What can you do to fix the MEDICARE/ MEDICAID System??

 

The item coalition, as well as NRRTS, RESNA, NCART, and countless other groups and manufacturers have been fighting a battle for the mobility challenged community.   For years, it has been up to our industry to police itself, and there have always been a few bad apples that have ruined our system, reducing our credibility and have forced CMS to take action.  As a long time supplier, I remember the signs “FREE LIFT CHAIR”, which providers abused until Medicare blocked the code, and made it difficult for consumers to get these items.  

Over the past few years, since powered wheelchairs have become fashionable and attractive; suppliers had found a loop hole which could be very lucrative.  We have all seen the people who receive powered wheelchairs, but can still walk.  We have also recently witnessed many providers becoming indicted for billing for this equipment and never providing it to their patients.  

I have repeated over the years, to my congressman, to organizations, consumers, and professionals; that the only solution is to rid the industry of its bad apples.  The problem stems from the manufacturers, who see increased demand of their equipment through outlets who do not offer service, customization, or any choice to the consumer.  If manufacturers demanded their suppliers were credentialed, and provided adequate service with the capacity to follow up the product; our industry would be very professional and respectable.  Instead today, suppliers are looked at as people you cannot trust; and only in it for the money.  

There is a genuine concern about the competitive bidding program that Medicare is initiating.  As a supplier my concern is that to put something out for bid in an industry which is already providing (in many cases) substandard equipment; the allowable for equipment will plummet.  Competitive bidding means that in a community all providers bid their lowest price they can provide a service for.  Since many suppliers are providing non-US equipment,  the price ceiling would most likely be set for these lower imported products.

 The obvious concern here is that when reducing costs so much, what happens to the service.  What many individuals do not understand is that most equipment that is provided (by responsible providers) requires an assessment from the provider, with a team consisting of a physician, therapist, and family to provide the best solution for the patient.  When you set a capped amount on equipment, both the choice of equipment   and the specialty of customizing, and fitting a mobility product will disappear.

 What most people don’t know, is that most physicians and therapists are not familiar with equipment and depend on the supplier they are working with to recommend the most appropriate equipment.  In reality the equipment that is being prescribed, is left up to the supplier to choose.  When you reduce the funding, and reduce the choices, you will lose the specialty providers; and have only a delivery system.  Would you rather a delivery person drop off your equipment, or a specialist who can instruct, train, adjust, modify and make suggestions to you?

The competitive bidding issue still has a long battle ahead, as there are too many uncertainties; like if you award a company a particular demographic; and they turn out to be a bad provider; what is the recourse.  When you award one provider the work for an entire area, you will certainly force many of the other providers out of business.  So how do you replace a provider that fails to perform?

The larger picture may be that by providing cheaper products that will be outsourced to non US countries, our Gross National Product declines.  To spend billions of US dollars on healthcare for most of that revenue to be sent outside the US , is not good for our country.  Even worse, is the amount of unemployed, skilled workers from local equipment suppliers, and from national manufacturers. 

Now is the time to get involved, voice your concerns to legislators; tell them of the importance of local providers who can supply, fit, repair and customize products.  Nothing in this world is free, when you see these ads for free power wheelchairs, no cost to you, qualifying people who can still walk- turn them in to Medicare.  We cannot be blind and turn away as this problem is not going away; and when you need Medicare benefits they are not going to be there. 

 

EDUCATION by ACTIVE

Repetative Strain Injury

 
This type of injury is becoming more and more prevalent in our society, from carpal tunnel syndrome to shoulder injuries suffered by a growing number of aging individuals in manual wheelchairs.  It has always been the stance of medical professionals and insurance carriers to limit the ability of walking impaired to manual wheelchairs as their principle means of mobility.  It makes sense that if you are walking impaired, that your calorie burn to intake ration is less, and using a manual wheelchair will help burn more calories, and help keep the user physically fit.  

As these clients who were prescribed only manual wheelchairs for their mobility are aging, many are finding themselves having severe pain in the shoulders, which is being diagnosed as repetitive strain injuries.  In addition to propelling their wheelchair throughout the day, within their homes, into the community and workplaces; medical professionals are realizing that the human shoulder has limited capacity for these functions.   

The movements of pushing a wheelchair, compounded with independent transfers, and daily routines it generally too much for the human shoulder to handle.   

