Transformations currently taking place in the world of power mobility devices (PMD) center not so much around technology but around issues of access. Consequently, it is becoming, in the words of National Rehabilitation Hospital Regional Director Ginger Walls, MS, PT, NCS, ATP, “more and more challenging to match clients with the exact right PMD.”
A big contributor to the problem has been the decision by the Centers for Medicare/Medicaid Services to narrow its interpretations of the in-home restrictions governing PMD choices, contends Atlanta-based Laura J. Cohen, PhD, PT, ATP, principal of Rehabilitation and Technology Consultants LLC. “[The in-home restriction rules] dictate clinical practice,” she says. “They tell me that I, as a therapist, must consider only the equipment a person requires in the home, whereas standard practice requires that I consider all of a person’s needs in the context of all environments they encounter—not just the home—so that they can return to their highest level of independence and functioning. My options for making recommendations as to what is most appropriate for my patient are now limited.”
- Xavier Castillo demonstrates the freedom offered by a new mobility system that uses multiple built-in computers that work in conjunction with gyroscopes for balance.
Cohen (who also is co-coordinator of the Clinician Task Force and a member of the American Physical Therapy Association’s Seating and Mobility member consultant group) laments that Medicare’s moves are too often embraced by third-party private payors across the board. “Medicare sets the agenda—they do x and the majority of payors quickly follow suit,” she says. “State Medicaid programs clearly have a responsibility to pay for products that can be used outside of the home, but now we see them and other private third-party payors widely adopting Medicare’s only-in-the-home policy.”
EXPANSION OF KNOWLEDGE
Although PMD base units, seating systems and accessories are available in plentiful supply, the same cannot be said of the physical and occupational therapists who know these products forward, backward and sideways, says Walls from her office on Irving Street in the District of Columbia.
“We’re getting around this limitation by investing heavily in the training of our staff with regard to PMDs,” she reveals. “One way we are doing this is by working closely with a number of manufacturers who come to our facility and provide PMD education. The key is understanding both the device and the regulations that qualify the patient for that particular device. If the manufacturer doesn’t do a good job of providing education about their devices, then it can be harder to figure out what’s going to work best.”
Even with training and experience, having the patient try the actual equipment is a key part of the assessment process. Accordingly, the equipment most often chosen is that which patients have “tried out beforehand, versus something sight unseen,” says Walls. “Most of the manufacturers and suppliers we work with are willing to provide evaluation models for us to use in our seating clinic. I can call these companies and describe the needs my client has. I can then lay out my thinking about what I believe will work, at which point I can also ask for a demonstration unit to test out my ideas. Generally, the response I receive is yes. Sometimes, the company is willing as well to assist with the in-home evaluation. In the end, we might not obtain the perfect size of demonstrator or have everything exactly as it would be on the definitive chair, but usually we can get pretty close. It’s an extremely helpful exercise.”
- Having the patient try the actual equipment is a key part of the assessment process. (Stephanie Kaplan, PT, left, and Xavier Castillo)
The good relationships many rehab practitioners enjoy with their technology suppliers may become a thing of the past—for looming large on the immediate horizon is national competitive bidding, a Medicare cost-cutting program exclusively for providers of home medical equipment.
Competitive bidding is intended to lock-in low, low prices for PMDs and other items such as hospital beds, respiratory products, and diabetic supplies, but it is also meant to purge from Medicare’s midst as many small vendors as possible—the theory around CMS being that this will help cut down the incidence of fraud and abuse, since some in the bureaucratic ranks there almost instinctively suspect every mom-and-pop outfit to be a criminal enterprise just waiting to happen. Kathy San Martino, PT, NCS, ATP, a clinical coordinator at outpatient services at Casa Colina Centers for Rehabilitation in Pomona, Calif, fears that the genuine fly-by-nighters Medicare wants gone will be the ones to survive, while the good companies with which she regularly deals are battered and driven out of business. “I’d hate to see it end up that the vendors we’re forced to do business with are those we would not ordinarily choose to form relationships with,” she says.
The rollout of national competitive bidding began earlier this year in 10 metropolitan statistical areas across the country, and within two years will debut in an additional 70. However, the launch has not gone without a hitch. Chiefly, many would-be bidders have encountered problems with CMS’s electronic bid-submission system, and others have not been able to complete the required accreditation process in as timely a manner as expected. As a result, CMS was forced to extend the bidding deadline in those initial 10 MSAs from early July to late October. Cynthia L. Wilson, general manager of UPMC Home Medical Equipment in Pittsburgh sees the extension as evidence that competitive bidding is a train-wreck in progress and may eventually have to be scrapped.
