How It’s Done

After finishing his studies and a clinical residency in the United States in the early 90s, Santiago Muñoz felt he was prepared for a career in O&P. When he returned to his native Ecuador, he realized he still had a lot to learn. The technology available, payer roles, patient income, and culture were completely different from what he had seen in the United States. “Of course, we’d love for all of the patients to have access to the very best of O&P,” says Muñoz, CPO, FAAOP, clinical educator specialist for Fior & Gentz, Germany. “But we have to realize what the reality is. Do they have daily access to clean water to wash and disinfect the liners? Are they able to come back every six to eight months for a replacement if the technology breaks?” Over the course of his career, Muñoz has seen O&P practices in the Caribbean, Dominican Republic, Honduras, Central America, Colombia, and Germany. The clinicians he’s met around the world all care about their patients, but their jobs vary widely depending on the resources and healthcare system of the country they work in. We asked Muñoz and other O&P experts for their perspectives on the differences and similarities in O&P care that they have seen around the world. [caption id="attachment_245621" align="alignleft" width="300"] Mikolette Moller/stock.adobe.com[/caption] Raising the Bar on the Standard of Care in Ecuador In 1995, the Cenepa War between Peru and Ecuador left several soldiers with transtibial amputations. Even though the Ecuadoran patients were financially covered by the army, the healthcare system didn’t have the infrastructure or technological capabilities to support them, Muñoz says. [caption id="attachment_245620" align="alignright" width="300"] pressmaster/stock.adobe.com[/caption] “At that time, I was the only practitioner in the country with this kind of education, but I didn’t have access to the army,” he says. “It was a stroke of luck that one day the mother of one of those young soldiers came to the [nongovernmental organization] that I was working at and asked for help.” The soldier he saw had a wooden SACH foot and was using wool socks instead of a liner. Muñoz had to cut the prosthesis in half to realign it, but soon the soldier was walking pain-free. When word got out, Muñoz was inundated by other soldiers seeking help. With the help of the army and connections in the United States, he was able to provide the soldiers with carbon fiber feet and WillowWood Alpha liners, technology that was durable and sustainable. “It was a huge quantum leap of technology thanks to the support of the army,” Muñoz says. “We were able to match the quality and treatment they were able to have in the US but in Ecuador.” He says that the materials were the same cost as in the United States, but he was able to provide the setup for a fraction of the cost. “Our labor is not as expensive,” Muñoz says. “It was the exact same quality, but a third of the cost.” Unfortunately, not everyone in Ecuador had the same financial support as the soldiers, he says. Many patients have to pay out of pocket for their devices and need them to be inexpensive but durable. “I’m not saying people with low income shouldn’t get high-tech devices, but we have to be responsible about what we are offering and make sure we are providing a sustainable treatment that won’t cause more problems than benefits.” What can be frustrating are well-meaning but naive practitioners who come to poor countries and give patients technologically advanced devices with no thought to how they will be maintained in the future, Muñoz says. [caption id="attachment_245619" align="alignright" width="300"] Ranimiro/stock.adobe.com[/caption] There isn’t thought about what kind of support this fancy prosthesis will need,” he says. “The devices don’t match what is available in the country to provide maintenance and care. The high-tech instead of being helpful is a hindrance. They didn’t spend enough time figuring out what would be best for the people they were serving.” Finding Creative Solutions in India As Bionic Prosthetics and Orthotics, headquartered in Indiana, grew to clinics in 12 states, the management realized they could make a contribution to underserved communities in other parts of the world. “Some of the clinical leaders had practiced in India prior to starting practice in the United States and wanted to support patient care advancement there,” says Tony Gutierrez, CP, the company’s national clinical specialist. In India, some prosthetics manufacturers have clinical care and won’t allow their devices to be fitted or serviced outside of their clinics, Gutierrez says. That meant Bionic had to find new ways to provide O&P solutions to their patients. “We’ve had to get creative in our partnerships,” Gutierrez says. “We have 50 clinics in the United States and deep ties with prosthetic vendors. That has allowed us to set up creative solutions to provide a higher level