 |
|
 |
|
 |
 |
|
 |
 |
 |
 |
 |
 |
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Post-publication Peer Reviews to:
|
|
![[Read P3R]](/icons/misc/sectionDOWN.gif){kind=icon}
Cost and Quality for DME
|
|
|||
|
Henry L Shapiro, Developmental Pediatrician All Children's Hospital
Send letter to journal:
shapiro{at}dbpeds.org Henry L Shapiro
|
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 |
|||
 |
||
|
||
Home | My Pediatrics | Journal Information | Current Issue | Past Issues | Subscriptions & Services | Contact Us Click here for faster international access © 2008 American Academy of Pediatrics. All rights reserved. |
||
|
||
P3Rs: