Should_Michigan_Medicaid_Pay_for_Durable_Medical_Equipment_

Walid K. Yassir HCM 703 Final Paper Introduction About 10 months ago, right after the election, a man brought his daughter to see me. Her complaints were of bilateral knee pain. On examination, she had completely dislocated kneecaps. She was tall for her chronologic age and because of the severity of her kneecap dislocations, I became concerned that she had Marfan’s syndrome, characterized by a defect in collagen fiber formation which resulted in increased elasticity of connective tissues, causing ailments such as flat feet, dislocating kneecaps, scoliosis, and more concerning, a dilatation of the aortic arch which could result in sudden death. I prescribed physical therapy, a pair of knee braces for her to help her kneecaps track better, referred her to the cardiologist for an echocardiogram, and the geneticist for confirmation of the diagnosis. She was a Medicaid recipient, enrolled in the Total Health Care plan. Our on-site orthotic and prosthetic company, Wright and Fillipis, is not an approved provider for Total Health Care. I provided a written prescription for the knee braces, which she would have to acquire from an approved provider. I asked her and her father to make a follow up appointment in 6 weeks so I could check on her progress and review her test results. 6 weeks later, they returned for their appointment. She had not yet received her knee braces or her consultant appointments. She was also complaining of flat feet at this visit, and on examination, her feet were extremely flat, yet flexible. Her father related to me his difficulty in getting the braces for her knees, because the Michigan Orthotic provider he had gone to insisted on first obtaining a preapproval for the braces, which takes over a week from Total Health Care, who are notorious for denying all reimbursement for care provided without authorization. The preapproval had been obtained, but they had not yet had a chance to pick the braces up. When it came to the girl’s feet, I felt that the flatness of her feet warranted an in-shoe orthotic. I advised the father that no insurance companies in Michigan, Medicaid or otherwise, reimbursed for them, but it was worth a try with an alternative diagnosis. At this point, the father, an imposing figure well over 6 feet tall wearing a Kente cloth hat, stood up and started yelling at me. “I was authorized to see you by my doctor, and everything you prescribe should be covered and available to me right now.” I agreed with him, and told him as much, but informed that unfortunately, I did not own the orthotics or the orthotic company, or I would gladly have provided them to him for free. His belligerence turned to a chant of “O-BA-MA! O-BA-MA! Things are gonna change around here!” I responded that I had voted for Obama, but that I wasn’t sure if he was going to make orthotics available for everyone any time soon. The man’s belligerence continued, and as he verged on becoming violent, security removed him. Lost in the chaos was the fact that his daughter had received none of the services I prescribed, although I felt that she really needed all of them. I had my nurse practitioner call the next day to make sure that they had, but their phone number was disconnected. We sent a certified letter to the last known address. About a month later, the father called to ask for a letter stating that his daughter had a medical condition, and that this should preclude them from having their gas shut off. We obliged. The Question This interaction raised for me many questions, one of which was whether or not the Michigan Medicaid program should pay for prosthetics and orthotics, and if so, under which circumstances. I will take the vantage point of the Janet Olszewski, director of the Michigan Department of Community Health, which oversees, among other programs, the state Medicaid program to discuss this. Michigan Medicaid is made up of 14 managed care plans which operate in differing coverage areas with some overlap. Low income families and children qualify for Medicaid in Michigan through an income test. There are other programs which are available to the working poor. Michigan joined the Medicaid program shortly after it was created and covers prosthetic and orthotic services. In 2008, 1.6 million people in Michigan were Medicaid recipients, the largest number in the state’s history, and the rolls are swelling by 15,000 per week. In June of this year, Michigan announced across the board cuts of 4% to hospitals in the state for Medicaid reimbursement. Michigan hospitals are running record deficits this year, with a bleak projected outlook, given the state’s newfound status as the first state in 25 years to have an unemployment rate above 15%. Michigan Medicaid currently reimburses for prosthetics and orthotics provided the recipient meets certain criteria. In addition to medical necessity, recipients are stratified according to their ambulatory ability, and generally, children who cannot ambulate are not provided lower extremity prosthetics or orthotics. The plans will generally cover an ankle foot orthosis, a device used to prevent a foot from slapping the ground during the swing phase of gait, but they issue blanket denials for foot orthoses or “shoe inserts” if the diagnosis is flatfoot or planovalgus foot, or any diagnosis containing the terms “flat” or “planovalgus” regardless of comorbidity, such as a genetic syndrome. When it comes to things like scoliosis, they will generally pay for one type of brace, essentially the modern day variant of the Milwaukee brace called the Boston brace, which is made of plastic and elastic cloth with firm padding inside that straightens the spine when worn. From an evidence based approach, the quality of the literature for all of these interventions is equally bad. That a person with a drop foot walks better with an AFO than without is obvious to the naked eye despite never having been subjected to a randomized, double blinded study. That a shoe insert may alleviate foot pain is not so obvious and harder to prove. That a scoliosis brace prevents the progression of scoliosis is known to be true in only 2/3 of cases, with very poor research to back it up. From a cost standpoint, a shoe insert costs about $150 dollars, while an AFO around $1500. A scoliosis brace costs around $3000. Ethical Analysis In utilitarianism, the ends justify