the amputee bill of rights

In our most recent podcast, Peggy and I share our thoughts about which amputee rights are so fundamental that they should be included in a new amp’d Amputee Bill of Rights. We talk about how this project started, the way in which we came up with the rights included in this document and gave listeners a glimpse into the reasoning behind our choices.

But what we have done so far is only version 1.0 of the Amputee Bill of Rights. In order to finalize it, we are seeking input from everyone in the limb loss / difference world. Our goal is to ultimately publish a document that has feedback from and the support of everyone with less than four complete limbs. So we are asking you – please review version 1.0 and share your thoughts with us.

How do you do that?

  1. Download the amp’d Podcast Summary (Episode 17) and review the amp’d Amputee Bill of Rights version 1.0.
  2. Let us know what you think. What did we miss? How can we improve what we’ve already got? You can reach out to us either by contacting us through our website, or by sending us an email at ampdpod@gmail.com. Either way, please include the words “Bill of Rights” in the subject line so that we can triage responses appropriately.

We look forward to your input. The deadline for submitting your comments is Friday, April 7th. We’ll publish the community-validated/created Bill of Rights the following week.

Thanks in advance for your help! We have already received lots of great comments and can’t wait to get more.

beware the patients!

beware the patients 08.26.14

If there is a Bizarro Earth occupying a parallel dimension, the one place I want to visit while there is a doctor’s office. Only in this twisted alternate reality will I ever experience something approaching satisfaction after pulling my car into a medical complex.

*   *   *

Last Saturday, Max and Caroline had an appointment with the same doctor. Jackson had a separate visit scheduled two days later. None of them had ever seen this physician before, but he was, multiple friends had assured us, “the best!”

The morning of the appointment, Cara directed me to a purple folder with paperwork for each of the kids that we needed to fill out before going to the office. She told me, “I printed them from the website. They were very clear that we need to bring this with us before coming in.”

I looked at the stack of papers and immediately cracked open my laptop. I knew that Cara had prematurely printed out the blank forms, failing to recognize that we could fill them out electronically, saving both us and The Best’s staff valuable time.

I navigated to the website and accessed the forms. I stared at the screen in disappointment. I was staring at pictures of preprinted forms. The only thing you could do with them was print and fill them out by hand. I went back to the purple folder and started writing.

I arrived at the office with all three kids – I figured maybe I could get them to see Jackson at the same time to avoid a separate trip two days later – at exactly the scheduled appointment time of 1 PM. The waiting area, big enough to hold upwards of 25 patients was nearly empty: just a middle-aged man with two kids too young to be seeing this specialist and a woman waiting for her husband to come back out from his patient room. I walked to the front desk where a 60-ish woman with an unsmiling face ignored me for 15 seconds before saying, without looking up, “Sign in.”

I stood for half a second with the 12 pages of information that they had told us to bring on pain of death and contemplated the heavily made-up and garishly lipsticked visage aggressively ignoring me. I signed in and then moved directly in front of Ms. Sunshine to give her the paperwork and make a request.

I waited another 15 second for her to acknowledge my existence in the largely empty environment.

“Yes?” she said, annoyed that someone wanted to speak with her.

“I have the paperwork for the kids here,” I said, handing her Max’s and Caroline’s. She brusquely pulled them from my hand and started to turn away towards her computer.

“I also have my other son’s information here,” I continued. “He has an appointment on Monday and -” She cut me off.

“You hold onto that. I don’t want to get confused if his appointment isn’t today.”

Dismissing the thought that receiving forms the practice requires every patient to fill out shouldn’t ever be confusing – especially since they existed for no other reason than to be physically placed in a patient’s folder – I gamely continued: “Well actually, I was wondering if perhaps he could be seen today to avoid another -” She cut me off again, shaking her head vigorously, exasperated with my stupidity.

“No, we don’t have any time. We close early today.”

I backed away from the reception desk like a camper who has unexpectedly stumbled across the path of a bear. I returned to the kids. Jackson asked, “Will they see me?”

“She’s a total drone,” I replied, not concealing my anger. “We’ll try to make more headway with the doctor.”

Half an hour after the scheduled appointment time, a nurse escorted us to the patient room. This brief illusion of forward progress quickly dissipated as we sat for another 15 minutes.

