Innovative Technology

[Music] Welcome to Medical Rehab Matters. Today we're talking about innovative technology. We consider some of the key barriers that people with disabilities face and accessing assistive devices and technologies and what can be done to address those. We also discuss some of the legislative and regulatory issues related to innovative technology. I'm Patricia Sullivan, Director of Communications for the American Medical Rehabilitation Providers Association. This episode is co-hosted by Kate Beller, AMRPA Executive Vice President for Government Relations and Policy Development and Dr. Robert Krueg, immediate past chair of the AMRPA Board of Directors and Vice President of Medical Affairs for Mary Freebed Rehabilitation Hospital Advisory Group. Our guests are Andres Gallegos, Chair of the National Council on Disability, Bruce Gans, AMRPA's Chief Policy Officer, Peter Thomas, Item Coalition Co-Core Coordinator and Managing Partner of Powers Law Firm, and Joe Nara, Item Coalition Co-Core Coordinator and Director of Government Relations for Powers Law Firm. [Music] Thank you, Patricia, and welcome everyone to today's episode of Medical Rehab Matters. My name is Kate Beller, and I'm the Executive Vice President of Policy with AMRPA. Today we're focusing on an issue, innovative technology, that is special implications for patient rehabilitation patients, but also for providers and consumers at large. We have a great panel of guests today. We will theme to touch on issues ranging from the expansion of traditional Medicare benefits to cover services such as vision, to diagnostic equipment access, to issues involving consumer adaptation of health technologies in their home. I'm looking at my own Apple Watch. As I say that, which is money, my own health data, so I'm certainly consumerized well that looks towards it today's episode. So with that, I'd like to welcome all our guests. First, we're honored to have Andres Gallegos, the Chairman of the National Council of Disability. He's joined by AMRPA Chief Policy Officer, Dr. Bruce Gans, AMRPA Council and Powers Law Firm, Managing Partner, Peter Thomas, Powers Law Firm, Director of Government Relations, Joe Nara, Peter and Joe also lead the Independence through enhancement of Medicare and Medicaid Coalition, or the Item Coalition, which is very active in the space. And of course, my co-host today is Dr. Bob Crouc, AMRPA Media Past Chairman and Vice President of Medical Affairs for the Mary Free Billitation Hospital Advisory Group. So thank you all so much for being here. And Bob, do you want to start off by giving the audience a general backer on this issue and why we're focused on it today? Yeah, thanks, Kate, and welcome everybody. I'm really excited about this topic. There's been so many advances in the field of rehabilitation medicine over the past decade alone. But I really feel like our best years are ahead of us. And we're just on the cusp of so many exciting breakthroughs with assistive technology. Many, if you think about how technology has impacted all of our lives on a daily basis, whether it's Alexa or Google Home or Siri. And that's just the tip of the iceberg. And so I'm really excited to hear from our guests and talk about how people's lives are going to be improved over the coming years. But some of the challenges from a societal standpoint about how we're going to pay for that as well. So let me give a bit of a background, Peter Thomas. I work with not only the AMRPA very closely, but I also work with this coalition, as Kate mentioned, the item coalition which seeks to expand and enhance coverage of assistive devices and technologies for people with disabilities of all ages. And it really is an amazing area. There's new breakthrough technologies coming forward at all the time. It's part of the big question, of course, is getting payers to cover those technologies and ensuring that people with disabilities and chronic conditions have access to those devices and technologies in order to improve their function, to live as independently as possible and really to enhance their quality of life. And we're seeing major, major moves take place in Capitol on Capitol Hill right now. The Congress is currently considering legislation. In fact, the House is marking up legislation this week that would expand Medicare benefits to hearing, vision, and dental care. Those are three major benefits that have been missing from the Medicare program since its inception in 1965. Now of course, Medicare Advantage plans often will cover some of those benefits as an enticement to join Medicare Advantage. But the FIFA Service Program, which still covers about 44 million people, does not offer those benefits under the regular Medicare program. So that's very exciting. Another issue involves trying to get new technologies or benefits that we know benefit people in a meaningful way covered, coded, and paid for by the Medicare program and other payers. Medicare usually is an often target because it's a federal program that you can impact. But clearly Medicare is a guide for other private payers, Medicaid, VA, and other folks that cover third party payment, health care services. One of the key issues we've been working on that AMRPA has really strongly supported and the National Council on Disability has taken a real major role in trying to promote is this notion of covering seed elevation and standing systems for people who use power wheelchairs. These are systems that have been on the market for 20 years at this point. There's a large body of evidence that demonstrates their effectiveness not only in improving function of individuals who use mobility assistance equipment