Suppose We Could Fix the Need for Double-Briefing
Trimming the cost of care has its downside
by Ken Edmunds

There was a time Polly remembers when she had more than enough pull-on protective underwear. Lately, though, Polly has had to seriously strategize how to stretch the products she is able to get. Polly’s local provider has explained that reimbursements have fallen in this product category every year, and that to meet plummeting reimbursements, manufacturers have changed the product.

Polly wears two pairs of protective underwear at the same time. This makes it harder for Polly to conceal her condition, and it makes each day more stressful.

The idea of “double-briefing,” the solution some Medicaid beneficiaries find to try and prevent leakage, is all too common these days. It exists for those living on their own, but receiving products from an entitlement program; for those living at home and paying for their own products; and for those living in long-term care communities.

As incontinence products decline in performance, the term “double-briefing” has been expanded to include the practice of placing all sorts of pads inside the briefs and protective underwear in an effort to increase absorbency.

While the vast majority of caregivers find the practice of using two briefs or two protective underwear at the same time to be unethical, quite a few will rely on bladder control pads to boost the performance of the brief or protective underwear.

Government Reimbursement Programs

For those either living at home dependent on government assistance or those living in a long-term care community unable to pay for an alternate product, chances are they are faced with two options when it comes to incontinence:

  1. Resort to some version of double-briefing and hope that it is successful in preventing leakage.
  2. Accept that leakage is part of daily life, and try to make the best of it.

Neither of these options is a clinically sound choice. The natural human reaction to leakage is to add what we believe is additional absorbency. (If one paper towel doesn’t handle the spill, we reach for another.) When a client lives at home under these conditions, he or she can choose to double-up to manage the situation. However, in long-term care that decision is made for us. If the caregiver sees that the patient is always leaking, the caregiver may choose the additional (secondary) product to either make the work easier and to strive toward a better level of care.

Private Pay at Home or in Long-Term Care

In my experience, for clients in a position to privately pay for long-term care:

  • Roughly 70 percent of people living at the assisted living level of care will opt to provide their own incontinence products.
  • Less than 10 percent of people living at the skilled nursing level of care will opt to provide their own incontinence products.

What these estimates don’t reveal is that as many as half of either category providing their own incontinence products were led to the decision in an effort to trim the cost of care for themselves or their loved one. In other words, the products that they will choose will be based on cost, not performance. On a side note, the sharp contrast between assisted living and skilled nursing in terms of incontinence being facility-provided versus resident-provided is a topic for another day.

The more interesting reality is that even with those that can or will choose their own incontinence products when they live outside the home, the majority will still seek a secondary product (usually a bladder control pad) to supplement the absorbency of the brief or protective underwear. Additionally, many believe that as the generational tidal wave of boomers crash into the shores of long-term care, we will see the number of people opting to pick their own incontinence products increase dramatically.

The number of Americans living longer, working longer and living in their own homes longer grows every day. All of these trends contribute to a rising number of active adults needing incontinence products that they will be purchasing themselves. Historically this has created a very healthy retail business at the store level, primarily for chains. Most consumers have traditionally been lured to purchase based on a combination of best price, most attractive packaging, and sheer brand recognition. The universal standardization of claims such as “extra absorbency, discretion, confidence, etc.” have left consumers generally confused or in many cases, indifferent.

What We Need to Know

  1. Wearing two briefs or two protective underwear at a time is not an effective way to address leakage. This holds true from a cost standpoint as well as a clinical standpoint.
  2. Placing typical bladder control pads in disposable briefs and protective underwear is also not an effective way to address leakage.

Both of these double-briefing methods put the patient’s skin in peril. Whatever limited breathability that a brief or protective underwear may have is further reduced by doubling the product. Additionally, once the initial product is fully saturated, any fluid yet to be released is trapped against the skin, creating the perfect storm for skin breakdown.

The typical choice for a pad to place inside of a brief or protective underwear features a moisture-proof backing. The result is similar to using two briefs or protective underwear at a time. The pad is easily overwhelmed with fluid and the moisture-proof backing prevents the fluid from efficiently draining down to the outer product. Again, this keeps fluid against the skin creating an ideal environment for not only skin breakdown, but a UTI as well. In both cases, most experts agree that this method is not effective in limiting or preventing leakage.

Polly eventually consulted with her doctor on this private issue. “You know Polly, there are several exercises, dietary changes and even procedures we can discuss to help limit or maybe even reverse these symptoms,” her doctor said. “For now, try adding one of these flow-through booster pads that don’t have a moisture-proof backing.” Polly left her doctor’s office with a smile and the comfort of knowing that her life would very likely be better now that she had a partner in gaining back her dignity and freedom.

This article is the third in a seven-part series. Each article will focus on a particular concern of the retail incontinence marketplace. Read the full series here.