Many in the home medical equipment services industry wonder why the “high-end” rehab community is constantly trying to differentiate itself from “the rest of HME.” The answer is really quite simple: Rehab is more service-intensive, has a higher risk factor in the payment area and requires more trained professionals to achieve the desired clinical outcomes and expectations of the prescribing physician and the customer. As one prominent rehab provider is fond of saying, “If rehab were easy and profitable, everyone would be doing it!”
To understand what goes into providing rehab and assistive technology, let's follow one consumer as he works his way through the process, from the day his physician prescribes a power wheelchair to the day when he and his provider agree that their goals have been met.
Our demonstration is based on the real case of “Bob,” who has been released from the rehab hospital after sustaining a spinal cord injury that left him with quadriplegia. While Bob's needs are more complex than some, they illustrate the elements that go into providing appropriate rehab products and services.
Bob's injury is such that he has minimal control of his right hand, poor trunk stability and no strength, voluntary movement or sensation from mid-chest down. He is 19 years old. He wants to return to college and perhaps go on to law school. His physician has expressed his desire to see Bob live as independently as possible but worries about pressure sores (he had two while in rehab) and breathing complications brought on by poor posture and positioning. With this in mind — and documented in Bob's medical record — Bob is referred to the rehab program's seating clinic.
The seating clinic must now define Bob's abilities and limitations, familiarize him with options to address his needs and work with him to decide who will take responsibility for which steps in the process.
A comprehensive assessment of Bob's physical status is performed, generally by a physical or occupational therapist (PT/ OT). A thorough review of his medical record provides the long-range prognosis so that whatever is provided will continue to be appropriate as Bob moves from the acute to the chronic phase of living with his disabilities.
Next, a complete evaluation is done on a mat table to assess everything from balance to tone and spasticity. Dozens of measurements are taken to insure proper fit of the products ordered. In Bob's case, particular attention is paid to the need to manage pressure on the places where he has already had pressure sores. Properly done, this evaluation takes from three to five hours.
At the same time, an environmental assessment must be completed to make sure that the equipment Bob needs will function in the various environments of his life. At home, doors are measured for clearance, hallways and tight spaces are measured for turning space and work surfaces like kitchen counters are checked for height and functionality. The environmental assessment will reveal whether or not products like ramps, automatic door openers or environmental control units (electronic switching devices that turn lights off and on, operate appliances and adjust heating/cooling systems) are needed.
In Bob's case, the environmental as-sessment includes a tour of the campus where he will be returning to class. The surveyor is looking for the location of accessible entrances to various buildings and identifying the grade and surfaces Bob will be traveling between classes. Transportation options between Bob's home and the campus must also be evaluated.
A thorough environmental assessment can be performed by a properly trained and experienced rehab technology specialist (RTS), and often takes most of a day to complete.
Once these assessments are documented, a team composed of the therapist, the RTS and Bob compare notes and begin to define the appropriate technology. The system that will work for Bob will not come out of a box — or even several boxes. It must be manufactured, configured, assembled and adjusted to meet his unique measurements, needs, abilities, limitations and lifestyle.
The wheelchair base is selected for maneuverability and its ability to traverse the various surfaces that are part of Bob's life. The team selects a motorized seating system that will enable Bob to adjust his position independently to reduce pressure. The tilt-and-recline system will enable him to get into positions where it is easier to breathe, and provide mechanical support for the attendant who helps Bob with transfers, dressing and other activities of daily living.
Because Bob has a history of pressure sores, the team decides on a custom-molded back and seat cushion. Even though Bob has little strength or movement in his arms, they are essential to his maintaining proper posture and position. Molded arm troughs are chosen to replace the conventional pads. Finally, his limited hand control requires a special “short-throw” joystick.
Once these recommendations are assembled — with Bob's input — it is clear that no one manufacturer can provide all the components he needs. Further, as the team makes the list of the necessary components, it is obvious that it is more complicated than what the physician has described as a “motorized wheelchair.”
Finally, someone has to reconcile the cost of what Bob actually needs — around $28,000 — to what his health insurance carrier is used to paying.
The next few weeks are spent identifying suppliers for the many components of Bob's mobility system, resolving payment issues, obtaining appropriate medical documentation in the form of a detailed letter of medical necessity from his physician, submitting a request for prior approval and keeping Bob advised of the order status. Eventually, the provider orders the components and begins assembly as they come in. Generally, this happens before the provider knows whether, or how much, he will be paid.
At this point, there are about 32 hours of professional time invested in Bob's system — and he's not done yet.
