The State of Seating and Positioning
- By Ellen Z. Harrison, Bob McCoy
- Jul 01, 2006
Imagine you're a clinician or rehab technology supplier (RTS) faced with shopping for the right seating and positioning system to meet the individual needs of your client. Enter DME's virtual supermarket of seating and positioning products. In produce, an array of cushions sprouts colorfully from an open market bin -- everything from low air loss to viscoelastic to gel-foam. In the deli, behind the glass, selections of footrests and legrests soldier alongside neon signs marked "adjustable" and "swing-away." The dairy and meat sections boast choice cuts and nothing but the freshest of laterals, thoracic braces, armrests, side guards, knee supports and headrests. Check aisles 10 and 12 for options like track and mounting brackets, and aisle three for angle-adjustable backrests -- both anterior and posterior. Need a dash of conformity among products so your shopping cart fare will work together? Try aisle seven. Point-of-purchase displays beckon, offering the latest products, the ultimate in technology and smart choices for your clients.
You make your selections carefully and then proceed to the self-checkout line. But your debit card, courtesy of the Centers for Medicare and Medicaid Services (CMS), doesn't quite mesh with the system. The electronic voice rattles off excuses like "item not found," "wait for cashier assistance," "funds not available" and "denied." The people in line behind you stare, impatiently tapping their feet.
Sound familiar? The rehab seating and positioning is a fast-paced world rife with ever-changing products and technology as well as the tumultuous climate of reimbursement. So, how does the industry cope? Home Health Products asked the Clinician Task Force for a behind-the-scenes look at the current state of S&P.
Filling Your Cart
Products develop in the rehab market at the speed of light, which can pose a bit of a challenge for clinicians and suppliers. "There's new product coming out on the market all the time," agrees Mike Babinec, OTR/L, ABDA, ATP, product manager of electronics, Invacare Corp., Elyria, Ohio, and Clinician Task Force member. "And, in many cases, product that was out five years ago is no longer available. As manufacturers we're just trying to get better at trying to provide the products that meet the needs for the users of seating and positioning. So, it's constantly, constantly changing."
Barbara Crane, Ph.D., PT, ATP, consultant, Wethersfield, Conn., and co-coordinator of the Clinician Task Force, says it's nearly impossible for clinicians to keep up with the changing products, so they rely heavily on RTSs to give expert advice. "We go to conferences and most of the manufacturers exhibit their new products and they also do in-service training and those kinds of things, but as a clinician, that's one of the biggest challenges is to try and keep up on all the new products that come out, as they come out, and to try and understand what the clinical benefits are," she says. "When we ask (an RTS) about a particular feature, they'll know whether that new product offers that feature or not. So, they're incredibly helpful in that aspect of it."
In addition, suppliers must know how all of the complex components fit together to form an integrated, functional seating system, especially since different pieces of one seating system can come from different manufacturers.
"It's really not unusual at all to find a seat cushion from one manufacturer, a back from a different manufacturer, the chair itself from a third manufacturer and then some of the positioning components, like the headrest and the laterals on the chair, even from a fourth manufacturer," says Babinec. "It's not unusual to mix and match to meet the needs of the user. One of the very cool things that I see is more clinicians are paying attention to comfort as being one of the primary goals of all the seating and positioning that they do -- comfort and function. And to achieve both of those, sometimes mixing and matching components (has) quite a few advantages."
Think of rehab as a complex puzzle. Clinicians make suggestions on what they need to address the needs of the client -- the shape of the puzzle piece -- and it's up to suppliers to track down the actual product to fit that need -- or find that shape in a vast array of similar puzzle pieces.
"Say if you have somebody with a spinal cord injury who's at high risk for skin breakdown, then you're going to need a seat cushion that has pressure-relieving characteristics or you might need a tilt system on a power chair, so that the person can pressure relieve," says Crane. "So, the therapist will help to kind of guide what features are needed without even talking about manufacturers or specific products, and then the RTS comes with the knowledge of what products have the features that the therapist is looking for. And so they do a matching process based on the clinical needs of features to specific products that can meet those clinical needs."
Suppliers perform the critical job of bringing products to test at the seating assessment. To get the right fit, clinicians might also use seating simulators that allow them to put many different types of supports on the chair to assess where the supports should go, what size is needed and how the supports should be mounted, says Crane.
"Our world has been rocked with basically dramatic changes in coverage policy, coding, pricing, documentation, supplier standards and then upcoming competitive bidding. So, despite ongoing innovation and development of technology, coverage policy is going to dramatically impair access of these new technologies to the people who need them." --Laura Cohen, PT, Ph.D., ATP, co-coordinator of the Clinician Task Force. |
No matter how smoothly a seating and positioning team operates, choosing the right seating system is always a challenge. "Regardless of how good all of us manufacturers think we are, there's still not one perfect cushion that's good for everybody or good for one disability," says Babinec. "People need choices to meet their needs, and balancing the choices to make the right decision is a tough decision sometimes for clinicians."
