An effort is under way to establish a separate benefit category within the Medicare program to improve and protect access to CRT products and services for individuals with significant disabilities and medical conditions.


BACKGROUND

LAURA COHEN, PT, PhD, ATP

LAURA COHEN, PT, PhD, ATP

Complex rehab technology (CRT) products and supporting services are used by individuals with significant disabilities and medical conditions. These individuals deal with physical, functional, and cognitive challenges every day and utilize CRT to maximize their function and minimize the extent and costs of their medical care. Unfortunately, significant challenges threaten appropriate access due to coding, coverage, and payment problems. These challenges have increased over the past several years and, without meaningful changes, will only become greater in the future. Consequently, there is an initiative being undertaken to establish a separate benefit category within the Medicare program for CRT.

CRT products and associated services include medically necessary, individually configured devices that require evaluation, fitting, adjustment, or programming. These products and services are designed to meet the specific and unique medical, physical, and functional needs of an individual with a primary diagnosis resulting from a congenital disorder, progressive or degenerative neuromuscular disease, or certain types of injury or trauma. While other products may ultimately be placed in the CRT benefit category, for purposes of this article, CRT refers only to individually configured manual and power wheelchair systems, adaptive seating systems, alternative positioning systems, and other adaptive equipment.

DON CLAYBACK

DON CLAYBACK

A core problem is that these technologies intended to meet the unique needs of a single individual are grouped within the broad Medicare benefit category of durable medical equipment (DME)—defined as an item that is able to withstand repeated use, ie, it could normally be rented and used by successive patients. This basic premise within the DME benefit category prevents adequate differentiation when it comes to establishing coding, coverage, and payment policies for the range of CRT.

CRT is dramatically different in many ways from standard durable medical equipment. The consumers’ needs are far more complex, requiring more extensive evaluation and fittings than standard DME. The products and equipment involved are more varied and require a more detailed matching of beneficiary need and technology than standard DME. The service/delivery model and the skill set, knowledge, and experience of the people who provide the services are very different from those providing standard DME. Finally, the Medicare beneficiary who requires this complex technology is not the typical senior Medicare beneficiary. A new benefit category would provide the best opportunity to address these differences in a meaningful way that would benefit not only Medicare beneficiaries with disabilities and significant medical conditions, and the Medicare program as a whole, but also state Medicaid programs and other third-party insurers that follow Medicare guidelines for coverage and payment.

PURPOSE AND OBJECTIVES

GARY GILBERTI

GARY GILBERTI

The overall purpose of obtaining a separate benefit category is to improve and protect access to complex rehab technology products and services for individuals with significant disabilities and medical conditions. The targeted changes and improvements will be developed with this statement in mind. The following five objectives have been identified:

  1. Develop clearer and more consistent coverage policies to appropriately address the unique needs of individuals with varied disabilities: Eliminate provisions of medical coverage polices that inappropriately limit the availability of certain products, such as the current limitation that recognizes consumer need only “in the home” and does not allow for recognition of work and community activities. In addition, the current coding system does not differentiate the full breadth of available technology. Policies and coding must allow for a proper matching of the individual’s medical and functional needs to appropriate CRT products.
  2. Establish stronger and more enforceable provider standards to promote appropriate clinical outcomes and consumer protection: The complexity of CRT warrants tailored quality standards and professional credentials to be sure that consumers get the right products through a professional process and that there is an adequate system to provide for ongoing service and repair needs.
  3. RITA HOSTAK

    RITA HOSTAK

  4. Obtain formal recognition of the depth and cost of the product-related and clinical services required to allow for appropriate funding: An adequate reimbursement system that recognizes both the cost of the product and the cost to provide and support the technology is critical. To produce an equitable payment system, the significant clinical and product-related service costs must be better recognized and considered in establishing reasonable fee schedules.
  5. Provide future payment stability to ensure continued access to products and services, and an environment that encourages product innovation and technology solutions to improve function and independence for individuals living with disabilities: The assistive technology available today is the result of research and innovation that have occurred over a number of years. For this product development to continue, there must be a business environment that fosters these activities and provides incentives for continued advancements.
  6. Produce an improved coverage and payment model that can be offered to Medicaid and other payors to follow: Many state Medicaid agencies and other third-party payors follow the policies of the federal Medicare program. Once this new system is adopted by the Medicare program, it can be easily adopted by other payors and thereby improve access to CRT under these other funding systems.

INITIAL ACTIVITIES

SIMON MARGOLIS

SIMON MARGOLIS

This is a major initiative and will require a great deal of time, energy, and resources. Its success will necessitate involvement and support from a wide group of stakeholders. The stakeholder group includes consumers, clinicians, suppliers, manufacturers, state associations, DME MAC medical directors, Centers for Medicare and Medicaid Services (CMS), and Congress. Consumer and clinician voices will be critical for achieving separate recognition for CRT.

A formal steering committee has been created to provide direction and coordinate activities. The committee includes representatives from four industry organizations: the National Coalition for Assistive and Rehab Technology (NCART), the American Association for Homecare (AAHomecare), the National Registry of Rehabilitation Technology Suppliers (NRRTS), and the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).

