I get these requests all the time. A durable medical equipment (DME) company advertises direct to Medicare beneficiaries offering electric scooters and powered wheel chairs almost completely paid for by the tax payers and all they need is get their doctor to fill out the required forms. These complex forms take at least 10 mins to fill out completely but ultimately amount to little more than a physician description of the patient’s medical conditions and the patient’s answers about things that the physician usually has no way to verify. I.e. do they really need a powered wheelchair or scooter to get around the house and is there actually enough room in their house to use one (Medicare won’t pay for powered wheelchairs/scooters for use out side of the house but this is what most patients end up primarily using it for).

In my experience, these requests almost always come from a patient who had previously been using their walker or manual wheelchair without difficulty and without any evidence of progressive weakness. Usually they show up in the office one day with these papers in hand and without any recent changes in their medical status and request a powered wheelchair or scooter in much the same way that thousands of computer geeks are going to decide soon that their $350 laptop is suddenly inadequate and they won’t be able to get any work done without a $900 Apple Tablet.  Except that the tax payers won’t be paying for Applet Tablets.

Recently the Dept. of Health and Human Services Office of Inspector General did a study of powered wheel chair claims for 2007 and found that a whopping 60% did NOT meet the required documentation. The result was a loss of $112 million in improper payments and this was  just for the first quarter of 2007! The total loss is almost $450 million per year or $1.34 billion in the last 3 years! And all just for electric wheelchairs! Your tax dollars at work . . or not.

Most of the problems were with erroneous or missing documentation in applications that got approved anyway by Medicare. Ergo, the obvious first thing to do is to fix government bureaucratic incompetence (good luck with that). The second thing to do is not only to simplify the documentation but to ask doctors only about what they know. Unless doctors make house calls, how the hell are they supposed to know if the patient has enough room to maneuver a powered wheelchair around the home? What are the diagnoses, medical history, and/or physical exam findings that may indicate the need for a powered wheelchair? Describe the patient’s mobility limitations and need for assistance when seen in the office/outpatient setting. These open ended questions can be as brief or extensive as the physician sees fit.

But much more needs to be done on the part of Medicare to oversee these requests.

I suspect that most requests for powered wheelchairs are not absolutely medically essential and in many cases may actually be detrimental. Show me a morbidly obese patient with chronic knee pain who gets a powered wheelchair and I’ll show you a patient who is going to gain even more weight, severely impair their ability to walk at all, and increase their overall mortality risk. In the vast majority of cases, it’s not overt fraud on the part of the doctor or patient but a natural desire by the doctor to please his customer and by the patient to get an expensive comfort device at next to nothing.

This fine line is similar to applications for disability but the government doesn’t just leave it up totally to a form filled out by a doctor to determine who qualifies for Social Security Disability Benefits. The same should be done for expensive DME applications, especially those that need to be carefully differentiated between being absolutely medically necessary and those that are going to be used primarily for comfort or convience. CMS can send an inspector/auditor out to the patient’s home before or after they get a powered wheel chair as they see fit or they can have an independent care provider evaluate the patient or order a physical therapy evaluation. These extra steps will cost more in the short run but will likely save Billions over the long run. Why else would they bother to do it with disability benefits?

All I can say is that I wouldn’t mind if there is extra vigilance on the part of the government before they spend my tax money and the ultimate De facto fiduciary responsibility for approving these DME requests needs to be removed from the shoulders of physicians who are too often pressured and put in an uncomfortable position of conflict of interest with their patients.

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