For that reason, manufacturers work hard to introduce to market continuous streams of new products that will target specific user needs. "Probably some of the most interesting things to me in the seating and positioning world is I think we're starting to see more of a combination of materials and modalities within the same seating product," says Babinec. "In other words, there are more cushions that are trying to combine foam with air, or foam with a viscous fluid, or sometimes all three of those together. You're finding more unique combinations or cushions that have different firmnesses of foam in different places of the cushion. I think you're seeing an interesting mix of materials and an interesting mix of how people are -- if it is a foam cushion -- how they're using the foams."
Checking Off the List
Understanding the clinical needs of the client is paramount to building a functional system. In the rehab market, the clients "are typically individuals with disabilities such as spinal cord injuries, cerebral palsy, multiple sclerosis and other disabilities and disease that may be progressive in nature," says Laura Cohen, PT, Ph.D., ATP, clinical research scientist, Shepherd Center/Crawford Research Institute, Atlanta, and co-coordinator of the Clinician Task Force. "And because of the nature of these diseases and disabilities, rehab and assistive technology products are highly individualized ? The proper equipment is critical to ensure that these people will be able to maintain their independence and meet their function goals. In addition, the proper equipment has a significant role in preventing or actually delaying related medical complications like bed sores."
A seating evaluation or assessment helps determine what those needs are, and for that, two heads are better than one. Crane says the seating evaluation typically involves the clinician, supplier, client and any family members or caregivers. "The therapists will do the physical assessment of the person, looking at their mobility skills, looking at their posture, determining what their impairments are, what problems they're having (and) how that's going to affect what you need in the wheelchair," she says.
This process could take up to three hours, and could mean several sessions. "It's a very labor-intensive process for the rehab client," says Crane. "Again, if it's a person who just needs a three-wheel scooter and doesn't need anything else, then that doesn't take long at all; that's not who we're talking about. It's the folks who have much more complex (needs), skin protection needs, posture support needs, those kinds of individuals."
But the time put in by the client is only a small fraction compared to the work that must be completed by both clinician and supplier. After the products have been selected, the supplier assembles the system and adjusts the components to the right configuration before the clinician and supplier can complete the final delivery.
In fact, managing time is one of the biggest challenges for suppliers and clinicians, especially when navigating the expensive world of rehab. As the saying goes, time is money. "Efforts to control costs from a clinician standpoint revolve around making sure that consumers get the right equipment the first time, by making sure they see a qualified clinician, have a chance to see and try equipment before it is provided, and are properly fitted and trained with the equipment once it arrives," says Susan Christie, PT, ATP, supervisor, Assistive Technology Center, Bryn Mawr Rehab Hospital, Malvern, Pa., and Clinician Task Force member.
Even if clinicians and suppliers get it right the first time, however, the paperwork required for reimbursement adds more time to the equation. "There's a lot of justification that has to go into completing a seating eval and then writing the justifications for the components for that eval," says Babinec. "Finding the time to get the paperwork done is a very, very big challenge. There's some justifications or some funding sources that require quite an extensive evaluation to be done."
A Reimbursement Medley
"Our world has been rocked with basically dramatic changes in coverage policy, coding, pricing, documentation, supplier standards and then upcoming competitive bidding," says Cohen. "So, despite ongoing innovation and development of technology, coverage policy is going to dramatically impair access of these new technologies to the people who need them. And there's a huge disconnect between the government priorities for funding research and development for technology and government policies regarding provisions of that same technology."
Perhaps one of the biggest concerns on the minds of clinicians and suppliers alike is competitive bidding. "Because of the complexity (of rehab equipment) there's often an ongoing need for service, adjustments, monitoring of these products to ensure that they continue to meet the medical needs of the individual," says Cohen. "Competitive acquisition will not work well for these products with unique configurations and specific combinations to successfully meet the complex needs of one individual. Also the evaluations and assessments are critical to ensure the best clinical outcomes, and competitive bidding will basically eliminate a large part of that."
On March 16, Rep. Ron Lewis, R-Ky., introduced legislation (H.R. 4994) to the House of Representatives that would carve out rehab from competitive bidding. Since that time, the National Coalition for Assistive and Rehab Technology (NCART), with the help of organizations like the Clinician Task Force, has been working tirelessly to educate representatives about rehab, urge the passing of the legislation and encourage a similar bill in the Senate.
"I believe that rehab seating must be carved out from the competitive bidding process, since each rehab chair is specified and constructed for the individual user, and each is different," says Christie. "While shipping a commode or walker from a central location to many users may be feasible, it is not for custom wheelchairs."
In fact, with "a rehab carve-out, you're talking about a small targeted population," says Cohen. "Only about 3-5 percent of all durable medical equipment is high-end or complex rehab and assistive technology, so we're talking about a small portion."
One of the major points of contingency is that the time needed to fit a client with rehab products makes it impossible to competitively bid rehab. "What we see as a big downside of the competitive bidding is that you may have a supplier who can go get the components and drop them off, but our concern is that you're going to lose that service end of the RTS who actually assembles all the components (and) adjusts them to the right configuration," says Crane.