- Unfortunately, a lot of the more complex, highly specialized products don’t show up on the Medicare Best-Pick lists.
Concerning competitive bidding, Wilson poses a question, which she then herself answers. “When Medicare patients go to a doctor, they get to choose who that doctor will be. Same with the hospital, the lab and other providers. But when it comes to HME, Medicare through competitive bidding is, in effect, eliminating freedom of choice. What I want to know is, why are we in home care so different from other providers that the freedom of choice needs to be stopped at our door? I don’t think we’re different at all.”
By that she says she means it could well turn out that the HME field is but the first step in a long march toward quashing patient choice at every turn. “Eventually, it may be that Medicare tells patients which physical therapist they can see, which rehab hospital they can go to,” she says. “Competitive bidding might become something doctors, therapists, hospitals and labs have to participate in too someday.”
SCHIP SETS SAIL
Adding to these worries is a federal health care initiative called SCHIP—State Children’s Health Insurance Program. “SCHIP will complicate matters for rehab providers and PMD suppliers at a time when we should be pulling together to work as cohesively as possible,” says Mark Schmeler, PhD, OTR/L, ATP, a faculty member in the Department of Rehabilitation Science and Technology at the University of Pittsburgh and a clinician in the Center for Assistive Technology at the University of Pittsburgh Medical Center. Prior to adjourning for their summer recess, the Senate and the House of Representatives passed bills to reauthorize SCHIP, which began on a smaller scale in 1997. “SCHIP’s aims are good, but it also includes a provision prohibiting first-month purchase of power wheelchairs,” Schmeler continues. “With power wheelchairs, we’ve traditionally advised the beneficiary to purchase the chair the first month so that the supplier can be paid in full up front rather than having to collect payment in the form of rent over a period of months. We feel this approach is helpful to suppliers because the product, the modifications and the service support all require a large outlay on their part. But now, with SCHIP, they’re going to have to bill the cost out over 10 months. I believe this will significantly affect access because many suppliers will not be able to carry so large an expense over that period of time.”
- There also are PMDs featuring improved motor and battery efficiency for longer range operation between charges.
SCHIP and all of the aforementioned challenges have driven some technology suppliers to assume a defensive posture by self-limiting the number of PMD makes and models they are willing to carry.
“There are a dozen or so major manufacturers we like to work with, but our suppliers are now saying they’re carrying products from only a handful of those, and they’re doing that in order to qualify for more favorable pricing and terms,” says Schmeler. “Some suppliers are narrowing our choices even further by having what they call a Medicare ‘Best-Pick’ list. Products on that list are the ones the supplier knows he can make a high enough profit on to meet their margins. I fully support efficiencies and streamlining product lines in this business when it comes to simpler interventions such as scooters or basic power wheelchairs, but, unfortunately, a lot of the more complex, highly specialized products we need don’t show up on those lists. Even though they’re more expensive, the profit margin on them is perceived as low by some suppliers. A lot of suppliers find the best profits are made by carrying low-priced, one-size-fits-all products. Therefore, sometimes, as a clinician, I need to be a little more persistent in advocating for my client needs, but also to push the funding sources to pay appropriately.”
A HAPPY ENDING?
Despite that, manufacturers have not abandoned the pursuit of excellence. For example, many of the PMDs they offer now boast a remarkable degree of seating-and-positioning modularity along with flexibility to accommodate the changing needs of users. There also are PMDs featuring improved motor and battery efficiency for longer range operation between charges, and many now sport electronics packages endowed with a remarkable degree of programmability (one manufacturer, as an illustration, came out not long ago with electronics incorporating full-color display, digital photo album, real-time clock, and battery level indicator). At the same time, showrooms are more often carrying highly maneuverable, six-wheel, independent suspension systems capable of handling rough terrain and 3-inch curbs—at least one brand of PMD makes use of technology to keep its sextet of wheels firmly on the ground at all times.
Meanwhile, experts observe that retail mobility continues to make strides, thanks to growing numbers of Baby Boomers eager to remain active: their heart’s desire is for products that are portable, maneuverable, stylish, quality-built and value-laden.
