A health policy specialist recently spoke to a community audience about the difficult ethical problems facing family members when serious illness strikes a close relative. After the talk a woman in the audience approached the speaker and said, "That was very interesting. May I ask a question?" "Of course," the speaker replied, "What is it?" The woman said, "Where can I get extra large adult diapers for my mother?"
This incident illustrates two points. First, the basic needs of elderly or ill people must be addressed before they or their family members can think about more abstract or long-term issues. Second, it is very difficult to obtain information about meeting these basic needs, especially when it comes to finding the right products or supplies. The policies and practices of third-party payers - whether private insurance, Medicare or Medicaid - are often confusing and inconsistent. Nevertheless, with a little persistence and some basic information, you can become a more knowledgeable and satisfied consumer. The reward will be an improved quality of life for both the elderly person and the caregiver.
There are two main types of products: durable medical equipment and disposable medical supplies. Both types are used at home to make it easier to manage the basic needs and medical care of elderly, ill or disabled persons. However, both broad categories cover a wide range of products in terms of cost, availability, and effectiveness.
Durable Medical Equipment and Medical Supplies—The Difference
As the name suggests, "durable medical equipment" is designed for long-term use. Often abbreviated as "DME," the category includes a variety of equipment such as hospital beds; mobility aids (walkers, scooters, wheelchairs); personal care aids (bath chairs, commodes, dressing aids); prostheses (artificial limbs); orthotics (therapeutic footwear); oxygen concentrators and other items. Disposable medical supplies, on the other hand, are used once and then thrown away. This category includes such items as blood sugar test strips (for diabetes), incontinence products (catheters, disposable undergarments), bandages and protective gloves.
As a caregiver or as a patient, you may be familiar with a few of these items, which are commonly found in a hospital or a doctor's office. However, although we often see people in wheelchairs or walking with canes in the community, we seldom notice the particular type of equipment they are using. Other, more personal items are by definition unseen and unmentioned. It is only when you become a purchaser or consumer of such products that they suddenly assume major importance. But, unlike new parents who enthusiastically share information about baby carriages and strollers and disposable diapers, adult users or purchasers of incontinence care items do not ordinarily talk about them or compare notes.
Making a well-informed decision about these products is particularly crucial when either your health or the health of someone you love is at stake. The importance of having the proper walker, orthotics, brace or other medical device cannot be underestimated. Using inadequate or improper medical equipment can seriously endanger the health and well being of a patient.
Smaller items, such as a specialized can opener or a convenient carry bag for a walker, give a patient increased independence. These items, however, are not widely advertised or readily available in stores. They must be sought out in special mail order catalogs or on the Internet. High-cost, complex machinery and supplies are even more burdensome to obtain because they require extensive expertise to make sure that the right kind of equipment and services are provided. Vigilance is essential when shopping, purchasing, arranging delivery and maintaining these machines.
Do Seniors Need Durable Medical Equipment and Medical Supplies?
With some exceptions, medical equipment and disposable medical supplies are not designed for people with a specific disease or condition. Rather they are designed for people who have a particular functional limitation that is a result of their medical condition. That is, they have trouble walking, using their hands to do chores or using ordinary bathroom fixtures such as showers and toilets.
Sometimes the need for these aids is immediately apparent, for example, when an elderly person breaks a hip. At other times the need appears gradually as people have more and more trouble doing things they have always done. Caregivers must be alert to the potential need for an assistive device, since older people may try to hide their increasing disabilities. Even a visit to the doctor may not reveal that there is a problem at home with walking or cooking.
The patient's limitation of function and the duration of impairment usually determine if a device is needed and, if needed, what particular type of equipment will best improve that function. A person who only has difficulty walking long distances will require a different kind of wheelchair from one who has suffered a debilitating stroke. A scooter may be the best answer for the moderately impaired person. The number of hours per day a person will be using an item is also important in determining which equipment will be most effective. The patient's ability to operate a medical device independently, or the availability of a caregiver, also dictates whether or not a product should be prescribed and, if so, which product.
Convenience and comfort are additional factors in deciding which assistive devices a patient needs. Cushions, pillows, heating pads, special moisturizers, specialized canes, lift seats, specialized clothing for the wheelchair-bound and other such products can make it much easier to care for a patient and can prevent some common problems such as skin breakdown. Safety railings, aids for transferring from a bed to a chair, special shower heads or other similar items can be extremely helpful when caring for someone who is able to do little alone.