When The Best finally entered the room, I stood up to shake his hand and introduce myself. He barely glanced at me as he picked up the kids’ newly created files, looked at Caroline and asked, “Ok, so why are you here?”

As I retracted my half-extended arm I realized that he had no intention of telling us his name,  or otherwise engaging in any interaction that would prevent him from exiting the room as quickly as possible. The appointments went by in a blur. The only thing I remember about The Best is that he wore a blue-faced Breitling watch that stared at me with about as much emotion and empathy as its owner. If I witnessed The Best mugging someone in broad daylight and tried to describe him to a sketch artist, I could describe the watch better than I could his height, weight, or face.

By 12:55 I was standing back at the reception desk, Ms. Sunshine gone, staring at a much nicer staffer responsible for scheduling follow-up appointments. I numbly made the necessary arrangements, wondering, “Why would I ever come back here?” as I did so.

“You’re all set,” she said, smiling at me.

“Wait, don’t I have to give you a copay or something?” I asked.

She looked up, startled. “What do you mean? Did the woman at the front desk [Ms. Sunshine] collect any money from you before you went in? If she didn’t, then I don’t think you owe anything.”

“Um. ok,” I replied. “I just don’t want to skip out without making any payments I owe you.”

“Oh, don’t worry,” she said, smiling broadly. “If you owe us anything, we’ll track you down.”

“I’m sure that’s true,” I answered, feeling like this was the only certainty in life as I started walking out the front door.

“Oh!” she shouted after me. “Can you please make sure to push the black door completely shut behind you when you leave?” Before I could answer she reconsidered. “Actually, no, you can leave it. One of our people is coming back – she’ll need to get in.”

Freed from the responsibility of protecting Ms. Sunshine and The Best from an unexpected attack from the outside world, I left.

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. 

time to move on

time to move on 01.27.14

I’ve written here and talked on Amp’d about how to select a prosthetist. In both forums, I’ve* briefly touched on the equally troubling topic of deselecting a prosthetist. In an ideal world, you find the perfect prosthetist as soon as you need your first prosthesis and you never have to look elsewhere for care. However, if you require a prosthesis in the first place, you’re already acutely aware that the world is rarely ideal. What do we do in those situations? When is it time to move on?

*”We’ve,” in the case of Amp’d, thanks to my podcast partner, Peggy Chenoweth aka The Amputee Mommy.

1. what’s the reason?

fit: a zero-sum game

I can’t sugarcoat it: prosthetic fit is all or nothing. You can either comfortably wear and use your prosthesis or you can’t. If you can’t, that high-tech, state-of-the-art prosthesis that got you (and your prosthetist) featured in your local newspaper has no value.

I’ve seen countless amputees show signs of end-stage “A-for-effort disease” when confronted with this situation. Common symptoms include prolific use of the phrases, “I really like him,” “He’s doing his best to figure it out,” and “He spends so much time with me,” all uttered while sitting down since the speaker can’t put weight on his prosthetic leg without requiring painkillers.

Let me be blunt: the prosthetist who’s a great human being, who tries really hard to solve your problems (but doesn’t), and who keeps you in his office 4 hours every visit not solving your problems has failed. That isn’t a personal indictment. It’s entirely possible that this individual has fit other people successfully. He undoubtedly is trying to fix things and make you happy. But so is the plumber you fire without a second thought after 3 consecutive visits to your house to fix the same leaking pipe.

Now the caveat: you have to apply a “reasonable patient” test. I knew amputees who came into our prosthetic facility thinking that every prosthetic issue they’d ever had would disappear immediately after receiving a prosthesis from us. But the process of getting a comfortable fit is exactly that: a process. If you’re lucky, it takes only a few weeks. Normally, though, it takes longer. While there’s no hard and fast rule here, my radar would start pinging after 3-4 months of consistent issues. Once you get to the 9-12 mark of non-stop problems, it’s probably time for you to hit the “eject” button.

psychological warfare

A close cousin to compromised fit, psychological warfare refers to the clinician who regularly reminds his patient that she just needs to “suck it up” because “pain is part of being an amputee.”

Unless you’ve got reflex sympathy dystrophy, daily crippling bouts of phantom pain, intermittent claudication, or some other medical condition producing regular and pervasive pain, using a prosthesis should not bring to mind being dragged across the scorching sands of a remote desert while tied to a racing stallion.

Unfortunately, I’ve heard countless tales of prosthetists trying to avoid responsibility for their own inability to fit patients comfortably by playing the “it’s not me, it’s you” card. And amputees – especially newer ones who don’t have as much experience as the prosthetist telling them this – often accept it as true. If you hear this, smile, think to yourself, “actually, it  is you,” and get out.

the price of greatness

At one time in my prosthetic-wearing life I went to a nationally-renowned facility that happened to be within easy driving distance of where I lived. My first scheduled visit there, I waited about an hour to speak to anyone besides the receptionist. I wrote it off as a bad day. My next scheduled visit – for casting – I waited 4 hours in the reception area without any explanation. At 1 pm, the clinician came out and told me he couldn’t guarantee that he’d see me that day but I could continue to wait if I wanted.

While Cara (appropriately) smoldered next to me, the following thought went through my head: “This guy’s one of the best in the world. Not thrilled about sitting here, but it’ll be worth the wait.” I sat for another 2 hours before he came back out and told me that I’d need to reschedule.

That should’ve sent alarm bells off in my head. It didn’t. This was just the cost of being a patient at the world’s greatest prosthetic facility, I told myself

While I ultimately received a great prosthesis, every trip to this facility reminded me of a simple military operation gone horribly, irrevocably wrong: think of a tactical strike devolving into an ongoing pitched ground battle against armed insurgents. Let me say this plainly: no prosthetist is so great that you should accept anything less than excellent customer service. Trust me, look hard enough for a prosthetist who can fit you well and run a practice that treats you with respect and you’ll find her. Don’t settle for one or the other: require both.

I owe what?!? 

What would you do if you went to pick up your brand new car and the salesman told you when you arrived that, oops, due to a minor addition error in the paperwork, you now owed an additional $3,000? My guess is that many of you would, at a minimum, have a colorful discussion with the salesman. I’m betting a clear majority would leave without the car.

As a patient, you have a right to know exactly how much you’ll have to pay: deductible, coinsurance, balance bills – the prosthetist should make everything clear before you receive the prosthesis. If I told you today that you could have the greatest prosthesis in the world – guaranteed – but you’d have to pay $7,000 out-of-pocket for it, I suspect most of you would reply, “I’d love to get it, but I don’t have that kind of cash taped to my air-conditioning duct like Walter White.” I’ve seen prosthetists seek $7,000 from patients after delivering a prosthesis without any previous financial discussion ever having occurred.

This puts you in an incredible bind – you’re using the prosthesis and feel a sense of obligation to make sure the prosthetist gets paid, but you’re getting blindsided financially. Nothing sours the patient-prosthetist relationship faster than financial disputes, even when you’ve gotten a wonderful prosthesis and have loved the prosthetist up to that point. In this scenario, patients quickly switch from, “What a great guy” to “He’s only in it for the money” mode. I’ve watched 100% positive patient-prosthetist relationships violently implode around these kinds of issues.

My guidance is to employ a zero tolerance policy for these kinds of “oversights.” Once they occur, it’s highly unlikely that you’ll ever feel the same way about walking into that facility or the prosthetist who’s treating you again.

why have you left?

I’ve presented 4 scenarios that I think compel you to find a new prosthetist. But I’m interested in your personal experience. If you’ve left a prosthetist of your own free will (excluding geographic relocation and other events you can’t control), why did you? For all of my prosthetic-wearing readers, I’d ask you to take one more minute out of your life and answer the survey below.

keep your hands away from the machinery!

keep your hands off the machinery 09.24.13The mechanical world and I don’t have a friendly relationship. When auto mechanics point to my car’s engine to show me what they’re working on, I nod wisely while understanding nothing. When I bought a power washer earlier this year and had to assemble the three different components that screw into the machine’s body, I had to redo the work 3 separate times before finishing. Unclogging a toilet represents the pinnacle of my technological abilities.

At the opposite end of this spectrum is my friend Craig. He works in the prosthetics industry and is a serial tinkerer. If I gave Craig a few screws, some scrap metal, and a wheel, he’d create some sort of gyroscopically-balanced motor-powered unicycle with an iPhone docking station for both navigation and music. (And there would be a few screws left over when he finished.)

