It has said that "Politics is the Art of Compromise",
so the recent announcement by HCFA suggests that
politics -- and not science -- is the basis on which such
decisions are made.   HCFA has now added a new and
previously undiscussed "four weeks" clause to the
PME requirement for electrical stimulation coverage.

And at the Multi-Specialty Conference on Saturday, Barbara
Woolner reported an email from Anthony Norris that said
the same requirement would be applied to biofeedback
for incontinence.   Everyone cheered.   Prematurely.

The "four weeks" clause apparently represents some
sort of compromise, but it isn't clear who or what is
being compromised besides the patients, who will now
have wait an extra month to PROVE that PME alone
didn't solve their incontinence problems.

    The requirement is somewhat reminiscent of abortion
    laws which legalized the procedure but required
    patients to "think it over" for 24 hours before
    proceeding.  But since when is it an ethical problem
    to seek help with incontinence?


One thing is certain -- there is no scientific basis for
the "four weeks" clause that HCFA has created.  There
is absolutely no scientific literature that even remotely
suggests four weeks of PME alone will benefit ANYONE.

Even organizations like NAFC, that vigorously promote
the use of "verbal instruction alone" through audio tapes
and pamphlets, acknowledge that it takes four to six
MONTHS of practice to achieve any significant
results.

Based on scientific literature, we can say with almost
perfect certainty that ALL patients will still show a need for
biofeedback after only four weeks of "PME alone".

So where did the "four weeks" clause come from, and
what purpose does it serve, except to delay the onset of
effective therapy?

Or is THAT the real reason?

Come to think of it, I don't recall any such "delay" clause
in coverage for drugs or surgery.  Do you suppose that
the real purpose of the "four weeks" is to give patients
an incentive to try these "traditional" remedies first?

Consider the poor patient who finally decides to do
something about her incontinence.  She goes to an
ethical urologist, who tells her that the Public Health
Service recommends that least invasive procedures
should be attempted first.   She can get biofeedback
right in his office, and it will be covered by Medicare.

However, there's a catch.  She will have to go home
and practice (following an "ordered" program) her
Kegels 30 minutes every day for 28 days, keeping
meticulous notes, to "prove" that she is a "failure".
Only then will Medicare shell out.

But, he says, there is an alternative that requires no 28-day
delay.   She can get surgery tomorrow morning (NPO
after midnight and, in fine print, six weeks to recover,
of course.)

OR, better still, she can pick up some Ditropan at
the pharmacy in the lobby.  No, it won't be
as effective as biofeedback (Burgio proved that), but
she can start taking drugs in just 20 minutes.


Can you imagine the outcry if HCFA demanded a
28-day wait for surgery or drugs???


There were at least three active recommendations made
to HCFA for implementation of the "pre-conditions"
for reimbursement mentioned in the famous "footnote 18"
of their October e-stim decision.

1. Initially HCFA staff members proposed that a documented
"history of failure of PME alone" would be the standard.
There was no mention of an "Ordered" program, and no
mention of "four weeks".

2. The Continence Coalition (and some others) focused on
the wording in the HCFA biofeedback statement concerning
the possibility that patients "who are unable to perform
pelvic muscle exercises" should also be eligible.   They
proposed that such an inability could be quickly
ascertained by a simple manual examination by an MD,
an RN, or a PT.  HCFA rejected that option.

3. The Association for Applied Psychophysiology and
Biofeedback argued that the inability to perform PME
contractions could be as readily -- and more scientifically --
determined in a simple EMG evaluation by any trained
clinician.  HCFA rejected that option also.


Instead of following the nearly universal clinical
experience OR hard "scientific" data,  HCFA opted
for a ridiculous 28-day delay before starting biofeedback
and/or stim treatment.  The right hand giveth, and the
left hand taketh away.

We can only conclude that something happened between
the October 6th announcement of coverage and the new
wording announcement.   Someone got to someone, and
the pharmaceutical-surgical establishment has suddenly
got a new lease on life -- or on our money, to be more
precise.

As Diane Smith said so cogently at the New Orleans
meeting, "I've never met a patient who had not tried
and failed Kegel Exercises before she came to see me!"

Now they will have to PROVE that they failed.

It appears that the battle is not over yet.   Don't throw
away those "How to Contact Your Representatives"
flyers just yet.   There is more -- much more -- to be done.


(To be continued)

John


   John D. Perry, PhD, MDiv, BCIA-C, FAACS
1192 Lakeville Circle * Petaluma, CA 94954 USA
   Phone: 707-789-9135  *  FAX: 707-789-9137
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         Website: http://www.InContiNet.com