Thoughts on the LCD
Thomas Cutler
Description
Collection
Title:
Thoughts on the LCD
Creator:
Thomas Cutler
Date:
8/11/2015
Text:
Hey Folks,
I am a delver. I delve. Today, I took a moment to delve into exactly what an LCD is (local coverage determination).
It turns out that the LCD used to be called the LMRP, or the local medical review policy. They changed it in 2003 while trying to save a consonant in the acronym. I think medical review is what we should get back to here. Here's why:
With the MAC at the helm, 50% of our patients are dead in 5 years.
50% lose the other leg in two to three years.
The expertise of the current MAC standards has 22% of lower extremity amputees being readmitted to the hospital where CMS will pay yet again for more costly services. Man! I want in on some action where I no longer have to eat the cost of a socket re-do!
According to Medicare, their outcomes are all about Patient Satisfaction
According to the Journal of American Medical Association in 2012, the 25% most satisfied patients have higher medical costs, higher medication costs, and a 26% higher mortality rate than the 25% least satisfied patients. Does this mean that if I am not happy, I will live longer? Gotta work on getting those satisfaction scores through the floor...hmm...
And with the MAC focused on reducing harmful incidents in hospitals, the New England Journal of Medicine publishes an article which focused on the fact that after ten years of their efforts, there was no change. For every 100 admits, there are still 25 harms.
I applaud the fact that the MACs are not being shortsighted and just seeing through the lens of their non-medical, administrative position. I am delighted that they believe that it takes a village to rehabilitate the amputee. Their patient-centered view is admirable and the whole process has been delightfully transparent. I am really glad that they look at the impact of the partnering professions and help them find cost-effective methods to expedite care.
So I guess I can say confidently that the FIRST PORTION of the LCD that is out is very interesting. I can't wait until the rest of it is published. Uh...I mean, there's more, right?
No...you're pulling my leg, dude! Seriously, this is all of it? But... wait, uhh... there's gotta be a link to the other parts that are relevant to the prosthetic process. I must have missed it. I miss a lot, you know.
Where is the part about managing the prosthesis? The PT is an extremely valuable part of the team, but they address functional goals and assessments as stated in their scope of practice. Heck yeah. I read that part of the LCD. It was right there in the section about the LCMP's. These are not the ROUS's (rodents of unusual size-see Princess Bride for further details), but the Licensed Certified Medical Professionals. That extra consonant is a pain, right? I didn't see prosthetic management anywhere.
We all know that the AOTA clearly states in their scope of practice that prosthetic management explicitly falls under their purview, right? I mean, if dealing with donning, hygiene, and volume management aren't part of the activities of daily living for amputees, they will certainly end up losing the other leg in about two or three years...uh oh...
Wait...that's not really what we need, is it? Well, a meta-analysis of occupational therapy journal articles with this demographic found an incredible number of ...well, actually just two... studies that show that patients benefit from the incorporation of an occupational therapist into their rehabilitation program. The OT gets paid (CPT 97761) to teach the patient how to manage the prosthesis. Amputees then go to the PT ready for functional stuff. I think that reasonable people agree that if the PT's are given one more thing on their plate, prosthetic management will get done as often as my boys floss. They are all about functional assessment and terrific at it. They'll likely revert back to it as soon as they deal with someone noncompliant...
Okay, back to the LCD. I am sure that I am simply developing dyslexia with all of the fun I have been having. The OT was mentioned briefly somewhere, but c'mon, the education isn't really a big deal. Just because diabetics have twice the rate of cognitive decline towards dementia isn't any reason to pay someone teaching ADL's to include prosthetic management. After all, it's just vascular dementia! It's not like it's the number one cause of dementia. It's number two.
Speaking of number two... here is my second thought on the LCD: appropriate amputation. What is an appropriate amputation? Is it the one wearing the longest skirt? Is it like the politician and his comment on pornography: I know it when I see it? I reviewed the VA/department of defense amputation protocol and the Commission on Accreditation of Rehabilitation Facilities section on amputation (CARF) and neither of them listed best practices for surgeries. The amputee rehab timeline in both publications was like an E.F. Hutton commercial. There was a cacophony of voices before and after, but a deafening silence of clinical opinion while the patient was provided the foundation upon which the quality of our entire field rests. Call me brash, but I would rather like to have the right to functionally assess the quality of the surgeon's work since it has a direct impact on the quality of mine.