on a daily basis, but also improving their health status, reducing falls, reducing skin breakdowns, and other kinds of secondary injury that comes from long term wheelchair use. So that's an exciting initiative that's taking place right now to try to get CMS to consider coverage of those two wheelchair systems. And then finally, before I turn it over to Joe, I wanted to mention the growing reliance, all Americans, all people across the world have on wearable technology, on monitoring your own health status on a routine basis, as Kate said on her iPhone or eye watch or other ways of monitoring diagnostic information at home, bringing rehabilitative technologies into the home, post rehabilitation. There's all kinds of applications of consumer electronics, and this is a whole new frontier for a debate in terms of access coverage by traditional health plans. And that brings with it a whole host of issues to deal with. Joe, let me turn to you. Thanks Peter. And one other issue that we wanted to bring up and sort of moving off of what Peter said is this issue of accessible medical diagnostic equipment. This is an issue that Chairman Gallagos can speak about quite eloquently and will do so soon. But many times people with disabilities face barriers to accessing even their own healthcare providers equipment, things like getting on the weight scale or examination table when they go to the doctor's office. And back in 2017, the U.S. Access Board, which is an independent federal agency that develops standards for accessibility for people with disabilities, they released a set of standards for accessible medical diagnostic equipment or AMDE that were published in 2017 in consultation with the FDA. Unfortunately, these standards were not made mandatory. And so they're not formalized in the law. They don't have any sort of enforceability aspect for healthcare providers. So this has been an ongoing issue. And many people with disabilities continue to face these issues and some of the stories are quite shocking. [MUSIC] >> Chairman Gallagos, please get some effected from you about your own experience with assistive technology as well as the current and future outlook for what the National Council disability plans to do in this area. >> Kid absolutely. And thank you for having me. I am a person with disability having sustained spine accord injury in a horrific automobile accident 25 years ago this coming November. I am dependent upon the use of assistive technology from Dragon Naturally speaking that allows me to dictate and utilize my computer today, reliant upon a permobile F5 with an elevated seat tilt and recline feature. When I was first injured and for the first 12 years of post injury, I had a rigid wheelchair that did not tilt and recline. I have given the level of my injury C5C6. It makes it difficult for me to conduct pressure relief some my own. And pressure reliefs are incredibly important for people with quadriplegia like myself because they allow us to reposition and take some pressure off our seat to avoid pressure sores, which could be detrimental and if not tended to could lead to significant health complications and inpatient hospitalization as well. Not only was it medically important for me to obtain technology to allow me to conduct those pressure reliefs, but the technology that I have today with the seat elevation and the tilt and recline, it just provides for a better stay in my chair on a daily basis. In my chair, often many people are for 12 to 18 hours in a given day. And if you had a chair that you had to sit in in your office, even though you're not disabled, but did not give a little bit for you to recline or was comfortable for you. That would be incredibly, incredibly difficult to live day in and day out. When I went to my dentist for treatment and they couldn't transfer me onto an examination chair for the absence of a lifting transfer equipment, which I'll talk about in a minute here. to remain in my wheelchair in that fixed chair that didn't tell the recline for all my dental care, for from examination to treatment and it made it incredibly, incredibly painful and awkward. And so what happens is people tend to not go to dentists or not go to situations where there's not accessible equipment or the ability to facilitate the examinations, which leads us to the bigger problem of using the healthcare system for disease management instead of disease prevention, with respect to that point, the National Council in Disability is laser focused on achieving health equity for people with disabilities. One way to do that for people with mobility disabilities is to ensure that we have accessible medical diagnostic equipment in all healthcare sites that we utilize. As Joe mentioned, the US Access Board developed standards for pursuing to directly in the Affordable Care Act and those were developed in 2017. The Department of Justice announced that its intention to adapt those standards into regulations, but it uncertainly withdrew its advanced nose proposed rulemaking in December 2017 under the guys of determining whether or not these regulations were truly needed. In response to that, we as a council had significant conversations with the Department of Justice and that led to the development of a report that we issued earlier this year on Accessful Medical Dagnastic equipment, not only demonstrating that the need is still there as it was in 2010, but the need is even greater today because of the growing number of people with mobility disabilities and their inability to receive comparable care at hospitals and doctors' office and dental clinics because there is not accessible medical diagnostic equipment or