WASHINGTON, July 16 For years, homecare equipment providers have cited the many ramifications of the Medicare program's inefficient guidelines for documenting the medical necessity of power wheelchairs for beneficiaries. It is the root cause of claim denials that are frequently reversed, the target of excessive audits and it restricts access to power wheelchairs for patients. But rarely, until now, have physicians offered their perspective.
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It is enlightening to hear physicians share their experiences with the documentation process for power mobility. Jerald Winakur, M.D., F.A.C.P., C.M.D., is Clinical Professor of Medicine and an associate faculty member at the Center for Medical Humanities and Ethics at the University of Texas Health Science Center in San Antonio.
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This is how Dr. Winakur describes the documentation process required by the federal agency that operates Medicare, the Centers for Medicare and Medicaid Services (CMS). This was published in the American Association for Homecare bulletin, "Mobility Matters:"
"I am a privately practicing internist and geriatrician. I have spent the last 35 years of my life trying to keep my frail and elderly patients at home, functional and independent for as long as possible. Thousands of my primary care colleagues are doing the same thing across the country. Our mission - whether as health care providers, loving family members, or concerned fellow citizens - is to respect our elders' autonomy, and support them in their desire to remain at home for as long as they can stay safe and secure. If I falter in my mission, I realize that my frail, elderly patient - often along with his or her spouse - will end up in a long-term care facility. Instead of helping me in my mission to keep my patients functional at home, CMS or Medicare throws stumbling blocks in my way at every turn it seems.
Take what should be a simple task: obtaining a power wheelchair for my patients when they need one to stay in their home. I cannot just order this device as I would a cane or a wheelchair or a walker, that is, by writing my request on a prescription pad and having it easily filled by a Durable Medical Equipment provider with minimal input and paperwork from me or my office.
No. My patient must come in for a CMS-mandated face-to-face 'Power Mobility Evaluation' examination. The equipment provider - prior to this special mandated exam - is in constant contact with my office gathering its own information from my patient's demographic and medical record. I am mandated to see the patient face-to-face even if he/she had just been in last week - at the time I suggested he might benefit from a power wheelchair.
I could have been - should have been - seeing another patient for a real illness. I can just picture my colleagues across the country in this same situation. How many of them would take a look at the requirements, glance at the thick stack of paper, burn with rage, and toss the forms into the trash, saying to office staff: 'Just tell Mr. So-and-So that I don't have the time for this. If he wants one of these things he's just going to have to pay for it out of his own pocket!'
Here is my epiphany: CMS wants me to react in this way. They want me and my colleagues across America to get angry and refuse to fill out the paperwork. They have promised our elderly and disabled countrymen the benefit of power mobility, and industry has responded to the need. Meanwhile, CMS looks down the road and sees a tsunami of old folks rising up out of the demographic ocean. We can't possibly pay for all these scooters and power wheelchairs, they whisper to each other in closed-door meetings. Let's just make it ridiculously hard for a doctor to get one of these things for his patient. Let's swamp 'em with paperwork! They hate paperwork!
I have now performed two or three 'Power Mobility Evaluations.' They take me most of an hour to see my patient, examine him or her, complete the redundant paperwork. I am also required to write a chart note in the patient's medical record re-hashing the same information I have put on a form, rather than just putting the form in the patient record. Then there is all the work my staff has to do behind the scenes - several communications with the provider by phone. I could have seen two ill patients - ones that really needed my ministrations - in this same time frame.
Even worse, doctors and providers cannot get clear guidance as to what information is required by CMS after the mandated 'face-to-face' encounters. It is a classic, bureaucratic 'Catch-22.'
This is how I feel: CMS has developed a hodge-podge response to the needs of our citizenry. Worse than overly bureaucratic, the agency is cynical of its own mission, suspicious of those of us - physicians, hospitals, industry - who are trying our best to work within the very arbitrary rules spewed out in what appears to be a flailing, ill-conceived, short-term fix to save dollars - one year at a time - without regard to the big picture. By its actions, Medicare stifles innovation, discourages physician participation in the program, and - most egregiously - restricts the autonomy of elderly and disabled citizens, the very ones it is the mission of CMS to help. And, paradoxically, CMS ends up spending more money, not less, in the long run. This is shameful behavior that deserves the transparent light of day shone brightly upon it.
At a time when our elderly population is burgeoning, at a time when the kinds of doctors needed to care for this population is plummeting, CMS continues to undermine our citizens and those of us who have devoted our lives to ministering to them.
Caregivers and providers of any and all ilk need to be empathetic, fair, and innovative. And honest. We should ask nothing less - expect nothing less - of our government and its agencies than that they perform in a similar fashion."
Mobility Matters is published periodically by the American Association for Homecare to inform Congress, the administration, policymakers, consumer organizations and the media about Medicare's power mobility benefit, and the need to sustain it. AAHomecare is committed to helping seniors and people living with disabilities regain their freedom and independence. To learn more about the Medicare power mobility benefit, go to www.aahomecare.org/mobility. American Association for Homecare, 2011 Crystal Drive, Suite 725, Arlington, Virginia 22202, 703-836-6263.
SOURCE American Association for Homecare
