Tuesday, August 3, 2004

In my medical practice, a number of patients fit this description: an elderly man with severe osteo-arthritis, experiencing considerable pain when walking, incapable of propelling an ordinary wheelchair. He no longer leaves his house and finds it increasingly difficult to get around inside.

Another type of patient familiar to physicians like me is a woman in her 40s or 50s with multiple sclerosis whose ability to function is progressively declining. She still has some strength, but it fluctuates day to day. So does her mobility. Unemployed and isolated because of her condition, she is vulnerable to depression.

For many patients like these — along with victims of conditions such as spinal injuries, cerebral palsy or congestive heart failure — the key to regaining a degree of mobility is use of a battery-powered wheelchair or scooter. Yet today, for those who depend on Medicare because of age or significant disability, it is increasingly difficult to obtain reimbursement. Those who cannot afford the minimum $5,000 cost face the possibility of long delays or outright denial. Administration of eligibility rules has become markedly more restrictive as the Centers for Medicare and Medicaid Services (CMS) prepares new guidelines governing power wheelchairs.

Difficulties worsened last year when the government began to crack down on abuses, including fraud, in the sale of power wheelchairs. That concern is valid, and there are effective ways to address it. Accreditation of suppliers by a disinterested body, for instance, should be part of the solution. (In case you’re wondering, my colleagues and I at the University of Pittsburgh Medical Center’s Center for Assistive Technology have no financial interest in manufacture or sale of such devices.)

What is not legitimate is to skew the guidelines, or the administration of them, in ways that deprive persons with disabilities of some level of normality in their day-to-day lives. Last year, CMS issued new guidance that drastically narrowed eligibility. Opposition from a variety of sources caused CMS to reconsider. But while a newer version is pending, the contractors CMS employs to process claims have been acting as if the 2003 dicta were in force.

The most onerous of those changes involves what wonks call “ambulation.” In English, that means the ability to walk. In practice, the government was attempting to reject a claim unless the patient would be confined to a bed or a chair absent the power wheelchair. That is, the individual’s ability to walk a few steps would be a deal-breaker. CMS imposes no comparable ambulation rule for hip or knee replacement, surgery more expensive than purchase of a power wheelchair or scooter.

Imposition of this rigid standard amounts to a sentence of immobility. A person may be able to walk for a moment or two but still be unable to get from the bedroom to the kitchen to the bathroom, let alone venture outside.

And for many such patients, walking even a short distance risks a bone-breaking fall or other injury.

In prior years, this issue was addressed as many others in medicine are, with the physician making a judgment based on the patient’s circumstances.

Eligibility was determined primarily on the basis of a “certificate of medical necessity” (CMN), which elicits relevant information from the doctor as a condition for granting the claim. For instance, the clinician is best able to determine if the patient is capable of using a manual chair. A recent U.S. District Court ruling in California validated that approach.

The CMS, like all domestic agencies, is under pressure to cut costs. But it would be sadly ironic if those with disabilities were forced to suffer what amounts to imprisonment for the sake of fantasy savings. Withholding power wheelchairs in many cases increases the chances of injury and can lead to mental depression. Hospital treatment or even custodial care may be required — expensive alternatives paid for with public funds.

One can only hope that CMS’ conclusion will be both reasonable and humane, with the patient’s legitimate needs and the physician’s considered judgment as the core criteria.

Dr. Michael L. Boninger heads the Center for Assistive Technology and is a professor at the University of Pittsburgh’s School of Medicine.

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