Many nonmilitary amputees needing prostheses are facing a financial squeeze because the cost for high-tech devices continues to rise while reimbursement from private insurance remains woefully inadequate or is even being reduced or eliminated.

These patients must either pay the difference between a device's cost and the insurance coverage or forgo prostheses that could provide a higher quality of life. Some use old artificial limbs that no longer fit correctly, which can lead to secondary medical conditions requiring costly treatments such as knee replacement surgery.

Health insurers often fail to adequately cover the cost of limb prostheses for amputees. (Photo credit: Peter Menzel/www.sciencesource.com)

The number of such patients will only increase as an aging population is coupled with a growing rate of diabetes and its associated risk of vascular complications that lead to amputations. Today, almost 2 million people in the United States—including 70,000 younger than 18 years—have limb loss or congenital limb abnormalities. Each year, an estimated 130,000 people undergo amputation.

Prostheses can be expensive. According to the Amputee Coalition of America, a standard below-the-knee prosthesis that allows a user to stand and walk on level ground costs between $5,000 and $7,000. A $10,000 device allows the user to become a "community walker" capable of going up and down stairs and traversing uneven terrain. For $12,000 to $15,000, an amputee can get a prosthetic leg that allows running and can function at a level almost indistinguishable from someone with 2 legs. Computer-assisted devices that adjust the prosthesis for degree and speed of swing cost between $20,000 and $30,000.

While some private insurers cover prostheses at levels equivalent to coverage for other medical conditions, the amputee coalition said others cap annual benefits at $1,000. Still others cover only one prosthesis per limb per lifetime, even for growing children.

Other amputees are seeing their coverage cut. An informal online survey of 660 members of the Amputee Coalition found that while 62% reported that their prosthetic coverage had remained the same over the past 3 years, 31% said it had been reduced and 7% said it had been eliminated.

This economic environment differs significantly from that experienced by military or veteran amputees. According to the Department of Veterans Affairs, the budget for its Prosthetics and Sensory Aids Service has grown from $1.12 billion in 2006 to a proposed $1.39 billion for 2008. And veterans are eligible to receive the high-tech prosthesis and even get an allowance to pay for clothing damaged through the wear and tear of using a prosthesis.

THINKING OF COST

In such a reimbursement environment, physiatrists need to adjust their recommendations for prosthesis depending on a patient's ability to pay, said Todd Kuiken, MD, PhD, a physiatrist and director of Amputee Services at the Rehabilitation Institute of Chicago.

"Private insurance is all over the map as to what they’ll pay, and prosthetics is not one of the things that's on a patient's roadmap when they sign up for coverage, so costs can come as a surprise," Kuiken said. "We’ll be very honest with the patients and tell them how much it will cost and say this is the best we can get for them."

To rectify these discrepancies in coverage, advocates for amputees, some physiatrists, and device manufacturers are mounting grassroots efforts throughout the country to get state legislatures to pass "prosthetic parity" legislation that requires insurers to cover prostheses just as they would other medical conditions. "Without legislation to ensure coverage, many people living with the loss or absence of a limb are facing discouraging obstacles when trying to obtain prosthetic care," said Morgan Sheets, national advocacy director of the Amputee Coalition of America. "This has a devastating effect on amputees and their families."

The grassroots campaign has had some success, with parity legislation passing in 9 states (California, Colorado, Indiana, Maine, Massachusetts, New Hampshire, New Jersey, Oregon, and Rhode Island). Similar efforts are under way in 31 other states. There also has been some movement on the federal level, with Rep Robert E. Andrews (D, NJ) introducing the Group Health Plan Prosthetics Parity Act of 2007 (HR 5615 [http://thomas.loc.gov]).

Not everyone is jumping on the parity bandwagon, however. America's Health Insurance Plans, a trade association representing almost 1300 companies covering more than 200 million people in the United States, opposes mandating coverage for specific conditions, said Susan Pisano, the association's vice president for communications. "There are thousands of mandates on the books," Pisano said. "The cost of health insurance has risen substantially due to all these mandates making it harder for employers to offer coverage."

WHAT IMPROVES COVERAGE?

So what would get an insurer to offer adequate coverage for prosthetics? "There are a couple of things that drive coverage in general—evidence about the successful application of a service or device, and the ability and willingness of purchasers to pay for it," Pisano said.

Bill Hanson, president of Liberating Technologies Inc (Holliston, Mass), underscored the importance of evidence. Hanson, whose company specializes in manufacturing powered upper limb components, said the limited documentation for the benefits of prosthesis use has dampened the ability of amputee advocates to raise insurance coverage levels. "Insurance companies have been reluctant to pay for new systems because of the cost and because they're not sure the new systems will provide greater functionality to the patient," he said. "For us, as an industry, we need to do a better job documenting improved outcomes."

Agreeing is Brad Ruhl, vice president of sales and marketing, technical orthopedics, with Otto Bock HealthCare LLP, the Minneapolis-based North and South American corporate headquarters of Otto Bock HealthCare, GmbH (Duderstadt, Germany). "Our field is tiny when compared to, say, the pharmaceutical industry, so it's not an intensively studied area," said Ruhl, whose company produces prosthetic and orthotic components. "Therefore, it's easy for payers to say, ‘You don't have any proof, and without proof, we're not going to pay.’ So we're starting studies to show benefit.

Ruhl said that small efforts have characterized improvements in coverage for prostheses. For instance, he said, company leaders who provide insurance to their employees often do not know the benefit limits for prostheses until someone becomes an amputee; then they seek better coverage. He added that insurers themselves are often unaware of their inadequate coverage. "Because the amputee population represents a very small percentage of an insurer's business, it often takes just a short talk with them, educating them about prostheses, and then the light bulb goes on."