Competitive Bidding: Outlook For OTS Bracing
Self-fitting has unknown consequences
How many newspaper articles or television reports have you seen about the inclusion of off-the-shelf (OTS) knee and spine braces in the Competitive Bidding Program?
Competitive Bidding is a well known topic within the orthopedic and O&P communities. But are Medicare beneficiaries aware of the realities and consequences of the new policies and provider restrictions that begin in January? How do patients feel about fitting and adjusting their own brace?
We know the Centers for Medicare and Medicaid Services (CMS) gave physicians, O&P professionals and brace manufacturers the opportunity to provide written comments. And we know the concerns expressed by these brace experts were ignored. What about the voice of the patient? Did any senior get to ask “how will fitting my own brace be better for me than having a medical profession fit my brace?”
In reality, CMS put this train in motion several years ago and nothing was going to derail their plans. The bidding is done. CMS will notify the winning bidders, and many Medicare providers will no longer get paid if they dispense OTS braces. When the reimbursements for OTS braces drop in January, patients who only meet the criteria for an OTS brace could end up getting their brace in a box, with no personalized care. And it is also possible they could get a lower quality or less effective brace than patients who meet the criteria for a Custom-Fit brace.
Patients can’t expect the same service when reimbursement drops
Since the creation of separate OTS reimbursement codes, Medicare has paid the same amount for OTS and Custom-Fit braces. Because the reimbursement was the same, the patients who were billed for an OTS brace often still benefitted from in-person fitting by someone with specialized training. By putting OTS braces into the Competitive Bidding Program, the government hopes their cost for OTS braces will drop by 50% or more. Most average size patients will get the short end of the stick, unable to qualify for Custom-Fit status. They may get their OTS brace by mail. It is the larger patients, and those with abnormal body shapes, who will have a better chance of meeting the criteria for a Custom-Fit brace. Their unique anatomy may require the expertise of a trained professional to optimize the fit.
How many controlled clinical studies did CMS rely on when making these changes? To my knowledge, none. If there are no comparative studies, is it reasonable (or risky) for CMS to assume patients who self-fit their OTS brace will achieve similar benefits and outcomes as patients who receive a Custom-Fit brace adjusted by a qualified professional?
Even if there was a comparison study of several braces, the results wouldn’t be universally applicable to the hundreds of other knee and spine braces that are routinely dispensed to Medicare beneficiaries. Virtually all of these braces were designed to be fit by medical professionals. Manufacturers rely on these trained professionals to ensure the brace fits and functions properly. Manufacturers also depend on trained professionals to teach patient how to position and secure the brace, and to watch the patient replicate the fitting procedure.
The government is leaving it up to the discretion of the provider (who is dispensing the brace) to determine which braces have structures and/or complicated adjustment methods that may make the product more difficult or dangerous for a patient to self-fit. The OTS braces they choose will need to be simple enough for the patient (or someone with no training) to fit and adjust by following written or video instructions.
In the 130 Competitive Bid Areas across the United States, we will get to see how this plays out for Medicare beneficiaries. For these older patients who have never tried on or worn a knee or spine brace, it seems unlikely they will have the ability and dexterity to confidently make the same adjustments as a certified orthotist.
Financial savings, or more costly treatments?
We know the Competitive Bidding Program will reduce the government’s front-end expenditures for OTS knee and spine brace. But we don’t know if the financial savings will be offset by subsequent costs and consequences if patients don’t properly fit and adjust their brace. Will future data reveal an erosion in compliance, or an increase in falls or other injuries? Will data show a spike in hospitalizations or other costly complications? Perhaps.
Brace experts have warned CMS about the inherent dangers of trusting novices to fit complex braces. Hopefully, the government or other consumer watch dogs will actively monitor the experiences and outcomes of the Medicare patients who get their OTS brace from a provider that is no longer required (or paid) to fit the brace.
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