Viewpoints on the scoping review for the development of a novel coverage and service delivery policy for complex rehabilitation technology

The article, “Complex Rehabilitation Technology: A Scoping Review” [1] is perhaps the first review that comprehensively investigated both the scientific and grey literature in this field to identify gaps, challenges, and opportunities associated with current complex rehabilitation technology (CRT) service delivery and coverage policy. This work is part of a larger federally funded research project to systematically investigate and design a new coverage policy for CRT within a contemporary and accountable care model. The Disability and Rehabilitation Research Projects Program: Research on Healthcare Policy and Disability funded by the National Institute on Disability, Independent Living, and Rehabilitation Research specifically investigates CRT by partnering with academia and key disability, industry, and policy stakeholders in a series of interrelated project activities to investigate how current CRT health policy impacts health and function, community living and participation of working age people with disabilities. Although this review identifies a lack of strong research, it does highlight common themes consistent with observations in practice from our perspective as seasoned clinicians and investigators. Current United States policy on the provision and payment of CRT developed by the Centres for Medicaid & Medicare Services (CMS) and adopted by many other payers has short-comings and is more about managing waste, fraud, and abuse than it is about ensuring people with disabilities (PwD) receive the proper equipment that meets their needs to function and participate in their communities. CMS policy for CRT also does not align with other civil rights legislation such as the Americans with Disabilities Act.

Although the field has seen growth and advancements over the years, the scoping review identified several barriers related to CRT service delivery including ambiguous guidelines, lack of expertise, long wait times, lack of repair service, limited consumer training on use and maintenance of the device, lack of follow-up, and coverage policy that does not consider the overall functional needs of PwD. The purpose of this article is to highlight these shortcomings and discuss strategies and opportunities to overcome these barriers in the form of a new policy and payment model for CRT using elements of an emerging accountable care model that is evolving throughout healthcare in the United States and globally.

A new policy should fully incorporate current and future iterations of the Wheelchair Service Provision Guide issued by the Rehabilitation Engineering & Assistive Technology Society of North America (RESNA) [2]. Although the guide outlines a stepwise approach to the provision of CRT, it intentionally falls short of assigning specific responsibilities to any particular discipline to provide a level of flexibility across varying service delivery models and settings. Future coverage policy should further operationalise responsibility across the interdisciplinary team to ensure all steps in the process are carried out. Regardless, any RESNA certified Assistive Technology Professional (ATP) involved in the process has the responsibility to ensure all steps are completed, especially proper assessment, fitting, adjustments, modifications, training, maintenance, repair, and follow-up.

Current CMS policy does require that an ATP supplier be directly involved in the assessment process; however, future policy needs to require ATP involvement and accountability throughout all steps of the Wheelchair Service Provision Guide and not just the initial evaluation. The ATP certification recognises only generalist knowledge across all assistive technology device categories and does not imply specific expertise in CRT. Therefore, future policy should support a more specialised credential such as the RESNA Seating & Mobility Specialist Certification in addition to the ATP to facilitate a higher level of competence and quality assurance. Payers who seek second opinion review of claims should also be required to use a practitioner of equal qualifications and credentials versus generalists to refute claims.

Current CMS policy primarily uses diagnosis codes to set criteria for types of CRT that are covered in certain situations. Although these criteria may be convenient to use, they do not necessarily portray the person’s impairments or functional abilities. In some cases, two people with similar impairments and functional abilities may qualify for different devices of differing qualities, solely because of differences in diagnoses, even when their needs are similar. This creates inequities in the service delivery process. Use of diagnosis codes also does not consider the individual situation including preferences, environmental factors, caregiver support, transportation, or performance demands. Current CMS policy considers mobility demands only within the home even though there is no historical legislative language that defined the statutory phrase “used in the patient’s home [3]. This restriction is also not applied to the field of Prosthetics and Orthotics, thus demonstrating a double standard within a similar benefit category. This policy should be replaced with more equitable criteria that include standardised and psychometrically validated assessment tools that represent all domains of the International Classification of Function, Disability, and Health (ICF) [4]. Such a classification system can be used to demonstrate a person’s need for different types of CRT based on impairments in body structures or function, limitations in activities or participation, and their unique personal and environmental factors. Similar criteria exist for lower extremity prostheses and can serve as a model [5]. Further, the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) [6–7] is a collection of standardised tests to assess people with spinal cord injury and could serve as a model to assess levels of impairment.