of care than some of the others can provide in India.” While there are some payer sources there, most of the O&P devices are self-paid, Gutierrez says. “Especially in the rural and underserved areas, it can be a challenge,” he says. “We try to provide the same level of care to our patients over there, but sometimes we only have 400 American dollars to work with.” Clinicians are tasked with stretching the dollars as far as they will go to provide an inexpensive, durable solution that works in that country. They’ve learned that devices and technology must differ based on the needs, culture, and climate of the people they serve, he says. “For example, the gel liner is the standard of care here in the United States, but not in India,” he says, explaining that the high heat and humidity cause excess moisture which, when paired with gel liners, can result in skin issues. The lessons from India have sometimes informed care in the United States, he adds. “We gain a lot of insights from practicing in India,” Gutierrez says. “We’ve identified a few products that have withstood the test of time and durability over there that we might not have considered using in the United States. “For example, a few devices have enhanced our patient care overseas. We have implemented the Össur Balance Foot J, the College Park Breeze foot, and Össur Comfort Gel Liners. “They are durable, lightweight and have proven to stand the test of time. We are able to implement these solutions for patients of all functional levels,” Gutierrez says. “Our vendor partners offer the solutions at a price that we can utilize to help contain our costs.” The type of care also differs because the patients and their needs differ, he says. In the United States, amputations from vascular conditions like diabetes are much more common. In India, amputations are more likely to occur from traumatic injuries such as car or train crashes. Patients, in general, even have a different aesthetic when choosing their devices, he says. In the United States, it’s become fashionable for prosthetic patients to show their metal and have devices that look like high-tech devices. In India, patients are more likely to choose devices that match their skin tone. “What they tend to want is more cosmetically natural,” he says. When Gutierrez traveled to India to celebrate a new office opening, he found a kind and welcoming culture. For four days, he saw 25 patients a day and helped them develop treatment plans utilizing these solutions. Some patients came in with homemade devices made of tin. “They had no other option and built what they could,” he says. “When you need to support your family and you need to keep walking, you do what you have to do. It was eye-opening to see that and also the level of appreciation and gratitude they had for the work we do.” Demonstrating Prosthetic Technology Around the World Prior to his current position as an upper-limb clinical specialist and consultant at his company Intersect OPS, Karl Lindborg, CPO/LP, traveled the world as a clinical educator for the Touch Bionics (now Össur Americas) i-Limb multiarticulating hand and partial hand solution. The high-tech device was the first of its kind and impressed patients and clinicians in countries all over the globe including Japan, China, Scandinavia, and Argentina, but the ability to access the technology varied from country to country, says Lindborg. “The multiarticulating hand was developed in Scotland, and yet the National Health Service in the UK would not cover that prosthetic device because it didn’t fit into their socialized medicine system,” says Lindborg. “It needed to be fully vetted.” The manufacturer knew that it had to make inroads in the United States to be successful in part because of the healthcare system here. “Because of our capitalistic healthcare system, it was more likely to get coverage here than in a structured, socialized healthcare medical system,” he says. Even then, it was a challenge. They submitted, and eventually received, an L-Code for the device that at least allowed Medicare patients to receive it and provided an official pathway for third-party payers to include in their upper-limb prosthetic coverage policies. That process took about five years, he says. In Canada, the decision about whether to cover the technology came from the province level, rather than the national level, he says. “Depending on what province you are in, there’s a different workman’s compensation arena that is separate from the socialized medical system.” While insurance is the primary option for coverage throughout the world, Lindborg states that there is a population where a cash-only system is utilized to obtain prosthetic devices. He’s seen people fundraise for their technology or pay for it out of their own pockets. “I once was involved in the fitting of a Saudi prince in Scotland who saw this technology and wanted it and came to the source that made