Physical Therapists: Colleagues or Combatants?

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By Miki Fairley

Almost universally, credentialed orthotists and prosthetists acknowledge physical therapists as clinical colleagues on the rehabilitation team and agree that the two professions are complementary and integral to best patient care. However, that's as individuals and fellow clinicians. From an organizational and legislative perspective, it's another story.

Terry Supan, CPO, FAAOP, FISPO
Terry Supan, CPO, FAAOP, FISPO

"The 'problem' is with the organization [the American Physical Therapy Association], not with the therapists in the trenches," Terry Supan, CPO, FAAOP, FISPO, says succinctly. And Supan should know. He and colleague Mike Brncick, CPO, who also was interviewed for this article, are battle-scarred veterans of the failed Negotiated Rulemaking Committee Meetings (NRM, or "NegReg") in 2003. The committee was formed to assist then Health & Human Services (HHS) Secretary Tommy Thompson in implementing the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), which includes provisions aimed at protecting Medicare patients from receiving orthotic and prosthetic care from unqualified providers.

Since, as Shakespeare noted, "the past is prologue," the present-day legislative battlefront between physical therapists and orthotists/prosthetists regarding Medicare physical therapy direct access legislation and increased physical therapy scope-of-practice provisions at the state level grew from BIPA and the NRM. The controversy centers around the educational and experience requirements for fitting prosthetic patients and the more complex orthotic cases which require highly trained patient evaluation, custom orthotic design for the specific patient, along with skilled follow-up care and adjustments.

Most certified prosthetists and orthotists acknowledge that physical therapists, as well as athletic trainers, physician assistants, and other allied health professionals, have the skills to fit many prefabricated orthoses, especially since many of these have improved in quality. But caring for amputees and orthotic patients with more complex conditions requires much more intense education and training--and continuing education to keep up with rapidly changing new technology and clinical research in O&P, most credentialed O&P practitioners believe.

At NRM, "There was a Y2K disaster for our profession that we still have not recovered from," says Supan. About 20 organizations regarded as stakeholders participated in the NRM. Supan represented state O&P licensure boards and Brncick, then NCOPE chair, represented that organization.

Legislative Saga

The original language of legislation introduced by Senator Tom Harkin (D-IA), which would later become BIPA 2000 was generic in nature, not naming any certifying bodies, but requiring education and examination of individuals, Supan notes.

Political maneuvering and pressures entered the arena. The saga was described this way:

 The National Orthotic Manufacturers Association (NOMA) wanted to make certain its manufacturers' representatives could still direct-market to physicians and other health personnel. During the House and Senate conference, a senator from Maryland added the name of the Board for Orthotist/Prosthetist Certification (BOC), and then the American Orthotic & Prosthetic Association (AOPA) brought the American Board for Certification in Orthotics and Prosthetics (ABC) into the language. Physical and occupational therapists were brought in also. In the view of some, this was considered a means to increase the power base of NOMA, which numbers physical and occupational therapists among its members' customers. "So instead of restricting who could provide orthoses and prostheses to those who had formal education in O&P as a means of controlling fraud and abuse, any salesman, physician, or therapist could get a supplier number and bill Medicare for custom-made orthoses and prostheses," Supan says with frustration.

The O&P organizations, including ABC, NCOPE, the American Academy of Orthotists and Prosthetists (the Academy), and the National Association for the Advancement of Orthotics and Prosthetics (NAAOP) were not happy with the legislation, Supan says, "But we were told at the time that it was the best we could get, and we would have to accept it."

The O&P contingent pinned hopes on Section 427 of BIPA, which required use of the negotiated rulemaking process by the Centers for Medicare & Medicaid Services (CMS) and which stated that the therapists had to be "qualified," that orthotists and prosthetists had to be "educated," and that everyone had to have a supplier number which required them to meet supplier standards. "No one could have imagined that the NRM would fail based on those very issues, and that the qualified provider' decision would be thrown back in the lap of CMS," Supan says.

