I recently read an opinion piece in the Ft. Worth Star-Telegram that was written by Dr. Justin Bartos discussing power mobility and its positive effect on countering falls - one of the leading causes of disability in senior patients. Dr. Bartos also discusses the pitfalls of the current Medicare program and the lengthy and difficult process of getting this important aspect of patient health to Medicare beneficiaries.

Referencing both current medical statistics and citing examples of the sometimes counter-intuitive Medicare processes, Dr. Bartos paints a discouraging picture of Medicare policy forcing patient health decisions based on short-term financial returns, rather than saving cost and improving patient health over the long-term.

Dr. Justin Bartos is a family physician with North Hills Family Medicine in North Richland Hills.

The Goal: Preserving health. The Obstacle: Medicare
By Justin Bartos (Special to the Star-Telegram)

I don’t agree with Michael Moore’s politics, but I was curious enough to see his docudrama Sicko. Everyone should be able to access basic healthcare, but market forces work against the notion of universal, equitable coverage.

As a family physician with a substantial number of seniors and elderly in my practice, I would caution Moore to be careful about what he asks for. Any government solution to healthcare would be politicized, and nothing would be as sensible or simple as depicted in the movie.

The folks who run our country’s largest entitlement program, Medicare, and at least some of their congressional overseers have been rationing medical care to my patients through stealth and budget design for as long as I have been practicing. They seem to be acquiring even greater control of my practice as they anticipate a rising tide of aging boomers entering a program that most government experts and economists warn will run out of money within a decade or so.

Their view is from the bottom line, not the bedside or exam room. The very real consequences to my patients of that budget-centered philosophy should give all of us pause about what a wall-to-wall government program might look like if the potential for profiteering, abuse and rationing without regard to medical need isn’t contemplated and checked. They offer a benefit only to regulate the ability to access the benefit.

These people put my patients at risk in two fundamental ways:

They continue to underfund the doctors — family physicians and geriatricians — who care for our growing Medicare population, as well as the training programs that would guarantee there will be enough of us to handle the oncoming flood of new Medicare patients.

They limit what I can do for these patients through a range of bewildering rules and regulations. Medicare prevents beneficiaries from receiving the benefits that the program approves by creating complicated forms for services such as oxygen, physical therapy, occupational therapy, wheelchairs, mobility devices, blood sugar monitors, adult diapers and others.

Physicians who feel strongly that their patients require these services must wade through this paperwork knowing any request that is considered inappropriate based on Medicare criteria could result in criminal penalties. The criteria are illogical, and for all of this fine work on behalf of the U.S. taxpayer, the physician will receive no reimbursement. Medicare considers it all part of the office visit.

Let me give you just one example.

For my physically strong patients, as well as my patients who are increasingly frail, the most immediate threat to their health is not illness. It is falling.

Each year, about 350,000 patients fall and break hips. Of those, 40 percent end up in a nursing home; 20 percent will never walk again.

The three risk factors are poor balance, taking more than four prescription medications and muscle weakness. My patients without these risk factors have roughly a 12 percent chance of falling. Those with all three, which is far more common, raise the risk to almost 100 percent.

If they can stay in their homes and remain mobile (and thus stay out of nursing homes), they are not only healthier and happier — they save the federal government a considerable sum. But Medicare, in the interest of cost efficiency, has at least two schemes that seem at times to conspire against my patients who are at risk of falling.

In its latest intervention into the practice of medicine, Medicare has created a drug plan with restricted formularies that result in medication changes and switches, further complicating very complex medical regimens for many patients. With medication changes, side effects and interactions are common, often raising the risk of falls.

For my patients who have reached a point where the risk factors for falling indicate the need for mobility support, Medicare has created a whole new set of rules that will sharply reduce prescriptions for mobility devices such as manual or motorized wheelchairs. In addition, Medicare has creative regulations mandating that these mobility devices be used only in the home and not to assist restoring the patient’s overall mobility.

Medicare is adding a required “low bid” process to reduce reimbursement that undoubtedly will result in lower-cost, substandard equipment. To top it off, the program has added a stack of paperwork that has more to do with discouraging me from prescribing than determining medical necessity, despite the evidence that maintaining mobility is less costly — and much more humane — than falls, fractures, hospitalization and nursing home placements.

My patients and colleagues can’t stop the aging process, but we can do something about the quality of their lives as they age. It is all a matter of spending tax dollars wisely.

Any reform plan that Congress contemplates, with or without Moore’s ideas, must balance the tough choices between cost savings and appropriate care. Physicians must be able to provide care in a reasonable manner. Medical students — future doctors — must want to become primary care providers for Medicare recipients in the future.

