Arizona Medicaid Changes Limit Benefits to Patients

Effective Oct. 1, the Arizona state legislature instituted significant
changes to the adult benefit package for the Arizona Health Care Cost
Containment System (AHCCCS) population. Among other substantial effects, these
changes will eliminate all coverage of orthotic devices for people older than
21 years.

  Tom Hamm
  Tom Hamm

Many O&P and other health care professionals in the state have
protested these changes.

“The effect to all of us is that L-codes aren’t covered …
even for the patients under 21,” Tom Hamm, BOCPO, president of Arizona
Desert Orthopaedic Center said.

This severely hinders orthotists’ ability to provide care to these
patients. Without orthotic devices, options are limited to plaster or
fiberglass casts, which may not be the best treatment for the particular

“In a nutshell, it takes much of orthopedic treatment back 40 to 50
years,” Hamm said.

Since patients will not be covered for this care, they will have to seek
care from their primary care doctors and orthopedic surgeons, many of whom have
not been formally trained in these areas of care, Jackie Forster, CLE, of
Arizona Institute of Footcare Physicians, said.

“Especially with the diabetic population that will be running into
problems because of the lack of funds for orthotics, which could help prevent
ulcerations,” she said.

Despite the practitioners, advocates and attorneys fighting against
these changes, the decision passed.

Now, “it’s going to lie in the hands of the primary care
doctor to know what to do and where to send the patient appropriately now,
because they’ve always referred them to podiatry,” Forster said.

Prosthetic care remains virtually untouched — AHCCCS eliminated
only microprocessor controlled lower limbs — but the prosthetic profession
in Arizona still will be affected.

Hamm told O&P Business News that he expects significant
increases in the number of amputations, especially for diabetic patients, and
in the cost of hospitalization for infections as wound care patients go

And since these complications are more likely to result in a trip to the
emergency room, Forster said she finds it unlikely that the state of Arizona
will be able to save much money.

“I think that once the primary care doctors and the orthopedic
surgeons and the wound care centers are inundated … I think when they
finally realize that they can’t handle it, that there will be some
speaking out to help reverse this,” Forster said.

She does not find her request to be an unreasonable one.

“On behalf of the state, I have to say that we’re broke, and I
understand that they had to make cost cuts somewhere,” she said.

But there are better ways the legislature could have approached the
situation, she said. For one, she had hoped that patients with diabetes would
have been exempt from these changes. Another option would have been to more
carefully designate covered patient diagnoses across the board. Older than 21,
since older patients with diabetes or vascular problems are more likely to
develop ulcers and other complications leading to amputation.

Hamm, on the other hand, said that he would have liked these decisions
to be based on individual L-codes. Without proper bracing after orthopedic
surgeries, for example, the amount of time spent in physical therapy sessions
will increase — up to the new limit of 15 visits per contract year —
which is another unnecessary cost that could be prevented with the right
postoperative orthotic care.

  © 2010

One more detrimental change to these benefits is the elimination of well
visits, a previously covered benefit that reduces the need for the emergency
room care that tends to increase the cost of health care throughout the United

Hamm said that he hopes to be able to warn people in other states about
these changes so that they can prepare for the worst.

“There still are a lot of what ifs,” he said. “This was
something that came about very quickly, and at this moment there doesn’t
appear to be much of a recourse.”

He, too, said that he wants to raise awareness, and that the only way to
change this situation is to rally together Arizona’s affected populations.

“We need the hue and cry of the affected population to be
heard.” — by Stephanie Z. Pavlou

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The impending changes will of course significantly impact O&P care
in Arizona. In fact, it will eliminate orthotic coverage completely. That said,
there is a budget crisis ongoing in this and many other states. My practice is
now built upon mainly those patients on AHCCCS. In fact, most of my 20 years in
Arizona practicing prosthetics, then orthotics and prosthetics, have been in
the care of AHCCCS patients. I can’t help but think of how much fraud and
deception I’ve seen in those years, and the many thousands, if not
hundreds of thousands, of dollars that could have been saved and used for
moments such as these.

My experiences include prostheses that are not needed but are provided,
and providing prostheses of incredible cost. AHCCCS is, after all, a welfare
program. Quality care does not mean you provide the latest and greatest, but
instead something that fits well and provides a minimum standard of care. Many
practitioners today, in this state, do not understand this, or simply do not
care. It’s possible they have been guided and instructed by their
superiors that they must provide items that create the most profit. It’s
possible they have been swayed by the manufacturers to the point that they
believe they are not helping unless the patients have a new, high-tech
microprocessor gizmo. Maybe practitioners of today do not know how to fit a
waist belt and fork strap, or do not comprehend how to instruct patients to use
their own bodies to control the prosthesis, but rather must depend on
technology to keep the patient “safe.” That said, AHCCCS has altered
prosthetic reimbursements to now disallow microprocessor knees, a move better
late than never.

A friend pointed out that the severe reaction to completely eliminating
all orthoses seems to suggest the lack of any need to ambulate or control
extremities for those requiring these devices. We all agree orthoses have an
important and meaningful part of patient care. While similar misappropriation
of limited funds by O&P practitioners has certainly taken place, a
correction in policy more closely resembling those in prosthetics might have
been a better choice.

This is my life, and I have committed many countless hours on nights and
weekends providing care to those who truly need it. My livlihood is being
challenged and threatened, to some degree by the economics of today, but also
by the greed and immorality of others seeking the almighty dollar. Mad? Yes,
and not just at the state of Arizona or the simple fact that there isn’t
enough money to go around.

— Steve McNamee, CP, BOCO

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