APTA Drops Bomb

The American Physical Therapy Association (APTA) dropped a bomb on the O&P group by unexpectedly declaring that "qualified" simply means "licensed" in the state in which physical therapists practice. Specific education requirements in O&P aren't relevant per se, but depend on what each individual state's licensing requirements are relative to scope of practice, as APTA's stand was understood.

"Prior to the beginning of the NRM process, the APTA led the ABC to believe that they were on the same side as strong advocates of education and credentialing," says Supan. "Before BIPA 2000, there was never any claim by the APTA that a licensed therapist was competent to provide custom orthoses or prostheses based solely on their license." It came as a shock when both the APTA and the American Occupational Therapy Association (AOTA) made that assertion at the very first meeting of the NRM, Supan adds. "It also came as a surprise to discover that several of the state PT practice acts were changed after 2000 to include fabrication and fitting of orthoses or prostheses as part of the responsibilities of a physical therapist. Low-temperature upper-limb orthoses have always been a therapy modality in OT, but this was new for PT."

After World War II, orthopedic surgeons and physiatrists became vocal advocates of the clinic team model of rehabilitation, Supan recalls. That was the beginning of bringing orthotists and prosthetists into the medical arena. It was common for the PT to have the administrative lead for these clinics, but even when O&P was still largely simply a trade or craft, Supan recalls, "Even the very experienced therapist knew to rely on the orthotist or prosthetist and would never have had the audacity to think that he or she could provide the orthoses or prostheses. It is even more apparent today with the advanced education and clinical training required of a CPO."

Clinical Colleagues

Mike Brncick, CPO
Mike Brncick, CPO

At the moment, in the real world, the clinical setting, scope-of-practice issues don't appear to be a problem. "In a clinical setting, our professions are complementary," says Brncick. "We respect each other's scope of practice and expertise."

For instance, prosthetists are more able than PTs to consult with orthopedic and vascular surgeons about levels of amputation that would best enable the patient to use a prosthesis. (Of course, in some trauma cases, the first necessity is saving the patient's life, and deciding the best amputation level for prosthetic fitting is not an option.) They can provide input on preprosthetic and postoperative care and componentry options. Postoperatively, the prosthetist can help reduce swelling and tissue trauma in the residual limb. The prosthetist and physical therapist can work together to help the amputee rehabilitate faster. Brncick also cites the example of working with stroke patients: the physical therapist can assess changes in patients' neurological abilities and work together with the orthotist to provide optimum care.

Helping amputees cope with phantom pain is another area of mutual cooperation. Both disciplines utilize modalities to reduce phantom limb pain; physical therapists may use TENS (transcutaneous electrical nerve stimulation) units; O&P students are likewise taught various methods. Brncick recalls how he and a physical therapist worked together to help reduce phantom limb pain for his father, who was a bilateral transtibial amputee.

In Brncick's experience, the physical therapists don't want to do O&P and will even say they are not qualified. Supan points out that generally physical therapists have had to be trained by a prosthetist in how to help their patients use an upper-limb prosthesis or how to help amputees learn to walk with a prosthesis. "And they continually come back to the prosthetist for more consultations on how to train amputees with new technology that comes out," he adds.

However, what the APTA is aiming for is that "licensed" equals "qualified to practice the entire scope of orthotics and prosthetics," according to Supan and Brncick. They reason logically that how can a brief introductory, overview course in O&P that perhaps a therapist may have had as long as 20 years ago, be equivalent of the 490 to 565 clock hours of training and learning a core curriculum of O&P? This is what's required in the NCOPE/Commission on Accreditation of Allied Health Education Programs (CAAHEP) schools--plus a one-year residency before being able to sit for the ABC exam. One could ask, "Who would you rather have providing prosthetic and complex orthotic care for someone in your family?"

Reasonable Solutions?

A reasonable solution that has been proposed by some is that to practice comprehensive O&P care, physical therapists should take the core O&P curriculum at an NCOPE/CAAHEP-accredited school, since, as Brncick observes, they do already have a good background in health science courses such as anatomy and physiology. He notes that there are some well-qualified physical therapists that are now excellent orthotists and prosthetists. These dual-credentialed individuals "did it the right way," says Brncick. "They came through O&P programs and went on to become certified."

