March 2001

Show Me the Money

By Karen M. Kangas, OTR/L

Show Me the Money

Show me the money! is an inimitable phrase that all of us recognize and understand immediately. Our entire society appears to be reflected in that phrase, with its “money first” attitude. In fact, recommending equipment for patients’ needs has also taken a money first attitude—partly because health care costs need to be kept under control. However, cost should not be the only issue considered when seeking funding for health care equipment.

For example, I recommended a patient/transfer lift system and the insurance company rejected it. Now what? I don’t have a secret second source of money; instead I utilize a process that obtains the necessary equipment. This process focuses on two important points. The first step is the medical justification report that includes a description of an equipment trial and rationale for the equipment, specifically matching the equipment’s medical necessity to the patient’s needs. It also includes a comparison and contrast of other equipment currently available.

The second point is that with newer equipment I expect an initial rejection/denial. Funding sources generally reimburse durable medical equipment based on codes and costs devised by those sources for “usual/standard” equipment. When the equipment recommendations are received by the funder, they are often reviewed by a single person who attempts to match the request to these predetermined codes/standards. When patient lift equipment is requested, it often does not match these standard codes or costs. It is often denied with a letter stating: “this product is not eligible because the equipment requested appears to be deluxe” or “after review the recommended piece of equipment is not standardly provided.” The entire, original report of medical justification may not have been reviewed completely because the requested equipment was not “standard.”

This denial must then initiate an appeal. Every funding source, private and/or public, has its own method of review.

Equipment Rationales

Following are two examples of equipment rationales that are often missing from medical justifications.

Ed is a 58-year-old with multiple sclerosis. Not all portable lift systems are able to reach down to the floor. Many systems do not allow a type of sling that can be readily placed on the patient, once they have fallen on the floor. Most systems were developed to lift a patient from a hospital bed to a shower chair or a wheelchair, in an institutional setting where there is plenty of uncarpeted floor space. In a home, the demands of a lift are quite different. First of all, the lift must be manageable by the spouse, which means that the lift must be fluid enough in motion to be retrieved and used by a single person. This lift in Ed’s case also needs to manage a large and heavier man safely and, most likely, from the floor after a fall, which means he may be injured or he may not be able to assist much in the use of the lift. A portable system then must have an electronically controlled lift so the spouse has free hands to assist in the movement of the patient into the chair. This lift must also be able to elevate the patient so that the spouse can then walk around to retrieve the chair while the patient is held hanging in the lift. To accomplish this, durability, efficient and smooth motion, and adequate supports must be readily available to the spouse.

With Lift A’s electronic control switch, emergency stop button, and base that expands to fit multiple situations (rather than a single fixed base width), it can move from the floor to manage lifting the person up to a bed or chair height. It can also tolerate lifting a weight of up to 360 lbs.

Ed needs a device that can safely lift his weight and size. It needs to be one that will not topple, and can manage his size safely from the floor to either his chair(s) or bed. It also needs to lift him not in a fixed position, but in a position that allows him to move into a seated posture for safe moving. The lift recommended has a “sling slide system,” which has adjustability in the lifting. This adjustability appeared to be critical to the safe lifting of Ed. Otherwise, the sling itself must be repositioned on the patient. This means putting the patient back down on the floor, then rolling him to one side, and physically getting down on the floor, and repositioning the sling on him. When Ed falls with only his wife present to help, she will not be able to position him on the sling, on the floor readily; he may also be injured and unable to roll from side to side.

The lift must have an adjustable base that will reach around both his manual chair and his powered chair. Yet, its base must have a low profile, in order to fit under the bed or couch. (Most lifts were developed for use in institutional settings with hospital beds—beds that moved and were used with two people besides the patient. Most lifts have too high a profile to be helpful in a home setting. The institutional bases also have a fixed size of openings to fit surrounding standard wheelchairs, not a power base like Ed uses.)

Ed’s lift must be operable by his wife so the electronic controls are critical. The sling and base must be able to be readily moved, without his large body “swinging” in space to topple him or the lift. This requires a unique portable and stable, yet flexible design that is not available on any standard hydraulic or hydraulic/electronic standard patient lift. The lift itself must be able to be moved to the patient, so it must be portable yet sturdy. Although other lifts are available and appear to be less expensive, they do not include all the features mentioned above.

Minnie is a 14-year-old with cerebral palsy. Minnie is a candidate for a ceiling track lift system. When attempting to use a portable standard lift system, she must be placed within a sling, and then the entire lift (with her swinging in midair) must be pushed, pulled, and placed near or over the surface she needs to use. Although the lift system’s electronic controls could lift her up and down (rather than the older, pneumatic crank controls that essentially are unscrewed to lower, are either on or off, and are difficult to control and stop at any point), the actual patient transport occurs awkwardly, laboriously, and quite unpredictably. In short, the mechanism itself is pulled and pushed by the feet, hands, and body of the mover, always with the goal of getting close to the new surface to be transferred into. In the case of the toilet, the lift and Minnie must be moved, and repositioned, and again moved to get exactly over the toilet. These lifts were originally designed to move immobile patients, ie, individuals with advanced paralysis with its lack of sensation.

This unpredictable swinging in the air actually causes patients like Minnie to have an increase in tone and flailing motor movements. Controlling the patient lift itself, moving it from one place to another solely by body power and by one person, means automatically that the parent must work from behind, and cannot touch Minnie or assist her in holding herself steady. A ceiling track system provides support and safety to the transfer. Since the lift mechanism is above Minnie, the parent moving Minnie can accompany her and pay attention to her during the entire transfer process. Guidance and support are then where they need to be when moving through space: with Minnie, not with the lift system itself.

This system always moves identically at the same speed and in the same direction, never varying. Minnie can learn to anticipate the motion, and then relax as the lift progresses. To a patient like Minnie with increased tone, this means that she can assist her body in maintaining control, by anticipating a consistent and regular pattern, rather than trying to balance herself, never quite knowing what will occur.

Previously, with the lift mechanism itself, our only choice was varied styles of cloth/fabric slings. These slings place the patient in a partially reclined posture. When a patient is moved from chair to toilet, this reclined posture must be corrected by the caregiver by grabbing the sling (and subsequently the patient) and trying to hold it steady in a seated posture while also trying to control the patient lowering onto the toilet. This is not only difficult, it often places the patient incorrectly and inaccurately over the toilet itself. Lift B’s mechanism is the only framed patient support commercially available. It has a permanent crossbar that opens and places trunk supports under the axillae, and has two separate, firm leg supports. This means the patient can be transferred in a fully upright seated posture. It also means that the clothes can be pulled off the buttocks, but not removed.

Minnie, within Lift B, was able to not only tolerate the lift and transfer, but after the equipment trial, was able to share (using her communication device) that she preferred it to any lift her mother had ever performed because she felt safe, and it was slower for her. With a ceiling lift and its subsequent track system, the path is predetermined, and the movements are less and more controlled, allowing the patient to maintain control and anticipate the outcome.

Conclusion Both of these systems were funded after review. The first review process consisted of a phone call to me and the physician and a true review of the original report, page by page. Minnie’s funder sent a nurse clinical specialist to her home who attempted to transfer her with a standard lift. The recommended ceiling track system was then funded.

To obtain funding, it is critical that the medical necessity and justification be outlined clearly and the needed equipment is described fully, including the results of an equipment trial and the comparison and contrast of equipment. Each part of the equipment must match the needs of the patient. It is also important to use equipment that can be provided and serviced locally.

As with all new equipment, expect an initial denial, be prepared to have the situation reviewed, and expect that through the review, funding will be obtained. Funding sources will always follow older clinical standards. Consequently, when utilizing equipment and rehabilitation techniques that are newly available, expect education and explanation to be required. This battle is the one we all should be fighting and winning.

Karen M. Kangas, OTR/L, is a seating and positioning specialist and clinical educator in private practice in Shamokin, Pa. She can be reached via email: kmkangas@ptd.net.

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