Assistive devices like these often ease the burden of what is called "custodial care." Third-party payers define "custodial care" as care for someone who does not require "skilled nursing care," a category used to determine whether someone is eligible for a professional nurse's visits. This is not to say that the "custodial care" patient does not require intense care, including help with personal care such as bathing, eating and getting out of bed (some of the activities of daily living referred to as "ADLs"). It simply means that the third-party payer has decided that the patient has no special medical needs such as wound dressing or IV infusion that require the skill of a nurse. Of course, many non-nurses, including family members with no training at all, often perform these same tasks. In these cases the care is called "informal," that is, unpaid.
Some durable medical equipment is more disease-specific than others. For example, oxygen cylinders are used for respiratory therapy for those suffering from asthma, emphysema and other lung diseases. A nebulizer - a machine that transforms liquid medicine into a spray - may also be used for patients with breathing disorders. Catheters and ostomy products such as drainage bags are used for patients who have lost normal bowel or bladder function due to surgery or illness. Artificial nutrition is supplied through liquids administered parenterally (feeding by vein) or enterally (feeding by tube inserted in the stomach). These products must be prescribed by a doctor.
Who Orders Durable Medical Equipment and Medical Supplies?
The answer to this question varies. For example, if an elderly person has been hospitalized with a broken hip, a hospital discharge planner - usually a nurse or social worker - is supposed to help the patient and caregiver order the proper equipment and supplies. If home care has been arranged through a certified agency, the nurse or supervisor is supposed to arrange delivery of necessary equipment and disposable supplies. If a patient has been in a rehabilitation facility or a rehabilitation unit in a nursing home, a physical therapist is supposed to evaluate the need for home equipment and coordinate the ordering. Sometimes a doctor will prescribe medical supplies such as nutrition supplements or needles for insulin injections, which can be obtained from a pharmacy. However, nothing should be taken for granted and the responsible person - whether the patient or the caregiver - must follow up to make sure the proper equipment is ordered and delivered on time.
Due to the current brevity of most inpatient hospital stays, the discharge plan may not be discussed until the last minute, leaving little time to plan for and obtain needed equipment and supplies. Furthermore, equipment used in the hospital may differ from that available for home use, so instructions provided in the hospital may not be applicable to the home setting. Some well-intentioned discharge planners may order equipment and supplies of the wrong kind because they are not adequately informed about a patient's specific needs and the home environment. Therefore, caregivers should offer as much information as possible and also should ask questions about equipment and supplies to ensure that the products will be provided. For example, ask if the hospital bed will have electric rather than hand-operated controls and be equipped with an air mattress to prevent pressure sores.
Based on prior conversation with the patient's insurer, the discharge planner may only present the equipment option for which the insurer will pay. Therefore, you should ask the discharge planner to inform you of all options, not just the one the insurance company approves. Some negotiation then may be necessary in order for other, more suitable equipment to be delivered and its additional cost covered by the insurance company or, if need be, paid out-of-pocket. It's up to the caregiver to be diligent in determining and obtaining what is best for the care recipient, even if doing so requires an appeal of the insurer's decision.
A discharge plan is just that - a plan to release the patient from the hospital safely. If other needs become apparent once the patient is home, the caregiver and the home care nurse (if one is involved in the case) should identify and obtain the necessary equipment or supplies.
Who Pays for Durable Medical Equipment and Medical Supplies?
The answer to this question is: "It depends." Medicare, federal insurance available to individuals 65 and over, disabled individuals, or persons with permanent kidney failure, has two types of insurance, Medicare Part A and Medicare Part B. Durable medical equipment is only partially covered under Part A if the insurance beneficiary (the patient) qualifies for the Home Health Benefit. This means that the patient must be incapable of leaving his/her residence, requires skilled nursing care and does not require only custodial care (bathing, toileting, etc.). If the patient does qualify for such benefits, then Medicare will cover 80 percent of the allowable amount for medically necessary durable medical equipment. Each state sets its own allowable amount for each item. For example, if a patient requires a specialized walker that costs $200 (assuming that all parties deem it medically necessary), and the allowable amount for walkers in that particular state is $100, then the patient would be required to pay $120 for the walker (80 percent of the allowable amount plus the difference between the allowable amount and the cost).