it,” Lindborg says. “They paid cash and got what they wanted.” But this is not the typical way of obtaining an O&P device. Although coverage for the device varied from healthcare system to system, Lindborg says he saw similarities. For example, most countries have a system similar to the United States’ K-level method to help establish the user’s potential to ambulate with a lower-limb prosthesis. “In Germany, they have a more refined system of assessing the potential of a person’s ability to ambulate with a prosthesis,” he says. Most healthcare systems he’s seen are also pushing more to measure their outcomes, which is understandable, Lindborg says, because the healthcare systems want to know that their dollars are being used wisely. “We are being pressured to do more objective outcome measures so we can show that progression,” he says. “We’ve done a bad job over the years compared to our counterparts in physical and occupational therapy.” He hopes that the more the profession can substantiate how people benefit from the devices, the more healthcare systems may be willing to cover them. “Until we can show that these technologies will save money and make the end user more successful in using it, then it’s going to be a real challenge to get these new technologies paid for.” [caption id="attachment_245622" align="alignleft" width="300"] belahoche/stock.adobe.com[/caption] Worldwide Similarities While healthcare systems might differ in what they choose to cover, the experts say there are similarities, including that patients and clinicians want to know about new technology, regardless if they have the means to pay for it. “Now that we are all carrying computers in our pockets, we have access to information, and everyone wants to get what is trending or new,” says Muñoz. Patients can see several options for their particular need, whether or not it’s covered and whether or not it’s best for them, Lindborg says. “Whether it’s approved or not, inquiring minds want to know,” he says. “Every manufacturer has their glossy flyer and patient ambassador that shows how well they use that product. But that doesn’t always translate to every user.” Muñoz says he’s not always sure how to handle that. “It’s one of the most challenging things,” he says. “As clinicians, we have to make decisions based on what is best for our patients, and we’re living in a time where everyone has access to the information in a matter of seconds. They’d like to get this device, but the moment we get to our L-Code system, we are limited.” Some of the more industrious patients are able to raise money even if their insurance carrier won’t cover it. He’s even seen manufacturers help patients start GoFundMe campaigns to crowdsource the cost of devices that may not be covered. “I see it more and more across the internet,” Muñoz says. “It’s the new normal now. But how does it fit in with our healthcare system? In the US, is that appropriate?” He’s not sure of the answer to those questions, but he does know that if a person has a mindset to get that device, they will keep pushing. “They are going to get it from you, or they are going to go to the guy across the street to get it,” he says. Another similarity across the globe is that O&P clinicians have to stay in business if they want to keep treating patients. The profitability of their businesses can vary based on their country. In Ecuador, Muñoz says he was able to make products for less because of lower labor costs. However, many patients there were poor and could only afford basic devices, he says. On the other hand, he says, the cost of living is also less there, so clinicians don’t need to make the same amount of money to make a decent living. That is similar in India, Gutierrez says. “I don’t think it’s profitable to be in prosthetics or orthotics anywhere,” Gutierrez joked. “There are margins, but we’re not out flying helicopters.” In the end, Gutierrez says, it doesn’t matter where an O&P practice is located. “As a clinician, most of us have gotten into this field and have thrived in it because we care about the patients. If you care about the patients, do your best, and make more right decisions than wrong ones, then the pay will come. I’d be willing to bet that is the same standard everywhere.” Maria St. Louis-Sanchez can be contacted at msantray@yahoo.com .

How It’s Done

How O&P Care Is Provided Around the World

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Related posts:

Remark Code CO-261

Amputee Coalition Names Strategy, Communications Officer

Amputee Coalition Names Strategy, Communications Officer

O&P JOBS

We’re Currently Seeking Certified Prosthetist/Orthotists (CPOs) for Opportunities Throughout Several States

Certified Prosthetist Orthotist or Board Eligible Prosthetist Orthotist

Certified Prosthetist / Prosthetist-Orthotist (CP/CPO) Gates Prosthetics + Mobility Clinic — Mountain Home, AR

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