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DataWatch

Wheelchairs, Walkers, And Canes: What Does Medicare Pay For, And Who Benefits?

Abstract

 
Medicare’s role in the distribution of mobility-related assistive technology has not been well documented, yet rapid growth and regional variation in spending, and concerns over "in-the-home" coverage criteria, highlight the need for facts. Using the 2001 Medicare Current Beneficiary Survey, we find that 6.2 percent percent of beneficiaries obtained mobility assistive technology under the Medicare durable medical equipment (DME) benefit. These beneficiaries were disproportionately poor, disabled, and users of both acute and postacute services. Average per item spending ranged from $52 for canes to $6,208 for power wheelchairs. Among beneficiaries who acquired such technology through the DME benefit, these devices comprised just 2 percent of overall Medicare spending.

Although the value of assistive technology is often cited, its predominant use in daily functioning rather than for therapeutic purposes has contributed to ambiguity in health insurance coverage. Most health plans cover this technology, but policies are typically stringent, and coverage disputes in this area are among the most common and problematic.⁵ Perhaps for these reasons, more than half of assistive technology users who are age sixty-five and older rely on personal spending to obtain such devices.⁶

Medicare covers assistive technology under its durable medical equipment (DME) benefit, although related spending accounts for only a small portion of program spending and has not been well studied to date. Several issues underscore the need for facts. First, dramatic increases in spending for power wheelchairs have generated media attention and controversy regarding Medicare’s coverage policy.⁷ Second, there has been a call to review and possibly eliminate the "in-the-home" criterion for DME, which bases coverage on a person’s demonstrated need inside his or her home.⁸ Third, 81 percent growth in spending on wheelchairs between 2000 and 2002, in conjunction with the mandate for competitive bidding demonstrations in the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, highlights the need for more comprehensive information on this benefit.⁹

Here we investigate use of the Medicare DME benefit to acquire the most commonly used form of assistive technology: mobility devices.¹⁰ We first describe the characteristics of beneficiaries by type of device acquired. We then describe the distribution of these devices and related Medicare spending (overall and per beneficiary). Finally, we examine the extent to which use of the benefit varied by individual-level characteristics as well as among the four DME Regional Carriers (DMERCs)—organizations responsible for reviewing and paying Medicare DME claims in different regions of the country.

Study Data And Methods

Top Study Data And Methods Study Results Discussion And Policy... NOTES

 
In this study we used data from the Medicare Current Beneficiary Survey (MCBS), a nationally representative survey of Medicare beneficiaries. The MCBS is a rich data source because of its large sample, extensive information on a wide range of health issues, and ability to link survey data to administrative claims for Medicare-covered services.¹¹ We examined the acquisition of mobility-related assistive technology for 12,691 community-dwelling Medicare beneficiaries of all ages who were continuously enrolled in fee-for-service (FFS) Medicare throughout calendar year 2001. The sample population is representative of roughly thirty million community-dwelling beneficiaries; those who died or were newly enrolled, resided in institutions, or participated in managed care were excluded.

Beneficiaries who obtained mobility-related assistive technology under the Medicare DME benefit were identified based on Healthcare Common Procedure Coding System (HCPCS) and related modifier codes listed in administrative claims data. Survey data were used to describe the sociodemographic and health characteristics of study participants by type of device acquired. We emphasize that this analysis is limited to Medicare’s role in providing mobility-related assistive technology; the extent to which the technology was acquired with personal or other funds was not captured in these data and is beyond the scope of our study.

Overall Medicare spending and spending per beneficiary for mobility-related assistive technology were examined by type of technology, as listed on adjudicated DME claims. HCPCS codes were used to categorize this technology into the following groups: canes, crutches, and walkers ("simple" technology); and manual and power wheelchairs ("complex" technology). Under the Medicare benefit, DME can be either purchased or rented; therefore, we differentiated between these forms of acquisition. We examined variability across DMERCs by type of device for both the overall and mobility-impaired population residing in each region. Finally, we used logistic regression to examine individual and regional characteristics in relation to technology acquisition. These analyses were conducted using SUDAAN to account for the MCBS’s complex survey design.¹²

Study Results

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Individual characteristics. During 2001, 6.2 percent of community-dwelling Medicare beneficiaries obtained mobility-related assistive technology under the Medicare DME benefit (Exhibit 1). People who acquired such technology were generally older, female, less educated, more likely to be dually enrolled in both Medicare and Medicaid, and in worse health than other beneficiaries. Use of health services (hospitalization, home health, physician visits) was much higher among people who acquired assistive technology than among those who did not but did not vary markedly by type of device. Average Medicare spending ranged from $19,400 among people who acquired manual wheelchairs to $26,907 among those who received power wheelchairs and was much higher than the $3,884 incurred by beneficiaries who did not receive mobility-related technology in 2001.