Prosthetic-wearing amputees live with mechanical devices in a particularly intimate way. Many of my prosthetic-wearing friends view the world more like Craig than like me. They see their prosthesis as something they can and should play with, breaking out allen wrenches and propane torches with the same nonchalance that I employ when using a remote control to change TV channels.

I am not one of those prosthetic-wearing people who adjusts his own prosthesis. Here are the three reasons why.

1. I’m stupid

Many years ago, I went from walking perfectly and without pain one day to seeing stars whenever I loaded the prosthesis the next. I first concluded that I had injured myself somehow, despite the total absence of any traumatic event. Next, I looked for cracks in the inner socket – perhaps I was catching my skin in the socket, again, despite any visible evidence of tissue damage.

Ultimately, my prosthetist swung by my house after work. He folded up two paper towels, slid them between the inner socket and rigid outer frame and instructed me to walk. Problem solved. The issue? Either because of a drop in humidity or a slight loss of weight (or a combo of the two), my leg slid just a little bit further into the socket, causing me to weight-bear on a tendon that the day before sat outside this danger zone.

Another time, just before a presentation in which I would serve as a patient model, my prosthetic knee stopped functioning. I and my prosthetist both panicked. We hadn’t touched the knee. Was this Murphy’s Law at work? Had a perfectly functioning device stopped working “just because?”

A second prosthetist unconnected to my care happened to be there as well. He looked at me walking and asked me to come over to him. He adjusted the alignment of my prosthetic foot and told me to walk. Bingo – perfect knee action. What happened? As my prosthetist tweaked my alignment to make sure I presented as the perfect patient model, he changed the rollover pattern on my foot in such a way that my intelligent prosthetic knee could no longer sense whether I needed more or less stability. Faced with inconclusive data, the knee erred on the side of doing less (i.e., not bending).

Moral of the story? Even though I know a lot about prosthetics by virtue of my time in the industry and the jobs I’ve held, I’m still, relatively speaking, a moron.

2. I create more issues than I solve

When I have experimented on my own in the past, I usually exacerbate the problem. I’ve tried to fix socket problems by adjusting my alignment, and tried to fix alignment issues by playing with the socket. I’m great at identifying symptoms. However, I stink at finding the cure.

3. I make it more difficult for my prosthetist when I get involved.

Assume, for the sake of argument, that you’re overseeing an experiment. You’re studying how to make humans run faster. You create a light-weight, motor-powered exoskeleton, and your hypothesis is that a person running 100M with this device can complete the distance in under 6 seconds. You put the person into the exoskeleton and she takes off.

But mysteriously, every time she reaches the 50M mark she falls down. The lead researcher reporting to you announces that he’s (a) recalibrating the exoskeleton so that it theoretically becomes more stable, and (b) adding a 3% incline to the 100M track to further decrease the risk of the subject wiping out again.

I should immediately fire my lead researcher, because he’s a moron.

By playing with multiple variables simultaneously, he now can’t determine what’s happening when the subject does complete the 100M without falling. Was it because he adjusted the exoskeleton? Or was it because he changed the grade of the track?

Let’s turn back to prosthetics. Let’s say I determine that I’m landing too far on the outside of my prosthetic foot. I adjust the screws connecting my foot to my knee, and I conclude that things feel better when I walk on it. But when I look at the prosthesis, I realize that the angle between my foot and knee is now, to put it in scientific language, goofy. So I go to the knee and de-goofify that angle. Now everything looks perfect again, but when I walk my prosthetic knee feels like it’s moving from left to right under me instead of from back to front. And that’s causing uncomfortable pressure in my socket because of the whipping motion underneath it. So I go and I add some pads between the inner socket and outer frame …

With all of my “troubleshooting,” I’ve erased the baseline. I’ve adjusted so many variables that the prosthetist can’t figure out where my prosthetic issues begin or end.

my conclusion

In order to protect my prosthetist from me, I do nothing when confronted with a prosthetic problem. I instead pick up this magical little device called a “telephone” and dial my prosthetist’s number. Yes, this may mean that I’m grounded until he and I connect. But I know this has saved me many lengthy trips to his office that I otherwise would have endured had I acted on my own. And, equally important for my own psyche, I don’t reveal myself to be the utter doofus that my solo troubleshooting invariably exposes. I’m not sure which of these two benefits matters to me more.

sea change

sea change 03.25.13

When I lost my leg in 1996, everything old became new again. Getting out of bed in the middle of the night presented new challenges. Getting dressed in the morning suddenly required thought and planning. And walking, one of the most basic and simplest human activities, now demanded intense attention.

