i don’t know why you say goodbye i say hello

As I opened my computer this morning and typed in my password, I realized that I hadn’t authored a single less is more post since September. That realization upset me. Writing this blog has always been a passion project. Every post – whether I personally loved it or not after hitting “publish” – means something to me. But I sputtered and stalled in 2015. After writing 40-45 posts a year for several years in a row, I fell off the writing wagon for large portions of the last 12 months.

As we head into 2016, I hope to return to the older pattern, posting once a week for most of the year. In the interest of getting reacquainted in the meantime, allow me to revisit 2015 with the “less is more Top 10 of 2015.”

10. The Beatles hit Spotify

Technically, this hasn’t even happened yet. But as of December 24 at 12:01 AM, the entire Beatles catalog will find its way to Spotify and other music streaming services. For those of you who dismiss this as “old music for old people,” or ask, “what’s the big deal?” allow me to share the following story.

My son, Max, had serially shrugged off every suggestion I made about the importance of listening to The Beatles. Last Christmas, armed with a few hundred dollars of iTunes gift cards, he took the plunge and bought their entire catalog. In early January he pulled me aside.

“I listened to The Beatles, everything.” He paused. “[Expletive deleted.] You were right. They’re [expletive deleted] great.”

Score 1 for the old guy.

If, like Max before this year, you’ve never “gotten” The Beatles, you have to give it a shot now. Here are the 5 albums you must start with: Help; Rubber Soul; Revolution; Sgt. Pepper’s Lonely Hearts Club Band; and Abbey Road. You’ll thank me.

9. i can still get nervous before speaking in public

MAC Public Hearing

Peggy Chenoweth and Your Humble Author at the Public Hearing

I spend so much of my professional life speaking to audiences of varying sizes that I’m largely immune to nerves. But that wasn’t the case this past August when I spoke for 6 minutes at a public hearing focusing on proposed changes to coverage, coding, and clinical care for Medicare beneficiaries. (See also, #1, below.) I haven’t been that nervous in years. Why? Because that speech, more than almost anything I’ve ever delivered, felt like it mattered.

8. college looms

The fact that in 2015 Max received his driver’s license and now has submitted applications to college is one of the great mind-benders of my adult life. The fact that 17 years have passed and he’s on the verge of starting a new phase of his life is something I still can’t fully comprehend. I can’t even write about it in a coherent way.

Anyway, it’s bizarre. And I’m happy for him but completely freaked out.

7. Amp’d ramps up

Peggy Chenoweth, my partner in crime and co-host of the Amp’d podcast, texted me two months ago. “Do you know how many people listen to our podcast?” As a proud web analytics agnostic, I quickly responded, “Nope.” When she gave me the number I couldn’t respond for a moment. The fact that for a given topic we have more than 11,000 people listening to us ramble is simultaneously thrilling and daunting.

Peggy and I have made a commitment that we’re going to try to increase our podcasts to a weekly (or near-weekly) frequency moving forward. Let me in advance apologize for the times we don’t meet this goal, because it’ll be entirely my fault and likely due to my travel schedule. But much more Amp’d to come in 2016! (In this case, more is more.)

6. Cheap Shots releases its first EP

Cheap Shots EP

Cheap Shots EP

Just as important as The Beatles catalog becoming available to streaming services was Cheap Shots’ release of its first EP in October. After losing his lead guitarist and bassist to college at the end of this summer, Max formed this new group. (He and I spent the better part of two weeks in Aruba tossing potential new band names around. Discarded names included Illysium and Kooster’s Last Stand, among roughly 830 others.)

Cheap Shots has played regularly through the fall and into the early winter, including a stellar gig at Webster Hall in New York City right before Halloween. The EP, The Things That Keep Me Up Late, is a blistering set of melodic pop-punk/rock tunes with a gorgeous acoustic ballad (“One More May”) thrown in for good measure. If you’re unwilling to submerge yourself in the Beatles discography, then commit to Cheap Shots instead. Actually – commit to them either way. If you want to hear soaring melodies and poignant lyrics that come right from Max’s heart, you’ll love Cheap Shots.

5. everything is impermanent

Back in March I wrote about the unexpected death of Phil Kreuter, my friend and the physical therapist who trained me to walk again after I lost my leg. Phil wasn’t old – only in his mid-50’s – but suffered a massive stroke that led to his death shortly thereafter. It shouldn’t take the passing of important people in my life or the near-misses in my own to remind me just how important it is to respect the time we do have on this planet with the people around us. But invariably, it does.

Be aware. Don’t sleepwalk through everything. We only get to climb on this roller coaster once, so enjoy the ride.

4. i have 3 amazing kids

In July, Cara unexpectedly wound up in the hospital for a week while we were in Aruba. It was a serious situation – she was admitted to the ICU, initially – and I suddenly had to spend the majority of my time in a foreign hospital. While she responded to treatment quickly and got out with enough time to enjoy the second week of our vacation, I had to depend on all of my kids in ways none of us could have planned for.

