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  • APTA Joins Critics of Proposed Medicare Prosthetics Restrictions

    A proposed change in how Medicare would reimburse for lower-limb prostheses is drawing mounting criticism from patients and stakeholder organizations—including APTA. According to the association, the proposals now being considered would negatively affect patients by "restrict[ing] the ability of a therapist to provide the appropriate medically necessary care if they are providing therapy to a patient who has received an ill-fitting, or non-customized prosthetic or component based on Medicare coverage policies."

    In a letter submitted to the durable medical equipment administrative contractors (DME MACs), the association takes issue with a proposal developed by the DME MACS that would impose extensive restrictions on who could receive a lower-limb prosthesis, what kind (or kinds) of prosthesis they could get, and when and under which conditions Medicare would pay for the devices. Though the DME MACs contend that the changes are necessary to counteract steep rises in prosthetics expenditures among Medicare beneficiaries, critics including APTA believe the proposal ignores the realities of rehabilitation and shortchanges the importance of clinical judgment.

    "APTA understands the difficult balance of providing quality care that is medically necessary while attempting to curtail costs," the association states in its letter. "However, this [local coverage determination] has the potential to result in lower quality of care while ultimately increasing costs. In the long run, costs could be higher to Medicare due to complications associated with prosthetics that were inappropriate for the patient due to restrictive requirements, provided untimely or not provided at all."

    APTA's concerns about the proposal range from what it views as overly restrictive definitions of terms in some sections to a lack of clarity in others, and addresses provisions that the association feels would minimize the importance of the expert individualized determinations made by appropriate health care professionals.

    Additional problematic areas of the proposal cited by APTA and other organizations include the potential for CMS to restrict patients to older-model artificial legs if the beneficiary has any form of mobility aid (such as a walker or cane) that they would use for limited purposes, and a requirement that the prosthesis must provide "the appearance of a natural gait." In its letter, APTA points out that "'Natural gait' is a subjective term—and potentially discriminatory, particularly when dealing with individuals with disabilities."

    Last week, opponents of the proposal staged a protest at the headquarters of the US Department of Health and Human Services (HHS), an event that drew coverage by CNN and other news outlets. The protest effort received a boost from former Nebraska Senator Bob Kerrey, who himself has an amputation and was quoted in a press conference as saying that "this is as stupid a rule as I've ever seen," and that the rule "completely ignores what's going on with amputees."

    The comment period on the proposed changes closed on August 31. CMS has not established a timeline on when any new rules would take effect, according to an article in Modern Healthcare.

    Comments

    • Thank you. Wayne Renardson, moderator AMP-L@u.washington.edu

      Posted by Wayne Renardson on 9/2/2015 9:06 PM

    • I agree with former Nebraska Senator Bob Kerrey, who himself has an amputation and was quoted in a press conference as saying that "this is as stupid a rule as I've ever seen," and that the rule "completely ignores what's going on with amputees."

      Posted by Mary Schlesinger on 9/14/2015 4:55 PM

    • Thank you for supplying your perspective clearly in you letter. Michael Domenicucci

      Posted by Michael Domenicucci on 7/18/2016 8:00 PM

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