I admit it. When it comes to all this new prosthetic technology, my "edge" is a little dull. Still, I keep hearing about it in the news. A recent article in my local newspaper called it "amazing technology"; a television anchorman referred to a recent advance as an "incredible accomplishment." You might recall when a German scientist told the world that Oscar Pistorius prosthetic running legs "give him a clear edge over able-bodied runners." Not too long after that, one of the largest automakers in the world debuted a television commercial featuring an amputee running using one of those same carbon-fiber blades. And a while back, someone sent me an e-mail about a gentleman who claims his computer-controlled knee saved his life by helping him descend 63 flights of stairs in his escape from the World Trade Center on September 11.
When I hear about new O&P technology, I know it's going to be one of those good-news, bad-news stories. The good news is that we can make legs that might allow a bilateral amputee to qualify for the Olympics; the bad news is that no one except sponsored elite athletes can afford them.
To borrow a phrase from Al Gore, it is O&P's "inconvenient truth" that reimbursement has not kept up with technology. Worse yet, it has kept a lot of good ideas just that—good ideas that never make it to the folks who really need the next "amazing technology."
Not only do manufacturers put an average of three to four years of time and money into developing new technology, but they also gamble on whether or not they will get an L-Code for its reimbursement. If they do succeed in getting a new code, it will have taken another 18 to 24 months to get it. To make matters worse, manufacturers often get what we used to call a "pig in a poke." They have no idea how the code will read or what they will get paid for it until it's out of the bag.
Bringing new technology to market is like Joseph Heller's Catch-22. You have to sell a certain quantity of a new leg or brace part in order to get an L-Code. But how can you sell something that isn't approved for reimbursement? Payers will say, "No problem—just use the description and one of the codes that end in 999." My office manager says the 999 comes from the number of times out of 1,000 that you will be turned down for payment. But if you don't use the recommended 999 and description, the record of that billing isn't counted toward sales for a new code.
So what happens? Manufacturers lean toward developing new devices that fit current codes and then argue that their "new" devices are functionally equivalent to devices that already have L-Codes. So, if it's new, but it does the same thing as an old one, then why would a patient need it? And when the auditor comes knocking on my door, I can't blame it on the manufacturer; he didn't sign the bill.
In some cases, insurers simply decide not to cover a device like a microprocessor knee because they deem it "experimental." Descending 63 flights of stairs in a building that's about to collapse should be all the proof we need that a device is not experimental. Truth be told, it's just another way to deny coverage. Has there been some abuse of the codes? Sure, but why continue to punish the innocent for the crimes of others?
When it comes to getting paid for new technology, the government and insurance companies have us right where they want us—fenced into old codes and fenced out of getting new ones. I guess they figure that will save them some money, at least in the short run. I don't have too many patients who are ready to qualify for the Olympics or even many who need to run down 63 flights of stairs. But I do have some who work on a farm seven days a week, ride horses, and chase grandkids. Don't those patients also deserve the best technology we can give them?
I guess it's like every other problem in life; you can sit in your rocking chair and complain about it or saddle up and do something about it. So I'm dusting off my saddle and riding over to my senator's office. Then I'm going to call all my other congress members and ask my patients and friends to do the same. I'm going to tell them that we are not DME—wheelchairs, walkers, crutches, and the like. We make custom devices with the best technology available, and we want to get paid so we can keep providing "amazing technology."
Now you know why I'm... Edgy.
Editors note: EDGY, as you might guess, is an amputee who works in the O&P profession. You can e-mail your own EDGY comments and stories to OandPedgy@aol.com