb amputees rely on, every step of every day.

The sad truth is that regardless of what Medicare and its contractors choose to do moving forward, the damage here has already been done.