Protest seeks to block Medicare policy changes on prosthetics payments

WASHINGTON – Ann Morris stood outside the U.S. Department of Health and Human Services on Wednesday on artificial legs. The 47-year-old St. Louis Park resident who lost limbs to diabetes had traveled to Washington for the first time in her life to make a point:

She worries that newly proposed restrictions on Medicare payments for prosthetics will hurt amputees.

Right now, she said, Medicare won't pay for the artificial legs best suited to her body.

Medicare's current coverage policy, said Morris, is "why pay for an Audi when a Hyundai will work."

What she and roughly 100 other protesters gathered in front of the Hubert Humphrey office building fear is that Medicare's latest proposal could limit coverage to a 1970s Vega.

The changes envisioned by Medicare, the government's health insurance agency, revise coverage for what are called "definitive prosthetic components." The proposed rules also require a medical exam by a doctor or health professional other than a prosthetics expert to determine "functionality." Additionally, the rules mandate participation in a rehabilitation program before amputees can get a "definitive prothesis" and limit Medicare payments for certain adjustments to prosthetics, as well as coverage for certain kinds of prosthetic technology.

Medicare's regional durable medical equipment contractors proposed the rule changes.

"CMS believes that Medicare beneficiaries will continue to have access to lower-limb prosthetics that are appropriate, and the intent of this proposed local coverage determination is not meant to restrict any medically necessary prosthesis," an agency spokesman said in an e-mail to the Star Tribune. "We welcome comments from the public and stakeholders on how to improve the proposal so that Medicare beneficiaries are able to get the lower-limb prosthetics they need."

The government is getting an earful from advocates for amputees and trade groups for those who make and fit prosthetics.

"I've heard from a number of constituents, along with patient groups, that have raised serious concerns regarding this proposed CMS policy," Rep. Erik Paulsen, R.-Minn., said in a statement to the Star Tribune. "I share their apprehension on what this rule would mean for patient access to prosthetic care and will be engaging with the agency to encourage them to pursue a different path."

The rules "are looking to disregard the recommendations of prosthetists," said Teri Kuffel, part owner of Arise Orthotics and Prosthetics in Blaine. "That's quite a slap in the face to our industry."

Kuffel stood with Morris and other Minnesotans outside Medicare's central office Wednesday in a show of solidarity. The protest followed a morning hearing in Baltimore, where many weighed in with concerns.

High on the list were the ways the proposed rules would withhold Medicare payments for technically advanced prosthetics that allow amputees to walk and for certain adjustments to amputees' existing devices. If that happens, critics say, not only will Medicare recipients lose coverage, but private insurers are very likely to follow the government's lead and limit options for millions more.

"They're limiting technology," said Bob Nichols, a 34-year-old sod farmer from Isanti who lost a leg in a tractor accident a year ago. "If you told Bill Gates 20 years ago that he had to limit technology, can you imagine what would have happened."

In addition to clamping down on coverage for state-of-the-art, the proposed rules do not allow payment for "socket changes or component changes on preparatory prosthesis for 90 days following delivery," the American Orthotic and Prosthetics Association, a trade group, says.

Amputees like Troy Benesh of Minneapolis say changes in swelling and scarring make constant tweaks in the preparatory device necessary.

"It comes down to fit," said Benesh, who lost both legs to an infection. "If it doesn't fit, you can't wear it. It's like you're banging the bone against the socket."

Other rules appear to disqualify amputees from prosthetic coverage if they ever use a walker or a cane, Kuffel said.

"Everyone at the beginning uses a walker or a cane," 44-year-old Scott Tjaden of Minneapolis said. He lost a leg to cancer in 1980 and has grown to appreciate the quality of life that technological advances bring.

"I've worn that old technology," he said. "You fall a lot. Today's technology is safer. What does a fall cost [Medicare] for someone in their sixties who breaks a hip compared to the cost of a new device."

In addition to Wednesday's hearing in Baltimore, the Center for Medicare and Medicaid Services will accept comments about the proposed prosthetic rules until Aug. 31. Final rules should come a few months after that.

Ann Morris, who is on her fourth pair of legs in five years, hopes the regulators listen to concerns of those like her. She believes that reducing their options also reduces their self-esteem.

"If I don't have my legs," she said, "I feel disabled."

Jim Spencer • 202-383-6123