"It’s stupid of insurance companies to insist on an inferior device costing 10 times as much," Roger Ebert wrote in a letter to the Editor of the New York Times last week. Ebert, the famous film critic, was responding to a feature the Times had recently published about Medicare only covering dedicated text-to-speech devices, even though those devices are typically far more expensive than multi-functional devices like the iPhone, which also offers text-to-speech applications. People who lack the ability to speak, perhaps due to ALS or Down Syndrome, often use text-to-speech devices to communicate.
At a time when everyone is debating how best to reduce costs and improve efficiencies in the U.S. healthcare system, it's easy to sympathize with Ebert's frustration. Why spend thousands of dollars more per patient when another device may work just as well for some patients who need text-to-speech technology?
Medicare decided to extend coverage to text-to-speech devices eight years ago, partly because they concluded that the devices were included within their definition for "durable medical equipment," which is the over-arching category for most medical devices for home use -- everything from wheel chairs to blood glucose monitors. You can bet that any reform that comes out of the focus on text-to-speech devices will have an effect on whether other medical services offered via mobile phones gain Medicare reimbursement.
The Medicare National Coverage Determinations Manual has a very specific definition for the "Speech Generating Devices" that Medicare covers: "Speech generating devices are defined as speech aids that provide an individual who has a severe speech impairment with the ability to meet his functional speaking needs," the manual reads. Among the requirements for coverage are: "Being a dedicated speech device, used solely by the individual who has a severe speech impairment; May be software that allows a laptop computer, desktop computer or personal digital assistant (PDA) to function as a speech generating device."
Characteristics of devices or software that result in exclusion from compensation, include:
"Devices that are not dedicated speech devices, but are devices that are capable of running software for purposes other than for speech generation, e.g., devices that can also run a word processing package, an accounting program, or perform other than non-medical function. Laptop computers, desktop computers, or PDA’s which may be programmed to perform the same function as a speech generating device, are noncovered since they are not primarily medical in nature and do not meet the definition of [durable medical equipment]. For this reason, they cannot be considered speech-generating devices for Medicare coverage purposes. A device that is useful to someone without severe speech impairment is not considered a speech-generating device for Medicare coverage purposes."
Clearly an iPod touch, iPhone or any smartphone is useful beyond any one application. Sure, it may seem wasteful if the U.S. government offered reimbursement for mobile phones and music players that also happen to have the ability of meeting some text-to-speech patients needs. The reality is, however, it's far more wasteful for the federal government not to offer reimbursement for these devices and/or their services, while offering reimbursement for expensive, dedicated alternatives.
Just eight years ago Medicare did not reimburse for text-to-speech devices (also known as Alternative & Augmentative Communication (AAC) devices), and it was a long road to convince Medicare that these devices were medically necessary and not just "convenience items." Here's what one proponent of Medicare coverage for text-to-speech devices had to say shortly after they gained reimbursement back in 2001:
"This Medicare policy change has been long in coming. For more than 10 years, the Medicare program had guidance that described AAC devices as 'convenience items,' effectively barring access to them by Medicare beneficiaries," Lewis Golinker, Director, Assistive Technology Law Center explained. "Even though Medicaid programs throughout the country and most insurers recognized the value of AAC devices to individuals unable to functionally communicate by speaking or writing, Medicare persisted with this view. The long-life of this policy had more to do with the small number of people who need AAC devices than with any scientific or policy reasons. AAC devices and the people who needed them simply were invisible to Medicare decision and policy makers whose agendas always seemed to be filled with problems that were more expensive, or that affected a larger number of beneficiaries. In fact, Medicare admitted in mid 1999 that it had no records whatsoever to explain why it called AAC devices 'convenience items,' yet it still took nine more months before it concluded the guidance containing this conclusion should be withdrawn."
Clearly, this type of reform will not happen overnight. Golinker's observation is still relevant: The slow wheels of change leading up to the 2001 decision had a lot to do with the small number of people who need text-to-speech devices simply being "invisible" to Medicare. The dedicated text-to-speech device makers argue that reaching this small population requires them to charge much more for the devices -- it's not easy or cheap to market to a small segment of the population that is spread throughout it, they argue.
Of course, mass consumer products like iPods and mobile phones don't have that problem, and, for the most part, their price tags reflect it.