Medicare and private insurers often pay more over the long term when they deny amputees replacement limbs, spinal orthotics and hip, knee and ankle orthotics, according to a study released Tuesday.
Patients who received orthotic or prosthetic services have lower or comparable Medicare costs than patients who do not receive such services, according to research commissioned by the nonprofit Amputee Coalition. Medicare saved about 10 percent — nearly $3,000 in lower overall costs — for those receiving lower leg prostheses than for those who did not.
Many of the savings were realized by patients avoiding hospitalizations and new injuries.
“Every person who has suffered limb loss, and who has received a prosthetic device appropriate for their needs, knows the value of the device for them personally,” said Susan Stout, interim president and CEO of the Amputee Coalition. “This study provides nationwide data which helps to corroborate this patient experience, and also points us to the need for more research regarding the value of prosthetics from both a quality-of-life and a financial perspective.”
The study was conducted by Dr. Allen Dobson, a health economist and former director of the Office of Research at the Centers for Medicare and Medicaid Services. The research encompassed nearly 42,000 sets of Medicare beneficiaries with claims from 2007 through 2010.
Devices might have a high initial cost, Dobson said, but they also encourage higher rates of physical therapy and rehabilitation. That can offset device costs and allow patients to avoid the hospital. Overall, the study found that the full-care group’s care cost an average of $27,007, while the lesser-care group’s cost $29,927.
“Looking at full costs and other outcomes over a 12- to 18-month period, our study concludes that patients who received the orthotic and prosthetic services experienced greater independence than patients who did not, with better or comparable health outcomes and generally lower Medicare payments,” Dobson said.
The full results can be found online: http://www.amputee-coalition.org/content/documents/dobson-davanzo-report.pdf
Thomas F. Kirk, president of the American Orthotic & Prosthetic Association (AOPA), said: “This is a clear win for patients and a win for taxpayers. Not only do patients who get full orthotic and prosthetic treatment benefit the most, but it also ends up costing taxpayers less in most cases.”
Advocates said they hope the data will give private insurers and Medicare officials the data they need to approve more devices for the patients who need them. In August 2011, an Office of the Inspector General report concluded that Medicare paid $43 million for lower-limb prosthetic claims that did not meet established requirements for payment. In addition, the OIG found another $61 million in claims for patients who had no record of a visit to their referring physician in the previous five years.
Medicare clamped down, sending letters to doctors reminding them to thoroughly document claims. The agency also increased its auditing of prosthetic claims. In some cases, advocates say, legitimate claims have been delayed and denied. Some doctors, they say, don’t want to bother with the requirements. In May, AOPA filed a lawsuit against the U.S. Department of Health and Human Services over those changes.
Younger patients’ experiences
But it has not just been Medicare that has made it tougher to obtain a prosthetic device, advocates say. Leslie Pitt Schneider lost her left leg when she was 6 years old after a truck hit her while she was riding her bike. Over the years, she refused to let that hold her back.
She got back into tap dancing, riding her bike and Girl Scouts.
But it was a battle with her insurance company nine years ago that discouraged her. After her doctor had approved her for a modern new prosthesis in which the artificial knee acted more like her real one, the insurance carrier refused to pay for it.
“They said it was not needed because it was investigational,” she said.
Pitt Schneider, 45, said her insurance company never did approve her device. But she works for Ottobock, a manufacturer of orthotic devices that has its North American headquarters in Plymouth. In exchange for her serving as a tester for the C-Leg system, Ottobock gave her the device.
A microprocessor controls the knee and smooths her gait. It was a more expensive device at the time, she said, but is now considered the standard of care. Many insurance companies and Medicare now cover the device.
Schneider said she feels much more stable and confident, going up and down hills and stairs and moving within a crowd. “It allows me to be fully active and to not even have to think about the fact that I wear a prosthetic knee,” she said.
Pitt Schneider, who has become a member of the Manasas, Va.-based Amputee Coalition’s board, said that fear of falling is the worst worry for those with lower limb prostheses. If patients have greater confidence, she said, they are more likely to continue therapy and keep improving.
“The results for the study very much ring true,” she said.