CMS can't ignore input

Friday, January 24, 2014

There’s a great deal of activity regarding healthcare policy changes with the goal of providing quality care and services in the most cost-effective manner. But to be successful, the process must include input from all parties so that changes are made in a fully informed manner and result in the most effective and positive outcomes. That’s not happening when it comes to Medicare’s coverage of complex rehab technology (CRT).

Medicare policy changes impacting CRT during the past year fall under negative reform. It’s reform that makes it harder for beneficiaries with significant disabilities to get the specialized equipment and services they need. It’s reform that will actually increase healthcare costs. And to compound the problems, Medicaid programs and private insurance plans may follow Medicare’s lead.

CMS has an obligation to administer the Medicare program in a responsible manner, which includes properly evaluating and implementing changes. This obligation necessitates incorporating input from knowledgeable stakeholders who can speak to how a change may increase healthcare costs, decrease quality of care, or have a detrimental impact on clinical and functional outcomes. CMS is consistently ignoring this critical requirement.

The most recent and egregious example is the disregard of public comments on a final rule issued Nov. 22, 2013, that included a reclassification of certain mobility and seating codes from the “routinely purchased” payment category to the “capped rental” payment category. 

CMS chose to ignore more than 170 letters and issued its final rule with virtually no changes. Many letters were from well-recognized national consumer and clinical associations. Commenters noted a major problem with a classification relying solely on Medicare claims data from 1986. Common sense indicates the methodology needs to be updated and additional criteria added. Letters also pointed out Congress set a precedent in 2010 that CRT items should be classified as routinely purchased given their specialized and individually configured nature. 

These and many other constructive comments and recommendations were completely ignored or discounted by CMS. If the rule is left unchanged, it will have significant negative impacts to Medicare beneficiaries with disabilities. Thankfully, interested congressional offices have agreed to look into this.

Sadly, there are many other recent examples where the disregard of constructive stakeholder comments produced bad policy and will hurt access: the new requirement that beneficiaries must go through the time and expense of a doctor’s examination before they can get their wheelchair brake fixed or their seat belt replaced; the drastic reductions in access to wheelchair repairs due to a competitive bidding program that took bids from companies offering unrealistically low prices without requiring them to actually do repairs at the new rates; and the various changes to how modified and custom manual wheelchairs are coded and reimbursed.  

Genuine collaboration can work if given a chance, as seen in CMS’s prior authorization demonstration project for certain power mobility devices. Upon initial announcement of this three-year demonstration, stakeholders endorsed the concept but pointed out significant problems with certain operational details. To the credit of CMS, it delayed the original start date, and took the time to hear and incorporate comments on how best to roll out a program that would increase safeguards, but not negatively impact beneficiaries. Why can’t this inclusive process, one that protected both the Medicare program and its beneficiaries, be replicated for other Medicare changes?

On a positive note, CRT issues and concerns have gotten the attention of Congress through federal legislation to create a separate benefit category for CRT (H.R. 942 and S. 948). Once this bill is passed, it will provide a foundation for improved safeguards, policies, and recognition on a federal and state level. 

There needs to be a change in mind-set and process at CMS. Knowledgeable national consumer, clinician, and industry associations remain committed to working with CMS to promote the provision of quality CRT and support services in the most cost-effective manner. But they need to be genuinely included. That’s what will produce the best decisions for both the Medicare program and its beneficiaries.

Don Clayback is executive director of NCART. Reach him at