OHP Kids Lack Wheelchairs Outside the Home
But opponents remain concerned about potential abuse and higher costs
September 28, 2010 -- Frustrated with how long it takes to get wheelchairs approved for children who have developmental needs, a group of pediatric rehabilitation specialists has proposed rule changes to expand coverage for wheelchair-bound children covered by the Oregon Health Plan.
The problem, according to Dr. Janice Cockrell, medical director of Legacy Health’s pediatric rehabilitation and development program, is that children are subjected to the same Medicare rules that apply to adults. Currently the Department of Medical Assistance Programs (DMAP) approves wheelchairs for adults to maintain their level of function.
But that’s not appropriate for kids, Dr. Cockrell said. “The issue is kids have developmental tasks before them. With children it’s not maintenance. You’re trying to move them forward.”
She said mobility has been associated with improved cognitive skills and proper positioning is important for motor control. “A key component of a child’s development is being able to get into the community and interact with the environment and with peers. Therefore, Medicare criteria are not appropriate for children.”
As such, wheelchair-bound children medically need a wheelchair outside their home to improve their functioning – not just to maintain it, she said. But that’s contrary to current Medicare rules.
The proposed rules allow for pediatric wheelchair patients to use the chairs “in their environment” as opposed to just at home. Documentation from a health professional – either a physical or occupational therapist or a physician – distinguishes the client’s abilities and needs within the home and/or how the chair will “significantly improve” the client’s “developmentally appropriate access” to the community.
The plan also requires the chairs to be provided by a company that has an assistive technology professional who specializes in wheelchairs, and who is directly involved with selecting the wheelchair for the client.
The cost of the changes, which are not yet in final form, has not yet been determined and both proponents and opponents were unable to put a price tag on the plan.
Dr. Chris Kirk, medical director of Mid-Valley IPA in Salem, is one of those opponents. The idea of expanding coverage for wheelchair-bound kids may sound nice on paper, he said, but it’s not possible in this current budget climate. “If we need to facilitate these kids’ education do we give them taxicab rides to go to school?”
Dr. Kirk said he’s personally seen instances of huge fraud and abuse perpetrated by wheelchair companies providing equipment to the state-sponsored plan. Those abuse cases, he said, were for adults, and he suspects that the number of children who would qualify for expanded coverage would “probably be a small number.”
Proponents of the change say while it might cost money upfront, overall it would actually save money in time and administrative hassles as children who don’t get their chairs on the first try must go through a lengthy appeals process and are eventually approved. “But in the meantime the child’s in a chair that’s too small,” Dr. Cockrell said. This can lead to a deterioration of posture and function as hamstrings become shorter and additional therapy – and cost – is needed to stretch them out again.
Don Ross, a manager at the DMAP, said the proposal was discussed at a meeting this summer and is being considered, but there’s not been a decision. “We need to analyze the impacts of changes like this one.” Another meeting hasn’t been scheduled.
Dr. Cockrell said she and her colleagues started noticing about five years ago that it was more and more difficult to get approval for pediatric wheelchairs and she started inquiring about how to change the rules.
Typically children who need a wheelchair have cerebral palsy, spinal cord injuries, traumatic brain injuries or muscular dystrophy.
For more information
To take a look at the proposed rule change, click here
Sep 28 2010