This article does not get to the heart of the problem when
pediatricians prescribe equipment mostly on the basis of vendor
recommendations, and even on recommendations of rehabilitation therapists.
There is often a total cost for the whole rehabilitation system, as well
as possible improvements in outcomes including quality of life. These
outcomes are hard to quantify, but ought to be explicitely considered in
making a prescription.
Many times, more than a prescription is needed. A Letter of Medical
Necessity, backed up by clear documentation (over time) of the medical
condition and goals for the patient is essential.
Pediatricians may not be in a position to determine the suitability
of equipment, including factors that may add or lower value, such as means
of transportation, home accessibility, child's cognitive ability, and
complications of using the equipment. For example, improperly configured
manual wheelchairs can increase the risk of shoulder injury. Power
wheelchairs are heavy, require maintenance, and depending on the child's
cognitive abilty, may require substantial training. However, a power
wheelchair or power-assist wheelchair might be the best choice for some
children.
For children with paralysis or sensory deficits, pressure sores are a real
risk. Choice of appropriate therapeutic/preventive cushions involves
specific technical knowledge.
Orthotics may be essential, but they are occasionally recommended for
conditions where there is little or no functional benefit. If orthotics
are not properly fitted or maintained, and parents are not trained to do
skin checks, can cause injury. They may also unnecessarily limit a child's
activity and cause an impression of more disability than is warranted.
The best equipment has little value if it is not used. A big
determinant of use has to do with satisfaction/suitability which may be
related to training, or taking lifestyle into consideration.
Physicians prescribing expensive assistive technology should have a
good understanding of the overall treatment plan and desired outcomes.
When physicians are used as "pass-throughs" or "signers", there is a
bigger case management problem going on.
In practice, there are a lot of constraints imposed by payers such as
Medicaid and private insurance. Better availability of guidelines and
decision support tools from these funders would make it more possible for
pediatricians to research patient equipment requests or provider/vendor
recommendations. More pediatrician involvement would also reveal problems
in the approval process which is often driven by cost more than value, and
little consumer follow-up or measurement of short term or long term
outcomes. Furthermore, pediatric DME rules are largely based on adult
guidelines.
Adult assistive technology is heavily influenced by the DMERC
(Durable Medical Equipment Regional Carrier) system; Medicaid is subject
to individual state management. States often have procedures to determine
medical necessity based on specific equipment.
Ideally, pediatricians would work closely with a team, and
participate in outcomes measurement. Given the shortage of pediatric
subspecialists who have experience in assistive technology, the primary
care pediatrician will continue to be the main prescriber.
Conflict of Interest:
None declared
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