LegiStorm

Summary:
What GAO Found

Medicare data show that 50,202 beneficiaries enrolled in traditional Medicare lost a limb in 2016. Of these, most lost a lower limb (96 percent) and were White (66 percent). Black, Hispanic, and dual-eligible for Medicare and Medicaid beneficiaries were disproportionately affected by limb loss. For example, 21 percent of beneficiaries who lost a limb in 2016 were Black, while 8 percent of beneficiaries in traditional Medicare that year were Black. 2016 was the first full year of claims data available using current medical coding and 2019 was the last full year of claims data prior to the start of the COVID-19 pandemic.

Medicare covers services for beneficiaries with limb loss, such as rehabilitative services and prosthetic limbs, if medically necessary and after other conditions are met. Of beneficiaries in traditional Medicare who lost a limb in 2016, nearly all received at least one selected rehabilitative service and 30 percent received a prosthetic limb from 2016 through 2019 (see figure).

Percentage of Traditional Medicare Beneficiaries Who Lost a Limb in 2016 Receiving at Least One Selected Rehabilitative Service or Prosthetic Limb, from 2016 through 2019

 



Note: Rehabilitative services and prosthetic limbs may not be medically necessary or appropriate for all beneficiaries who lost a limb. N=50,202 beneficiaries.

Most beneficiaries in traditional Medicare with limb loss in 2016 experienced adverse health outcomes within 4 years. For example, 61 percent of beneficiaries died within 4 years, compared to 20 percent of all beneficiaries in traditional Medicare. A stakeholder representing providers said beneficiaries who experience limb loss do not necessarily die as a direct result of losing a limb. Instead, underlying health conditions in individuals living with limb loss (e.g., diabetes and vascular disease) contribute to a beneficiary's overall health and could lead to fatal events such as heart attacks, according to this stakeholder. For example, 71 percent of beneficiaries with limb loss in 2016 had diabetes compared to 24 percent of all beneficiaries in traditional Medicare.

The 10 stakeholders GAO interviewed reported challenges beneficiaries with limb loss face that could affect their ability to access care, such as issues with care coordination among health care providers and affordability of prosthetic limbs.

Why GAO Did This Study

The loss of a limb—all or part of an arm or leg—is a life-altering event. It is estimated that over 2 million individuals in the United States live with limb loss. That number is expected to almost double by 2050, according to researchers. Individuals 65 and older are at the greatest risk of having amputation surgery.

GAO was asked to review the health care services for individuals with limb loss. This report describes (1) characteristics of traditional Medicare beneficiaries who lost a limb in 2016, (2) the percent of those who received rehabilitative services or prosthetic limbs, (3) the percent of those who experienced selected health outcomes, and (4) challenges to obtaining rehabilitative services and prosthetic limbs. The report also includes information about care for veterans with limb loss received from the Veterans Health Administration (VHA).

To do this work, GAO analyzed traditional fee-for-service Medicare claims and beneficiary enrollment data from the Centers for Medicare & Medicaid Services (CMS), for the years 2016 through 2019. GAO also reviewed VHA data and information. GAO also interviewed officials from CMS and VHA and representatives from 10 stakeholder groups representing health care providers, patients, and prosthetics and rehabilitation facility industry groups.

The Departments of Health and Human Services and Veterans Affairs reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate.

For more information, contact Leslie V. Gordon at (202) 512-7114 or GordonLV@gao.gov.