Every prosthetist in the United States should be able to relate to that experience. Because in the last 18 months, everything old and reliable has become new and undependable.

color by numbers

When I owned my own prosthetic facility, the process of providing a patient a prosthesis presented few challenges. I could file a claim with Medicare and other payors and predict the likely outcome with 90% certainty. I knew which claims would get paid and which would get denied. I could even predict the likely basis for denial in most instances.

I left the patient care side of prosthetics in late 2006 to work for a prosthetic component manufacturer, but the basic model for filing claims remained the same. The prosthetist examined the patient and recorded his findings. Those findings got incorporated into a letter of medical necessity that the prosthetist sent to the patient’s doctor. That letter detailed the patient’s condition and her need for a new socket, knee, foot, liner, or a new prosthesis entirely. The doctor would write the requested prescription and the prosthetist would then file the claim.

So long as you established the medical necessity of the prescribed device, Medicare would pay you. Private payors were nearly as predictable.

Medicare rarely audited claims. Private payers did so even less. Until everything changed.

the shift

In August 2011, the Office of the Inspector General issued a report on lower limb prosthetics. OIG’s concluded that Medicare erroneously paid $97M in prosthetic claims, or roughly 16% of the total annual Medicare spend on these devices. (Many in the O&P industry dispute  OIG’s conclusions. However, what no one can contest is that this report shaped the federal government’s perception of prosthetic claims.)

Almost simultaneously, each of the four contractors hired by Medicare to process claims in different regions of the United States issued “Dear Physician” letters. These letters required doctors to record specific patient information in their medical records. They included a list of desired clinical findings stretching across 14 bullet points. The contractors noted that these clinical criteria were by no means exhaustive.

Next, Medicare’s auditing contractors swung into action. These Recovery Auditors started reviewing old claims, sometimes looking back as far as three years while applying the standards set forth in the Dear Physician letters retroactively. Since the vast majority of claims filed before the Dear Physician letters lacked that level of documentation – especially in the prescribing physician’s medical records – the RA’s ruled that they didn’t comply with Medicare’s requirements and demanded immediate repayment from prosthetists.

On top of retroactive audits, the same contractors that had issued the Dear Physician letters began launching “widespread prepayment claim reviews.” Focusing on the documentation supporting particular types of claims – generally those that involved the delivery of higher-cost prosthetics – these reviews occur after the prosthetist delivers the prosthesis but before Medicare pays the claim.

By the end of 2012, the limited evidence available suggested that audits had become the rule, not the exception for O&P businesses. An American Orthotic and Prosthetic Association survey of its membership last fall revealed that more than 75% of the prosthetic facilities in the United States were fighting at least one audit.

In a little more than 12 months, filing a Medicare claim had gone from color by numbers to the equivalent of trying to replicate a Salvador Dali painting, stroke for stroke … for every claim.

what’s old is new again

In my current role, I get to speak to prosthetists around the United States about the state of the prosthetics profession. I present my vision of how to navigate the claims process successfully. It’s one of my favorite parts of the job. I’ve delivered countless talks at national conferences, at local events, and at seminars over the past 24 months.

The tenor and content (and title) of these talks have changed dramatically since I began delivering them in February 2011. The ideas I presented that seemed like overkill then receive a very different reception now.

Prosthetists express dismay, anger, sadness and frustration in equal parts when talking about how a process they understood and depended on changed so quickly. As I watch and listen to them describe these sudden and profound shifts, I can’t help but think about the hundreds of new amputee consultations I participated in when I still owned my facility.

I would shake my head sympathetically as people described how their life had taken this inexplicable turn, how everything they knew and understood had become alien. I would reassure them. I told them, based upon my own personal experience and conviction, that someday – I couldn’t tell them when, but someday – they would wake up and the act of putting on a prosthesis and walking with it would be a natural part of their lives.

It’s hard to overstate how much the claims process has changed in just over a year. I can shake my head sympathetically as I talk with these small business owners. I can offer my thoughts about how to successfully operate a company in this environment. And I can tell them that as they improve their internal systems and shore up their claim processes, what they see as inefficient and mechanical today will become second nature tomorrow.

It used to be that patients and prosthetists shared an experience that revolved around the patients’ rehabilitation. Now they also share the experience of having to relearn everything they took for granted.

The prosthetists who figure out how to rehabilitate their businesses quickest will have a decided advantage over those who can’t. The difference is that you can measure a patients’ success by how many steps they take or how dextrous they are with their prosthetic hands and fingers. We’ll be measuring a prosthetist’s success by how many are still operating in 2014.

prosthethics (part 1)

I spent the last week in Las Vegas attending the American Orthotic & Prosthetic Association’s Annual Convention. I could write a whole post about Las Vegas, which as far as I can tell having been there twice, may be the fourth of the seven circles of hell, but I’ll refrain. Instead, I want to deliver a reconstructed “transcript” of the presentation I was asked to give to the assembled prosthetists and orthotists on Thursday. Titled “Doing the Right Thing”, it focused on ethical issues confronting the field. While it was designed for the people providing patient care, I think it’s equally important for people with limb loss/disability to know about and understand these issues as they seek and receive it.

So, this week features the first half of that presentation. Next week, we’ll bring you the powerful, awe-inspiring, and captivating conclusion.

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The purpose of my talk today is to discuss ethical issues that everyone here in the audience has to deal with. But I want to do this in a different way than you may be expecting. Put someone with the job title “VP of Legal” in front of a room, and you probably expect that you’ll be seeing lots of text-heavy slides and listening to someone read mind-numbing statutory and regulatory language to you. I’m not going to do that.

I think that we need to discuss ethics in a completely different way. So instead, I want to tell you a story. And this story has three chapters.

The first chapter sets the scene. It gives you the background you need, because the ethical issues we’re going to discuss today don’t occur in a vacuum. The importance of those issues and how you deal with them are at some level dependent on the broader environment in which they occur.

The second chapter introduces us to the two main characters in the story. These are the Federal laws that govern the ethical issues I’m going to be talking about today. The first main character is big, strong, and powerful. He can hurt you. But he’s also predictable. You know roughly when and how he’ll snap.

The second main character is his younger brother. He’s smaller and not as strong, but he’s also psychotic and volatile. You have no idea when or why he’ll lash out, and he can take you down without any warning whatsoever.

The third and final chapter comes with the twist you’d expect in a good book. It involves a character – this industry – who, it turns out, has a bit of a split personality. And when we get to that chapter, I’ll give you my recommendation for how we go about resolving the tension that results from this less-than-ideal mental health state.

But before we dive into Chapter 1, there’s a prologue. And the prologue is called “Change or Die.” This is a book that was written by Alan Deutschman, and in it, he explored why people don’t make changes in their lives when they seemingly have no other choice. The first and best example he uses is the following.

You walk into your doctors’ office complaining of chest pain, shortness of breath, and dizziness. The doctor runs some tests and determines that the arteries leading to your heart are 90% occluded. You’re rushed into the OR for treatment, and when you come out, your doctor looks at you and gives you the facts. He says, “You came out of the surgery just fine. You’re going to live a long and healthy life but you need to make some lifestyle changes. You need to stop smoking. You need to work out more. And you need to eat fewer fried foods and more vegetables.”

You return to the doctor a few weeks or months later for follow-up. When he asks you if you’ve made these changes you admit that you haven’t. And he moves from facts to fear: “If you can’t follow my recommendations, maybe I haven’t made myself clear enough. If you don’t change those behaviors, you are going to die.”

Now, faced with that very plain choice – change or die – what do we do? What would you do? Would you make the changes? It seems like a simple enough choice, no? If I were told to change things on the one hand, or I’d be dead on the other, I’d change them, wouldn’t I?

Well, in fact, the data says that I wouldn’t. According to Deutschman, within two years of undergoing invasive heart surgery, 90% of people in this situation revert to their previous lifestyle, many of them requiring additional surgery and care as a result. So why does this happen?

Among the many explanations Deutschman has for this phenomenon, I want to talk about facts and fear, because neither works particularly well in motivating people to change. When we give people facts, we assume they’ll respond to them because they are, after all, rational creatures. Except we’re not. And that’s because of the power of our various ideologies, which is a fancy word for “worldviews.”

For example, if I say “Obamacare” in this room, everyone here will have an immediate and powerful reaction to that concept of healthcare. That’s because it fits into an ideology that you have. And importantly, ideologies are powerful, resistant to change, and we apply them almost subconsciously.