But now you say Tom! What's your point?
My point is that if you get perspective, you will see that the MAC has so mismanaged prosthetic medical policy that beating up the littlest guy in the room isn't the answer. Belligerent failure from the MAC means that they lost the authority to claim a second chance to make it worse. The ANSWER for amputees: an entirely new look at how we do prosthetics. A bigger perspective from pre-op until delivery. Essentially, all we have left is bathwater, no baby. As I wrote in a post last Tuesday, the ROI on amputees is huge in the PR department. I had an idea for something called Project 53/55 (50% lose the other leg in 3 years, 50% dead in 5). We reach out to the community with the simple statement: 50% of leg amputees lose the other leg in three years, half are dead in 5. Now that you have their attention, you tell them Amputees are trying to get people to take an entirely new look at the process. But without public pressure, Medicare will just go through with their plans to cut back on even more. Isn't it time for a bigger perspective? People are tired of nobody listening and they have suspicions about this health care racket...all we have to do is use that suspicion to help create (force through public opinion) a positive transformation of a narrow demographic.
Because right now, we are just waltzing right up to the battle lines that the paper pushers have drawn. They have chosen the high ground. They have chosen the terms. They have chosen to win, not to compromise.
With a difficult problem, people sometimes want a good scapegoat more than they want a good solution.
With deepest respect to my colleagues fighting the good fight,
Tom
PS: Project 53/55 is just an idea bouncing around in my head. I have thrown it out simply for the consideration of the many minds and voices in the field. In the words of an African proverb: If you want to go fast, go alone. If you want to go far, go together. With the deadline for comments, I chose to move fast. If we find such a concept (or another concept) to have merit, I suggest we seek others affected by this and leverage public opinion. Finally, a movement that allows individuals to demand that their healthcare providers gain a bigger perspective. They may find demanding accountability more engaging that simple awareness.
Thomas J. Cutler, CPO, FAAOP, CPHMLimb.itless, LLC113 N. Church StreetSuite 312Visalia, CA 93291559-334-3741 phone559-553-8837 fax
I am a delver. I delve. Today, I took a moment to delve into exactly what an LCD is (local coverage determination).
It turns out that the LCD used to be called the LMRP, or the local medical review policy. They changed it in 2003 while trying to save a consonant in the acronym. I think medical review is what we should get back to here. Here's why:
With the MAC at the helm, 50% of our patients are dead in 5 years.
50% lose the other leg in two to three years.
The expertise of the current MAC standards has 22% of lower extremity amputees being readmitted to the hospital where CMS will pay yet again for more costly services. Man! I want in on some action where I no longer have to eat the cost of a socket re-do!
According to Medicare, their outcomes are all about Patient Satisfaction
According to the Journal of American Medical Association in 2012, the 25% most satisfied patients have higher medical costs, higher medication costs, and a 26% higher mortality rate than the 25% least satisfied patients. Does this mean that if I am not happy, I will live longer? Gotta work on getting those satisfaction scores through the floor...hmm...
And with the MAC focused on reducing harmful incidents in hospitals, the New England Journal of Medicine publishes an article which focused on the fact that after ten years of their efforts, there was no change. For every 100 admits, there are still 25 harms.
I applaud the fact that the MACs are not being shortsighted and just seeing through the lens of their non-medical, administrative position. I am delighted that they believe that it takes a village to rehabilitate the amputee. Their patient-centered view is admirable and the whole process has been delightfully transparent. I am really glad that they look at the impact of the partnering professions and help them find cost-effective methods to expedite care.
So I guess I can say confidently that the FIRST PORTION of the LCD that is out is very interesting. I can't wait until the rest of it is published. Uh...I mean, there's more, right?
No...you're pulling my leg, dude! Seriously, this is all of it? But... wait, uhh... there's gotta be a link to the other parts that are relevant to the prosthetic process. I must have missed it. I miss a lot, you know.
Where is the part about managing the prosthesis? The PT is an extremely valuable part of the team, but they address functional goals and assessments as stated in their scope of practice. Heck yeah. I read that part of the LCD. It was right there in the section about the LCMP's. These are not the ROUS's (rodents of unusual size-see Princess Bride for further details), but the Licensed Certified Medical Professionals. That extra consonant is a pain, right? I didn't see prosthetic management anywhere.