a safe means by which transfers from our mobility devices to other services. There's no question that the need continues to increase. I know many rehabilitation hospitals that have had to set up GYN clinics, urology clinics for that very reason because you can't get access into an accessible GYN office or urology office. Many women go without their yearly monitoring and surveillance testing and it's really a travesty. And the problem is systemic. It's not limited to one class of providers, it's not limited to only Medicaid providers and Medicaid providers or are federally qualified health centers. It's in all delivery models of healthcare. Well thank you so much Dr. Gaitis for providing such a real world example of the issue that we're focusing on today. Dr. Gans, I would love to get some of your initial thoughts on the conversation so far as a physician, a staunch patient advocate, and someone who sends them this fair time building computers. And I'm also a rehabilitation engineer by my long-distant training and have been involved in trying to make useful technology available to individuals with disabling conditions for very long time with only modest success in the long run looking back at it. There's no question what Bob Krube was just saying, access to physician care. One of the most fundamental issues is tremendously inhibited for many people who are at mobility impaired in a chair. As an example, you just look at the physical construction of most private physician offices and you'll see that they're small, always tight corners to be turned, narrow doorways, everything as if it was designed intentionally to keep people in wheelchairs out of the setting. One of the themes that people have known for a long time and looked at but perhaps still isn't really fully embraces the notion of universal design where you look at creating products, aspects of the environment that are universally accessible by intention and you don't make it something special for a person with a disability, you make it the norm. We've have examples in our daily lives when curb cuts became something that cities and communities were forced to do to make clear streets accessible. It turned out that lots of folks were really happy to have those slopes down to the street, women pushing baby carriages, delivery men pulling carts. It is a simple example of how had we simply thought more carefully about all of those sorts of individual circumstances and situations where people need wheel access and a curb represents a potentially serious barrier, literally a physical barrier to getting access. It's just a simple example. Now, of course, not everybody is going to need some of the kinds of technology that is uniquely beneficial for individuals with physical limitations, but incentivizing the manufacturers and incentivizing architects and incentivizing builders and incentivizing especially medical device manufacturers to see the fundamental wisdom of incorporating universal design into their situation in a hospital, one of the most common problems that hospitals face is injuries in their workforce. And those are typically injuries associated with patient handling, typically trying to help move a patient between not knowing the right kind of body mechanics between having physical environments that are absolutely not facilitating getting into the right body mechanics to do it well. So there would be huge savings and benefits to the able-bodied workforce as well as to making accessibility for individuals who are being restricted from access to these things. And those are just simple examples of educating and helping manufacturers realize that they can actually have improved market share for their products if they can design them. So that's just one example of how thinking creatively and advocating for not just for my special needs, but things that will benefit everybody in the long run can advance accessibility of this kind of technology further. You bring up excellent points and certainly if you look at the macro trends in the aging demographics of the country, there's never been more of a reason, you know, we're an incentive for builders to use universal design and I think we are seeing that more and more, but we still have a long way to go and no doubt. And if I can add, we still have a long way to go, particularly in the area of healthcare. So to Dr. Gaines' point, there's only 11 states in the country that have adopted safe patient handling laws. And these were laws that are enacted to protect the workforce, to protect the able-bodied nurses and patient care technicians when moving patients with mobility disabilities to utilize safe patient handling techniques, which includes having a team of trained individuals if they have to physically lift a person to do so, to have an array of lifting transfer equipment available in hospitals and in nursing homes for these structures are applicable. But more importantly, to grant a bill of rights to patients so that they have a say and can direct the method in which they prefer to be transferred and to have that, have that respected because absent that if you don't have a tilt and recline the advanced features on a wheelchair, you're receiving physical examinations while you remain in your wheelchair. Women are receiving gyneological examinations while they remain in their wheelchair. And it's just horrible. What has taken place since a matter of equity and the ability for us to receive the equal treatment and care at hospitals and doctors offices that people who are not disabled receive. So it's a matter of equity. Chairman Gallagher, I just wanted to perhaps for you to talk just a moment about the report