Hurdling the Barriers: Helping Patients Achieve and Succeed with Multiple Upper-Limb Devices

Although in many cases people with upper-limb amputations want and need multiple prosthetic devices as well as specialized terminal attachments that enable greater capabilities and open more opportunities for both work and recreation, a number of obstacles stand in their way: affordability issues, and insurance denials and delays; a lack of knowledge and understanding of what’s available to them, plus appropriate guidance and training to build a comfort level that supports long-term use of their devices; and a need for partnerships that offer ongoing and future support. Several experts in upper-limb prosthetics shared their impressions and methods to address these shortfalls. Affordability/Insurance Challenges John M. Miguelez, CP, FAAOP(D), president and senior clinical director, Arm Dynamics, California, points out that work-related trauma presents a greater obligation for the workers’ compensation insurance carrier to address functional loss, while private insurance is not necessarily obligated to restore a patient to their pre-injury level of functional ability. “That amounts to a much more difficult authorization process for multiple prostheses with private insurance, although work-related trauma and claims can also present challenges.” He reports success using outcome measures that objectively assess a patient’s functional performance with the prosthesis and compares it to the function of a healthy, unimpaired arm. Those measures also track prosthesis wear time, providing additional evidence that the patient is not only capable of using the device effectively, but is actually incorporating it into daily life. “There are patients who receive multiple prostheses and never use them, contributing to the high abandonment rate associated with auxiliary prosthetics, so it’s understandable that insurers want us to demonstrate that the patient is actually going to wear and use more than one device,” Miguelez says. “If I were an insurance company, I would also ‘trust but verify.’ “Analytical data is necessary to support my expectations regarding what a patient can achieve. Providing insurers with objective outcome data, including functional performance and wear time, along with patient videos, also allows their decision-makers to see the individual’s progress firsthand. That transparency helps build trust and can make future cases easier to resolve successfully.” In general, Miguelez finds the authorization process with payers increasingly challenging. “There are more hoops to go through, and sometimes an insurance company won’t even fully consider the extensive letter we’ve prepared explaining what we found during the evaluation and why we’re making a particular recommendation. They simply issue a denial.” Fortunately, Arm Dynamics’ Justifications, Authorizations, and Billing Department has extensive experience navigating the authorization and appeals process and a strong record of success, he notes. “That team is exceptional at taking the clinical information and presenting it in a way that is meaningful and understandable to the insurance company and then having the necessary conversations about the individual patient,” Miguelez says. “It’s not simply a matter of sending a letter and waiting for an authorization or denial. There can be a great deal of discussion and advocacy involved.” That level of engagement also helps payers understand the commitment being made to the patient and the clinical rationale behind the recommendation. “Our prosthetic abandonment rate is very low compared with reported industry rates, and over time that helps build trust with payers because they know we’re not recommending devices that are unlikely to be worn or used.” “And that goes beyond the cost of the prosthesis,” he adds. “When a patient does not wear a prosthesis, there can be secondary health consequences and comorbidities that ultimately have a significant impact on long-term medical costs.” Tim Bump, MSPO, CPO, clinic manager, Handspring, Utah, notes that convincing insurance companies to cover more than one device is always a challenge, even with workers’ compensation, and success sometimes depends on more than clear justification of a single additional need. “There’s a little bit of crossover; we talk about the patient’s needs, their interests, and the things they do on a daily basis, and which of these might be doubly served by one multipurpose device: if they have interest in biking, for example, and they also go grocery shopping regularly. Where a hook might not be ideal for either of those activities, having a type of prosthetic terminal device that would help with either riding a bike or using a shopping cart could be a beneficial thing. Sometimes you can get those crossover types of devices covered that will help both with things at home and things for fun. “It can be a little easier to justify multiple devices for partial hand patients, as their devices may have less crossover in function, especially with workers’ comp, where we have sometimes been able to obtain coverage for multiple devices—for example, a silicone aesthetic and functional restoration in addition to a myoelectric, activity-specific, body-powered, or passive positional prosthesis,” he says. “Sometimes we’ll get people assistance through agencies like the Challenged Athletes Foundation. It is becoming more common with the So Every BODY Can Move movement, but legislation requiring coverage for activity-specific prosthetic care has only passed in certain states, and those laws apply only to certain types of insurance plans.” Shane Grubbs, CPO/L, FAAOP, director, ProCare Ottobock.care, Georgia, says that it’s not uncommon to get initial denials from insurers, which can sometimes be overcome if you explain the situation well. “If patients can advocate for themselves with the insurer, it helps quite a bit, especially if they’re trying to go back to work, or they’ve got kids or family members to care for. There’s a lot of justification there for the necessity to be able to do a variety of things, conveying that one prosthesis won’t safely, efficiently, and consistently support all the activities that are required to do life every day. “We’ve been successful with our responses to quite a few denials over the years, but we’ve also run into gatekeepers that are just adamant—and if it’s written as an exclusion in their policy, there’s not much we can do.” Brooke O’Steen, OTR, ForMotion, Indiana, explains