We all know that the AOTA clearly states in their scope of practice that prosthetic management explicitly falls under their purview, right? I mean, if dealing with donning, hygiene, and volume management aren't part of the activities of daily living for amputees, they will certainly end up losing the other leg in about two or three years...uh oh...
Wait...that's not really what we need, is it? Well, a meta-analysis of occupational therapy journal articles with this demographic found an incredible number of ...well, actually just two... studies that show that patients benefit from the incorporation of an occupational therapist into their rehabilitation program. The OT gets paid (CPT 97761) to teach the patient how to manage the prosthesis. Amputees then go to the PT ready for functional stuff. I think that reasonable people agree that if the PT's are given one more thing on their plate, prosthetic management will get done as often as my boys floss. They are all about functional assessment and terrific at it. They'll likely revert back to it as soon as they deal with someone noncompliant...
Okay, back to the LCD. I am sure that I am simply developing dyslexia with all of the fun I have been having. The OT was mentioned briefly somewhere, but c'mon, the education isn't really a big deal. Just because diabetics have twice the rate of cognitive decline towards dementia isn't any reason to pay someone teaching ADL's to include prosthetic management. After all, it's just vascular dementia! It's not like it's the number one cause of dementia. It's number two.
Speaking of number two... here is my second thought on the LCD: appropriate amputation. What is an appropriate amputation? Is it the one wearing the longest skirt? Is it like the politician and his comment on pornography: I know it when I see it? I reviewed the VA/department of defense amputation protocol and the Commission on Accreditation of Rehabilitation Facilities section on amputation (CARF) and neither of them listed best practices for surgeries. The amputee rehab timeline in both publications was like an E.F. Hutton commercial. There was a cacophony of voices before and after, but a deafening silence of clinical opinion while the patient was provided the foundation upon which the quality of our entire field rests. Call me brash, but I would rather like to have the right to functionally assess the quality of the surgeon's work since it has a direct impact on the quality of mine.
But now you say Tom! What's your point?
My point is that if you get perspective, you will see that the MAC has so mismanaged prosthetic medical policy that beating up the littlest guy in the room isn't the answer. Belligerent failure from the MAC means that they lost the authority to claim a second chance to make it worse. The ANSWER for amputees: an entirely new look at how we do prosthetics. A bigger perspective from pre-op until delivery. Essentially, all we have left is bathwater, no baby. As I wrote in a post last Tuesday, the ROI on amputees is huge in the PR department. I had an idea for something called Project 53/55 (50% lose the other leg in 3 years, 50% dead in 5). We reach out to the community with the simple statement: 50% of leg amputees lose the other leg in three years, half are dead in 5. Now that you have their attention, you tell them Amputees are trying to get people to take an entirely new look at the process. But without public pressure, Medicare will just go through with their plans to cut back on even more. Isn't it time for a bigger perspective? People are tired of nobody listening and they have suspicions about this health care racket...all we have to do is use that suspicion to help create (force through public opinion) a positive transformation of a narrow demographic.
Because right now, we are just waltzing right up to the battle lines that the paper pushers have drawn. They have chosen the high ground. They have chosen the terms. They have chosen to win, not to compromise.
With a difficult problem, people sometimes want a good scapegoat more than they want a good solution.
With deepest respect to my colleagues fighting the good fight,
Tom
PS: Project 53/55 is just an idea bouncing around in my head. I have thrown it out simply for the consideration of the many minds and voices in the field. In the words of an African proverb: If you want to go fast, go alone. If you want to go far, go together. With the deadline for comments, I chose to move fast. If we find such a concept (or another concept) to have merit, I suggest we seek others affected by this and leverage public opinion. Finally, a movement that allows individuals to demand that their healthcare providers gain a bigger perspective. They may find demanding accountability more engaging that simple awareness.
Thomas J. Cutler, CPO, FAAOP, CPHMLimb.itless, LLC113 N. Church StreetSuite 312Visalia, CA 93291559-334-3741 phone559-553-8837 fax
Citation
Thomas Cutler, “Thoughts on the LCD,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 25, 2024, https://library.drfop.org/items/show/237638.