Spending by type of mobility technology. Overall spending for mobility-related DME were approximately $1.5 billion during 2001 (Exhibit 2). Average per item spending ranged from $52 for a cane to $6,208 for a power wheelchair. Spending by type of technology was highly concentrated: Canes, crutches, and walkers accounted for 53 percent of all items but just 8 percent of costs to Medicare (Exhibit 3). In contrast, power wheelchairs accounted for 8 percent of items but 66 percent of costs. The most common types of mobility-related assistive technology received under the Medicare DME benefit were walkers (36 percent) and manual wheelchairs (39 percent); walkers were typically purchased, while manual wheelchairs were most often rented. Medicare rules preclude the direct purchase of standard wheelchairs; therefore, they are typically rented for a period of time, beyond which people have the option to purchase or continue to rent them. Power wheelchairs are typically customized to the individual; therefore, they are predominantly purchased.

View larger version (18K): [in this window] [in a new window]   EXHIBIT 3 Distribution Of Mobility-Related Assistive Technology Under The Medicare Durable Medical Equipment (DME) Benefit And Related Spending, 2001

In contrast, mobility difficulty was the dominant factor related to the use of the DME benefit for complex assistive technology. After controlling for sociodemographic characteristics, difficulty walking was associated with an elevenfold greater likelihood of acquiring a wheelchair of any type, versus a 4.5-fold increase for home health use and only a small increase associated with having incurred an inpatient hospitalization.

Given a recent Government Accountability Office (GAO) report showing geographic variation in spending for power wheelchairs, we were interested in examining regional variability associated with all forms of mobility-related assistive technology, after controlling for regional sociodemographic and health characteristics.¹³ We did not find variation in acquisition of simple assistive technology across DMERC regions, but we observed variation in use of the DME benefit for complex devices. After the sociodemographic and health characteristics of the population residing in each region were controlled for, beneficiaries in the South (Region C) were 30–39 percent more likely than those in the Northeast and Midwest (Regions A and B) to obtain complex technology.

Discussion And Policy Implications

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In 2001, 6.2 percent of Medicare beneficiaries obtained mobility-related assistive technology under the Medicare DME benefit, accounting for $1.5 billion in program expenditures. We found that almost half of all mobility-related items distributed under the Medicare DME benefit were wheelchairs. Notably, power wheelchairs accounted for 8 percent of devices and 66 percent of spending for mobility-related assistive technology, whereas canes, crutches, and wheelchairs accounted for 53 percent of items and 8 percent of spending. Although these data are limited to Medicare’s role in acquiring mobility-related assistive technology, our findings have broad policy implications in several areas.

Acquisition process. Our finding that beneficiaries who used the DME benefit for assistive technology were likely to have been hospitalized or to have received home health care in the past year suggests that the use of the DME benefit supports acquisition of assistive technology, and particularly simple assistive technology, in response to acute health events rather than gradual declines in disability. By definition, hospital social workers, discharge planners, and home health nurses are highly attuned to patients’ ability to function independently at home, and they may facilitate the acquisition of technology by patients who are returning home after a hospital stay or who are homebound and require skilled care. These data do not allow us to infer causality; however, it is logical to surmise that trained medical professionals who are familiar with navigating the Medicare system may be most adept at facilitating access to needed equipment under the Medicare benefit.

Implications for "aging in place." Medicare’s focus on covering DME for use predominantly within the home is not consistent with the promotion of aging in place—in the home and in the community—and is being actively challenged.¹⁴ Although we cannot comment on Medicare costs or savings related to eliminating the "in-the-home" coverage criteria, our data show that among beneficiaries who acquired mobility-related technology in 2001, related spending constituted just 2 percent of overall annual Medicare spending. Even the most costly item, power wheelchairs, constituted only 16 percent of overall annual Medicare spending among beneficiaries who acquired a power wheelchair, in the year of acquisition. This is an important consideration, given that these items, by definition, have a life expectancy of several years. Moreover, beneficiaries who acquired wheelchairs reported difficulty with three or more ADLs, on average; more than one-third were dually enrolled in Medicare and Medicaid; and many lived alone. If these relatively more costly forms of technology allow people at high risk of institutionalization to remain independent, the costs could offset quality of life, health, and economic gains.