It has always been my belief that there is a balance between manual and powered mobility for individuals who are confined to a wheelchair, and dependent for their mobility.  From a mobility stance, having the ability to use manual mobility within the home and work place, as the chairs are smaller and more maneuverable is certainly an advantage.  Manual wheelchair burn more calories, reducing the potential for excess weight gain; and increases strength allowing for independent transfers.  Powered wheelchairs allow a user to travel across greater distances, which put users at risk for repetitive strain injuries.  

Repetitive strain injuries can cost funding sources tens of thousands of dollars, not to mention loss of employment to the wheelchair user.  This loss could be simply reduced by providing both a manual wheelchair, and powered system to long term users of mobility aids.  It would make sense (and reduce costs) by providing this equipment to specific diagnosis; that generally develop these types of injuries.   

A possible solution to save money and benefit the wheelchair population, would be to provide both types of equipment; and prompt an education program for potential injury groups to explain the benefits of using both types of equipment; thereby reducing medical care costs, and risk of obesity from inactivity.

 

Thinking out Side the Box

 

It amazes me how many times I hear clients tell me that their old equipment suppliers/providers told them NO it couldn’t be done.  For many industries this may be the case, but for our industry, the custom seating and positioning industry; telling people NO, can mean the difference of independence, or the equipment not being used.

Of course our company says NO, when it liability or safety is a concern; but we offer our client’s the option to customize their equipment to the extent is makes their lives easier or more independent.  

Our company advertises its ability to provide custom mobility and seating equipment. If we advertise this we must be able to deliver.  Our company continues to offer off the shelf products when needed, offering molded seating systems, customized seating frames, tilt in space, recline, elevating seat, and standing options.   

To further our out side of the box thinking, we have the ability to add, specialty lighting to equipment.  Many of our clients are children and young adults who were robbed of the ability to own, customize and drive a car.  We have been offering neon and other lighting packages to accessorize their rides.  Kicking it up a notch, or octave is mounting stereo systems, amplifiers, and speaker systems to the chairs for the entertainment of themselves and their peers.   

A new addition, has been adding rear view camera and display systems for clients who have difficulty seeing behind the chair.  For may wheelchair users, there is a big blind spot behind their chairs.  We have been offering a camera that mounts to the rear of the chair which is attached to a LCD screen on the front of the chair to enable clients to see what is behind them.  

Our company still strives at providing systems that fit, and interact with it’s users.  We challenge ourselves everyday in enabling our clients; maximizing their abilities!!!! 

 

MODULAR RAMPS

Up until a few years ago, providing a ramp to a client in a rental property, or with out outward swinging door was a real problem.  The only solution was to find a contractor to pour concrete; which poses a problem in a rental property.  Many families would find a handyman to build a wood ramp, but with the humidity and wet climate the wood ramps need constant attention over the years.  New modular ramps could be the answer.  For the same amount of money for a concrete ramp, a modular ramp could be constructed.  The modular ramps can account for steps, and great rises by adding returns and platforms.  These ramps are made out of aluminum which makes the ramp system worry and maintenance free.  

 

ELEVATING LEGRESTS AND EDEMA

There is a misconception that using elevating leg rests is the means to reduce leg swelling.  Elevating legrests by themselves are not necessarily a good idea.  Unless the patient using the legrests is a child, then most likely their hamstrings cannot tolerate the extension without changing the seat to back angle.  You see this in nursing homes all the time; all the chairs have elevating legrests and most of the patients slide out of the chair.  When hamstrings are tight, and the legrests are elevated the body has to adjust, many times causing the body to slide.  Back to the subject of Edema; it has been shown through medical journals that without raising a body part above the heart, there is minimal reduction of edema.  The only way to reduce swelling with the combination of tilt and/ or recline in the wheelchair frame, with the addition of legrests.

 