the means. If Director Olszewski subscribed to subjective utilitarianism, she might conduct a cost-benefit analysis for each of these types of orthosis and possibly determine an individual’s willingness to pay for the intervention. Problems with this approach are that poor people are generally willing to pay less than rich people. In Medicaid programs, the enrollees are poor by definition, and are not typically expected to have the ability to make additional payments for services, being exempted even from co-pays for office visits. Were she an objective utilitarian, who believes that people don’t always make good choices for themselves, these interventions would be subject to a cost effectiveness analysis. Because of the need to compare across varied interventions, QALYs should be determined and then a cost effectiveness ratio in dollars per QALY calculated for each intervention. A policy decision could then be made about whether or not to cover each intervention taking into account a budgetary threshold, which might also include how many people would utilize the intervention. Libertarians believe that only negative rights deserve protection. In the unlikely event that Director Olszewski were a Libertarian, her main concern might be how to close down a partially funded Federally mandated program such as Medicaid, because of her strong belief that taxation is theft. Alternatively, she could seek non-tax revenue for the program, such as voluntary donations. In either event, the likelihood that she would be interested in paying for anything, let alone orthotic devices, is small. If, on the other hand, she was an egalitarian liberal in favor of redistributive taxation, she would maintain that the right to choose would be meaningless without resources, and would favor a positive right to a minimum level of services. The main ethical conflict she would face is whether or not she believed that health care represented a special case over other goods and services that people are free to purchase. If it did not, then people would be given money to purchase health insurance, as much or as little as they wished. If she believed that health care was a special case, then the decision becomes whether or not to be concerned with health care for all or health status for all. In the former scenario, she might favor no reimbursement for orthoses in exchange for providing care to the most people. In the latter, orthoses which elevated health status could be favored in cases where they truly made a difference, most likely something like an AFO, but less likely a shoe orthotic or scoliosis brace. Communitarianism focuses on kind of society and kind of person the state is trying to create. In universal communitarianism, there is one correct path, such as in the monotheistic religions or Maoism. Were the state Medicaid director a universal communitarian, she might be more interested in having people embrace her philosophy. Reimbursement for orthotics would be a secondary concern. Were she a relativist communitarian, she would believe that each society determines its own correct path. To the extent that a shoe insert or AFO could be shown to keep people on the correct path (forgive the pun), she might be willing to pay for them. If she believed, as the Italians do, that your appearance is a reflection of your soul, then she might be inclined to pay for a scoliosis brace to keep a young girl’s back from becoming crooked and twisted. Economic Analysis Medicaid solvency in Michigan is in jeopardy. With 15000 new enrollees weekly in a state with a $920 million budget deficit and the highest unemployment rate in the nation, additional Medicaid cuts beyond the 4% applied across the board this June are very much on the table. In that environment, Director Olszewski will be looking at every expenditure with an eye towards cutting it. This all takes place in a background of impending health insurance reform, with a revenue source for expanded coverage unclear at best. One of the buzzwords of the coming reform has been comparative effectiveness, and this certainly will first be applied to programs receiving federal funding. Barring the perfect storm that jeopardizes reimbursement for all things like orthotics just to keep the program alive, and despite the fact that orthotics make up a small portion of the budget, they will eventually have to prove their worth. While the private sector charges anywhere from $90 to $400 for foot orthotics, shoe stores sell off the shelf orthotics as good as custom ones for $24 at retail. While refusing to cover any foot orthotic seems draconian, it seems less so when the indications are murky and the effectiveness in question. While $24 is still beyond the reach of many, especially those on Medicaid, it becomes more accessible at this price, both to the individual and to the plan. One strategy would be to loosen slightly the diagnoses that might qualify for a foot orthotic but specify coverage only for the off the shelf variety. This would allow access to those who could benefit without breaking the bank. A similar development to that of the off the shelf foot orthotic has occurred in the ankle foot orthotic market, with a new, low cost, rapidly customizable from off the shelf stock AFO available for around $150, about 1/10th the price of a custom AFO. Medicaid has already made a coverage decision on ineffective orthoses, such as the new SpineCor scoliosis brace, invented in Montreal and only proven to work in studies conducted by its inventor. When controlled trials at other centers failed to show the brace had any efficacy in preventing the progression of scoliosis, Medicaid and other insurers refused to cover the brace. The inventor released the brace system to chiropractors who now charge upwards of $6000 to unsuspecting internet savvy families of means. It is counterintuitive that in almost every case for the above described conditions, Medicaid will pay for surgical treatment at much greater expense and with equally little literature on effectiveness. There is not one study which proves the value of scoliosis surgery except in extreme cases of curvature above 90 degrees. There are multiple operations for flat feet in children, all equally of unproven value. Political Analysis Health insurance reform, if it passes, may increase number of insured children. Without additional money, how these children could possibly receive orthotics