Proposed Medicare restrictions on artificial legs: should they roll back to 1970s standards of care?

Great Debates
1

Medicare has sent out a proposal to restrict prosthetic coverage and reimpose 1970s standards of care, allegedly.

Here’s the website opposing the new standards: http://saveprosthetics.org/

Here’s a petition to rescind the medicare proposal. It needs 100,000 signatures by Aug 30th. It has about 7900 to go.

If I understand it correctly, they don’t want to cover devices costing about $20,000 - $40,000. Medicare proposal to limit amputees with prosthetics

Another article:

Old thread: a poster was frustrated that insurance wouldn’t cover a ~$45,000 computerized leg: Why Is a “Real” Limb Worth more Than a Prosthetic Limb Argument: real legs can rack up medical bills of $100,000 - $1,000,000. So why do insurance companies cap out at $3500 for a new prosthetic leg?

Debate: 1) Are the above characterizations accurate? 2) Should Medicare refuse to provide $20,000 prosthetic devices to Medicare patients? After all, crutches and wheelchairs are cheaper. Canes are incredibly cheap, as are walking sticks and spears. Or should we consider Medicare to be an insurance program that should cover lost legs and arms? 3) Should posters sign the internet petition at whitehouse.gov?

2

Here’s an advocacy piece by Peter D. Rosenstein, former Executive Director of the American Academy of Orthotists and Prosthetists (AAOP). He opposes the rollback: [INDENT]The current standard of care in prosthetics is routinely depicted in the media as individuals with once disabling conditions returning to active, healthy lives; re-engaging in employment; pursuing recreational and athletic interests; and even returning to active duty military assignments. Due to the current standard of care, limb loss is simply not the disability it once was for all Americans including Medicare beneficiaries.

…The proposed LCD (DL33787) is a comprehensive re-write of Medicare’s entire lower limb prosthetic benefit based on virtually no evidence to support it. It would dramatically reduce beneficiary access to the current standard of prosthetic care. [/INDENT]

3

And people get upset about “Socialized Medicine”.

Medicare was never intended as primary insurance - it is a “if nothing else, at least this much” system. Coverage is 80%, not 100% of covered expenses.

One exception is kidney failure - for CKD* Stage V, Medicare picks up the tab - even if you do not qualify for Medicare any other way.

Now we want it to pick up top-of-the-line prosthesis. Nobody is saying ‘you can’t have that’, just ‘this is what we will pay for’.

I am reminded of a tug-your-heartstrings column in a newspaper 30 years ago wherein the author was at a drugstore and observed an elderly gent trying out walking canes. He really liked the nice, soft tip, but the clerk informed him that his insurance would pay for only the cheap, hard one. In the story, the old fellow leaves with his painful-to-use hard tip.

My question was: How much did the deluxe tip cost, and why didn’t the author buy it for the fellow?

This is just another example of people being quite willing to spend other people’s money - “You should pay for it!” - Ummm - how much have you contributed to a fund to buy $40,000 legs for the indigent?

  • Chronic Kidney Disease - newspeak for ‘kidney failure’.
4

Factual correction: These aren’t necessarily top of the line prostheses we’re discussing. Under the status quo, the quality of the prosthesis is tied to your needs: if you just amble around the house you don’t get the top stuff for example.

The proposal wants to allegedly turn back to 1970s standards of care. I’m not sure what that means, except that computerized legs weren’t available back then.

Factual correction: Medicare recipients are elderly. This isn’t a program for the indigent, any more than social security is. This comes out of your payroll taxes.

Oh sure. 80% of $20,000 would be fine, if that’s the standard. I’m all on board for uniform policies: that’s what I’m advocating.
My suspicion is that for some reason people who would accept a $100,000+ bill for open heart surgery balk at the prospect of paying $20,000 for a thing. Which is sort of odd since a lot of that cost involves fitting, etc. if I understand things properly.

(Disclosure: I have a friend who is a prosthetist who passed on this info. I have no direct financial interest. Nor do I really have expertise. That’s why I posted this.)
Aspects of this thread

  1. I could be wrong in some fundamental way: I haven’t read any decent treatments of this subject.

  2. Cost control is a big issue in health care debate. It’s also hard to wrap your head around.

  3. usedtobe is correct that the rubber hits the road here in terms of the welfare state. I’m arguing that Medicare is a form of insurance, because well it is. Incidentally, according to this website computerized legs top out at $70,000. I understand that experimental ones can be more (it’s R&D after all) and they are often fitted to our soldiers who fought in Iraq.

  4. From This paper.

There are about 2 million amputees in the US and about 185,000 amputation surgeries per year. This isn’t just an indigent thing.

A $5000 - $7000 unit lets you walk on level ground.

“A prosthetic leg in the $12,000 to $15,000 price range will facilitate running and functioning at a level nearly indistinguishable from someone with two legs.” I think Klaatu would disagree with that last characterization.

C-legs start at $20,000 - $30,000. “These take readings in milliseconds, adjusting for degree and speed of swing. Above-the-knee amputees can walk with a C-Leg without having to think about every step they take.” So it appears that the author of the piece doesn’t exactly agree with the preceding characterization as well. If you have to think about every step, I wouldn’t call the general experience indistinguishable from somebody with 2 legs. IIRC, Klaatu wrote about the possibility of falling down on his face with a low-tech leg if he wasn’t careful.

  1. So is the Medicare proposal intended to curb C-leg prescriptions? Or are they pushing the $5000 models? I haven’t a clue.