CHILDREN AND POWER WHEELCHAIRS

This concept is very difficult for many insurance companies to interpret.  Most Insurance guidelines state that a person requiring a mobility aid must qualify for a powered wheelchair.  This means that they have upper weakness, or the inability to self propel in a manual wheelchair.  What many insurance carriers do not take into consideration that the children pushing these wheelchair have to be very strong; as the wheelchair in many cases weighs more than the child.  A wheelchair for a small person could weigh as much as sixty (60) pounds with prescriptive seating; weighing as much as double the child's weight.  As an industry, insurance carriers demand that the wheelchair, or mobility aid last five (5) years.  With a growing child, the only way to do this is to oversize the wheelchair, which makes it increasingly more difficult to reach the wheels, and adds extra weight.  With all these physical demands on a child who is already disadvantaged, keeping up with their peers can be difficult to impossible.  Keeping up with the demands of school work, carrying books, going across a campus can leave a child behind in academics.  There are many studies about repetitive strain injuries from pushing excessive weights, with poor ergonomics.  For adults there are many studies, but for children these studies are limited.  It would make sense that if there are injury risks for adults pushing wheelchairs; than chairs that are more than a child's weight set up for a five (5) year growth period; could be causing long term physical damage to them.  It makes sense to provide a child with a powered wheelchair at an early age; sometimes as early as twelve (12) months.  There are many developmental studies that link a child walking to accelerated learning.  If a child cannot crawl or walk they miss the ability to explore and learn about their environment.  Children in powered wheelchairs (at an early age), have shown improvements in their development.  Use of powered wheelchairs have shown the ability to compete and stay with their peers, instead of being left behind watching.  It makes sense offering children powered wheelchair for long term savings in both physical, mental and community well being.

 

CERTIFICATIONS IN DME

This may be the single most important legislation we pass in our industry.  There are talks in Congress how to go forward with competitive bidding.  Congress is trying to minimize spending in DME, and reduce fraud and abuse.  It is my opinion that by mandating credentialing to DMEs specializing in seating, mobility and DME specialty equipment would take care of much of these problems.   If we certify ATS, RTS, CRTS individuals who are schooled in the specialties, and make them accountable for selecting, suggesting, and delivering the appropriate equipment the first time.  It seems to me that there is much fraud, and abuse not only to the funding agencies, but also to the clients.  Many providers who don't know better, or only care about the bottom line will purchase equipment from the cheapest manufacturer (usually out of the country), and sell it for the same amount as better made and warranted USA products. 

By making providers certified, each company will have to pay a specialist, making their overhead higher, and helping maintain the price of equipment across the community.  Let's face it if a company isn't paying a high salary for a specialist, they then can sell equipment cheaper (not necessarily the right equipment, or the best equipment).  Having a certified professional that has signed a ethics statement would help reduce fraud and abuse to the consumer and the funding agency.  Having companies lose their license for fraud, abuse would certainly save money, and bring a professionalism to our industry. 

Look at other industries, such as O&P (esthetics and prosthetics).  They are credentialed, certified, and do not get treated like we do (like car salesman).  Their allowable for equipment go up yearly, not down like DME.  They have organizations and lobby organizations that help maintain stability in their industry.

 

SOCIETY AND WHEELCHAIRS

The society that we live in is quite unfair.  We are all looking for status quo, we all have faith in the cure for medical conditions.  It amazes me that we still hide or look the other way when dealing with folks with wheelchairs.  We will spend 10's of thousands of dollars to normalize appearances, instead of accommodating for conditions.  Wheelchairs are a sign of weakness; President Roosevelt used crutches and a wheelchair, but was never shown on Television or in pictures using these adaptive devices.  There is a new movement called the Independent Living Movement; which the members do not want to be cured, they feel that disability is a natural state, and they expect and deserve inclusion, and seek accommodation.  It is amazing that the disabled community has only recently been recognized to have civil rights with the passage of the ADA.  As a society we will spend thousands of dollars on prosthetic limbs to achieve normality; but will question, and complain about a few thousand for a wheelchair.  Prosthetics only last months to a few years when a child is growing, and insurance will pay to change out outgrown devices; but a wheelchair is expected to last five (5) years.  Our value system is screwed up in this country, we will not question a heart surgery, we will not question a liver transplant, but we question a wheelchair.  Many funding sources, call expensive wheelchairs, luxury items.  You find me a person who wants to be in a wheelchair, or wants to be cumbered by unnecessary items.  

 

90-90-90 SEATING

For many years, therapists, manufacturers and suppliers were taught that clients should sit with their pelvis, neutral with a 90 degree seat to back angle, 90 degrees at the knees, and 90 degrees at the ankles.  This position was actually derived from an anatomy chart.  After clinical studies, and experience; it is now believed that this 90/90/90 posture is only used a reference position.  All of us human beings, need to move.  We need a relaxing position as well as an action position in which to function.  Each person is unique, and positioning should incorporate their functioning needs as well as their physical needs.   If we put a person in an action position, and overlook the ability to relax we are forcing them into a static position.  Able bodied people move every 6-10 minutes to change their position to achieve comfort, and to reduce pain.  We slouch, stretch, stand, lean, and lift ourselves.  Individuals in wheelchairs that are unable to change their position are asked to put up wit pain and discomfort.