Lymphedema Funding Inequities in Canada. Summer 2022 Pathways.

The following pages are excerpted from the Summer 2022 issue

Advocacy

Inequities in garment funding across Canada Where are we in 2022?

By Mona Al Onazi, Erica Park, Michelle Phung

I

n 2017, the Canadian Lymphedema Framework (CLF) published the results of a Canada-wide survey to provide insight on the reimbursement of lymphedema supplies and treatment services across Canadian provinces. At the time, considerable disparity was found, with some provinces providing full public funding for supplies and treatment, and others not providing any coverage at all. This article provides an update to the 2017 reimbursement document specific to the funding of compression garments, compression bandaging supplies, and nighttime compression systems to support self-management.

For many Canadians, access to funded lymphedema supplies can make the difference between having good control of their condition, or not.

The problem It is estimated that over 1,000,000 Canadians live with lymphedema or chronic edema.1 Once lymphedema develops, the journey with this lifelong condition begins. To best control lymphedema, individuals with the condition require ongoing monitoring and adherence to self-management strategies such as skin care and compression therapy.2 If left untreated, lymphedema is a progressive condition.

Symptoms are common and include pain, fatigue, and limb tension and heaviness—symptoms FIGURE 1 that can further lead to psychological distress, and reduced self-esteem and quality of life.3,4 In advanced stages of lymphedema, the skin Basic supplies recommended for lymphedema management. becomes hardened and compression system) to daytime use of a has a leathery feel, and is more compression garment for individuals with prone to wounds and infection.5,6 Cellulitis breast cancer related lymphedema in the (a skin infection) is common, and may lead maintenance phase of treatment.11 to systemic (entire body) illness requiring Good adherence to a prescribed selfurgent medical treatment and even management routine is critical for long-term hospitalization.5,7,8 Given that there is no control of the swelling and to avoid episodes of cure for lymphedema, proper management is cellulitis.2,12 However, an individual’s ability to critical to prevent progression of the condition, adhere to self-management is also dependent and to lessen the impact on the individual’s on access to needed supplies such as daytime quality of life and overall health.2 compression garments, bandaging materials, Lymphedema management involves an and nighttime systems.12 The cost of these intensive treatment phase to reduce the items is not insignificant, and is a known swelling, followed by a maintenance phase of barrier to effective lymphedema care.13,14 For self-management.2 During the maintenance example, a single compression garment costs phase, best practice recommendations stress in the range of $150 to $600 CAD. Current a self-management regimen that includes clinical guidelines recommend provision of skin care, use of a daytime compression four garments per year;9 thus, the annual cost garment, application of multilayer bandaging of daytime garments alone, for a single limb, as needed, good weight management and can range from $600 to $3000. If not covered regular exercise.9,10 A recent Canadian study by the public health care system or private provided evidence to support the benefit insurance, the individual must pay out of of the addition of nighttime compression pocket, and this type of ongoing expense may (through self-bandaging or use of a nighttime

Mona Al Onazi BScPT, MSc, CLT, is a doctoral candidate in the faculty of Rehabilitation Medicine at the University of Alberta. Mona’s clinical practice and current research interests involve breast cancer related impairments, including lymphedema.

Erica Park BSc is a recent Bachelor of Kinesiology graduate from the University of Alberta.

She completed her practicum as an Exercise Specialist at the Cancer Rehabilitation Clinic.

Michelle Phung BSc is an undergraduate kinesiology student at the University of Alberta.

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Summer 2022

TABLE 1

REIMBURSEMENT ACROSS THE CANADIAN PROVINCES - 2022 Component

British Columbia

Alberta

Saskatchewan

Manitoba

Ontario

Quebec

New Brunswick

Nova Scotia

PEI

Newfoundland & Labrador

Daytime compression garments Inclusion

Postmastectomy and lumpectomy

Primary and Secondary LE

Primary and Secondary LE

Primary and Secondary LE

Primary and Secondary LE

Primary and Secondary LE

Primary and Secondary LE

Primary and None Secondary LE

Primary and Secondary LE

Coverage %

100% sleeves (based on income & annual PharmaCare limit prior to receiving full coverage) Glove/gauntlet $150 maximum for ready-made & $300 maximum for custom garment

75% of benchmark price

100%

100% for low income only

75% of garment cost based on list of approved garments and manufacturers

75% adult up to a government maximum

100% for low income only

100% for low income only

None

100% for low income only based on assessment

2 garments and gloves/gauntlets

3 ready-made garments

2 ready-made

1 per year

None

2 per year for those who qualify.