that NCD put out just last month in the forum that you held. And I thank you for being invited to speak at that. I was it was a real pleasure for me to participate in that. But with respect to accessible diagnostic medical, which NCD National Council on Disability has played a major role in for years now, what can be done to get more teeth into that guidance, those non enforceable standards that were issued in 2017? Well, they have to be enforceable. The only federal agency that has adopted those standards is the Veterans Administration. And we need to make sure that all other healthcare systems and all other agencies that adapt that as well. What we're trying to do move that along. As Peter mentioned, we did unveil our Accessual Medical Diagnostic report and enforceable standards. They have to be adopted. We unveiled that in a webcast that Peter was was on along with Department of Justice as well as Health and Human Services offices, civil rights because those are two agencies that have the ability to adopt enforceable standards regulations that apply to all healthcare providers that receive federal financial assistance by way of Medicare and Medicaid to incorporate accessible medical diagnostic equipment into their facilities and into their practices. So what we're doing and following up from that webinar, we're having individual meetings for both Department of Justice later this month. And we're coordinating meetings with Health and Human Services Office civil rights again, imploring them to adopt regulations that enforce the standards that were adopted by the Access Board. We're also meeting with CMS and having them discussing the issue of Medicare coverage or complex rehabilitation technology and breakthrough technology as well. You know, One of the things that's often missing in this discussion is that it's Difull's innovation in the marketplace. If Medicare does not embrace coverage, it's a breakthrough technology, because manufacturers are not going to spend significant money on inventing technology. If they know there's not a market for it in the biggest market, it is Medicare. And also the V8 in buying this kind of technology. So that needs to be addressed as well. In addition, what we want to do also is improve the process by which requests for coverage of complex rehabilitation technology is made, increasing transparency within health plans and managed care organizations, to ensuring that the peer review process is not just some doctor who has no semblance of knowledge of what the life of a person who the spinal cord injury is or quadriplegia, but it is an MD who is a physiotherapist who's looking at these issues and as a request, but also that my peer is involved in that process. And that as a person with disability has an equal say in our request for this kind of technology through a health care plan. There's no doubt that it's a really complex issue with a whole host of different variables that need to be looked at and addressed. The expense is real. I think we need to look at that to your point. We absolutely need to incentivize manufacturers and different institutions to develop breakthrough technology. But I think we also need to acknowledge that there are DME vendors and that don't have breakthrough technology in just repackaged things at an absorbing cost and some of that needs to be winded out so that we can afford all of this for everyone. That is an excellent point. Any time you put accessible disability label on any product, the price increases in multiples. And in a Catholic economy, profit is good, but too much profit for wheelchairs is just obscene what many manufacturers are doing. And I learned this recently a couple of years ago, I had to get my replacement chair into the chair that I have. Currently the promobile F5 and my insurance is through my wife's employer and they are self-funded. So when they received the quote from promobile for the chair, the chair was an excess of $73,000, which again, it's just absolutely outrageous. Something needs to be done in that area as well. To that point, there are wheelchair vendors who historically have gone to the airways and to the TV, to direct market directly to patients. And many individuals are getting the Mercedes or Rolls Royce, so to speak, of wheelchairs when they don't necessarily need all of that technology. Some folks in question will do. And I think that just speaks to that. There really needs to be a clinical provider, a clinical team that is part of that equation to make sure that folks are truly getting what they need to be independent and to keep them healthy and safe. Absolutely. First part of it is not payment. Part of it is coverage, whether they consider various types of technology or devices or components to be covered benefits, whether it's Medicare or many, many other payers. And that we're seeing in this issue around coverage of seat elevation and standing systems in power wheelchairs. Medicare does not cover those benefits. Why they don't cover them is beyond me. They basically say that they're they're not primarily medical in nature, which doesn't make a lot of sense when you consider the fact that the Tilton recline feature that you mentioned, Chairman Gehago's who use in your own power chair is considered primarily medical in nature and is a covered benefit. It doesn't make sense. So there is a proposal pending, as you well know. And we wanted to thank you for agreeing to go in and meet with CMS and talk about this set of issues because access to appropriate technology for people with disabilities is can mean literally the difference between ability and disability. I happen to use two artificial limbs since age 10 and the technology has dramatically increased over the last 47 years. To the point where I'm pretty much do what I want to do. I mean, I'm not running marathons. I'm not reclining rock walls, but I do a fair amount. I'm pretty active. And it's because of the technology and the and the clinical care, the link to that healthcare system from the physiatrist through the prosthetist and orthodist through the actual technology application itself. It's a real success story in healthcare. But if certain aspects of the benefit are just not covered and not considered medical in nature and of convenience to the beneficiary, the beneficiary never sees the benefits of that. Can you talk a little bit about that particular issue, the seed elevation and standing systems issue, Chairman? So Peter, as you know, we've had conversations prior to us meeting with CMS in the coming week. But the coverage issue is absolutely critical. And again, it's not just the seed elevation and the standing system, but again, for the breakthrough technologies as well. I mean, there's significant medical benefits to being able to stand from the strengthening of the bones to the prevention of osteoporosis and other conditions for cardiovascular benefits as well. Instead of remaining seated for the entirety of a day. So, but I would like to challenge the system and push back on medical necessity and view this as health equity, right? Because what we don't take into consideration is the benefits of having those functions not just medically, but what a detrimental well-being of an individual to be able then to with greater confidence engage in aspects of employment, engage in social activities, engage in recreational activities. Technology, four years ago, allowed me as a quadriplegic to go from 7,300 feet at the base of Pike Peaks Mountain, Colorado Springs to 14,100 feet to its summit in six hours, pushing a manual wheelchair as a quadriplegic with push assist system with that technology that allowed me to get an extra push every time that I would push on the rims of my wheelchair going up Pike's peak because before my accident, I used to be the marathon runner Peter. And so I missed that. And so what I found because of technology, since technology, it allowed me to get involved in recreation and live the life close to what I lived before enjoying those things that I did before. So there's a a there's a liberating aspect. There's an integration aspect. There's a social and mental well-being aspect that's not being considered one request for medically necessary equipment is being made. And I think that needs to factor in such a question as well. Yes, ensure that they receive the technology that they absolutely need, but look at what else it does for the individual in terms of their their mental well-being, their ability to truly integrate in society as as the ADA intended. Does that suggest that we really should be putting a lot more energy in trying to define medical necessity to incorporate human performance as well as the physiology and pathophysiology of disease? I absolutely think so because again, when you look at it through the lens of disease prevention and and disability, something that should be prevented, and if not then managed. No, if disability truly is part of the human condition, then let all aspects of the human condition be considered when making a decision whether or not the purchases technology are invest in this kind of technology. The language in the definition of reasonable and necessary and medical necessity has some really archaic word as malformed member to improve the function of a malformed member. And it's just led us down the garden pathway of having to invent medicalizations of things that are clearly you'd only use this thing in this way because you had a particularly physical limitation. And it's just forced a lot of distortions created the super expensive products because they have to be like as you said, label the medical and therefore we can triple the price because insurance is going to pay for it. It just is spiraled into a great difficulty and maybe going back to the foundation of reasonable definitions that would enable reasonable interpretations and have proper constraints and control so that it is not abused and that there are standards that can be met. Now it's not a small task, but we've just got ourselves tied up in knots around the stuff and it's been that way forever. We do and the individual's experience makes a difference, right? So the individual, the patient in order for a rational medical necessity to be approved by my insurance carrier or health plan, that letter of medical necessity has to be drafted in a form that makes it sound as if I'm not able to function in any someone's or meaningful way without this technology. And when you're reading that as an individual, you lose sight of the fact of why it's written or the audience that it's written for and you start to internalize was being written on the paper in terms of how limited you are without without this type of technology. And again, it does have a detrimental effect, I think, on people who are requesting this equipment. (upbeat music) - Well, I can't think of a better segue into this whole issue around new wearable forms of technology that are commonplace embedded in typical devices that we use every day, the watch or the cell phone or wearable technology that helps monitor health status. And if we're talking about a health system where we prioritize wellness and not just treat disease, and try to keep people as healthy as possible, the definition of medical necessity around all of that, that whole new fleet of technology that is readily