How we eat, our attitude towards exercise, our lifestyle in general – all are part of our ideology. We can’t change those behaviors just by flipping a switch, because they’re part of a broader worldview.

So, tying this back to ethics in O&P, as a profession we have a particular ideology. The somewhat provocative thesis that I want to throw out to you is that our ideology is now out of step with current regulatory and legislative reality. People have operated in a particular way for so long that it has confirmed a worldview about what they can and can’t do. The problem is that the world in which we’re living is changing so fast that our ideology no longer maps to the world we live in.

And that brings us to fear. The reason fear doesn’t work is that people can’t handle it. Big, scary concepts like Death generally don’t motivate because they’re simply too overwhelming. And so, we put our hands over our ears, shut our eyes, and just hope that everything will work out fine, even though that’s totally irrational.

So I’m not going to throw dramatic images up on the screen behind me to try to scare you. I’m not going to talk about the terrifying penalties that will result if you break the laws we’re going to discuss. Instead, I’m going to tell you a story to persuade you that we need to confront and deal with these ethical issues. So let’s now open our book to Chapter 1 and begin.

chapter 1: they’re coming

Let’s talk about some basic trends that affect the prosthetic and orthotic profession. First, over the last 40 years we’ve seen a steady and significant increase in the cost of health care as a percentage of our GDP. In 1970, the combined total of private and public spending on health care was 7%. We’re now at 18% and climbing. For frame of reference, that means we spend more on health care than we do on defense. We spend more on it than we do on pensions. And we spend more on it than we do on education.

In addition to this long-term trend, we have the costs of health care reform, which will lead to at least a short-term spending spike. The Congressional Budget Office estimates that between 2010 and 2020 the costs to implement reform will be close to $1 trillion. And though the CBO says this investment will lead to savings in the long run, I tend to be skeptical about these kinds of numbers, no matter who is sitting in the White House. So I try to look for other data points that might give us some guidance.

The most obvious place to look at is Massachusetts. Federal health care reform borrowed extensively from Massachusetts’ law, which was implemented back in 2007. So if you look at what has happened in that State, it’s not a bad indicator for what we might be talking about in four years nationally. And the one thing you can unequivocally say about Massachusetts is that while the law has reduced its uninsured rate to the lowest in the country, it has also cost dramatically more than anyone thought it would. With that in mind, I apply the same rule to health care reform that I do to home improvement projects: if a contractor tells you that it will cost “x” to complete the project, multiply that number by one and a half.  So, to summarize, we’ve got a long-term trend of increasing health care costs, and we have a reform law that is going to drive those numbers up even more in the short run.

And that leads us to the final part of Chapter 1, what I call the Triangle of Death. This is acronym hell – OIG, RAC’s and MAC’s. Let’s deal with each in turn.

The Office of the Inspector General released a report in mid-August about lower limb prosthetic billing. If you haven’t read the report, you should. I don’t want to discuss the validity of the numbers OIG throws around or the methodology it applied in reaching its conclusions. While both of those considerations are relevant and AOPA will address them with OIG directly, I respectfully maintain that the final numbers are less important  than the conclusions that OIG draws from them. What matters most is what OIG thinks about prosthetics, and the report makes clear that it views this area as “at risk” for fraud and abuse.

Specifically, OIG concluded that a little over $100M of the $655M Medicare spends on lower limb prosthetics is suspect. That’s roughly 16% of the total. With the data in hand, OIG believes that reflects a larger reality in the world of prosthetics.

If you’re not convinced, let me share another quick story. A few months ago I had the good fortune to attend a meeting with Dr. Donald Berwick, the Administrator of Medicare. I was part of a group speaking with him about the definition of “essential health benefits” in the health care reform law. I was telling him why I thought prosthetics and orthotics needed to be explicitly included in the definition of EHB. And he turned to me, sitting in the seat to his right, and earnestly asked me, “With all due respect, isn’t this [i.e., prosthetics and orthotics] an area where we’ve had fraud and abuse problems in the past?”