Both upper and and lower, custom and non-custom

Custom compression garments and compression wrap should meet specific criteria

2 set ups every 2 years

Number per year

100% for low-income only

OR

100% for low income

4 daytime garments (garment and glove) per limb

6 garments per limb per year

2 custom compression garments per affected limb Details

100% paediatric and low-income

3 per affected limb ready- made or custom

6 for children 3 standard or custom garments for the trunk VELCRO® fastened devices are are also covered.

2 per limb per year.

Annually: 1 garment per limb can be replaced with a VELCRO® wrapped system

Additional: 1 non-elastic compression garment (e.g. VELCRO® wrapped system)

Paediatric patients assessed for eligibility and need

Accessories: garment glue or donner or rubber gloves (1 per limb) Multilayer compression bandaging Compression multilayer bandaging

No

Types of bandaging supplies

Yes (if patients are seen at public hospital only)

Yes

Yes (if patients are seen by Homecare)

No (unless patient seen by Homecare.

Eligibility varies by region)

Yes

Yes Yes (if patients are (if seen by seen at a public Homecare) hospital only)

Coban 2; tubigrip/ flexigrip/ surgigrip; edema wear: foam; stockinet; moisturizers and cleansers

Bandaging supplies: foam, artiflex, short-stretch bandages, swell spots and scar pads

Coban 2 provided if treated by Homecare

Variable

1 set of multilayer compression bandages per limb

Short stretch bandage and foam/cotton padding

2 sets of Comprilan with comfort layer for patients who self-bandage

No

Coban 2 provided if treated by Homecare

Coban 2 plus certain products related to wound care and edema covered through hospital or community based clinics

Include: Comprilan, Cellona, foam, stockinette, Coban 2, short- stretch bandages

Accessories/ supplies: gel sheets, adhesives, stocking applicators, donning gloves

Yes (if seen by hospital or community based clinics)

Patients attending private clinics purchase their own bandaging supplies

Nighttime compression garments Nighttime compression garments

No

Number and Frequency

Not applicable

Summer 2022

No

Yes – for clients with stage 2/3 lymphedema 1 per limb every 2 years

No

Yes - can replace one of the set ups above

Yes

Yes – can replace one of the set ups above

No

1 per limb per year 2 per child per year Trunk and neck garments – if approved

No

Based on clinical assessment and need 2 per year for those who qualify.

Both upper and lower, custom and non-custom

L y m p h e d e m a p a t h w a y s . c a 13

For more detailed explanations including wound care inclusions refer to references@pathways.ca

be prohibitive. For many Canadians, access to funded lymphedema supplies can make the difference between having good control of their condition, or not.

Methods To update the CLF’s 2017 reimbursement document, we first searched websites for government funding programs and provincial lymphedema associations across Canada. We abstracted information related to provincial healthcare coverage of supplies and equipment provision for lymphedema. We then contacted provincial lymphedema associations and specialist lymphedema clinicians in each province to verify the data collected and to obtain further details.

Findings Based on our updated data, there is still

significant variation in reimbursement of lymphedema garments and supplies across Canada (Table 1). For example, an individual with lymphedema who happens to live in Saskatchewan would receive full coverage for two compression garments every six months or four garments a year—a level consistent with best practice recommendations. On the other hand, an individual with lymphedema in Nova Scotia would receive coverage for two compression garments a year but only if they were classified as low-income residents on government assistance. Bandaging supplies are provided for individuals who reside in Alberta, Saskatchewan, Ontario and Quebec; however, access to supplies may be dependent on where the individual receives treatment. Nighttime compression systems are available to those living in Saskatchewan, Ontario and Quebec, and for those classified as low-income in

New Brunswick. The provinces of Quebec and Saskatchewan provide additional funding for accessories such as garment applicators and gloves to support proper donning of a compression garment.

Figure 1 (page 12) lists the provision of basic supplies needed for lymphedema self-management and maintenance.

Conclusion All Canadians with lymphedema need access to the necessary garments and supplies to support self-management, regardless of their location of residence.

Identifying this type of inequity in reimbursement across the country supports advocacy efforts. LP A full set of references can be found at www.lymphedemapathways.ca

Lymphedema Supplies for Therapists & Clients For a complete product list and

to order online:

www.cdnbandageshop.com

phone

306.757.7173

NOW STOCKING! Grey Channel Foam

14 L y m p h e d e m a p a t h w a y s . c a

fax

306.347.0092 No GST on long & short stretch bandages with physician’s prescription Accepting all major credit cards

Summer 2022