June 2019

OUTCOMES COULD BE AFFECTED: Is Reimbursement Reduction Imminent for Most Off-the-Shelf Braces?

By Rick Riley

My perspective on the future reflects my professional interest in lower-extremity injuries and conditions that can be treated by knee braces and by ankle-foot and knee-ankle-foot orthoses. An aging population and other market demographics seem to indicate there is an increasing need for braces; new manufacturing methods, including interesting composite materials and 3D printing, seem to point toward a future of technical innovation. However, the economic forecast for dispensing braces could undermine the quality of these products and the face-to-face care provided to patients.

Insurers and the Feds are Transforming the System

Although the Medicare allowable rate for lower-extremity braces has stayed virtually the same over the past decade, many providers of orthoses, prostheses, and durable medical equipment (DME) have been compelled to sign contracts with private insurers based on a reduced fee schedule (as much as 50% less than historic reimbursement). The Federal government has studied both the lower rate of reimbursement that providers are accepting from private insurers and the prices of various off-the-shelf (OTS) braces available from hundreds of websites. To reduce expenditures for bracing Medicare beneficiaries, the Center for Medicare and Medicaid Services is including 23 Healthcare Common Procedure Coding System (HCPCS) L-coded products in the 2021 Round of the Competitive Bidding Program (CBP). This action will cause significant changes in the market for OTS braces.

The government seems comfortable with the notion that patients can self-fit and self-adjust a range of OTS braces—thus creating “split codes” as a bridge to including OTS braces in the CBP and then expanding the definition of an OTS. Instead of targeting more simple devices, such as walking boots and semi-rigid OTS ankle braces, the government is targeting devices covered by HCPCS codes L-1833, L-1851, and L-1852: namely, rigid and semi-rigid knee braces with reimbursements greater than $600.

The Unpleasant Fallout

It is possible that, before Lower Extremity Review reaches its 20th anniversary, first, virtually all OTS braces could be included in future rounds of the CBP and, second, private insurers will make parallel reductions in reimbursement for OTS braces. Because reimbursement for custom-fit and custom-fabricated braces should stay much higher than for OTS braces, the Federal government and private insurers will increasingly push providers to use OTS braces. Only the most severe and complex cases, and the most obese patients, will qualify for a custom brace.

Physicians who have financially benefitted this past decade from their internal DME program could opt out of billing braces. O & P clinics could have limited interest in dispensing OTS braces, and focus instead on custom bracing and prostheses. Durable medical equipment companies, including those set up to distribute nationwide (ie, shipping braces to the patient’s home address), could become the primary providers of lower-extremity OTS braces.

Most patients will no longer benefit from the expertise of a qualified fitter, and will be forced to depend on written or video instructions. Manufacturers will need to dumb-down their braces so patients can figure out how to fit the brace themselves or with the help of a loved one. It is likely that patient adherence and satisfaction will decline because not all recipients of a brace will be successful in fitting and adjusting their device.

Regrettably, it might require thousands of injuries and medical complications for the Federal government and private insurers to realize the immense value of having a qualified provider properly assess, fit, and instruct patients who are prescribed a brace.

Rick Riley is Chief Executive Officer of Townsend Design, Bakersfield, California, an orthopedic brace manufacturer and a subsidiary of Thuasne USA (www.Thuasneusa.com). The opinions and predictions presented here are his personal perspectives and not necessarily those of other Townsend executives or the management of Thuasne. 

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