Current CRT payment is based on a “Fee for Service” model whereby the supplier is paid in full for the equipment upon delivery. There is no requirement thereafter to provide follow-up service, maintain, or repair the device. Although many suppliers do provide repair service, it has been reported that this is often done at a financial loss and sometimes provided only for customer retention purposes [8]. This likely results in businesses not allocating necessary resources to repair services but rather focussing resources on the upfront sale of the device where the majority of revenue is obtained. Repair times have been reported as being lengthy or incomplete with adverse consequences occurring as a result [9–13]. Further, CMS will not cover device maintenance, and the users are expected to maintain their own devices, which is contradictory to the literature that indicates many users are not sufficiently trained or able to maintain them [10,13]. The cost of maintenance could be covered in a new policy model either as an added warranty in the cost of the device or within a “Pay for Performance” model. A new service delivery standard should also highlight and require consumer training on basic maintenance of equipment at the time of delivery. Industry organisations should also document best-practice guidelines for maintenance and replacement of parts to better inform consumers and payers. This could further reduce adverse situations and eliminate the time and burden associated with obtaining payer authorizations to replace parts that are already known to require replacement at specific time intervals. The qualifications of people who perform CRT maintenance and repair should be established with the Durable Medical Equipment Repair Technician serving as a viable example [14].

Lack of follow-up was highlighted in the review although it is documented as an important step in the Wheelchair Service Provision Guide. Strategies do exist to provide follow-up, but they have not been completely implemented. Clinicians are typically not reimbursed for follow-up care related to wheelchair services unless there is a face-to-face encounter. Likewise, suppliers argue they are not reimbursed or required to provide follow-up and encounters with the user typically occur only when a repair is needed. Policy and payment for routine follow-up and maintenance should be incorporated into future policy. Telehealth, device connectivity, and remote therapeutic monitoring are examples of emerging strategies that could be considered to improve follow-up service with minimal burden to consumers and providers.

The review mentions that policymakers and payers are open to new methods provided they can demonstrate improved health outcomes and reduce costs. Unfortunately, the levels of research evidence to demonstrate the benefits of CRT has been historically weak. It is also difficult to implement rigorous research studies such as randomised clinical trials in this area which needs to be acknowledged by policy makers and not used as justification to ignore consideration of new procedures and payment models. Alternatively, large datasets and registries have been identified as a method to investigate the outcomes of CRT across large populations of equipment users [15–17]. However, a standardised set of metrics and common data elements are needed [18]. Data can be collected at all stages of the service delivery process, from pre-intervention to repair, maintenance or follow-up across the reasonable useful life of the equipment. Such an outcomes management system could also fulfil quality assurance requirements for clinic and supplier accreditations. Researchers could access de-identified data to investigate various outcomes of interest, improve levels of evidence, and more conclusively demonstrate the value of CRT to inform policy and practice.

The review indicates the current service delivery process is not timely, and research further indicates it takes on average 100 days to receive a device from initial assessment to delivery [19]. Improved standardisation and operationalisation of the service delivery process could result in less ambiguity and greater efficiencies to reduce these wait times. Standardised processes and well-defined coverage criteria could reduce burdens and delays currently associated with documentation, payer reviews, and claim denials.

These strategies set the stage for developing a new and more equitable service delivery and policy model. It is acknowledged that these policy changes could be disruptive, and implementation would undoubtedly require more in-depth investigation, time, new resources, and a shift in existing resources. Although implementation is not within the scope of this broader, federally funded project, implementation science is at the forefront of all tasks as it would be pointless to propose new policy that cannot be carried out in a practical manner.

Work in several areas is currently underway in the larger project, including a method to standardise the CRT assessment process using validated tools and measures. Large datasets are being leveraged to calculate the cost of CRT across its lifespan, including the costs associated with follow-up, maintenance, and repair. Results will be used to propose a “Pay for Performance” model whereby providers would be paid and rewarded based on outcomes. The new policy concept will further be guided by the Quadruple Aim, that focuses on improving health, enhancing patient experience, reducing health costs, and minimising clinician burnout [20]. The value of the CRT provision process is not found simply by matching a diagnosis to a device. Real value is achieved when it allows people to be healthier and realise their full potential as functioning members of society.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The contents of this publication were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DPGE0014-01-00). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this publication do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the Federal Government.