Babinec agrees. "Those products are pretty complex," he says. "And there are a lot of services that go on behind the unpaid scene to get that product to the user and get it set up and configured for them appropriately. And if we put a competitive bidding process in place and try to provide those same products, there's a good chance that in order to provide this lowest bid, that some providers may have to cut out some of those services because they won't be able to afford them. We can't afford to lose the services of those qualified RTSs when it comes to getting the right equipment configured the right way for these people."
Another cause for concern is the proposed power mobility device codes that are looming. While it is impossible to predict how the codes will impact seating and positioning until a fee schedule has been released, clinicians are worried about what could happen by combining seating and positioning into a "mobility package."
"The one thing that the codes have done in terms of seating and positioning is bundled some of the typical components in with the mobility systems, so things like legrests and armrests, seat positioning, pelvis positioning devices or seatbelts have been included in the basic equipment package that is supposed to be supplied with the power base," explains Crane. "What that does in terms of seating and positioning is possibly -- and again we don't know how this will come about until we know what the reimbursement rates might be -- but it may limit choices for things like arm supports or foot supports. Because if it's an item that's a little bit unusual, the supplier can no longer bill it as a separate component. And there are some components, because of the adjustability or the durability, that are more expensive than other components."
Babinec, on the other hand, sees the new PMD codes as a potentially good thing for rehab. "I think there's going to be some growing pains with this, and (there) has been some significant pain so far," he says. "But I think in the long run, I applaud the efforts by CMS to develop a code set that's going to allow us to match the technologies that are available to the needs of the user. I think the old days of having just a couple of codes worked adequately when the codes were developed, but since that time, the number of chairs that have been introduced in the market, the number of new technologies that didn't exist back then, it's just mind boggling. The technology's changing so rapidly, that I think this expanded code set, if we continue to be smart about it, will better allow the clinician (and) the RTS to match the technology to the needs of the user."
How Is Obesity Impacting Pediatric Seating?
As obesity continues to plague the population, clinicians are feeling the blow with pediatric clients. The challenges of fitting pediatric clients in rehab systems that grow are compounded by the fact that many pediatric clients no longer fit into pediatric equipment.
The good news is that past modalities of adult equipment that do not grow are changing as more manufacturers respond to the bariatric market. "We're actually moving away from the concept of separate pediatric vs. adult products in some categories of equipment," says Barbara Crane, Ph.D., PT, ATP, consultant, Wethersfield, Conn., and co-coordinator of the Clinician Task Force. "Manufacturers are starting to recognize that it's not just pediatric products that need the ability to be grown or adjusted. At the other end of the spectrum, they're actually (making) bariatric products that can be grown."
Mike Babinec, OTR/L, ABDA, ATP, product manager of electronics, Invacare Corp., Elyria, Ohio, and Clinician Task Force member, says that manufacturers are indeed building more flexibility into products. "You see a lot of rehab chairs (with) seating systems on them that can change in width and change in depth, and this is a pretty good thing for both the provider and the user. When you've got flexibility built into the base to adjust sizes as the user's needs change, then the RTS can modify the configuration of the chair to continue to meet those needs."
Rehab Fly-In
On May 22-23, rehab technology suppliers, rehab manufacturers, consumers and clinicians met in Washington, D.C., for a Rehab Fly-In organized by the National Coalition for Assistive and Rehab Technology (NCART). The group, lobbying for the House bill (H.R. 4994) introduced March 16 to carve out rehab from competitive bidding, hosted a rehab fair and made congressional visits.
At the rehab fair, the group "brought in different kinds of seating systems and different kinds of headrests and standers and manual wheelchairs and power wheelchairs with the idea of demonstrating to members of Congress and their staff what complex rehab is all about, what the equipment is because there's not a good understanding of rehab and assistive technology on the Hill," says Sharon Hildebrandt, NCART executive director. "When they tend to think of durable medical equipment, they tend to think about things like hospital beds ? Since we're trying to get a carve out, an exemption from the National Competitive Acquisition Program for rehab and assistive technology, we felt that they needed to know a little bit more firsthand (with) sort of a hands-on demonstration as to the kinds of equipment that we were talking about and how the equipment is used by consumers."
Clinicians staffed the fair and consumers demonstrated how their equipment worked and why rehab and assistive technology could not be competitively bid. Hildebrandt estimates that more than 100 visits were scheduled on the Hill with approximately 55 people attending the fly-in.
"There was a general interest, a good interest, and a better understanding once we talked (the members of Congress) through, and we showed them through the various kinds of products what rehab and assistive technology was all about," says Hildebrandt. "A lot of them didn't know. They thought, for example, that (rehab was) just a wheelchair, and we showed them the complexities of a wheelchair and the different kinds of systems that go on a wheelchair."
To learn more about how to participate with NCART's efforts, visit www.ncartcoalition.org.
This article originally appeared in the July 2006 issue of HME Business.