Is Medical Necessity at Odds with Functional Independence?

In late 2015, news of wheelchair pedestrian incidents trended. What they said: Height matters. The consumer moves at a low, fixed, static height which does not line up well with today’s higher, larger vehicles.

Many drivers are in a hurry or distracted, and navigating crosswalks—to cross the street or cross the parking lot—is dangerous enough sans being seated. Now suppose a new product could make wheelchair users safer, so they can see and be seen.

At Medtrade Spring in March 2018, the team at Pride Mobility Products introduced the forthcoming Jazzy Air 2, its cantilever lift gleaming under the convention lights, declaring lower seat lows and higher seat highs. Central region manager Zach Branson and I spent time talking about mobility and the hazards and helps of dealing and using mobility equipment.

I learned that the enhanced higher seat position of the non-coded retail, cash-only product could be considered a safety benefit (for a better chance of making eye contact with drivers), a quality of life benefit (to be an active participant in social gatherings), an assistive technology feature (to assist with transfers between surfaces, and living independently), and the equipment costs roughly $5,000.

I also gathered that an enhanced mobility product such as this can help people who are not physically impaired to the degree of those who need a complex rehabilitative power wheelchair, but who are physically impaired enough that life is extremely limited, stressful and challenging.

The features and accessories of many sophisticated mobility products—while they lend themselves to the concept of functional independence and a health reaching effect—just don’t jive with the terms of medical necessity. This keeps people who are moderately (and more) impaired at a huge disadvantage as they face barriers to work and health care, and challenges to living independently.

Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category. The Medicare coverage program itself states that one of its health outcomes of interest is “longer life and improved function and participation.” Yet, the elevator seat height feature is not covered—even though the new high and low positioning may make a considerable difference in the life of the user, from a safety standpoint, toward better health and continued independence, for success at work, and from a person-centered care standpoint.

“We have created another industry—retail—that gives the consumer a choice,” Branson said, and he added that he’d like to see the rules around medical necessity change. He is not alone.

With all that is covered under the term “medical necessity,” there are questions about what’s in currently, and how to prioritize and fund additional benefits based on the good they could do for people, depending on their circumstances.

Assistive technologies, such as enhanced mobility devices and other tools, are seen as one way to compensate for the current and future caregiver crisis, for example, but it takes much more than this to find a place in policy. It takes so much more than a good idea.

One of the terms we often hear today? Outcomes. National coverage determination requires, for example, extensive literature or an important study, and technological advance with potential major clinical or economic impact.

Since May is National Mobility Awareness Month, let’s talk about this. Does medical necessity help or hinder mobility, independence, quality of life and, ultimately, better health, for whom, and in what kinds of circumstances? Suppose we focus on functional independence and an optimized function standard for equipment.

People are talking about the future of things. I would imagine the future of disability will find its way into the lineup. It’s been there before. In 2007, the National Academy of Sciences, Engineering and Medicine published a consensus study report titled “The Future of Disability.” Now, where the evidence lives for what has grown out of this effort is hard to see, but there are people out there who are interested and looking.

Would you like to join this discussion? Connect with me via email at [email protected].