Access denied: consequences of federal policy on seating and wheeled mobility.

Much has been written about the potential positive and negative sequelae of the Medicare Modernization Act (MMA) of 2003. The prescription drug benefit has been the most publicized and maligned. However, the impact on consumers who need complex, high-end seated positioning and wheeled mobility systems and on the practitioners and suppliers who serve them is significant. The MMA calls for competitive acquisition— national competitive bidding—on seating and wheeled mobility products by the year 2007. On the commodity side of durable medical equipment (DME) and supplies, competitive bidding may make sense. Competitive acquisition is not appropriate, however, for high-tech seating and wheeled mobility systems. By nature, the provision of these products falls to companies that have a unique business model that involves a high level of personal involvement between the provider and consumer and the integration of licensed healthcare professionals throughout the process. The products provided are uniquely configured for the individual consumer based on diagnosis, prognosis, and lifestyle. Moreover, while products may be classified (for competitive bidding) in the same national Healthcare Common Procedure Coding System (HCPCS) code, they are not equal in regard to their capabilities to meet the medical and functional needs of a consumer. Competitive acquisition will result not only in suppliers reducing services to people with disabilities but also in consumers receiving products that are selected based on cost and not on medical and functional appropriateness. Such a reduction in services, or limitation of products based on price alone, will have a severe negative impact on clinical outcomes associated with the provision of high-tech rehabilitation and assistive technology. Even though Congress has mandated the implementation of a system of competitive acquisition for certain items of DME, they have recognized the need to differentiate among different products. Language contained in Section 302(b) of Public Law 108-173 of the MMA also gives the Secretary of Health and Human Services, through the Centers for Medicare and Medicaid Services (CMS), the authority to exempt certain products when competitive acquisition “is not likely to result in significant savings.” This is certainly the case with complex, high-end seating and wheeled mobility products, which make up a miniscule part of Medicare expenditures. In addition, the provision specifies that in implementing this competitive acquisition authority, “the Secretary may consider the clinical efficiency and value of specific items within codes, including whether some items have a greater therapeutic advantage to individuals.” Congress recognized that while product may be classified in the same HCPCS code, they are not necessarily equal in regard to their capability to meet beneficiaries’ medical needs. Congress therefore authorized the Secretary to carefully analyze whether individual products within broad product classifications have sufficient clinical benefit to be treated differently than other items in that code, that is, to be excluded from competitive acquisition. This language serves to document the intent of Congress that the Secretary uses competitive acquisition judiciously after careful reflection, study, and analysis, and that price should not take precedence over medical best practice. There is a clear course of action that should be followed to assure that consumers receive the appropriate seating and wheeled mobility systems in light of competitive bidding requirements. To determine the relative therapeutic benefit of seating and wheeled mobility items, the Secretary should immediately impanel a working group consisting of— • Physicians with training and experience in the rehabilitation of persons with significant disabilities requiring complex, high-tech seating and wheeled mobility products. • Experienced, credentialed occupational therapists and physical therapists.