The annual Medtrade Fall conference takes place this month [October]. Schmeler says he for one can scarcely wait to see what PMD innovations are unveiled at it. “I actually think the innovation will be centered around new materials and processes that allow the manufacturers to produce product less expensively,” he says.
Boomers will, of course, soon reach the age when they become eligible for Medicare, but San Martino thinks those seniors-in-the-making who already use a PMD may be in for a rude awakening. “Frankly, Medicare puts people who need a PMD in a bind,” she says. “People are required to come in and prove that their existing PMD is in such a state of disrepair that it makes more sense financially to obtain a new one. So, they have to wait until their chair is ready to fail before they can ask for that new one. On top of that, if a new one is approved for them, they then are faced with a wait of several months before they can receive it—and during that time the old one cannot be repaired. The vendors we’ve chosen to work with are those who’ve made it a policy to stockpile old parts and components so that they can perform makeshift repairs without having to submit claims—performing the work free of charge, in other words—and, in so doing, avoiding administrative problems for the patient during the time he or she is waiting for that replacement PMD.”
And so, Medicare beneficiaries may have to fight the system hard in order to obtain exactly the PMD they want and need. “It’s very sad that, here in the United States where we have so much good equipment and so much good knowledge to draw on, the people with significant disabilities are more and more being treated like second-class citizens,” San Martino laments. “If you ask me, we’re shooting ourselves in the foot as a society. If these people are not receiving the equipment they need, they’re also being forced to live at a level of independence and productiveness that is less than where they should be. I’m not so sure that anything Medicare and the third-party payors are currently doing is going to save much money by implementing tough, new rules and programs. The more likely outcome is that we’re going to do an incredible injustice to the people who need PMDs.”
Rich Smith is a contributing writer for Rehab Management. For more information, contact .
THE GIFT OF COMMUNICATION
by Carrie Kane, MS, CCC-SLP/L, ATP
The challenges and opportunities of augmentative and alternative communication are discussed.
The American Speech and Hearing Association (ASHA) defines augmentative and alternative communication (AAC) as ways, other than speech, that are used to send a message from one person to another. It is important to recognize that AAC does not only refer to high technology voice output devices, but covers a continuum from very basic gestures all the way to high tech products. Universal augmentative communication techniques include facial expressions, gestures, and writing, and they are used by all of us as part of our daily lives.
AAC began to emerge some 50 years ago and there have been significant changes not only in the growing variety of AAC products on the market, but also in how people are assessed for those devices. Like nearly all early technology, the devices were often bulky and not at all user friendly, and people with physical impairments were not easily able to use them. In many instances they were keyboard and typing based devices, and people with decreased literacy skills or limited dexterity were not good candidates. Also, the devices were considered luxury items and were not funded by insurance companies, making AAC very difficult for many people to afford.
ROLE OF SPEECH PATHOLOGIST
This is a growing field and there is a tremendous need for more speech pathologists to work with AAC. A challenge for speech pathologists is that their caseloads are immense and therapists are hard pressed to keep up with the demand for their services. This pressure on their time makes it harder for therapists to complete research or continuing education to improve their AAC skills. Apart from AAC requiring a significant time commitment to become knowledgeable and competent in the field, AAC evaluation and treatment also requires more intensive documentation than traditional ST services. There are different billing codes for evaluations and treatments and insurance funding reports are often five to six pages in length. Managing this increased amount of documentation is crucial for the individual and for the institution as it enables the speech pathologists to be of better support for their clients.
Access to the actual AAC devices may also be challenging to the speech therapist as they are often expensive and some facilities may not have the budget to purchase devices for evaluations. In these instances, there are creative ways to secure devices, but that takes precious time to research. Individual hospital and rehabilitation facilities, schools and other healthcare organizations must be committed to assisting therapists with ongoing AAC education to enable them to keep up with the ever-changing technology.
Institutions that are fully committed to improving the lives of people with disabilities through the use of technology typically complete and host ongoing training and in-servicing for their therapists. They invite regional representatives from various device manufacturers to educate their staff members when new devices are available. And they purchase devices for use in their evaluations and tend to have a wide variety of AAC systems available at all times.
Good Shepherd Rehabilitation Network, based in Allentown, Pa, is an assistive rechnology resource center (ATRC) through Pennsylvania’s Initiative on Assistive Technology (PIAT) based at Temple University in Philadelphia. The PIAT lending library has more than 4,000 pieces of assistive technology available for free short-term loans.