accessible if you have money to purchase it out of pocket. But to what extent are those, should those be covered benefits? Raises all kinds of questions coming forward. - It truly does. And with the advent of this new technology, number one, we wanna make sure that in the initial conception and design accessibility is taken into consideration because it's easier to make things from the get-go as accessible than as the retrofit or modify later because of federal requirements to do so. But we have to also make sure that the technologies is affordable and can be acquired by people that don't necessarily have the means and who are dependent on ungovernment assistance just to subsist, but we need to make sure that technology certainly is affordable. - Looking forward to where is technology going? And we all know that there's a strong aspiration for self-driving cars as an example, where you simply somehow tell the car, where you want it to take its passengers and it just goes and does all that stuff on its own. That will be an amazing degree of freedom for many, many people with physical limitations, with cognitive limitations. And we're gonna get pushed. There's no doubt we're gonna push. That was at medical. Well, for me, as an able-bodied person, no, it's convenience, it's transportation. But if it's the only option for somebody who's got a physical limitation, we're gonna have to figure out how to acknowledge that the device is medical, it's that the person's need is because of this disabling condition that justifies their particular accessibility, getting assistance economically, helping to specify it so that it's really proper for that person and their individual needs. We're gonna be faced with this issue increasingly. Large notions, robots are coming, Elon Musk. It's really as disclosed that he's not manufacturing cars. He's manufacturing robots that take people places. And he's already announced a vision of creating it, a humanoid robot. A robot that could physically do tasks would replace caprician monkeys in the helping hands program, could replace care. It's going to be an incredible boon if it actually works. But we're gonna have to grapple with those kinds of issues. I mean, what an exciting time to be disabled, given all the technologies that exist today, in all seriousness. And when you mention the autonomous driven vehicles, it's a game changer for people with all kinds of disabilities. We gotta make sure again, from the inception, that it is accessible to us, and that it's affordable as well. But it truly would be a game changer. When I was first injured 25 years ago, I spent six months in the real rotation instead of Chicago. And when I was released within the first year, I was trying hand controls on my minivan, the new minivan that I had acquired. And that's a different conversation but talk about cost of accessible transportation, it's just outrageous. But I couldn't use it. It just, I was too soon in my journey to really use it with any confidence. And so I banded all together driving and I haven't driven in 25 years. And I don't want to drive, but I don't want to be driven. So the autonomous vehicle, it diminishes my reliance on, on family members of third parties to take me here to there. But in many areas throughout the country, where public transportation is not available, that truly is going to be a game changer. But also where public transition is available, but not fully accessible, which is and it happens in many, many jurisdictions. That is going to make a meaningful difference. And in all the where we're migrating from the fleet of taxis to these ride sharing paradigms, those aren't accessible. And there's losses throughout the country against Uber and against, lift to make those services accessible as well. So again, what a great time to be a person with disability with the technology is now coming about. - Chairman, you mentioned the importance of reframing this issue is one of equity and accessibility, which is one of the stated areas of focus of the Biden administration. So I just wanted to talk here about how AMRPA member hospitals can partner with NCD and others to advance some of the policies we've been discussing here, to make more meaningful differences to the patients in our hospitals. - The voice of your members matter, right? And so I would encourage them that as we release our various initiatives and we're on the verge of releasing our framework for health equity for people across all categories of disabilities and a portion of that is the accessible medical diagnostic equipment, the portion of them that also addresses the availability of assisted technology, expanding national coverage determination for the complex rehabilitation technology that we discussed. But we're gonna need to push within the legislature to get this passed and to get this fully embraced. And so I would encourage your members once that's publicly unveiled to reach out to their respective representatives, their federal representatives and encourage embracing the NCD framework for health equity for people with disabilities. And we'll get you more information specifically on that case. - That'd be fantastic. Thank you, Chairman. And just for our listeners, NCD is national coverage determination. - And it's also a national council on disability. So this is-- - Oh, yes. (laughing) - It's a bit of a confusion there. - I think it's important for obviously organizations and individuals that are represented by groups like AMRPA and other groups, consumer organizations and the like. You know, those organizations take part in efforts to try to move the ball forward, whether it's the legislative process, the regulatory