No one can deny that cutting government waste in Medicare is good, but when well-intentioned policies deny access to wheelchairs for Medicare’s seniors and individuals with disabilities, those policies need to be changed.
Since 2003, when the Centers for Medicare and Medicaid Services (CMS) launched Operation Wheeler Dealer to combat abuse in the Medicare wheelchair benefit, the agency has completely revamped coverage rules, billing codes, and payment levels for manual and power wheelchairs and scooters. CMS aggressively pursued audits of wheelchair claims and scrutinized clinical documentation to demonstrate medical necessity.
At Congress’ direction, CMS also implemented in 2011 competitive bidding in 100 urban areas to determine new payment levels which led to dramatic reductions in reimbursement for mobility devices — not a bad thing from the taxpayer’s point of view, assuming beneficiaries have continued access to the benefit.
A recent GAO report, however, reveals that the number of beneficiaries receiving Durable Medical Equipment (DME) in competitively bid areas decreased by 17 percent between 2012 and 2014. Beneficiaries are, in fact, being harmed.
CMS’s competitive bidding system created a flawed pricing model where suppliers offered exceedingly low bids on mobility devices to win contracts, only to turn around and sell those contracts to other companies, leaving consumers with fewer choices for products and services. The bid prices were unrealistically low, resulting in inferior quality and choice of mobility devices provided to beneficiaries.
CMS also tried to apply these deep reimbursement cuts to complex rehabilitation technology (CRT) wheelchairs, despite Congressional intent not to do so.
Congress correctly exempted from competitive bidding power and manual CRT wheelchairs, which consist of advanced, individually-configured mobility devices for individuals with the most significant, long-term disabilities.
A wide variety of CRT accessories allows these mobility devices to meet the individual needs of beneficiaries. CRT is used by approximately 10 percent of Medicare beneficiaries with severe mobility impairments, and access to these devices allows these individuals to remain healthy, functional and live in their homes and communities, avoiding premature admission to costlier nursing homes.
CMS applied competitively bid pricing to manual wheelchair accessories in January 2016 — contrary to Congressional intent, and tried to apply the same pricing to power wheelchair accessories — which are fundamental components like tilt-and-recline systems and customized seat cushions for people with severe disabilities. Congress disagreed with this approach and responded by passing a one-year extension of existing pricing for power CRT accessories running through the end of 2016 in order to preserve access to this important benefit.
Meanwhile, competitively bid pricing was extended to all suppliers of Medicare wheelchairs and other medical equipment, including in all rural areas. These deep cuts, between 30 percent and 60 percent off existing reimbursement levels, was phased-in last year across the country, half the cut taking effect in January 2016 and half in July.
The end result is quickly becoming a disaster for beneficiaries. Early indications suggest that Medicare beneficiaries are being systematically denied access to care, especially in rural areas, as more and more suppliers no longer serve Medicare beneficiaries. A study by Dobson DaVanzo indicates that, on average, suppliers under the competitive bidding program are reimbursed only 88 percent of their costs.
Suppliers have no choice but to provide cheaper, less functional mobility devices and offer fewer choices of models, brand names, and accessories. Waiting times for wheelchair deliveries and repairs are increasing, keeping people immobile when they could be leading an active life in their homes and communities.
Thankfully, Congress continues to listen to our concerns and we are grateful. The 21st Century Cures legislation was passed in December 2016 and provided a measure of temporary relief on these two problems. The bill retroactively reduced some of the cuts for rural providers, but only through the end of 2016, and it also pushed back the application of bidding-based pricing for wheelchair accessories another six months, to July 1, 2017.
These provisions will help the provider community weather these major shocks in reimbursement for now, thereby benefitting patient access to appropriate care, but a permanent solution is needed to stabilize reimbursement policy for all Medicare wheelchairs, including CRT manual and power wheelchairs and accessories.
These issues are admittedly technical and complicated, but they are of critical importance to any Medicare beneficiary with a mobility impairment or disability. As the 115th Congress and newly-installed Secretary of Health and Human Services, Tom Price — formerly an orthopedic surgeon with an understanding of wheelchair policy — get to work on a range of important healthcare issues, we hope a permanent solution for these issues gets the attention it deserves. The mobility, health, independence, and safety of millions of Medicare beneficiaries with disabilities depend on it.
Peter Thomas is a coordinator of the Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition. For more information visit, https://itemcoalition.org/.