Medicare should not reverse standard of care for amputees

Today, Medicare officials have before them a draft rule that would increase the suffering of hundreds of thousands of men and women who are working hard to make their way in the world as amputees.  It is not an exaggeration to say that research into advanced prosthetics will not only cease but the standard of care will regress back to the good old days in 1969 when I was first fit with a wooden leg.

I am an amputee; more specifically I am a right below-the-knee amputee and have been dependent on the skills, dedication and artistry of prosthetists since entering the amputee world as a consequence of an injury in Vietnam in 1969. For more than half of my life I have experienced the ups and downs of wearing an inanimate object.  Some days are great.  Some aren’t.   Some days I experience very little pain.  Some days I experience nothing but pain.  

When it comes to paying for my prosthesis, I am a very lucky man because under federal law I have a claim on the incomes of all Americans to pick up the tab for my prosthesis.  The law says that all I have to do is prove that I was injured in a war and every tax-paying American (including me by the way) chips in a few pennies to cover the cost of fabricating, fitting and maintaining my limbs.  

If Medicare’s misguided rule goes into effect, it will be little more than a minor inconvenience not worthy of an entry into my diary.  But that’s not the case for up to two million amputees who depend on Medicare either directly for reimbursement or indirectly for the same through the private payers who will follow the lead of Medicare in this matter.

Here are four of my chief concerns about the Medicare rule proposal:

1.     Prosthetics should not be in the same category as durable medical equipment, such as wheelchairs.  Ironically, I do expect that the likely result of this draft rule will be more amputees being relegated to durable medical equipment, including wheelchairs, in order to be mobile.  Medicare’s draft rule seems to say that “If you use a cane or anything that reduces the chances of a fall, we won’t pay for your prosthetic limb.”  That would be a huge step backwards for amputees.

2.     Learning to walk with a prosthetic limb is a bitch.   The draft rule states the patient has to be “motivated to be ambulatory.”   The draft Medicare rule makes it sound as simple as getting an adolescent to do their homework.  Trust me, it is a hell of a lot more difficult than that. It’s not like putting on a new shoe.  As it stands, the rule unreasonably places the burden on the prosthetist to bear the cost of this decision.  I do not need to be a professional psychologist to predict the outcome: Fewer amputees will be encouraged to push through the early pain and suffering. 

3.     In a remarkable example of language only our government would use, the draft rules states:  “If there is no qualifying amputation, claims will be denied as not reasonable and necessary.”  To that, the rule adds this:  “If any part of a prosthesis is denied as not reasonable and necessary, all-related additions will be considered unnecessary.”  With these two new federal mandates in place, an amputee who depends on Medicare will find precious few prosthetists who will be willing to take on the financial risk of helping them.   

4.     The draft Medicare rule states that feet and ankles that utilize a microprocessor are not reasonable and necessary for many amputees, despite the fact that this technology has become the current standard of care.  Please, do not do this Medicare!  If the federal government does proceed with this policy, it should send the same message to our pharmaceutical companies, our surgeons, and our oncologists: Our government will not pay for any technology it decides is too expensive.  This is America and we don’t turn back the clock on care for other patients and amputees should not be the exeption to the rule.

Here’s a note for budget hawks:  Total prosthetic limb spending for Medicare peaked in 2010 and has decreased every year since. Total spending on prosthetic limbs and orthotic braces by all payers in this country is less than $2 billion a year.  To put that amount in perspective, we spend $7 billion a year for hip and knee replacements.

My recommendation is that the entire rule should be thrown out.  Instead, Medicare should undertake a real discussion with stakeholder groups to resolve any concerns it may have about the status quo.  Otherwise, this really is a case of the government creating a problem rather than solving it. 

Kerrey served in the Senate from 1989 to 2001. He was governor of Nebraska from 1983 to 1987. He served as a Navy Seal in the Vietnam war and received the Medal of Honor.