Medicare limits on bed use leave caregivers searching for answers

HCFA Catch-22 favors cure over prevention

If you’re venturing into the strange world of Medicare reimbursement for home care specialty beds, be prepared for a system that makes little sense and is fraught with frustration. 

Medicare policies in that area are more stringent than in inpatient care, and according to one expert, they are "misguided and contradictory." The main problem is that the rules neglect any real emphasis on wound prevention yet allow for high-cost equipment required once patients have severe ulcer problems, says Tom Dyevich, president of Atlantis Medical, a distributor in New Brunswick, NJ. 

What puzzles — and often infuriates — clinicians as well as bed manufacturers and distributors, Dyevich says, is that Medicare Part B, the policy covering home care support surfaces (and other durable medical equipment) for home care, will pay the high costs of beds for patients who have stage III and IV ulcers, for instance, but stipulate a relatively low payment ceiling for surfaces and mattresses that might have prevented those ulcers from developing or worsening in the first place. 

The minimal focus on prevention, he says, makes these policies "doomed for failure from the start, because patients who don’t have skin breakdown are put at risk when they are exposed to support surface interface pressures above capillary closure."

Three categories

For home health, support surfaces are broken down into three categories (Groups I, II, and III) encompassing increasing complexity and cost. (For definitions of the groups, see story, p. 50.) Entitlement to a particular type of bed is determined by the severity of a patient’s condition. Group I surfaces are nondynamic, include foam and gel overlays, and are used primarily for patients who have not yet developed wounds. But reimbursement levels for Group I are insufficient, Dyevich says, and limit clinicians to a selection of surfaces that are inadequate for ulcer prevention in many patients. 

Group II beds, which rely on power sources, are far more costly. "It’s a fundamental fact that if a bony prominence sustains interface pressures higher than 30 to 32 mm/Hg, the skin breaks down because capillary blood flow shuts off," Dyevich says. "Under Medicare, patients who don’t have skin breakdown, even those at risk, are exposed to high interface pressures. Lying on a two-inch piece of foam or a one-inch gel mattress is not going to offer pressures low enough to prevent breakdown over a long period. The end result is that the skin breaks down and patients then require more expensive mattresses." 

To illustrate the disparity, consider this example: One durable medical equipment suppler tells Wound Care that its most expensive foam overlay (a Group I surface) for Medicare patients in the home is reimbursed at a $185 purchase price. Had the home health company paid $250 for that same surface, Medicare still would limit payment to $185 because of its coding system. 

In contrast, for a particular low-air-loss mattress (Group II), the same supplier is eligible for reimbursement of $663 per month for the first three months and $497 per month for the next 12 months — a whopping total of $7,953 and a huge jump from a typical Group I reimbursement. 

"Wouldn’t it make sense to intercede early in the process with the appropriate product?" Dyevich asks. "So the fundamental decision is to pay now or pay a lot more later." He asserts that patients who don’t have ulcers but are at risk for skin breakdown should be provided with the support surfaces that best prevent pressure ulcers; without prevention, the ensuing costs inevitably will be far higher. 

Atlantis Medical has introduced a $750 nondynamic mattress designed for pressure ulcer prevention. Yet Medicare patients in the home currently cannot receive reimbursement for the mattress because the cost is well above the ceiling for Group I equipment. The system is so inflexible that by the time those patients qualify for the appropriate level of reimbursement, they’re required to qualify for Group II status (multiple Stage II pressure ulcers) as well.

Nothing in between

Dyevich’s opinions are echoed in the experiences of home health nurses who regularly encounter obstacles obtaining appropriate support surfaces designed to prevent pressure ulcers. "Group I surfaces theoretically can make a difference, but they’re not nearly as effective at relieving pressure as Group II surfaces," says Ben Peirce, RN, CWCN, clinical manager of the Wound Education Program for Columbia Home Care–Southeast Florida in Ft. Lauderdale. "Group I surfaces are pressure-reducing; they push on the skin less than a standard hospital mattress. Group II surfaces are pressure relieving and, according to their manufacturers, reduce tissue interface pressures below 32 mm/Hg." 

But the jump in cost and reimbursement from Group I to Group II is large, and Medicare offers no intermediate level of reimbursement for surfaces that might be more advanced — and possibly more effective — than those currently covered in Group I. 

"It would be nice to have something available between Groups I and II," Peirce says. He says a Group IB category may be in the offing, although Medicare has made no official announcement. 

What can be done to move the system toward equilibrium? There’s no easy answer, Dyevich says. He suggests contacting your congressional representatives and senators. "Let them know what’s going on. If you belong to some trade or professional organization, encourage them to fight. There’s not much else you can do." 

But take heart: Victories are not unheard of. Several years ago Dyevich joined the campaign to decrease the U.S. Food and Drug Administration’s 510k process required for introducing new medical devices substantially equivalent to products already on the market. The process typically took nine to 12 months. Industry activity was intense. Dyevich met with his congressman as well as with Senator Bill Bradley (D-NJ). "A lot of pressure was put on the FDA, and lo and behold the 510k process is now down to less than 90 days," he says. 

Industry efforts to lobby the Health Care Financing Administration (HCFA) to change the current policies have had no meaningful results, Dyevich reports. Ironically, managed care companies don’t balk at paying for Group I support surfaces that fall beyond the range of Medicare reimbursement. 

Particularly bewildering is the apparent policy contradiction among various agencies of the federal government. For instance, the Veterans Administration has purchased Atlantis’ new bed, says Dyevich. "I’ve brought this contradiction to HCFA’s attention. How can you have one taxpayer-funded organization aggressively implementing a policy of prevention while another, HCFA, goes out of its way to squash it? I’ve never gotten an answer." 

Add to the puzzle the fact that another arm of the government, the Department of Health and Human Services, publishes extensive guidelines dealing with the prevention of pressure ulcers. 

It’s true that Group I surfaces aren’t perceived as being as effective as Group II surfaces in ulcer prevention, Peirce says. "So the manufacturers are largely right. But if you read the guidelines for Group I, you’ll see that they include patients who have not yet suffered any skin breakdown. So here’s Medicare actually paying for prevention. That’s a positive sign, at least. But the reimbursement available for Group I turns out to be not enough money to let clinicians stretch the envelope very much."