Under Medicare's Part B, the co-pay is the same - 20 percent of the allowable amount and any additional expense after that. However, the patient does not have to qualify for the Home Health Benefit. If the physician or the physical or occupational therapist considers it medically necessary, then the patient can acquire partial reimbursement for the walker.
Medicare, however, does not cover all types of durable medical equipment. Hearing aids are not covered, and usually home adaptation items, such as lifts, grab bars for bathroom safety and ramps are not covered either. However, this can vary by state.
Medicare does not generally cover disposable medical supplies, although there are some exceptions for patients with diabetes, ostomy patients and patients with feeding tubes. What Medicare does cover, however, is severely limited. Ostomy supplies, for example, are limited (depending on which product) to a certain number per month. A patient can appeal this limitation to receive additional items, but is only through an involved process including re-approval by a doctor and Medicare.
Medicaid, a federal-state program that insures populations with extremely low incomes, also varies state by state, but usually covers a wider selection of equipment and supplies and a larger portion of the expense (if not all of it) than Medicare. Medicaid, for example, covers the costs of hearing aids, as long as the patient fulfills certain criteria (i.e., has a severe hearing loss, is visually impaired or is cognitively impaired). Medicaid does not have the same strict limitations on duration of use and the number of supplies as does Medicare.
Another government program that is particularly helpful in providing durable medical equipment is the Veterans Administration (VA). The VA has extensive experience in this field and is a major resource for eligible persons.
As a general rule, private insurance companies do not pay for disposable supplies for home use. However, it does not hurt to ask. You may get some partial reimbursement, but most often the answer will be that these costs are the patient's responsibility. This is not a trivial cost: incontinence supplies alone may run up to $200 or $300 a month.
Many of these disposable items are available through mail order catalogs and on the Internet. They are also more or less readily available in your local community. Adult incontinence products, for example, are available at wholesale store chains, which generally have more competitive prices than medical supply companies. However, these stores may not carry as wide a variety of products as are available through catalogs or medical supply stores. If you need a special size or type of product, you may not be able to buy it off the shelf.
Disease-specific or medically necessary supplies, such as ostomy bags and parenteral and enteral nutrition, are at least partially covered by some private insurers. Careful research by the consumer is necessary in these situations because, although having the insurer pay for some of the cost may seem like the best deal, it may not be. A consumer may find that purchasing the item at a non-contracted or "out of network" vendor whose price is lower ends up costing less in the end. It is also possible that the convenience of using an out-of-network vendor might provide a better value, despite any extra cost. That vendor may be willing to deliver, keep track of your order, call with reminders about reordering or send regular shipments and otherwise provide the kind of service that counts for a lot. It is important, to say the least, not to run out of essential supplies. Delivery of bulky items can also be a great help, especially if transportation is a problem.
Even with the most generous insurance coverage, it is unlikely that the entire cost of durable medical equipment will be covered. Even if a private insurance policy covers durable medical equipment, the company will generally approve only the lowest level of equipment or provide a modest payment toward the cost of a more costly item. These decisions can be appealed if there is extensive medical justification, but the outcome is far from certain.
When third-party payers are involved in the purchase or rental of major durable medical equipment, a doctor's order for the item or for an evaluation by a trained therapist is necessary. The evaluator should be someone who has expertise in that specific piece of equipment, preferably a certified physical or occupational therapist. Generally the therapist and the vendor work together with the patient and caregiver to determine the patient's needs and the available options. The third-party payer may determine the choice of therapist and vendor. All third-party payers now contract with one or more vendors who supply particular types of equipment. Of course you may choose another vendor, but there is no guarantee that the insurer will pay the full amount or any amount in that case. You should ask for a list of approved vendors, but recognize that you might have difficulty obtaining it.
Supply companies may also be regionally specific. If you live in Florida, you may only be able to order supplies from a company based in Florida, whether or not they supply what you need or have the best prices.
The choice of whether to rent or buy durable medical equipment is often made by the insurance company. If they decide on rental, then the equipment must be returned to the company that provided it after it is no longer needed. Customers who will be paying for expensive items must decide for themselves whether it is better to rent or buy. For very short-term use rental is clearly the better choice, although many vendors have minimum rental periods of a month. When the item must be customized, such as a wheelchair for a severely disabled person, purchase is probably the only option. There is a private market in resale of some used or previously owned wheelchairs, scooters, and especially outfitted handicap vans. Usually these are advertised in disability newspapers or on the Internet.
