Breaking Free

Statements of fact and opinions expressed herein are those of the individual author(s) and are not necessarily those of the Society of Actuaries or the respective authors’ employers.

Rose is a 50-year-old woman with chronic obstructive pulmonary disease (COPD). She has shortness of breath and relies on supplemental oxygen to breathe. While she moves around her apartment with the assistance of a walker, she cannot walk down the block due to her condition and requires a wheelchair to leave her home. However, because her Medicare insurance will not fund it, she must pay privately for a wheelchair.

Harry is a 70-year-old man with brain damage due to a seizure disorder. He is unable to sit upright without support, and his posture will likely worsen without the appropriate equipment to provide the positioning support he needs. Like Rose, Harry has Medicare as his medical insurance, and Medicare will not fund the equipment he needs.

While many individuals successfully obtain wheelchairs through Medicare funding, Rose and Harry are two examples of patients who cannot afford necessary equipment due to Medicare’s funding regulations. Medicare, state Medicaid programs and the Veterans Administration (VA) fund the majority of wheelchairs in the United States, and Medicare is often used as the model on which other insurance companies base their policies.¹ This article will highlight some obstacles patients and clinicians face in attempting to secure medically necessary wheelchairs through Medicare funding.

Determining Wheelchair Necessity

Occupational and physical therapists work with patients to determine their wheelchair needs. They also work with the equipment vendors that supply the specialized equipment, including wheelchairs that range from standard to complex. Standard wheelchairs differ from complex wheelchairs in that they are typically for short-term use, have minimal adjustability² and are easily obtained because any doctor can prescribe one. In contrast, complex wheelchairs are for individuals with permanent or chronic disabilities, are customizable to individuals’ unique needs³ and are obtained following a thorough evaluation by a trained clinician.⁴ When making recommendations, therapists balance the medical needs of patients with what their insurance deems medically necessary. If insurance will not fund recommended equipment, patients are faced with the decision to pay for it privately or forgo the equipment altogether.

There is additional complexity in federally qualified health centers (FQHCs), whose mission is to serve all patients regardless of their ability to pay. Any patient in need will receive services necessary to secure a new wheelchair. Since the equipment is supplied by a third party, however, it is not subject to the mission of the FQHC and must be fully funded. Frustration often results. Patients ask, “What was the point of that evaluation?” when they learn that Medicare will not fund recommended equipment that can cost hundreds or thousands of dollars.

Necessity Nuances

Indeed, many in the profession do not understand some of Medicare’s coverage guidelines. While therapists try to recommend equipment that Medicare covers, there are situations when they cannot—the cases of Rose and Harry are prime examples. In Rose’s case, Medicare will not fund a wheelchair for community use because Medicare only covers mobility equipment for use in the home.^5,6 This rule can render individuals homebound and can result in patients using inappropriate equipment. Equipment meant for in-home use—on indoor, level surfaces—may be inappropriate or not durable enough for use outside. But it might be used outdoors anyway, resulting in more frequent breaking, costly repairs and significant amounts of time where patients are without their equipment.⁷

Harry cannot receive the specialized supports he needs because of Medicare’s diagnostic-based coverage policy for several wheelchair accessories, including specialized cushions. This means that Medicare has a list of diagnoses that qualify individuals for these cushions, regardless of their symptoms.⁸ Harry’s inability to sit upright necessitates a specialized back cushion; however, his seizure diagnosis does not qualify him. His posture will therefore continue to worsen unless he pays for the equipment himself.

Equipment Challenges and Implications

Medicare’s approach to funding wheelchairs can also limit patients’ access to equipment. In many areas of the United States, Medicare funds standard wheelchairs through a competitive bid process: Suppliers submit bids for standard wheelchairs and Medicare awards contracts to those with the lowest bids that also meet applicable standards.⁹ A temporary gap in the competitive bid program will begin Jan. 1, 2019, and is expected to last through Dec. 31, 2020, so the Centers for Medicare and Medicaid Services (CMS) can determine if changes to the program are necessary.¹⁰

Suppliers of standard wheelchairs typically are able to provide equipment to patients quickly because, as the primary Medicare suppliers of standard wheelchairs, they carry these items in bulk. In my experience, however, one consequence of the low reimbursement rates for standard wheelchairs is that suppliers often lack sufficient resources to provide the highest quality equipment and services. Additionally, suppliers are often unable to provide prescribed specialized accessories due to high cost or infrequency of need. For example, a supplier providing a standard wheelchair to one of my patients had to return to the clinic with the wheelchair five times before bringing the correct chair. The supplier did not carry the recommended equipment and independently swapped the prescribed accessories for inappropriate ones. The competitive bidding program can increase the likelihood of such mistakes since suppliers likely feel compelled to sell extremely large quantities of equipment as quickly as possible in order to be financially sustainable.

The functional and financial implications of receiving inappropriate equipment are significant for both patients and the larger health care system. Without necessary wheelchairs, patients cannot leave their homes to work or run errands. Homebound individuals have high rates of disease and higher mortality rates than nonhomebound individuals,¹¹ and individuals are more likely to develop secondary medical conditions when using inappropriate equipment,¹² further increasing their medical costs.

According to Cornell University’s 2016 Disability Status Report: United States, noninstitutionalized working age adults (ages 21–64) in the United States with ambulatory disabilities—defined as “serious difficulty walking or climbing stairs”—had an employment rate of 24.9 percent in 2016.¹³ Comparable adults without disability had an employment rate of 78.9 percent.¹⁴ The question is glaring: Would this statistic, the face of health care and the socioeconomic status of people with disabilities change if all patients received the equipment they need? The answer is simple: Likely, yes.

Copyright © 2018 by the Society of Actuaries, Chicago, Illinois.