Operation Wheeler Dealer: U.S. Government's Crackdown on Wheelchairs Highlights Tensions between Health and Disability Policy

In 2003 the U.S. Centers for Medicaid and Medicare Services (CMS) launched project "Operation Wheeler Dealer" to crack down on power wheelchair fraud in the United States. Operation Wheeler Dealer stimulated a mighty stream of responses from consumers, clinicians and industry who view the project and subsequent attempts by CMS to clarify its position as imposing further restrictions on the availability of power wheelchairs for those who need them. Wheeler Dealer may be a platform to launch more comprehensive challenges to Medicare as coalitions form to bring about a second generation of Disability Policy.

CMS's September 2003 get-tough stance on power wheelchair reimbursement was precipitated by what it called an explosive growth of Medicare payments for power wheelchairs over the past few years. A CMS representative in Dallas, Texas cited an increase in claims caused by fraudulent submissions by providers resulting in significantly increased reimbursements. In December 2003, CMS issued a clarification of its power wheelchair coverage policy. To some, the clarification appeared to revert back to a particularly restrictive 1985 provision that requires power wheelchair beneficiaries to be otherwise bed or chair confined to qualify for any type of wheelchair. The Wheelchair industry representatives, clinicians and consumers were invited to air their concerns about Wheeler Dealer at two listening sessions CMS held in Baltimore, Maryland. The health mobility industry is particularly concerned with reimbursement issues. They argue that CMS's eligibility guideline "of otherwise bed or chair confined" is too ambiguous and unclear. CMS should adopt the guideline of "functional nonambulation" which indicates that a user's ability to perform activities in the residence is restricted.

Clinicians have primary responsibilities to their professional codes of ethics and standards of practice. These codes and standards require that they do no harm to their clients, many of whom may be harmed if they do not have access to equipment. Clinicians recommend that CMS adopt a standardized, objective definition of nonambulatory. The World Institute on Disability and other consumer groups interpreted Operation Wheeler Dealer as a severe blow to citizens as tens of thousands of Medicare beneficiaries who need power wheelchairs to improve their health and quality of life could lose access to these devices. They expressed frustration that the CMS process provided no appropriate forum to include input from beneficiaries or their advocates. In March, 2004 CMS retracted the clarification. Interested parties were left with a host of questions. However, several coalitions of industry, clinicians and consumers are poised to more broadly challenge Medicare policy.

Medicare does not have an assistive technology benefit category so mobility equipment is categorized within a durable medical equipment (DME) benefit category. CMS's interpretation of DME as equipment primarily for use in the home sharply contrasts with the American with Disabilities Act. The ADA names technology as an important means to support equal opportunity and participation in society. The health mobility industry, clinicians and consumer coalitions have responded to these policy contradictions by developing platforms for change and organizing coalitions to deliver the message. Consumers and providers formed the ITEM Coalition (Independence Through Enhancement of Medicare and Medicaid) http://www.itemcoalition.org/ . The health mobility industry has formed Restore Access to Mobility Partnership, RAMP. Both have attacked CMS's restrictive interpretation of ambulation.

These coalitions have highlighted differences in approaches to eligibility for wheelchairs and other equipment by two key U.S. government agencies, the Social Security Administration and CMS. CMS limits durable medical equipment to use primarily within the home. Social Security guidelines provide examples of equipment use outside the home. In a letter to the Secretary of the Department of Health and Human Services, the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) suggested that CMS restrictions do not conform to evidence from medical research. RESNA compared CMS' focus on testing a client's muscle strength to Social Security's more prevention-oriented consideration of the impact of repetitive use of muscles on individual function and health. RESNA and other organizations also argued that fraud may be more effectively checked by the adoption by CMS of certification requirements for wheelchair providers rather than placing further restrictions on wheelchair availability. In another context, Mark Schmeler, a Clinician at the University of Pittsburgh's Center for Assistive Technology pointed to another example of contradiction, this time between two programs CMS administers. The Medicaid-based Pennsylvania Medical Assistance program refers to a condition in which the individual lacks functional ambulation. Function inevitably leads to questions about capacity to carry out activities not merely questions about medical condition.

AIMMM (Advancing Independence Modernizing Medicare and Medicaid) is perhaps the coalition most sensitive to the contradictions between Medicare and the ADA. Founded by Bob Williams and Henry Claypool, AIMMM has the benefit of their vast experience as advocates and their years of service as advisors to the Department of Health and Human Services. A visit to the website at www.aimmm.org will almost immediately bring the reader to a quote from the ADA on equality, participation and independence. AIMMM is advocating for a second generation of disability legislation that will modernize Medicare and Medicaid. Taking aim at CMS' homebound restrictions on eligibility to benefits from home health care services and in-the home restrictions on durable medical equipment, including wheelchairs, AIMMM provides examples of the contradictions between disability policy and health policy. The ADA, the Ticket to Work and Work Incentives Improvement Act and other disability policy identifies technology and personal assistant services as a means of realizing full participation in the community. Medicare policy routinely restricts coverage of these services to the home.

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