The system needs to allow us to provide the right care in the right setting at the right time, as in this example, before patients fall. Keeping an elderly patient mobile and out of an institution for as long as is medically possible makes both economic and medical sense. We need thoughtful, appropriate policies, not an over-regulated process.

According to the report, nearly seven million people under age 65 qualify for Medicare because they have severe and permanent disabilities. About 1.5 million Americans are in the Medicare waiting period. Twelve percent of people in the Medicare waiting period die each year while waiting for their coverage to begin.

The response from the conservative think tanks predictably warns against opening the entitlement floodgates. Robert Moffitt, an analyst at the Heritage Foundation, said in a Dallas Morning News article that "Medicare is a financial wreck, with $33 trillion in unfunded liabilities", adding "This would be another nail in the coffin". Joseph Antos, a health care expert at the American Enterprise Institute, said, "Instead of opening the door to everyone, let’s do better at calculating financial need". He added, "Some people do have other sources of insurance, so we should be careful about expanding a program that’s already facing serious financial problems itself". (See Moos, Dallas Morning News, 4/26/07).

A more strident or at least less cautious conservative warning "while not speaking directly to this particular proposal" comes from a guest column by Pepperdine Economist Gary Galles. "Americans are sacrificing the future to the elderly-political complex," Gary Galles, wrote in a Baltimore Sun opinion piece: "For all their talk about future generations, seniors’ political groups are far more concerned about their short run than their heirs’ long run", Galles writes, adding, "That is reinforced by politicians’ bias toward immediate benefits and make-or-break issues for those who vote". As a result, "rather than reining in Medicare’s exploding liabilities, [seniors’ groups] constantly push to expand their benefits, increasing the burdens they will leave their children and grandchildren", according to Galles.

I suspect that many physicians, regardless of philosophical bent, take a different view from the exam room, where they are treating a disabled patient and can’t do anything for them other than pay the hidden tax of treating the patient gratis or for a below-cost discount. Let’s see what some of you have to say about this.

There is an underlying pattern. When the Congress won’t make what are obviously politically tough choices, the regulators are left to take up the slack. They trim and cut by rule and oversight. Tightening down on frail elderly patients’ mobility support needs is just one manifestation of a concerted effort by CMS to rein in what the government calls, euphemistically "entitlement" spending and doctors call medically necessary care. The budget hawks, who see Medicare not as a complex delivery system, but rather a cost center full of red-inked line items, approach this by excising the outliers with cuts to reimbursement (outpatient diagnostic imaging) redefining appropriate care terms(ESRD), price rollbacks (power mobility devices), and retooling the complex reimbursement methodologies (geographic cost indices and non-physician workforce component).

There are two of these guides, depending on the patient’s mobility needs: one for the more modest "scooter", and one for a more sophisticated a power mobility device. We’ll be very interested to hear your own evaluation of this guide

"The SCOOTER Store, by virtue of being the nation’s largest supplier of power mobility devices (PMDs), has by far the most contact with physicians who have, or are contemplating prescribing a PMD for their patients. Their expertise in screening a patient on the front end is without peer. Working with the patient’s physician, The SCOOTER Store typically finds that only a fraction of patients seeking a PMD are found by careful review to require this kind of sophisticated and relatively expensive mobility support. What they see every day by the hundreds, a practicing physician sees far less often.

That’s why The SCOOTER Store created a Physician Advisory Board, a panel of doctors with expertise treating elderly patients and others with unique mobility support needs. These physicians provide common sense guidance as part of The SCOOTER Store’s ongoing efforts to communicate more effectively to a prescribing doctor.

This blog is a logical extension of that outreach by offering a forum for new ideas "good or bad" and "group therapy" to alleviate the frustrations of those who see the often unmet medical needs of the elderly every day.

This is rationing by stealth and program design, and ironically, will ultimately cost far more money when these patients are assigned equipment designed for indoors only and in many cases inadequate to even navigate between rooms in their homes. As every doctor already knows, patients’ physical and mental health inevitably deteriorates when they lose the freedom to move about and pursue the everyday tasks the rest of us take for granted.

These changes are not a mere inconvenience for budgetary sake. They will add unnecessary pain, injury and rapid disease progression to patients already in need of mobility assistance. Patients with degenerative conditions such as multiple sclerosis, heart disease, arthritis, and other debilitating chronic diseases will end up with broken hips, bedridden, or confined to a long term care facility. More mobile patients will find their motorized chairs running out of power on sidewalks, parking lots and other more dangerous venues.

The changes also result in a hidden tax on Medicare patients who can manage to scrape up enough money to pay the difference — usually a thousand or more dollars– to get the mobility device their doctors ordered for them. Most are on fixed incomes and will not be able to afford what their hard earned tax dollars should grant them, the ability just to get around and stay healthy.