When the only medical center in Nevada performing cochlear implantation for children on Medicaid stopped doing the surgery, Matthew Ng, MD, an otolaryngologist there, stepped into the role of activist. Unlike many of the hearing devices he places in kids, the task wasn't necessarily a comfortable fit.
It had never occurred to Ng that one day he would have to become a public advocate for funding of his life's work, a path he chose many years ago after he did a residency stint at a Los Angeles clinic for hearing-impaired children. “After that, it really was what I wanted to do, and really all I wanted to do,” he said.
Now he wonders if he will be able to keep doing it. And he is far from alone. Other places are facing similar fiscal challenges, including Kansas, New Mexico, and North Carolina. (Medicaid Watch: State Medicaid Health Cuts and Expansions, September 2011; Kaiser Commission on Medicaid and the Uninsured, May 2011.)
Are these “Medicaid kids,” as they are sometimes called, in danger of staying deaf in states across the country? In Nevada, they certainly seem to be running such a risk. “In effect, this means that, while newborn babies are screened for hearing deficits, we are not allowed to treat them when it would help the most,” Ng said. “We know that one to two years old is the time to intervene with a cochlear implant; otherwise that part of the brain responsible for hearing will not adequately develop in the absence of sound.”
Now, he and others are working with cochlear-implant companies to slash costs by offering older implants made before the current generation of technology.
‘NOT A SOLUTION’
At University Medical Center in Las Vegas, the facility that had been performing the procedure, the devices were costing about $35,000, which put every Medicaid-paid cochlear implant in the red. Even so, the news that the surgery had been dropped came as a shock to Lynn Carrigan, Chief Financial Officer of the Division of Health Care Financing at the Nevada Department of Health and Human Services. She said she had no indication that the compensation was insufficient because “UMC submitted the claims, and we paid them.”
Once it became clear that the surgical procedure had been dropped by the medical center, her office changed its processing so that ambulatory surgery centers, which generally had not been performing cochlear-implant surgery for Medicaid patients, could be reimbursed for the procedure. A rate study was conducted by her office over six months, and an adjustment in reimbursement from the state's Medicaid plan was made following the review. The sum for cochlear-implant surgery was increased approximately 15 percent to about $19,430.
Soon, ambulatory centers will be able to submit claims to her office, and when that happens it seems likely the implant procedure will shift to some of these locations, she suggested. “There has been interest [from some surgical centers], and that is why we are reprogramming our claim system,” Carrigan said, noting that such centers may be paid the same amount as UMC. This shift may solve some of the continuing need for the surgery, she said.
But portions of the deaf patient population have other medical issues, which require a hospital setting, Ng pointed out. “Moving cochlear implantation to the surgery center setting is not a solution,” he said.
Last year, an American Academy of Otolaryngology-Head and Neck Surgery survey of surgeons, nearly all of whom currently participate in Medicare, showed that many were likely to limit Medicare acceptance in the future if proposed cuts are carried out. That bodes poorly for Medicaid participation as well, which often mimics Medicare. (Health Serv Res 1995;30:1-26.) Nearly half of those who answered the poll said they also intend to refer complex cases elsewhere if reimbursement drops further. (2010 AAO-HNS/Surgical Groups Survey of Medicare Participation; http://bit.ly/MedicareSurvey.)
So, if Ng and like-minded advocates—audiologists, speech pathologists, and industry representatives—succeed in restoring cochlear implantation, their solution may be a salvo heard nationwide.
Delaying implantation or not doing it all because of financial factors “doesn't make sense ethically, economically, or logically,” said Blake Papsin, MD, Director of the Cochlear Implant Program at the Hospital for Sick Children in Toronto.
Few approaches in medicine have proven to be as drastically cost-saving over time as cochlear implantation, he said, adding that giving young children implants reduces the need for individualized, more intensive education and allows them to attend regular school.
“I don't mind having a target on my back about this because this is a situation in which it is important to be an advocate,” Papsin said. “This is one of the most successful interventions in medicine; it is at the top of the list.”
At Papsin's institution, early access to cochlear surgery is done completely without regard to funding, with the physical need for the intervention as the major consideration. Stimulation to the lower brainstem that leads to acquisition of verbal skills simply cannot be achieved at the same level after early childhood, Papsin said. “This is a critical period of minimal deprivation that is lost with time. The idea that we would sacrifice this [window of opportunity] for a few thousand dollars makes me sick to my stomach,” Papsin said. “Our healthcare delivery system [in Canada] is not perfect, but there is no waiting list here for this. None at all.”
The effect of the cochlear implant procedure typically can be seen a few months following surgery, often during the first visit to the sound booth. There, the baby will show signs of hearing never before seen, such as turning toward a noise, explained Jessica Hagan, Clinical Audiologist in the Cochlear Implant Program at Oregon Health & Science University (OHSU) in Portland. OHSU accepts Medicare and Medicaid recipients for the surgery.
“It's pretty amazing for parents,” she said. As the baby learns the significance of some noises, sounds begin to be paired with a person: A door opening at a certain time of day means dad is home; mom has special footsteps that signal she's nearby. “This is something that the parents will talk about, how their baby is learning voices and will babble and coo,” she said. For children who are implanted later, such milestones take much more time and work on the part of audiologists and speech pathologists.
Implantation is “not like a pair of glasses you put on and you suddenly see; the gratification takes a while,” Hagan said. And, in older children, “the gaps tend to be wider,” she added.
What is the future for the “Medicaid kids” born deaf in Nevada who are good candidates for cochlear implants? Ng refuses to lose hope, but there are hurdles beyond the purchase of the implant itself. No national charity, local business, or wealthy philanthropist has offered to offset the other costs involved. Even the uptick in Medicaid reimbursement would not be enough to cover the fees for surgical staff to perform the procedure nor the time in the operating suite or even the necessary ancillary support to help ensure post-operative success.
“We discussed starting a foundation, but the money raised would only meet the hearing needs of very few individuals and would not address the statewide needs,” Ng said.
No one is easier to disenfranchise than the poor, Papsin observed. Meanwhile, at the Hospital for Sick Children in Toronto, more than 150 devices are implanted annually, and typically the children undergo it four to six months after being identified as candidates for the procedure.
Using a previous generation of implant, as has been proposed in Nevada, probably won't make much difference in outcome, but it is shocking nonetheless, Papsin said. “The USA is the greatest country in the world, and this is offensive.”
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