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Proposed Medicare change would limit access to prosthetics

Proposed Medicare change would limit access to prosthetics

A proposed change to a Medicare coverage policy could limit access to prosthetic limbs.

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Edd Sewell walks with a hitch in his step. His Virginia Tech students simply think the international communications professor emeritus is, well, old. It’s not until he pulls up his trouser leg and lifts his left leg into an extreme half lotus pose, which even the most flexible among them would envy, that they glimpse why Sewell’s gait is different.

He wears a high-tech leg with microprocessors in the knee that allow him full rotation and a speed that syncs up with whatever pace his natural leg allows. Quite an improvement over the prosthetics he wore after losing his leg to a congenital deformity in 1957. Those devices carried him at one wobbly speed, causing him to fall if his body’s pace differed from that of the artificial limb.

“Quite literally they were wooden legs,” he said. Now the government proposes to put him back in the same rudimentary leg he wore in the 1970s.

Manufacturers don’t even make those types of components anymore, said Doug Call, president of Virginia Prosthetics and Orthotics, a 49-year-old Roanoke-based company with 16 locations in Virginia and North Carolina.

Call is incensed that a proposed change to Medicare coverage would strip mobility from his patients. Early Wednesday, Call and a busload of 20 people, who walk well because of their modern-day prosthetics, are heading to a Department of Health and Human Services hearing on the proposed benefit change. They seek to let Medicare know just how life-altering the change will be. The agency closes the window on public comment on Aug. 31.

The proposed change would eliminate or restrict coverage for many modern knees, feet and ankles and replace them with outdated technology. It would also do away with the practice of assessing a patient’s functional potential that could come with more sophisticated technology, increase the time a new amputee waits for a limb, and eliminate coverage for fitting techniques and materials that best protect skin from chafing and sores.

Call said if Medicare refuses to pay for prosthetics that keep people moving and active — an amount that now makes up one-third of 1 percent of its overall budget — it will pay more for wheelchairs and the treatment of diseases that come from sedentary lives.

Those opposing the benefit change, including more than 107,000 people who signed an online petition at saveprosthetics.org, are concerned that if Medicare scales back on paying for prosthetics, private insurers and the VA will follow. Medicare generally sets the billing codes and standards.

A Centers for Medicare and Medicaid Services spokesman said the agency welcomes hearing from those affected by the proposal. When asked why Medicare seeks to change coverage of lower-limb prosthetics, he offered a one-paragraph prepared statement noting that “beneficiaries will continue to have access to lower-limb prosthetics that are appropriate,” and that it is not meant “to restrict any medically necessary prosthesis.”

But what is deemed medically necessary would change. Call explained that if the patient still needs to use a cane or crutch in the middle of the night to use the bathroom or does not have a “natural gait” with the use of a prosthetic, then Medicare will not cover the cost of a more technologically advanced limb when it comes time to replace the old one, even if it would improve function.

The part about a natural or normal gait is particularly odious to Call and his patients, especially those who start the day walking well and end the evening with a slight hitch, not unlike their friends whose natural body parts are wearing with age.

And for Sewell, a limp is his natural gait.

The Defense Department and Veterans Affairs pumped millions of dollars into advancing the research and development of prosthetics in order to restore the mobility of service members who lost lower limbs during the long-running wars in Iraq and Afghanistan.

The technology allows Sewell, an upper-leg amputee with a $32,000 leg, to run through life and easily tour countries around the world, and it gives Richard Eichenbaum, a lower-leg amputee, the use of a $8,500 prosthetic to play with his grandchildren, tend his yard and, most importantly, stay healthy and mobile enough to keep from losing his other leg to diabetes. The technology provides Vickie Waldron with an energy-storing foot that helped her to not miss a stride as manager at the Salem Antique Market after losing her leg to MRSA in 2012.

It isn’t just the prosthetics that will be scrapped. The silicone gel sleeves that prevent skin from chafing and breaking down would also be considered medically unnecessary.

“The socket interface is what Medicare seeks to limit. It is vital to a below-the-knee amputee,” Call said. “It will be a cookie-cutter approach that won’t allow us to fit individuals.”

Eichenbaum knows all too well how limiting an ill-fitting limb can be. His first one, following surgery in California in 2013, was not made with the same precision to fit his body as his current prosthetic.

With the new one, “you get up on your leg and you want to walk,” he said. “I wouldn’t want to go back.”

Call likened today’s prosthetics to hip replacements in which surgeons select components based upon each patient’s body and lifestyle.

He had his hip replaced in 2013 with an artificial joint tailored for him, not a one-joint-fits-all device manufactured 20 years ago.

Call can only guess that money is prompting the change. Technological innovations caused costs to rise significantly between 2005 and 2010, when Medicare expenditures for prosthetics peaked. Since then spending has decreased, Call said, but Medicare is ignoring the downward trend.

The proposal, technically known as a Local Coverage Determination, is handled through Medicare and does not require Congressional approval. Opponents are seeking either for it to be rescinded, or, since it involves substantial change, to have a wider review.

The online petition is posted on the White House website and should generate a response since it reached the 100,000 signature threshold to prompt attention.

The local contingent has also written to its Congressional delegation without much response.

A spokeswoman for U.S. Sen. Tim Kaine, D-Virginia, said he is monitoring the issue and that he “believes that controlling the rising cost of health care is essential to solving our long-term fiscal challenges, but that we must not compromise beneficiary access to continuous and quality care.”

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