Small items such as special can openers, TV remote control devices and aids for dressing are available from medical supply or self-care catalogs or on the Internet through home care product Web sites. Payment for these items is always the patient's responsibility.
What to Remember When Purchasing Medical Supplies and Equipment
Medical supplies and durable medical equipment that a patient may have used in various facilities may not always be the proper, most effective or best product for the patient. Incontinence products used in a rehabilitation facility may have been given to the patient simply because they were cost effective or readily available. These products are generally not tailored to the specific needs, body size and preferences of each patient. Therefore, the brand with which you are familiar may not always be the best product for the patient. Learning about the range of products and their differences becomes increasingly important when deciding which item to purchase. Although a tiresome method, trial and error may be the best way to find the right product for the patient.
Although a hospital bed or a standard wheelchair can be delivered in a day, situations arise in which the delivery of customized durable medical equipment might be delayed for months. It is not uncommon for the insurance company's period of authorization to run out before the equipment arrives, requiring the whole process to be started again. Delays also might occur when there are complex product specifications, miscommunication between vendor and payer or insurance problems. Any or all of these problems can make the process painstakingly slow. Despite all best efforts, the wrong product still may be delivered. Again, careful and frequent inquiries and documenting all phone, in-person and written communications are advisable in order to avoid misunderstandings and to keep the process progressing smoothly.
Maintenance of Equipment and Observing the Efficacy of Medical Supplies
Post-delivery evaluation, maintenance and modifications are also extremely important. Even if the correct product is delivered, it may prove inadequate for the patient, due to miscalculation of need in the original assessment and may cause discomfort or increased disability. Observe how the product works for both the patient and the caregiver. Is it uncomfortable? Is it working? Does it cause unnecessary pain? If so, perhaps trying another type of product might remedy the situation. As the caregiver, it is important not to underestimate your own perspective of the patient's needs and condition.
Correct and adequate maintenance of durable medical equipment also is imperative. Oxygen for respiratory therapy and nebulizers are particularly complex. Safety and sterilization are two extremely crucial issues for these types of durable medical equipment because the health and well being of the patient and the entire family are at stake. All forms of home oxygen therapies need to be kept away from heat or flames, as oxygen is extremely flammable. Nebulizers need to be cleaned after each use and sterilized often; otherwise the health of the patient is seriously compromised.
How to Pick a Wheelchair for an Elderly Parent
Since wheelchairs are probably the most complicated and expensive piece of medical equipment a consumer may purchase, here is some basic information.
There are two broad categories: manual and powered. Manual wheelchairs are propelled by the rider or pushed by the caregiver. The standard wheelchair, the product most commonly used until the 1990s, is a heavy, difficult-to-maneuver chair. These wheelchairs are used in hospitals and nursing homes because they are the least expensive and serve the immediate purpose of transporting a patient from one floor to another. They are not suited for continuous use and require a good deal of energy to propel or push.
Lightweight manual chairs are the most commonly used type today. They range in weight from 12 pounds to 45 pounds. Most are collapsible, which is extremely useful for travel. Some wheelchair users prefer the "sports lightweights" even if they do not participate in wheelchair sports, because they are easy to propel.
Customized chairs are necessary for people with particular conditions or limitations. For example, a person who has had a stroke may not be able to propel a wheelchair using both arms and will need a wheelchair adapted for that problem. Third-party payers may balk at paying for these expensive customized chairs, so be prepared for a lengthy approval process or a big bill.
Powered wheelchairs use either gel cell or wet cell batteries that must be recharged regularly. The user can operate the wheelchair with only a finger or even by mouth with a straw. These wheelchairs are particularly useful for people with limited upper body strength. However, they are heavy and bulky.
The choice of wheelchair should depend on the way in which the chair will be used and the particular functional limitations of the user. Some people have two wheelchairs - a manual one for indoors and a powered one for outdoors. If the residence has been adapted for a roll-in shower, a special shower wheelchair is available as well.
