Stakeholders call on CMS to overhaul prosthetic policies

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Wednesday, November 22, 2017

BOSTON – A growing gap between technology advancements and what Medicare and other payers will cover creates safety issues for amputees, says a new study.

The Rand Corporation, in a study released in October, says microprocessor-controlled knees (MPKs) prevent falls better than older artificial lower limbs. Twenty-six percent of patients with MPK limbs fall per year, compared to 82% of patients with non-MPK limbs.

“As a clinician, I have experienced with my patients that they are at a greater risk of falling when they do not have access to MPK technology,” said Dr. Michael Oros, CPO and president of the American Orthotic and Prosthetic Association during a press conference. “Stability and safety mean everything to amputees.”

MPK devices do cost more than non-MPK devices: $15,083 per year vs. $13,382 per year. But they are associated with a reduction of $3,676 per year in direct health costs and $909 in indirect costs such as lost wages, according to the study.

“Are the extra costs in line with other things that we fund?” said Dr. Soeren Mattke, managing partner, Health Care Practice, for the Rand Corporation. “Amputees have a much lower probability of falls with MPK and that translates to follow-on costs and quality of life implications.”

Despite advances in technology, Medicare total payments for prosthetics declined 15% between 2010 and 2014. Additionally, in 2015, the four DME MACs released draft local coverage determinations for lower limb prosthetics that would severely limit access to K3 and K4 devices.

CMS needs to overhaul its policies to better reflect technological advances. Even MPKs, which are considered “new” by prosthetic standards, have been around for nearly 20 years, says Oros.

“The current operating environment for coverage is outdated and needs to change,” he said.