is unclear. A decision about expanding or even maintaining orthotic coverage would certainly contain political challenges. A political analysis should take into account the players, their power, their position, and the public perception of the problem. Players The players in this scenario would certainly be Director Olszewski, and a representative from MOPA, the Michigan Orthotic and Prosthetic Association. Physicians who prescribe these for their patients would be represented by the Michigan Medical Society and the Michigan Orthopaedic Association. Patients would be represented by the well organized groups that support the rights of the disabled. Power The power in this situation is mainly concentrated in the hands of the Medicaid director. In the heady days of better employment, physicians could threaten to stop taking participating in Medicaid, but in the current economic climate, Medicaid is starting to represent a larger percentage of any given provider’s patients. The orthotic companies are in a similar situation. The best they can hope for is a cost neutral solution in which they don’t lose money caring for Medicaid patients. Advocates for patient’s rights may have legal avenues to sue for the provision of services, but many of the recipients do not qualify as disabled, so the approach is far from assured of success. Position Director Olszewski will maintain that Medicaid should not be paying for services that are unproven, and that this is one of the main causes for the rise in health care expenditure. As an egalitarian liberal, she feels that covering unproven services jeopardizes her ability to provide basic care for more people. The MOPA will argue that physicians are the best judge of what patients need, not a program stuffed with government workers intent on denying coverage. The physicians will argue the same, that an inability to prescribe these devices to their patients deprives them of necessary medical care which prevents disease, mitigates disability, and improves quality of life, and the studies proving this will be done in the next few years (if they could just get paid a little more, which would give them the opportunity to carve out protected research time). Patients’ rights advocates will argue that patients deserve these resources, and that the decision should be between physicians and patients, and not the plan, and will encourage letter writing campaigns to local politicians and the governor. Perception The public perception of the problem is colored by a long history of government programs refusing benefits based on arcane rules. The poor, who interact with the government often, know that the rules are complicated, and they must be followed. They are confused that their doctor can suggest something which will not be provided, and their perception of where physicians fit into this is often unclear. In the example given, the gentleman felt that I somehow had the power to authorize the payment for the devices his daughter required. Recipients of the care will be angered at government and insurance company denial while others will see crooked dealers who game the system, such as the “orthotic shoe game” where custom shoe makers split revenue with patients who acquire custom shoe prescriptions. Medicaid is valued by some and vilified by other based on their politics. It is always subject to complaints of wasting the taxpayers’ money while others view it as a necessary if imperfect cornerstone of our social safety net. Conclusion Director Olszewski has a particularly difficult time ahead of her. The state Medicaid rolls are swelling so rapidly that difficult decisions of the past will be dwarfed by those upcoming, and every covered person in the program cannot have access to every possible intervention. A blanket denial of foot orthoses seems unreasonable, because they certainly don’t occupy a position as controversial as some well know examples of quackery, such as coffee enemas for cancer. A more reasoned approach that involves judicious use of low cost, over the counter devices seems more appropriate and quite defensible. When it comes to ankle foot orthoses, the basic requirements of a patient who may benefit from the device should be maintained. They are critical for the mitigation of disability for so many people that denial would result in unnecessary disability. The transition to lower priced, customizable devices seems reasonable, especially because of the 10 fold difference in cost. Scoliosis bracing represents a controversial area because an expensive device is combined with efficacy that can be affected by many factors. Scoliosis braces only work if children wear them, a truth that is sometimes lost on teenagers and their parents. They don’t work in all cases, especially boys, and it may not make sense to provide an orthotic for a boy or a noncompliant girl, and then pay for an operation. Brace efficacy is also dependent on the skill of the brace maker, and the prosthetic and orthotic field suffers from an unclear path to certification. Ideally noncompliant patients would not qualify for braces, but determining this ahead of time is difficult and prejudicial. Denying braces for boys while providing them to girls would certainly raise legal challenges, especially if the small number of boys who could successfully be braced were now subjected to surgery, regardless of the confounding factor that they are Medicaid recipients. This, coupled with the natural history of untreated scoliosis, makes the decision even more difficult, as most people with curves in a natural history study performed in Iowa over a 65 year period went on to have lives that did not differ from that of the general population, except in the rare case that their curve exceeded 90 degrees. This may not hold up in an increasingly image conscious society, and the visible deformity accompanying scoliosis makes it difficult to ignore, even to an egalitarian liberal who is interest in breadth rather than depth of coverage. Director Olszewski should insist, in conjunction with other state Medicaid directors, that the Scoliosis Research Society and/or the Pediatric Orthopaedic Society of North America develop clinical practice guidelines on bracing and surgery for scoliosis that take cost effectiveness into account. This could be funded through an RFA from AHRQ, and should be used to make future determinations about bracing and surgery.