The American National Standards Institute (ANSI) has approved a complete set of standards for wheelchairs consisting of standard methods of disclosing information, such as the way in which the width of a seat is measured, and tests to determine the chair's strength. Potential purchasers can ask manufacturers if their specifications conform to these standards. If they do not, ask for an explanation of how they differ.
Like any other machine, wheelchairs must be maintained properly. The manufacturer's guide will offer instructions for regular maintenance, and these should be followed carefully. Also like other machines, wheelchairs break down. Ask the vendor how they handle repairs, whether they have 24-hour emergency service, whether they supply a loaner and how long a typical repair takes. Once a user gets accustomed to a particular wheelchair it is difficult to be without it.
Although they are at the other end of the cost scale, incontinence supplies are no less important to get right. A typical medical supply catalog offers several brands of products, each of which has several varieties and sizes. There are pull-on briefs, adult diapers with different types of tapes and waistbands, night-time briefs, waterproof shields, products for men and women, disposable pads, underpads for bedding or chairs, skin care products, male external catheters, sterile catheters, drainage bags, suppositories and more.
Personal preference plays a large role in making appropriate choices. Some factors to consider are: absorbency, fit, ease of changing and price. Buying by the case saves money.
As already noted, a physician must prescribe oxygen therapy. The prescription will include the flow rate (in liters per minute) and the amount of time you need to use oxygen. Some people need oxygen continuously, while others need it only while they are sleeping or exercising.
Three common methods of providing oxygen therapy are compressed gas, liquid oxygen or oxygen concentrator. With compressed gas, oxygen is delivered to your home in a cylinder. Small portable cylinders are available for out-of-home use, since the large tanks are heavy and not easily moved.
An oxygen concentrator is an electrically powered device that separates oxygen from the air, concentrates it and stores it. It is less costly than liquid oxygen, however, a power failure can cut off the supply. Backup cylinders of oxygen should be kept on hand and users should alert their power company that this type of oxygen is in use.
As with wheelchairs - perhaps even more so - the vendor's availability for delivery of supplies and service is critical. Instructions for keeping the equipment clean should be followed carefully. Safety procedures and infection control must be followed scrupulously.
Today, elderly people and their caregivers have many choices among products that will help keep them safe, healthy and comfortable at home. While the process of selection and maintenance can be difficult, it is well worth the effort. In almost all cases there is a financial cost to making the best choice. The key is finding out as much as you can, choosing what seems to be the best option, and being willing to reexamine those choices as the situation changes.
Questions to Ask About Medical Equipment and Supplies
Obtaining and using equipment and supplies:
- If the senior has been recently hospitalized, has the hospital discharge planner helped determine and order the proper equipment? Have all equipment and product options been discussed?
- If home care is provided by a certified agency, has a nurse or other supervisor assessed the needs of the older person and arranged for delivery of needed equipment and supplies?
- If the senior is returning home from a rehabilitation facility, has a physical therapist evaluated the need for home equipment and coordinated the ordering?
- Have you (or another caregiver) followed up to assure that the proper equipment and supplies are ordered and delivered in a timely manner?
- Have instructions for use of equipment been provided to and understood by all caregivers? Have all questions been addressed?
- Does the equipment require any home modification to support its use such as additional electrical power?
- If the need for additional or other equipment and supplies arises, does the caregiver know how to obtain them?
- Assessing the appropriateness of items of equipment and/or supplies:
- How many hours per day will the equipment be used? Can the equipment provided withstand the use it will receive?
- Will the elderly person be able to operate any medical device independently? If not, will a caregiver be available when needed?
- Is rental or purchase a better option? Is customization necessary?
- Are there assistive devices/gadgets available that can provide comfort and convenience to both the senior and the caregiver? Will the insurer provide any payment for these devices/gadgets?
- Are "disease-specific" devices needed? If so, have they been prescribed by a doctor?
- Has the caregiver researched the best prices when supplies are an out-of-pocket expense? Even if the insurer pays, does an out-of-network vendor provide better value and/or greater convenience?
- Are the senior's needs and comfort periodically assessed?
- Handling a dispute with the insurer or vendor:
- Has the caregiver made frequent and careful inquiries?
- Has all communication (in person, phone, mail, email) been well documented?
- If the insurer disputes the need for particular equipment or supplies or rejects a claim for a more costly but medically justified item, will an appeal be necessary?
- Does the caregiver know how to file an appeal?