Once the system is assembled, the team gets together to reassess their recommendations and begin adjustments, from the placement of the joystick to the sensitivity of the controls. Bob begins what can best be described as hours of “driver training.” Additional adjustments are made during this training phase, and it is common for the team to discover that there are better ways to address Bob's needs than those that were recommended initially. Switching one component often leads to more adjustments and, thus, more technician time.
Moreover, his rehab system may need several adjustments and service calls as Bob learns to use the new equipment. A survey of several rehab providers reveals that, on average, they invest 40 or more hours of staff time at a rate of $15 to $20 per hour in each power mobility system they sell. This does not include the cost of filing insurance claims, securing additional documentation when requested or collecting co-payments.
So why would anyone go into the high-end rehab business?
Bob's provider puts it this way: “Rehab is simultaneously the most frustrating and the most rewarding business you can be in. You can't buy the sense of accomplishment you get from seeing a customer who had been described as ‘too disabled' roll off into the sunset in pursuit of their dreams.”
Many referral sources require providers to stock certain high-end products for demonstration purposes and patient trials as part of the seating clinic. This is inventory that rarely generates enough income to cover the expense — and sometimes is "lost" completely.
The staff time it takes to provide rehab and assistive technology — evaluation, fitting, training, adjusting, etc. — is not covered under any health care insurance.
In My View
Wheelchair ‘Accessories,’ the New Orphan Drugs
Late last year, the Centers for Medicare and Medicaid Services and the durable medical equipment regional carriers issued new HCPCS codes and fee schedules for a number of “wheelchair accessories.” Providers should have seen trouble on the horizon when the bureaucracy started referring to essential components of personal mobility systems as “accessories.”
Webster defines accessory as “…a thing of secondary or subordinate importance, an object or device not essential in itself.…” Most of the items included under the new codes are essential to the operation of the personal mobility systems provided by qualified rehab technology companies. They are no more accessories than a brake pedal in an automobile.
Worse, in an effort to assign codes — but not create too many new codes — products that the DMERC staff may never have seen demonstrated were lumped into limited codes, which were then subjected to the mysterious “gap-filling” method of establishing fee schedules.
One example amplifies the egregious nature of this process. E2328 is a new code described as “head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware.” The Medicare allowable is $3,236 to $3,877 for this code and is the basis for reimbursement under most Medicaid, and many private, insurance plans. Previously, items that now fall into this code were covered under HCPCS K0108 — miscellaneous wheelchair accessories — and providers received an average payment of 80 percent of the manufacturer's suggested retail price (MSRP).
For some consumers, independent control of their personal mobility system can only be accomplished by using a very high-tech system that detects small movements of the head, processes the information and transmits the appropriate command to the wheelchair drive system.
There are two manufacturers of these systems, and the total market is 240 to 300 units per year. However, for those consumers who need them, there are no generic alternatives.
Both systems are very high-tech, require extensive training and frequent maintenance and were developed through a lengthy and expensive research-and-development process. Moreover, there is significant product liability and provider responsibility associated with these products. MSRP ranges from $5,850 to $7,500 — and that's a bargain!
CMS' effort to clarify the coding of wheelchair accessories has once again failed. This example shows the gross inadequacy of their actions in sharp relief. Congress has acknowledged the unfairness associated with the high costs and associated access problems for “orphan” drugs, or pharmaceuticals designed to treat disease such as cystic fibrosis and certain rare forms of cancer that affect small segments of the population.
HCPCS E2328 and other new wheelchair accessory codes contain several new “orphans,” essential components of personal mobility systems for a small number of people with severe disabilities that are so under-reimbursed that rehab technology companies can't afford to supply them, regardless of the needs of the consumer. Would the drug companies take a $2,200 loss on every prescription of an orphan drug? No! They have prevailed on Congress to subsidize an orphan drug program.
Congress promised to facilitate the independence, productivity and integration of people with disabilities in the ADA, Ticket to Work/Work Incentives Improvement Act, the Tech Act and the Individuals with Disabilities Education Act. CMS and the DMERCs seem determined to deny this constituency access to the available technology that can turn these promises into realities.
When asked about this issue, a CMS official indicated that the agency will “study the matter to determine if any errors were made in applying established procedures for gap filling.”
When this writer pointed out that these are not “errors,” but examples of the apparent indifference CMS and the DMERCs display toward consumers with disabilities, one CMS staff member responded, “Well, you tend to get emotional about these things.” You bet I do! And so should everyone else!
