The above graph is from the Dartmouth Atlas of Health Care and shows the Medicare expenditure per patient for medical equipment in each state. As with most Dartmouth graphs, the point is to highlight tremendous variability across the country. The rules of payment are the same across the country yet the system fails to follow the rules. Consistency means reliability, but the opposite is also true, inconsistency means unreliablilty. Medical equipment includes such things as nebulizers, wheelchairs and walkers to name a few.
Sadly, the medical equipment business is a hotbed of fraud and incompetence. There are just as many elderly people per capita in Iowa as Florida, but Florida has no grip on costs. Arizona monitors Medicare equipment spending quite well, but Texas is out to lunch.
There are so many problems it is hard to know where to start, here are a few examples:
- The rules for equipment are incomprehensible (just look at the CMS web site for proof) so States have difficulty following the rules and crooks can easily submit fraudulent claims.
- Wheelchairs are essential for quality of life for many people. But, for many elderly people who have other people push them around the much less expensive “transport chair” is sufficient.
- Compressor/nebulizer equipment for asthma and COPD is 99% boondoggle and 1% needed. Patients who have a prescription for an inhaler do not need a nebulizer — but medical suppliers pass them out anyway. Medicare should not pay for nebulized medications in the first place since the usual medications are generic. There is near-universal agreement (except for suppliers) that a meter dose inhaler (MDI) is more effective than a nebulizer. So if Medicare is bent on providing inhaled medication at least provide the cost effective MDI. Canadian doctors rarely find a need for nebulizers because the government provides MDIs.
- Walkers are a good hedge against falling. A broken hip is a lot more expensive than a walker. But, why does Medicare pay $65 for walkers that probably cost $20 to manufacture?
- The idea of letting the supplier get the prescription directly is inviting fraudulent behavior. The local supplier does not have the staff to investigate the truck-loads of rules so what do you think happens? Forms are filled out like the ones that passed the system before, the equipment is delivered (mostly) and Medicare pays.
- Set a national Medicare budget for equipment with some sort of priority if the budget is tight.
- Medicare should nationally purchase large volumes of commonly used equipment then send it to people by UPS or FedEx (like Amazon)
- Physicians should prescribe equipment by computer directly to Medicare (or a national clearing house). Medicare and insurance companies could then monitor the indications electronically before providing the equipment. Also, this would allow contract bidding for the equipment. The equipment vendor makes no decisions except how to deliver the goods.