Medicare coverage. Given the GAO’s recent report on power wheelchairs, we anticipated finding geographic variation in access to complex assistive technology.¹⁵ Disproportionately high spending for power wheelchairs in the South (Region C) has been linked in part to fraudulent claims, and the Centers for Medicare and Medicaid Services (CMS) has taken action to ensure oversight and realign spending.¹⁶ However, it remains significant that a single national coverage policy for DME has not facilitated consistency in the distribution of services. Although our analysis confirms other reports of variation in Medicare coverage policy, it suggests that movement toward uniform coverage decisions, as has been recommended, might not be sufficient to guarantee regional equity in access to covered benefits.¹⁷

Medicare’s narrow focus on restorative rather than compensatory care is a well-documented problem for people with chronic diseases and disabilities.¹⁸ It has been argued that the coverage process undervalues many important services, such as assistive technology, where demonstrated evidence of therapeutic effect is limited.¹⁹ Given the known ambiguity surrounding coverage for assistive technology and recognition of the importance of clarity in coverage policy for promoting equity in access, the CMS should at a minimum specify the circumstances that make the acquisition of mobility assistive technology "reasonable and necessary."²⁰

Long-term care. Assistive technology holds promise as a means of improving self-care and may reduce the need for both paid and unpaid help.²¹ Observed trends toward greater use of paid help create a more pressing need for families, third-party payers, and policymakers to understand and promote effective and low-cost approaches, such as assistive technology, by which older adults can use self-care strategies to cope with disability.²²

Editor's Notes

 
Jennifer Wolff (jwolff{at}jhsph.edu) is an assistant professor in the Department of Health Policy and Management and Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland; Judith Kasper is a professor in that department. Emily Agree is an associate professor in the Department of Population and Family Health Sciences, Bloomberg School.

The authors gratefully acknowledge the valuable comments of Gerard Anderson, Robert Herbert, and Helen Hoenig. This study was funded by Partnership for Solutions, a program of the Robert Wood Johnson Foundation.

NOTES

Top Study Data And Methods Study Results Discussion And Policy... NOTES

 

1. A.I. Batavia, "Of Wheelchairs and Managed Care," Health Affairs 18, no. 6 (1999): 177–182[CrossRef][Medline]; B. O’Day et al., "Health Plan Selection Criteria by People with Impaired Mobility," Medical Care 40, no. 9 (2002): 732–742[CrossRef][ISI][Medline]; National Council on Disability, Federal Policy Barriers to Assistive Technology (Washington: National Council on Disability, 2000); and G. Dejong et al., "The Organization and Financing of Health Services for Persons with Disabilities," Milbank Quarterly 80, no. 2 (2002): 261–301.
2. K.G. Manton, L. Corder, and E. Stallard, "Changes in the Use of Personal Assistance and Special Equipment from 1982 to 1989: Results from the 1982 and 1989 NLTCS," Gerontologist 33, no. 2 (1993): 168–176[Abstract]; and J.E. Norburn et al., "Self-Care and Assistance from Others in Coping with Functional Status Limitations among a National Sample of Older Adults," Journals of Gerontology, Series B—Psychological Sciences and Social Sciences 50, no. 2 (1995): S101–S109.
3. L.M. Verbrugge, C. Rennert, and J.H. Madans, "The Great Efficacy of Personal and Equipment Assistance in Reducing Disability," American Journal of Public Health 87, no. 3 (1997): 384–392[Abstract/Free Full Text]; E.M. Agree and V.A. Freedman, "Incorporating Assistive Devices into Community-based Long-Term Care: An Analysis of the Potential for Substitution and Supplementation," Journal of Aging and Health 12, no. 3 (2000): 426–450[Abstract/Free Full Text]; H. Hoenig, D.H. Taylor Jr., and F.A. Sloan, "Does Assistive Technology Substitute for Personal Assistance among the Disabled Elderly?" American Journal of Public Health 93, no. 2 (2003): 330–337[Abstract/Free Full Text]; and W.C. Mann et al., "Effectiveness of Assistive Technology and Environmental Interventions in Maintaining Independence and Reducing Home Care Costs for the Frail Elderly: A Randomized Controlled Trial," Archives of Family Medicine 8, no. 3 (1999): 210–217.[Abstract/Free Full Text]
4. National Alliance for Caregiving and AARP, Caregiving in the U.S. (Washington: National Alliance and AARP, 2004).
5. S. Singer et al., "Decreasing Variation in Medical Necessity Decision Making" (Stanford, Calif.: Center for Health Policy, Stanford University, 1999), 1–84; and W.H. Donovan, R.E. Carter, and M.A. Wilkerson, "Profile of Denials of Durable Medical Equipment for SCI Patients by Third Party Payers," American Journal of Physical Medicine 66, no. 5 (1987): 238–243.[ISI][Medline]
6. M. LaPlante, G. Hendershot, and A. Moss, Assistive Technology Devices and Home Accessibility Features: Prevalence, Payment, Need, and Trends, Pub. no. 217 (Hyattsville, Md.: National Center for Health Statistics, 1992).
7. U.S. Government Accountability Office, Medicare: CMS Did Not Control Rising Power Wheelchair Spending, Pub. no. GAO/HEHS-04-716T (Washington: GAO, 2004); and "Testimony of Herb Kuhn, Director, Center for Medicare Management, Centers for Medicare and Medicaid Services, on Power Operated Wheelchairs before the Senate Finance Committee," 28 April 2004, www.cms.hhs.gov/media/press/testimony.asp?Counter=1025 (6 April 2005).
8. Medicare Rights Center, "Forcing Isolation: Medicare’s ‘In the Home’ Coverage Standard for Wheelchairs" (New York: Medicare Rights Center, 2004).
9. Medicare Payment Advisory Commission, Health Care Spending and the Medicare Program (Washington: MedPAC, 2004).
10. J. Russell et al., Trends and Differential Use of Assistive Technology Devices: United States, 1994, Pub. no. 292 (Hyattsville, Md.: National Center for Health Statistics, 1997).
11. G. Adler, "A Profile of the Medicare Current Beneficiary Survey," Health Care Financing Review 15, no. 4 (1994): 153–163.[Medline]
12. Research Triangle Institute, SUDAAN User’s Manual, Release 8.0 (Research Triangle Park, N.C.: RTI, 2001).
13. GAO, Medicare: CMS Did Not Control Rising Power Wheelchair Spending.
14. Medicare Rights Center, "Forcing Isolation."
15. GAO, Medicare: CMS Did Not Control Rising Power Wheelchair Spending.
16. Ibid.; and Kuhn, "Testimony."
17. GAO,, Medicare: Divided Authority for Policies on Coverage of Procedures and Devices Results in Inequities (Washington: GAO, 2003); and S.B. Foote et al., "Resolving the Tug-of-War between Medicare’s National and Local Coverage," Health Affairs 23, no. 4 (2004): 108–123.[Abstract/Free Full Text]
18. G. Anderson and J. Knickman, "Changing the Chronic Care System to Meet People’s Needs," Health Affairs 20, no. 6 (2001): 146–160; and J. Eichner and D. Blumenthal, Medicare in the Twenty-first Century: Building a Better Chronic Care System (Washington: National Academy of Social Insurance, 2003).
19. C.M. Clancy and E.M. Andresen, "Meeting the Health Care Needs of Persons with Disabilities," Milbank Quarterly 80, no. 2 (2002): 381–391.
20. Singer et al., "Decreasing Variation"; and Foote et al.,, "Resolving the Tug-of-War."
21. Agree and Freedman, "Incorporating Assistive Devices"; and Hoenig et al.,, "Does Assistive Technology Substitute?"
22. K. Liu, K.G. Manton, and C. Aragon, "Changes in Home Care Use by Disabled Elderly Persons: 1982–1994," Journals of Gerontology, Series B—Psychological Sciences and Social Sciences 55, no. 4 (2000): S245–S253; and B.C. Spillman and L.E. Pezzin, "Potential and Active Family Caregivers: Changing Networks and the ‘Sandwich Generation’," Milbank Quarterly 78, no. 3 (2000): 347–374.

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