  2. Here’s the sort of thing that makes usedtobe’s skin crawl, or so I’m guessing. Mainly because it does the same to me: “Amputee advocates insist that access to limb prosthetic devices and services are a medical right and not a privilege.” Nice try, I say. It’s more an issue of a) how much we care about somebody who lost a leg in Iraq due to an IED, b) how much we care about a kid born with a deformity or an elderly person who lost a leg due to diabetes. This is an insurance issue: it could happen to anyone though of course lifestyle choices such as exercise and girth control are a factor, as is genetics and random variation.

Remember: 185,000 amputations a year in the US: we all bear this risk to some extent.

5

Have you personally ever done something like that? In my world, it sounds like it would be socially awkward. Most people would refuse such a form of charity, and may even suspect that it’s a scam.

Personally, I much prefer a decent safety net with uniform rules over handing dollars to panhandlers. Or strangers at the local pharmacy.

6

How should we think about this problem? Rawls’ approach might not be a bad one. Imagine yourself in the original position: figure out the principles of limb replacement behind a veil of ignorance: pretend that you have some risk of losing your limb and set the societal standards accordingly. Of course in this case everyone does face such a risk: here, we’re only simplifying the problem by saying that the risk you face is equal to the societal average, or 1.9 million over 310 million. That’s 6/10ths of 1% or about 12 times that (7.4%) for an extended family of 12. Ignore friends. For those who play board games, the odds of rolling a 10 are 8.33%. (Rolling a 12 is 2.78% in contrast.) Meh.

Well damn, getting insurance for a $5000 - $7000 leg so I or a family member can at least hobble around sounds reasonable, at least in the US. 80% of 15K - 20K doesn’t seem way out of wack either, and plenty would go higher. The lifetime cap of some US insurance policies of $10,000 seems off and a little odd.

But that’s my WAG: I would welcome a systematic QALY-type study. International comparisons would also be appropriate. That would provide a better foundation for reasoned policy.

SB 98, proposed in 2008, extends prosthetic coverage. This advocacy piece (pdf!) provides some numbers. They claim the annual cost per insurance member is 13-25 cents. But that’s not a systematic analysis in my view.

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My brother had an above the knee (AK) amputation due to cancer in the mid to late 1990s. He had Medicaid coverage* and was somewhat limited in options for a prosthesis. Fully computerized limbs were only in the development stage. And so my brother ended up with a run of the mill leg.

He did have to think about every step since his was an AK amputation. And it didn’t fit quite right as his stump continued to change for quite a while. It wore blisters into his skin if he used it for very long. Net result, he didn’t use it often.

And if he had, there are limits as to how often he could get a new prosthesis. Once every few (3 to 5?) years? Don’t recall the exact time frame.

And this is the real problem with covering for a top of the line prosthesis. They wear out and need to be replaced. It’s not a one-off $30,000. It’s $30,000 every 3 or 5 years. More often if it is for a growing child.

So cheap legs may not end up being used consistently. Expensive legs can be REALLY expensive. Need to figure out how to make the top of the line one more modular so only the worn part need be replaced.

  • Lest anyone be harsh on him he was working and had COBRA coverage for a decent health plan with a well known carrier. His prior employer pocketed his premium checks and did not send the money to the insurer. Yeah, fraud. Thus my brother lost good coverage in the middle of cancer treatment and ended up on Medicaid.
8

Damn, must be time for the draft Final Rule…

I’m hopeful that this will get beat back into the ground where it belongs.

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Well, here is the real problem. People think of Medicare as “welfare”. Which is of course wrong. I’m disabled, on the job accident and I recieve disability and Medicare. I PAID for that benefit through payroll taxes. However, when people regard it as welfare they suddenly think those of us on it are free loaders.

I counter with the argument that you totaled your car. Why should insurance pay for it, it’s expensive to replace your $40,000 car. You haven’t paid in that much in insurance, so why should they pay that much out? But, but I paid for coverage. Right Chief, so did I and everyone else on disability/Medicare.

10

Yes.

And this is why we have safety nets. The glibertarian solution would be to have your brother sue his employer. Reality tends to be messier and more fraught with surprises.
The other reason is that people are over-optimistic about the quantity of their retirement savings. Kevin Drum: [INDENT] If you ask current workers, only a third think that Social Security will be a major source of retirement income. But if you ask current retirees for a reality check, two-thirds report that Social Security is a major source of their retirement income.

Why the big difference? If workers think Social Security benefits are likely to be cut, that’s probably a part of the explanation. But a bigger part is almost certainly just invincible optimism. Current workers are sure they’re going to save enough, or get a big enough return on their 401(k), or get a big enough inheritance, or something—and this will see them through their retirement. Social Security? It’ll just be a little bit of extra pin money for fun and games.

But in reality, that’s not how it works. For most people, it turns out they don’t save nearly as much as they think, which in turn means that their little Social Security check is what keeps them solvent. If more people understood this, public acceptance of conservative plans to cut Social Security benefits would probably be a lot lower. [/INDENT] Another example: I understand that most of Medicaid is actually paid out to the elderly in nursing homes.
Social Security Is More Important Than a Lot of People Realize – Mother Jones

All that said, I understand from my friend that it’s not unusual for prosthetic devices to no longer fit after a few years, especially if the patient gains or loses weight. It’s a problem as the rules aren’t particularly generous under such circumstances, for better or worse. I frankly don’t have a solid grasp on existing policies, never mind what I think they ought to be.