They were all, in their own ways, amazing. When everything around them was going to hell, they supported each other, me and Cara. I couldn’t have gotten through that week without them there. I don’t remember a lot of what happened over those 5 days, but I distinctly recall sitting with my kids around a dinner table and telling them how proud I was. “When the chips are down, families are supposed to pull together and look out for each other, no matter what,” I said. They did that and then some. Thanks Max, Jackson and Caroline!

3. your humble author cries

Eastman Theater

Eastman Theater

I’m not particularly emotional. But earlier this month, Max performed as a member of New York’s All-State Chorus. This is an honor afforded to less than 300 students in the entire state, all of whom qualify based on a formal vocal audition. As I sat in the packed Eastman Theater in Rochester and listened to the songs, I began to quietly cry.

It hit me that Max was moving on (see #8, above) to new opportunities in less than a year. I realized that while I’ll still be his father and always part of his life, I’ll be losing him, to some extent. The thought of 2:30 PM rolling around and Max not walking through the door to shoot the breeze with me about his day at school and the music he’s working on or listening to hit me hard.

In that moment I was filled with equal parts pride and sadness. Prediction: I’ll be a total mess when he leaves for college. Thank god for Skype.

2. New York’s one-limb-per-life restriction overturned for 2016

As an amputee living in New York, I found it particularly galling that amputees paying premiums for plans purchased through the state’s insurance exchange were subject to a 1-prosthesis-per-limb-per-lifetime restriction. As President of the National Association for the Advancement of Orthotics and Prosthetics (NAAOP), I helped support an effort driven largely by a friend and fellow amputee, Dan Bastian, to get that restriction changed.

First the good news: the Director of NY’s exchange added language that requires insurers to additionally cover prosthetic repairs and replacements beginning January 1, 2016. Now the bad news: it’s not clear that this language will carry over into 2017. Additionally, even though the NY House of Representatives unanimously supported a permanent legislative fix that would cover prosthetic devices whenever medically necessary, the Senate refused to bring that bill to the floor for a vote.

So there’s still work to do in NY in 2016, but at least amputees in my home state requiring prosthetic repairs or replacements during the next 12 months will get them.

1. amputees successfully thwart proposed national coverage changes

We the People Petition

We the People Petition

I won’t belabor the point since this was the subject of virtually all of my posts and Amp’d podcasts from August of this year on. Medicare’s contractors published a draft local coverage determination that would have fundamentally changed prosthetic clinical care, coding, and costs if implemented. NAAOP launched a successful campaign that led to 110,000 signatures in 30 days on a petition requesting that the White House instruct Medicare to rescind the draft document.

In October, the White House and Medicare issued joint statements saying that the proposal would be shelved for now in favor of a federal workgroup tasked with analyzing current prosthetic best practices. While we will continue to need to fight over the coming year to make sure that the workgroup possesses complete and accurate information, the decision not to implement a policy that would have returned prosthetics to an average standard of care worse than what I experienced as a new amputee in 1996 was a huge win for amputees across the United States.

It shows how powerful we can be when we speak together with one voice. Here’s hoping there’s much more of that to come in 2016.

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. 

draft LCD comments – deadline and mine

deadline and mine 8.31.15

Today, August 31st, is the final day that you can submit comments about the DME MACs’ draft Local Coverage Determination, which would have a significant impact on lower limb prosthetic clinical care, coverage and coding. To say that this is an important issue for amputees in the United States is an understatement: I have worked full-time on nothing other than this since the beginning of July.

If you have not had the chance to comment already, please do so immediately! You need to submit them to the following email address by 5 PM ET:

DMAC_DRAFT_LCD_Comments@anthem.com

Your should address your letter to Stacey V. Brennan, M.D., FAAFP, Medical Director, DME MAC, Jurisdiction B, National Government Services, 8115 Knue Road, Indianapolis, Indiana 46250. (To be 100% accurate, the DME MAC Jurisdiction B website says that comments must be received by “close of business” tomorrow – whether that’s 5 pm ET, 5 PM CT, or 5 PM PT isn’t specified. I suggest ET as the cutoff to ensure that you don’t miss the deadline.)

If you have questions about how to draft an effective comment letter or other LCD-related questions, I’m “on call” through tomorrow. You can either submit questions to me on Twitter using “#askampd” followed by your question or on Facebook on the newly-created Amp’d podcast page (big props to Peggy Chenoweth a/k/a The Amputee Mommy and my partner on the Amp’d podcasts for putting that together). I’ll be watching both through the day and will try to answer questions as quickly as possible.

I have spent a considerable amount of time working on my own comments, which, I’m happy to report, I just completed and submitted a little after midnight. In lieu of a full-blown post either summarizing those comments or cutting and pasting them into what would be by far the longest post I’ve ever drafted on less is more, I’ve opted instead to link to a pdf for your reading pleasure, below.

If you’re in the mood for 12 pages of analysis describing why I think the proposed changes are a bad idea, then you’ll be very happy. If you’re looking for a “normal” less is more post, stay tuned. I’m coming back with lots of new stuff in the coming weeks. In the meantime, thanks to everyone who has worked so hard on this important issue over the last 45 days. It has been a remarkable summer.

McGill Comments to Draft LCD