that private insurance typically allows one style of prosthesis, either body-powered or myoelectric, plus one terminal device, while workers’ compensation might cover a body-powered device with two or three attachments, a myoelectric device with two attachments, and a silicone terminal device—all of which patients would be successful in using appropriately—at a price tag of about $150,000. She agrees that patient self-advocacy can not only make an immense difference in influencing their insurer’s decision to approve multiple prosthetic solutions but might also create a major trend change in the industry. “Patients who make that call to the insurance company and advocate for this industry as a whole are in the best position to make it clear that these are not just wants—these are things that they absolutely need.” With minimal encouragement and preparation, she stresses that these patients can be extremely effective. Josh Kinsey, CPO, ForMotion, says that these patients need not advocate for themselves from the perspective of an occupational therapist (OT) or prosthetist. “They only need to explain how their daily life has been affected by the traumatic loss of their hand—and mention a few of the things they no longer can do without that hand and how that has made their life very difficult—even including the need for an extra replacement device, in case this utterly essential one should break from the constant use it is sure to get.” “It’s not uncommon for a bilateral patient to have one or more backup sets,” Miguelez agrees, “because if a primary prosthesis goes down, that person may become completely dependent on a caregiver. Our goal is to maximize independence, and losing that independence can have a profound effect on a patient’s confidence and outlook. For bilateral patients, backup prostheses can be critical, and insurers need to recognize the importance of having at least one backup set.” Outcomes data can be especially valuable in supporting that need, he explains. “If we can show that a patient wears their primary prosthesis ten to 12 hours a day and that one of those devices has required repair multiple times over the past two years, the conversation changes. The question becomes, ‘How do we keep this person functioning independently, avoid unnecessary attendant care, and prevent the consequences that can come with a loss of independence?’ “Those are the kinds of conversations we’re able to have because we’ve built trusting relationship with our patients’ insurers.” Guidance and Training for Success “Is somebody going to be a long-term user or not? Sometimes that great divide is dependent on therapy—or appropriate training,” says O’Steen. In addition to ensuring patients have the right tool for the right task, the ForMotion team of clinicians, OTs, and technicians work together to train patients toward comfortable proficiency in needed skills and adaptability, she explains. While new patients may have some ideas based on what they’ve seen on Google and YouTube, they often don’t have a clear grasp of what is realistically possible for them, nor what may be available to them based on their insurance coverage, O’Steen says. The educational process begins during their first visit, through initial interviews and evaluation, and continues throughout their relationship as they learn tips and tricks that help them increase their proficiency. Since all prostheses are designed from scratch, patients learn that its design is not necessarily based on what they want, but how it will fit and work. “The more they understand about the variables that go into the design, the more comfortable they’re likely to be in adapting to it. Guiding and educating them throughout is a part of the process,” Kinsey explains. “One of the priorities that we focus on is what we call modified independence,” O’Steen notes. “It’s going to be an arduous task for patients if they’re not taught how to manage their upper-limb devices themselves, absolutely. I am a very big stickler on this point: If they can’t do it by themselves, then they’ll have to rely on somebody else—and that means they’re never going to wear it long-term, and that’s a problem. “Josh and I and Trinity, our tech, work very hard to develop a device that is going to suspend, going to give [patients] range of motion and range of function, but yet is also something that they can get on and off by themselves. None of those things outweighs one another, and if you were to ask me, I’d say that is our secret sauce in how we make our patients so successful.” Since patients do a lot of changing back and forth between multiple devices throughout the day to use the right tool for the right task, they become very proficient, she says. Miguelez also believes that a patient’s success with multiple devices relies on a combination of great fit, the right technology, and really good training. “When we believe a patient has reached an appropriate level of proficiency, we incorporate community reintegration into their training,” he explains. “A therapist may take the patient to a place like Home Depot and have them shop in a real-world environment. Suddenly, they need to be able to grasp, release, rotate, and manipulate objects with dexterity while managing the added pressure and distractions of being in public. That experience helps build both skill and confidence. “Even something as simple as taking a credit card out of a wallet can become much more difficult when there are people behind you and you’re struggling to grasp it. Those situations create valuable learning opportunities. We can then return to the clinic, identify where the patient had difficulty, and provide additional training as needed.” Because Arm Dynamics has prosthetists and therapists working full-time in its centers, Miguelez notes that patient evaluations incorporate both clinical perspectives. “Bringing the prosthetist’s and therapist’s perspectives together gives us a much more complete picture of the patient and often leads to more creative and successful results.” Grubbs observes that some patients with upper-limb amputations adapt well on their own, finding ways that allow them to more easily grab with a prosthesis to manage tasks—like putting tabs or buckles on things they interact with every day. Some can maneuver and perform tasks without such helpful tricks, others can’t. “There’s so much of that ability to adapt that’s taken for granted. Learning to use a prosthesis takes patience, practice, and support; when a prosthesis