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.

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Comments

Dr Kirk should be ashamed. Just because there may be abuse and fraud in Oregon's DME system doesn't mean that children with disabilities should not receive mobility equipment that enables them to participate and share their other abilities in their community.

The cost of wheel chairs for disabled children or youth is not any where near $20,000. This is a red herring to distract from the real issue of withholding services to vulnerable children and youth in order to increase income for managed care groups. It is a classic conflict of interest that the OHP system allows and perpetuates. The MC groups in Oregon are well known for withholding durable medical equipment from disabled children. Dr Cockrell is to be applauded for sharing the abuse. Individuals will always rise up to victimize the vulnerable; that is no surprise. The surprise is when the general public finds out about the abuse and, through their silence, give tacit agreement to the immoral acts. I am never surprised by the Dr. Kirks or Dr Dannenhoffers of the world. I am surprised by the community which does not call them out for what they are- people who cheat children out of whatever productive lives they might have for money. The state of Oregon rewards and condones this type of behavior and we as the citizens of Oregon continue to allow it. That's what makes me sick.

I don't think that Dr Kirk needs to be ashamed of speaking the truth. Many things are nice to have and even medically necessary but are not a covered benefit under the Oregon Health Plan. Limited resources are a reality we cannot ignore, especially as deficits are rising. From what I understand, many of these specialized chairs cost 20,000 dollars or more and need to be replaced as the child grows. What other needed services and people will we have to cut so that one child can have a designer wheel chair? This is not the economy to be looking at increasing benefits.

I also have to mostly agree with Dr. Kirk. There is significant manipulation of the wheelchair evaluation process at times, and as a Medical Director of another health plan in the state, I see this in the requests we get for wheelchairs and other durable medical equipment. While I don't disagree with the proponents of the idea, in that it would be helpful for more children to get wheelchairs, where is the realistic discussion about the cost it would create? As Dr. Kirk points out, we have limited resources. I'm curious what Dr. Cockerill would propose we give up in order to pay for such equipment, or is she merely proposing that her favorite issues get funded with total disregard for the costs incurred? Everybody wants health care to cost less-unless it involves something important to them.

Having worked in the healthcare system for over two decades I have never seen a pediatric wheelchair that cost anywhere close to 20K.

I have a very unique perspective in this particular case. As a mother of a disabled child and having gone through the unbelievably difficult labyrinth of getting a wheelchair (I take offense at designer wheelchair as stated above) for a growing child who's development, independence, and life depends on having a very specifically designed chair. And this is WITH "good" health insurance - not OHP. I am also a Family Practice doctor in the Portland area and can't describe how frustrating it is to see the increasing myriad of elderly patients coming in to my office demanding electric scooters (because the commercial on t.v. says Medicare pays for it). Most of these patients have mild/moderate arthritis or frankly are caring too much weight and are deconditioned and need physical therapy NOT an electric scooter. I'm very strict with my authorizations for such items but I KNOW other physicians aren't. I agree we have very limited resources but looking at how durable medical equipment such as wheelchairs affect each patients life and being better advocates for need and standing up to abuses is integral in a cost conscious health program.

As I told the reporter, I doubt that there would be a significant increase in the number of children who receive wheelchairs. Currently, the denial then the appeals process can take up to two years, tying up many valuable resources and negatively impacting the child's physical status. With regard to "designer" chairs, in order to propel a wheelchair, it has to be the right weight and the wheels need to be in the proper position; pediatric wheelchair prescriptions are difficult, as one has to take into consideration growth, motor abilities, positioning to minimize tone overflow, etc. Therefore, most children (as opposed to adults) require a custom chair. One of the recommendations we wanted to make was for the vendor and provider (therapist or physician) to have pediatric wheelchair experience, as I often see wheelchair prescriptions that are inappropriate and have to be redone. However, this could be challenging for children in rural areas. It is a complex issue, and this is really not my "favorite" one, but it is one that could be addressed relatively easily and could hopefully save money in the long run. Dr Janice Cockrell

To consider Medicare rules appropriate for pediatric equipment is just wrong on the face of it and to make a blanket statement that the suppliers of this equipment commit “huge fraud” is just a blatantly misleading, inflammatory remark. The “wheelchair companies” that employ RESNA certified assistive technology professionals can, and do, lose their certification if they do not comply with the RESNA code of ethics. Additionally, there are many agencies that specifically look at these providers and can revoke their ability to bill governmental agencies and close them down. Not to mention the fact that contracted OHP plans may exclude any provider they see fit. “If we need to facilitate these kids’ education do we give them taxicab rides to go to school?” Nuf said.

Wheel chairs for children do not cost $20,000. I will support the arguments about scare resources when medicaid and medicare reduce the number of open heart surgeries, a procedure costing millions of dollars per year. Several managed care plans in Oregon have made themselves quite a reputation by withholding treatment/equipment for a relatively small number of disabled children. They use the word 'efficacy' over and over but the truth is, they withhold what they can get away with in order to keep more money for themselves and their 'plans'. There are many ways to efficiently and effectively provide children and youth with special needs the equipment and procedures they need to have a chance to maintain or develop new skills but first there must be a VALUE given to the developmental potential of these children. The ability to make or keep money by withholding needed services has always led to conflicts of interest. We have proven that managed care groups will withhold from disabled children. Shame on Oregon's OHP system that allows this level of abuse and neglect. Individuals will always rise up to cheat and steal from the vulnerable. We that tolerate that abuse are as guilty as those doing it. Let's call it what it is-unethical, immoral and it should be illegal. If any believe this is going to get better in the brave new world of Oregon medical care you had better wake up. Now is the time to change the system and limit the ability of a few who don't mind harming the vulnerable children of Oregon. Thank you, Dr Cockrell, for being a voice for the disabled children.

I'm not saying it's right, but the pediatric wheelchair thing gets conflated with adult motorized wheelchairs. From the OIG, referring to the Medicare motorized wheelchairs, a big ripoff of the system. http://oig.hhs.gov/oei/reports/oei-04-07-00400.pdf $686 million for motorized wheelchairs for Medicare beneficiaries in 2007 Medicare was supposed to start requiring competitive bidding in 2006. As of 2009 in this report, it had not yet happened. To my knowledge, I don't think they ever started competitive bidding. Medicare allowed an average $4,018 for a motorized wheelchair with an average acquisition cost of $1,048. The beneficiaries copayment of $804 covered about 77% of the acquisition cost. Of course, the DME companies throw on the bells and whistles, and pressure the doctors to provide documentation to support it. Patients exert their own pressure as well. Complex packages go as high as $11,507 for a complex package with an acquisition cost of $5,880. Then add on the services they provide after the sale, average of five, up to seven for the complex packages. The chairs are advertised heavily on television, surely you've seen the commercials. Patients pressure the doctors to fill out incredibly burdensome forms, long narratives, pushing you to fudge data, to get these complex chairs. I tend to refer these out to physical med and rehab docs now, adding still more to the cost. Most of the time, the chairs are not necessary, and in fact may make things worse by deconditioning the patient. Bear in mind, all this refers to adults. Children are different, but unfortunately get conflated to the adult problem.