For more information regarding the PIAT lending library, refer to the following Web site www.temple.edu/instituteondisabilities/programs/assistive/atlend/
Communication is a basic human right. We ultimately cannot forget that people with communication disabilities have the right to be evaluated for the use of technology. Technology not only improves people’s lives, it also allows them to have a more meaningful and independent life. It is the speech pathologist’s ethical responsibility to ensure that assessments are completed even if it means referring his or her patients to an AAC specialist when necessary.
The AAC process begins with traditional speech, language and cognitive evaluations to determine the person’s current level and mode of communication. The preferred approach to the AAC evaluation and treatment is to focus on the person’s strengths, not on what he or she is unable to do. The next step is to take those strengths and match them to an AAC system that will most closely meet functional daily communication needs. Any use of AAC can be regarded as a successful outcome and, in many instances, a thorough evaluation identifies a course of action that does not call for the use of a high-tech device.
An example: A young man with severe to profound autism was exhibiting severe behavioral outbursts on a daily basis at his day program and group home. He could walk and was a large man, so it was very possible that he could seriously hurt himself or others.
At the evaluation, it was discovered that he was communicating “yes” by making brief eye contact with his therapist, and “no” by looking down at his lap. His primary caregiver did not realize he was able to communicate in that way. The other caregivers at his respective programs were educated regarding his use of yes and no. When they started to engage him in choice making by having him answer yes and no questions, negative behaviors decreased significantly. This is a successful outcome that required no technology.
An example with the use of assistive technology: A gentleman who has ALS (Lou Gehrig’s Disease) was unable to speak. In addition, he had minimal to no active physical movement anywhere in his body. Using his eyes, he was taught to control a communicator as well as to independently operate his computer. He remains active as the owner of a music store and has his own website, which he updates through his AAC system. (I receive emails from him often and his life has improved immeasurably as a result of the use of his AAC system.)
FUTURE OF AAC
Communication device companies continuously upgrade and incorporate new technology into their equipment and this will continue to benefit AAC. One of the advances that we are already beginning to see is that people will not only be able to communicate using AAC, they will also have computer access through many AAC systems. Communicating via e-mail has become the most convenient, efficient and least expensive form of communication, and having computer access through an AAC system will enable many people with disabilities to communicate with friends, family and colleagues freely for the first time.
Good Shepherd’s speech therapy department has been active in the area of AAC for more than 20 years, helping its residents at Good Shepherd’s Raker Center LTC facility communicate to their fullest potential.
Carrie Kane, MS, CCC-SLP/L, ATP, is a speech pathologist and assistive technology practitioner at Good Shepherd Rehabilitation Network, Allentown, Pa, where she is coordinator of the outpatient AAC program at the Assistive Technology Center at Good Shepherd’s Allentown campus. The facility offers programs in adaptive driving, wheelchair seating and mobility, adaptive computer access, electronic aides to daily living, augmentative and alternative communication, as well as a pediatric assistive program.
AAC systems can be loosely placed into two primary categories — unaided and aided systems. Unaided systems include sign language, facial expressions, gestures and vocalizations, and require no external devices. Aided systems require the use of an outside source for communication. Aided systems can be simple, “no tech” or “low tech” products such as a picture or letter board. At the other end of the scale is a complex voice output system that enables alternate means of access and environmental control capabilities..
There are categories within the aided systems as well. As of January 1, 2001, Medicare, along with most other health insurance companies, has covered and provided reimbursement for Speech Generating Devices or SGDs. The current E codes that all SGD devices and accessories fall into, as documented by Medicare are as follows:
E2500 — Speech generating device, digitized speech, using pre-recorded messages, less than or equal to 8 minutes recording time.
E2502 — Speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less or equal to 20 minutes of recording time.
E2504 — Speech generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes of recording time.
E2506 — Speech generating device, digitized speech, using pre-recorded messages, greater than 40 minutes of recording time.
E2508 — Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device.
E2510 — Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access.
E2511 — Speech generating software program, for personal computer or personal digital assistant.
E2512 — Accessory for speech generating device, mounting system.
E2599 — Accessory for speech generating device, not otherwise specified.
In the case of digitized speech, voices must be recorded into a device by therapists or caregivers, while with synthesized speech the device comes with computerized voice output hardware and software installed.