I thought a lot about that question after the meeting. My best guess is that Dr. Berwick doesn’t spend a lot of his free time thinking about prosthetics and orthotics because they make up such a small percentage of the overall Medicare spend. I think he focuses on things that he believes will significantly impact the entire system like Accountable Care Organizations and other programs that may fundamentally change the way we receive and pay for health care. But his question came from somewhere. I suspect that the people who briefed him before our meeting are Medicare’s O&P specialists, and they gave him the data that led to his question. (Again, the perception is what matters here.)

If you need any further confirmation, just consider the fact that OIG report made six recommendations about measures that should be taken immediately to prevent inappropriate payments to prosthetists and orthotists. Medicare agreed with five of them.

That brings us to the Recovery Audit Contractors. These entities conduct audits on Medicare’s behalf to recover overpayments made to you. If you’ve been walking the halls here this week and talking to your colleagues around the country, you’ve heard about the dramatic increase in RAC audit activity this year versus last year. In fact, since late 2010, the RAC’s have ramped up their activities, focusing on how prosthetists document their patients’ activity level, which – probably not coincidentally – was an area of focus in the OIG report, as well as on coding for test sockets and other matters. These audits generally lead to demands to recoup overpayments made to you, and the RAC’s get paid a percentage of what they collect, so it’s unlikely that we’ll see that program decrease in intensity as health care costs continue to rise.

And then you have the Medicare Administrative Contractors. How many of you have seen the “Dear Physician” letters that the MAC’s have sent to physicians participating in the Medicare program? In those letters, the MAC’s remind doctors that they are responsible for documenting the patient’s activity level in their notes and for seeing the patient before writing a prescription for prosthetic care. Again, this maps back to the OIG report, which claims that a significant percentage of claims were paid without the physician having seen the patient in the five years before the most recent prosthetic prescription. OIG sees that as a sign of fraud and abuse. Again, whether they’re right or wrong is at one level immaterial for the purposes of this analysis. The only thing that matters is that this is OIG’s mindset.

So, to conclude Chapter 1: we have a long-term trend of increasing health care costs; we have a short-term spike about to hit us in connection with reform; and we have the Triangle of Death scrutinizing the profession with increasing intensity and with the power to demand money back  that you’ve already received. In a health care system that is hemorrhaging money, finding dollars anywhere that can be brought back into the system becomes increasingly important.

chapter 2: The long arm of the law

We now meet the main characters in our story of ethics: the Anti-Kickback Law and the False Claims Act. The Anti-Kickback Law is the big, bad bully who you fear but who is ultimately predictable. It’s purpose is simple: to prevent money from influencing clinical decision-making. The most obvious example of behavior that would fall on the wrong side of this law is the following: I walk into your office with $100,000 in a suitcase; I tell you, “I was never here. You take this suitcase and buy nothing except my company’s products for the next year.” If I offer you the cash and if you take it, we’ve both violated the Anti-Kickback Law.

Now, that’s an obvious example, but the behaviors in the real world are usually less extreme. And this is where you see why the Anti-Kickback Law is so powerful – it’s an incredibly broad piece of legislation. In fact, the exchange of anything of value implicates the statute. So let’s talk about those everyday scenarios that are in play.

Can you accept gifts from a manufacturer when a child is born or a relative dies? What about meals? Can a manufacturer offer you a meal and can you take it? How about entertainment – tickets to sporting events or shows? And what about the universe of what I call “branded items”? Tee shirts and polo shirts with company logos? Company-branded post-it pads, pens, and mugs?

You may listen to me read this list and the first thing that pops into your head is, “Dave, how on earth can you say that a company-branded pen or mug influences what products I put on my patients?” And my answer would be, “I hope that it doesn’t. I’m not personally persuaded that a pen makes a difference in what you order. But the data suggests otherwise.” Believe it or not, there are psychologists who study whether giving things of minimal value changes the recipients’ behavior. And the answer, generally speaking, is yes, it does.

The published literature shows that if I give you a trinket, junk – a 35-cent pen with my company’s logo – you feel a subconscious urge to reciprocate somehow. The mere act of offering you something and your acceptance of it influences your future interactions with me. In light of that reality, how should you handle each of the ethical scenarios we’ve just discussed? Where do you turn for guidance?

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Next week, we continue Chapter 2 with an introduction to the Anti-Kickback Law’s psychotic and unpredictable younger brother. We learn what the answers – at least from one perspective – are to the questions raised in the last paragraph. And you’ll learn what my proposal is to cure the split personality that we’ll meet in Chapter 3. Until next time …