Monday, January 31, 2005

Medicare sprints ahead with new coverage criteria
WASHINGTON - CMS has fast-tracked its efforts to develop new coverage criteria for wheelchairs and should have a final policy in place by mid to late March, said Sean Tunis, CMS’s chief medical officer.
Sean Tunis

CMS opened its National Coverage Determination Dec. 14, and under most circumstances the process to develop new coverage criteria, or leave it unchanged, takes 270 days. But with providers lobbying hard against the current bed-or-chair-confined coverage, CMS decided to speed up the process, Tunis said.

Last summer, Tunis chaired the Interagency Wheelchair Workgroup. CMS charged the group with examining the existing wheelchair coverage criteria and recommending whether it should be changed or not. The group released the report in December. In it, they recommended that CMS stop using the bed-or-chair confined criteria and adopt a more functional criteria, one that centers on whether a person can cook and carry out other activities of daily living without the aid of a wheelchair. HME News talked with Tunis in late December about the Workgroup’s report. Here’s what he had to say.

HME: CMS’s announcement of an NCD for wheelchairs took the industry by surprise. Most people thought your group’s report would serve as new draft coverage policy, not a recommendation. What happened?

Tunis: We started the Wheelchair Working Group without any preconceived notions of what it was going to come up with. We didn’t anticipate that we would be developing a framework of this type and didn’t get our legal counsel engaged until fairly far along in the process. When they looked at how this was evolving, it became clear that we needed a formal process.

HME: Your group suggests that CMS base its wheelchair coverage criteria on a definition of functional ambulation. What do you see as the problem with the existing bed-or-chair confined criteria?

Tunis: It is not clear or precise enough. Bed of chair confined is a term that is open to a lot of different interpretations, all of which may be equally correct. We are also aware that there are interpretations of bed or chair confined that are clearly out of the boundaries of what bed or chair confined means.

HME: For example?

Tunis: Bed of chair confined meaning literally that one cannot get out of a bed or chair. I think for the most part people were using reasonable judgement to interpret the spirit of what bed of chair confined meant. But not everyone was using good judgement.

HME: What is the spirit of bed of chair confined?

Tunis: I think the spirit of the term is what the Wheelchair Working Group came up with. It was really meant as a place holder for the way we have now interpreted it, which is in the context of identifying a group of people for whom mobility will make a significant difference in their functional level of activity.

HME: In a nutshell, someone who needs a wheelchair to move safely around his house should get one.

Tunis: Exactly. You could take this to the extreme that anyone with the slightest limp could in certain circumstances benefit from powered mobility. The challenge is trying to find some sort of reasonable dividing line between what makes a meaningful improvement in functional ability due to a medical condition and what is a convenience that the large majority of people over the age of 65 might like at the end of a long day.

HME: Will a functional mobility criteria eliminate the confusion surrounding who qualifies for a wheelchair?

Tunis: I think it will narrow the boundaries of the uncertainty. I think it will be useful to have a document that lays out as clearly as possible what the factors and the policy are. It’s not as if someone will be able to take this document and walk up to Mr. X and say he clearly does or doesn’t qualify. I think it will simply make all the discussions that have to go on that much more informed with a common framework for thinking about the issue.

HME: Will more people qualify under this criteria?

Tunis: I don’t know. That wasn’t part of our goal to think about whether this would increase or decrease the numbers. The goal was to get it to the right people.

HME: The report addresses the in-the-home requirement only in passing and doesn’t state an opinion for or against it. Why?

Tunis: It is because the focus of our assignment was to address the issue of providing a more useful definition of bed or chair confined. There is a lot of interest in the agency to have a parallel path to re-explore the issues around the in-the-home restriction, but the coverage process is not the place to do it.

HME: The report seems to recommend providing a wheelchair to a beneficiary only if it would enable him to resume mobility related activities of daily living. What about providing a wheelchair to someone soley to prevent further deterioration of his condition, regardless if he’ll be able to resume activities of daily living?

Tunis: I don’t know if we would or wouldn’t under the guidance, but I think that is a legitimate point for someone to make and that will be made. I think that is the kind of feed back that will be very useful in terms of further revision.