process, the judicial process, whatever it might be. And I must tell you that AMRPA has been very interested and very focused on this issue through its participation in the ICO-Olishment and other direct ways. There are entities out there that are fighting to not just preserve access, but to enhance access to assistive devices and technologies and anything that people can do to assist that when the time is right is greatly appreciated. I'll give you one small example. There are about to CMS, the Centers for Medicare and Medicaid Services is about to open a national coverage determination on this issue of standing feature in seed elevation and power wheelchairs. When that happens, which we expect in the next, we don't quite know, weeks to a couple of months, hopefully. There will be an open comment period and the CMS will take public comments. We'll be widely distributing that and hope that people communicate with CMS about the importance of covering these two, and in particular, these two wheelchair technologies. That's just one small example. Many of these opportunities happen routinely. Joe, maybe you could just quickly mention that what CMS just did yesterday with respect to the medical and necessity definition and maybe where that winds up going in the future. - Yeah, thanks, Peter. And this sort of ties into our overall discussion about innovative technology. There was a regulation that was proposed at the very end of the Trump administration and actually finalized just about a week before President Biden's inauguration. And that covered two policies. One was the Medicare coverage of innovative technology pathway, which would have allowed FDA designated breakthrough devices to receive temporary coverage under the Medicare program. And the second piece was codifying the definition of reasonable and necessary in the Medicare regulations. Now part of that was simply codifying language as already in existence in subregulatory guidance in particular the Medicare benefits policy manual. But it also went a little bit farther in allowing CMS to for the first time consider commercial insurance coverage for devices and services when determining whether or not they would be appropriate for Medicare coverage. Now the Biden administration had, it didn't fact yesterday just proposed to repeal that rule and its entirety, there is some, what some conservative stakeholder is about various impacts of the rule. But the administration is going to be looking for additional opportunities to increase access to innovative technology, both through utilizing existing pathways and maybe expanding the use of those pathways as well as new regulations. But in particular, we're going to want to keep close eye on what Medicare does to change the definition of reasonable and necessary. Another opportunity is to incorporate some of those additional functional and community integration pieces that were mentioned earlier in addition to simply the medical necessity piece. - And Kate, I would just-- select down underscore comment that Peter made. And then as we respect your members and how they can get involved. The involvement also, I think would be incredibly helpful if they could communicate what's taken place to their patients as well. And encourage their patients to be active and use their voices to provide comments to these CMS requests for input on the NCD, the national coverage determination. - That's really helpful. I mean, this has been actually one of our top priorities to 2021 is actually Dr. Cruz initiative to really more integrate our patients into our advocacy work. And we didn't have a patient advocacy committee. It's a very active group now with an AMRPA. We're looking to have our first patient fly-in on the hill in the coming months. So I think this will be a really helpful conversation to bring back to the committee and discuss and hear different examples from our hospitals patients. And you see what we can do as an association to make sure that their stories are amplified to Congress and to CMS. They make a difference. Those stories make a compelling difference. So the more that we can collect and the more voices we can have, the better. - All right, well, I think we are just about at time. So I want to thank all our guests. This was a fantastic conversation. One that I think will be very interesting for our listeners to tune into. Dr. Cruz, any parting words? - Just appreciate everybody's time. I think it was a great discussion. As you said, really appreciate all the work that everyone continues to do on behalf of our patients and the aging demographic in our country. - Thank you, Chairman Gagas. - Thank you for having me. - Thank you. - Thank you. - This episode is brought to you by Murr's Therapeutics. Part of the Murr's group, a privately held family-owned company. Murr's Therapeutics is committed to improving the lives of patients who suffer from movement disorders, spasticity and neurological conditions. Focusing on advancing neuro-modulator technology, Murr's Therapeutics offers Xiamin, a uniquely purified therapy that's FDA approved for six therapeutic indications in the United States. Please note that Xiamin has a boxed warning and could result in potentially serious life-threatening side effects. Visit xiamin.com for important safety information and full prescribing information, including a boxed warning. You will also find information on how to connect with a local sales representative, reimbursement specialist or medical science liaison. - Thanks for listening to Medical Rehab Matters, a podcast by the American Medical Rehabilitation Providers Association. 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