Don Clayback serves as committee chair and is executive director of NCART (dclayback@ncart.us). Other NCART representatives are Gary Gilberti, president of Chesapeake Rehab Equipment ( ), and Rita Hostak, vice president of government relations at Sunrise Medical ( ). NRRTS is represented by Simon Margolis, NRRTS executive director ( ). AAHomecare representatives are Tim Pederson, president of West Med Rehab (), and Walt Gorski, vice president of AAHomecare (). RESNA is represented by Elizabeth Cole, director of clinical rehab services at the VGM Group ( ). The clinical liaison position is held by Laura Cohen, PT, PhD, ATP, of Rehabilitation and Technology Consultants ( ). The consumer liaison position is held by Paul Tobin, president of the United Spinal Association and member of the ITEM Coalition.

PROGRESS UPDATE

TIM PEDERSON

TIM PEDERSON

To date, a great deal of activity has occurred. The steering committee has been meeting regularly and specific work groups have been established. The work groups have been organized in four areas: coding, coverage, payment, and quality standards. Within these groups, the current issues and needed changes are being identified and documented for broader discussion.

Ongoing education and outreach activities have been a priority. To this end, throughout the last quarter of 2009, there were multiple webinars, a panel discussion at Medtrade, and a Consensus Conference to solicit comments and suggestions. Information dissemination activities have included stakeholder organization communications, press releases, industry publication articles, and Web site materials. These activities will continue as we move forward.

In March, the steering committee released a discussion paper titled “A Starting Point for Obtaining a Separate Benefit for Complex Rehab Technology,” as a starting point for conversation, followed by multiple webinars and opportunities for ongoing input. In addition, a Washington, DC-based policy consulting firm has been engaged to assist with developing the needed legislative and regulatory assessment and strategy.

ELIZABETH COLE

ELIZABETH COLE

In April, the NRRTS/NCART Continuing Education and Legislative Advocacy (CELA) Conference was held in Washington. Attending were CRT advocates including industry professionals, clinicians, and more than 50 consumer representatives. It was a great showing that resulted in more than 220 in-person Congressional office meetings that allowed for initial discussions with Congress on the issues and needed assistance. Based on feedback and formal meeting reports, attendees received positive responses. We will be building on these in-person meetings to produce a greater awareness of CRT and to increase the level of Congressional support.

As this process moves forward, the educational activities and outreach will be expanded to include a broader group of organizations and individuals. As the specific details and required legislative and regulatory steps are identified, additional discussions will be held with Congress and other policy makers.

CALL TO ACTION

PAUL TOBIN

PAUL TOBIN

To learn more about this project and lend your support, visit the NCART Web site at www.ncart.us. There you can do the following:

  1. Download the “Separate Benefit for Complex Rehab Technology” position paper that provides an overview on the initiative and additional background information.
  2. Download the related discussion paper titled “A Starting Point for Obtaining a Separate Benefit for Complex Rehab Technology” that outlines the details and initial proposal based on stakeholder input to date.
  3. Sign up for e-mail alerts so you can receive regular updates on this and other CRT issues.

Work on the Complex Rehab Technology Separate Benefit initiative is ongoing. Input and suggestions are being sought from the consumer community, the clinician community, suppliers, and manufacturers to provide details and insights into what additional fixes and changes are needed. The support of consumers with disabilities, physical therapists, occupational therapists, physicians, and other clinicians will be critical in taking the need and message to Congress and CMS. It will be through these combined efforts that the ultimate goal of improving and protecting access to CRT products and services for individuals with significant disabilities and medical conditions will be achieved.


Laura Cohen, PT, PhD, ATP, is the principal of Rehabilitation & Technology Consultants, LLC, and clinical liaison to the CRT Steering Committee; she can be reached at or (404) 370-6172. Don Clayback is executive director of the National Coalition for Assistive and Rehab Technology (NCART), and chair of the Separate Benefit Steering Committee. He can be reached at or (716) 839-9728.

COMPLEX REHAB TECHNOLOGY PRODUCTS INCLUDE:

  • Individually configured mobility products: Such as individually configured manual and power wheelchairs. Complex rehab manual and power wheelchairs are available in a variety of types including ultra-lightweight, heavy duty, bariatric, tilt-in-space, and reclining. These products also include a variety of alternative driving controls for power wheelchairs that enable people with significant disabilities to move about and control their environment.
  • Individually configured seating and positioning products: Such as individually configured seat cushions, back supports, trunk supports, molded seating systems, headrests, chest harnesses, hip belts, and trays. In addition, a variety of other specialized positioning items are used in supplying custom configurations based on the person’s needs.
  • Other specialized equipment: Such as standing frames, gait trainers, strollers, car seats, activity chairs, specialized bath chairs and commodes, and specialized walkers.

WHO USES COMPLEX REHAB TECHNOLOGY PRODUCTS?

People benefiting from this equipment represent all age groups, from pediatric through geriatric. The diagnoses and disabilities are varied and include, but are not limited to, the following:

  • Cerebral palsy
  • Multiple sclerosis
  • Spinal cord injury
  • Stroke
  • Muscular dystrophy
  • Amyotrophic lateral sclerosis (ALS)
  • Spina bifida
  • Traumatic brain injury
  • Other diseases and disabilities with postural and mobility impairments