A New Benefit

While we read a lot about our industry’s top legislative and regulatory issues such as competitive bidding and oxygen, there is one just beginning to gain momentum that requires further resources and attention. That is the need to have Congress segregate from the Medicare durable medical equipment benefit a separate benefit category for complex rehab technology.

This is a critical step toward updating the Medicare DME benefit. But more important, it is necessary to ensure that people with disabilities with complex needs will have continued access to the items and services they need.

Last year, Congress recognized that complex rehab items and services were different from other DME when it carved out these items and services from the DME competitive bidding program. This effort builds upon last year’s recognition that complex rehab is “different” than other DME items and should be treated differently under the Medicare statute.

Created in 1965, the DME benefit — which also included “iron lungs” — was created to address medical equipment needs of seniors. The equipment was limited and was intended for people with limited life expectancies.

In contrast, today’s technology would be unrecognizable to those in 1965; it includes complex power wheelchairs controlled by complex computer technology, highly configurable manual wheelchairs, sophisticated adaptive seating and positioning systems and other specialized equipment such as standing frames and gait trainers. This technology is customized to meet the specific medical and functional needs of patients with life-long needs.

Complex rehab technology serves individuals different from the traditional elderly Medicare population. People in this population group typically qualify for Medicare based on their disability, not their age. These people have diagnoses of cerebral palsy, muscular dystrophy, amyotrophic lateral sclerosis (Lou Gehrig’s disease), spinal cord injury and spina bifida.

Complex rehab technologies require a much broader baseline of services than what is required in the provision of standard DME. Devices in this category require a technology evaluation completed by a certified specialist that involves matching physical and functional needs with the appropriate technologies.

Because the equipment is complex and becomes an extension of the patient, training and education requires more time than for basic technology. In addition, Medicare requires home assessments for complex rehab, unlike traditional DME. Each device requires a different evaluation and assessment, measuring, fitting, simulations and demonstrations, mixing and matching of products, refitting and then additional modifications.

The Medicare program requires that complex rehab companies employ specialized staff to analyze the needs of individuals with disabilities and assist in the selection of the appropriate equipment. These specialized personnel, called Assistive Technology Professionals, are certified by RESNA and are unique to complex rehab devices.

An analogous situation is when Congress recognized the unique nature of customized medical equipment in the Balanced Budget Act of 1997. In this law, Congress recognized the specialized service component inherent in custom-fit orthotics and prosthetics and created a separate benefit and payment category for O&P that recognizes the essential service component.

Medicare has traditionally failed to consider the range of services furnished by complex rehab companies and the complexity of the equipment itself. But the implications of continuing to define complex rehab within the traditional DME model do not bode well for consumers. Product choice is likely to be limited, and critical services such as simulations may be curtailed. A full range of services may be unavailable to the patient, jeopardizing access to the most appropriate equipment.

A new and separate benefit category for complex rehab technology would explicitly recognize the customized nature of the technology and the broad range of services necessary to meet the unique medical and functional needs of people with disabilities.

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A specialist in health care legislation, regulations and government relations, Cara C. Bachenheimer is vice president, government relations, for Invacare Corp., Elyria, Ohio. Bachenheimer previously worked at the law firm of Epstein, Becker & Green in Washington, D.C., and at the American Association for Homecare and the Health Industry Distributors Association. You can reach her at 440/329-6226 or [email protected].