feels too complex or there’s too much friction to incorporate it into someone’s day, it can become discouraging. Patients need tailored guidance and coaching with a well-fitting socket to build their confidence and the skills to achieve the independence they’re striving for. “We would love it if all our patients worked with an OT—especially those that focus on upper-limb amputees,” he says. “I’ve always enjoyed working with them because they have a different approach to interacting with the world and training patients to mentally prepare for what they’re about to do. I’ve learned a lot from watching them do that.” Sometimes, however, a patient’s home location and funding issues may limit them, Grubbs notes. “People who live in rural areas might have to drive great distances to reach an OT,” he says. “But if we can find a physical therapist in their local area that we can help to provide with education or resources, they can understand how we can try to work together to help the patient.” Partnership/Support Miguelez spends time building productive relationships with patients as well as insurers. “My primary responsibility is to the patient, but that also means recommending what is clinically appropriate,” he says. “Sometimes patients feel that because they were injured, they should receive whatever they want, including the most expensive prosthesis available, even when it may not be the best option for them. I want to help every patient succeed; but I also have a responsibility to be a good steward of the resources available. Recommending something that isn’t justified can make it more difficult for the next patient who truly needs it.” Funding may limit the number or type of activity-specific devices available, he notes, but it does not limit the prosthetic team’s ability to customize a solution around the individual patient. “Our goal is to make patients want to wear their prosthesis. If we can customize the aesthetics in a way that makes them feel more confident, more comfortable, or simply more excited about wearing it, that’s a win.” The team first determines the most appropriate prosthetic option and then considers how best to individualize it. “We can customize everything from the thickness of the carbon fiber and the type of silicone interface to the gelcoat, colors, and overall design. There is an incredible range of possibilities, and ultimately, it’s about creating something the patient feels comfortable and confident wearing.” At one time, he recalls, most patients wanted an upper-limb prosthesis that looked as much like a natural hand as possible. That has changed, and today many patients embrace the opportunity to personalize their prosthesis with colors, team logos, family photographs, or other designs that reflect their personalities and interests. While some patients immediately know what they want, others need more guidance. “Sometimes we must draw it out of them. We may ask them to find an image or design they really connect with, and then we work to incorporate that into the prosthesis. We can also show them examples of designs we’ve created for other patients to help generate ideas while still creating something unique to them.” That personalization is part of what Miguelez describes as staying “super tight with patients” throughout rehabilitation. “Because our holistic approach brings the therapist, prosthetist, and technician together and gives them significant time with the patient, we gain a much deeper understanding of the individual’s personality, priorities, and motivations. That helps us guide decisions that go well beyond the appearance of the prosthesis. “One of our clinical measures helps us better understand each patient’s personality, motivations, communication style, and individual needs. That insight allows us to identify potential barriers to rehabilitation early, tailor our approach to the individual, and address those barriers before they interfere with progress.” Kinsey recognizes that helping to ensure that the patient’s insurer provides funding to cover the devices they need is an essential part of a successful patient partnership. Since patients’ voices can be most eloquent in expressing their needs, a partner’s guidance and encouragement toward self-advocacy may be invaluable. “Patients sometimes guard themselves from the technical details of their condition,” he says, “but a sincere, earnest, and unscientific call to an insurance company or workers’ comp gatekeeper could make a big difference in gaining approval. All they need to share is a simple description of the daily difficulties they face as a result of their loss, and the important difference a prosthetic solution would make in meeting their needs and improving their life.” It’s the small things that make a big difference in supporting upper-limb patients, Grubbs notes. “We focus on helping them gain proficiency with their prosthesis in necessary areas like cooking or folding laundry, pumping their own gas, using the card reader, and walking out of a store being able to hold things with one hand and get into your car with the other. Those are things that we try to build on, because frustration can build during that extra time it takes them to do these things many people take for granted. Practice and proficiency build confidence.” He points to a resource that prosthetists should share with their patients and then explore the possibilities together. “ Hands Free: A Beginner’s Guide for Adaptive Equipment & Helpful Gadgets from Enhancing Skills for Life catalog is filled with adaptive equipment for the home and life. Although created with people with bilateral upper-limb amputations in mind, the catalog is a compendium from which [patients] can source many items for around the house that will help them in partnership with whatever type of prosthesis they have. It’s also a source of inspiration for patients and clinicians, letting them know what’s out there, and giving them more ideas to iterate or build on.” The catalog includes simple types of cuffs or attachments that patients can use to assist with brushing their teeth or managing bathroom hygiene.. Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.

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Conceiving the Extraordinary: Groundbreaking Solutions to Upper-Limb Challenges

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Certified Prosthetist/Orthotist (CPO)

Now Hiring: Certified Prosthetist Orthotist (CPO)

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