Another possibility is a tiered system of qualifications required to practice O&P at various levels, such as already exists with ABC and BOC.

To maintain their certification status, certified prosthetists and orthotists are required to earn a specified number of continuing education credits. This reporter has been unable to find out if any physical therapist licensing statute requires continuing education credits specifically in O&P, a necessity to keep up with the rapidly advancing technology and new clinical research and efforts to establish practice guidelines in this constantly evolving field.

Ironically, prosthetists and orthotists perform some of the functions of physical therapists in gait training and teaching patients use of the prosthesis--but they can't bill for it, since the HCPCS L-Codes include the service component. However, PTs can bill L-Codes for devices they provide, plus bill CPT codes for time spent. To put the frosting on the cake, to payers and consumers, the devices supplied by PTs may appear cheaper, since they may overlook the skilled service aspect included in the global L-Codes.

Analysis

In overall strategy, there often are linking objectives--a sort of "connect-the-dots." The APTA is working hard to get the Direct Access to Physical Therapy legislation passed. Thus, PTs could treat Medicare patients without a physician's prescription, providing whatever services they deem necessary and that are allowed by the individual therapist's state practice act and licensing requirements. Obviously, the more physical therapists can enlarge their scope of practice in each state to include O&P, or a higher level of O&P, the better.

Tying in with this is APTA's goal of an entry-level doctorate degree (DPT) and its "Vision 2020." The APTA website ( www.apta.org) gives this vision sentence and statement:

Vision Sentence: "By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other healthcare professionals as practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health."

Vision Statement: "Physical therapy, by 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists. Consumers will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services. Physical therapists will be practitioners of choice in clients' health networks and will hold all privileges of autonomous practice&."

What is the rationale for having professional (entry-level) DPT programs?

The APTA on its website ( www.apta.org) includes the answer in a list of FAQs. Among reasons are:

  • "Societal expectations that the fully autonomous healthcare practitioner with a scope of practice consistent with the Guide to Physical Therapist Practice be a clinical doctor; and
  •  "The realization of the profession's goals in the coming decades, including direct access, physician status for reimbursement purposes, and clinical competence consistent with the preferred outcomes of evidence-based practice, will require that practitioners possess the clinical doctorate (consistent with medicine, osteopathy, dentistry, veterinary medicine, optometry, and podiatry)
  •  "Many existing professional (entry-level) MPT programs already meet the requirements for the clinical doctorate; in such cases, the graduate of a professional (entry-level) MPT program is denied the degree most appropriate to the program of study."


What's Next?

So, what's next? Effective October 2005, providers in states that require O&P licensure must be registered with the National Supplier Clearinghouse (NSC) as one of the specialties allowed to bill for O&P, or they will no longer be reimbursed for prosthetic and certain custom-fabricated orthoses. As of press time, CMS is expected to soon implement nationwide the qualified provider provisions set out in BIPA.

Under congressional authorization, CMS will soon mandate orthotic and prosthetic quality standards for all O&P patient care locations, notes ABC. "For our profession, the Medicare requirements will effectively raise patient care standards to the uniform standards of accreditation. This is an important milestone in the evolution of O&P patient care, as the accreditation standards measuring patient management, quality care, assessment, eval­uation, and safety will ensure a basic care level for all Medicare patients. We can expect that the Medicare standards will be adopted by other third-party payers."

Besides legislative efforts, what else can the O&P profession do? Working to attain more public recognition of the O&P profession is another avenue to increase awareness of the value of the credentialed prosthetist and orthotist, Brncick points out. The return of war-wounded soldiers and the high-tech, visionary prosthetic research underway by the military are capturing the public's attention. High-profile elite disabled athletes likewise are garnering much more media attention. "We need to let people know that we are the profession that takes care of these people--not only military amputees and veterans, but also the growing population of people with diabetes and other conditions who need O&P care," says Brncick.

"The educated consumer of healthcare is a good consumer of healthcare," he continues. "We need to make people aware that when they or a family member needs orthotic or prosthetic care, to ask questions of providers--for instance, 'Are you certified?' "

Editor's Note: The O&P EDGE has requested that the American Physical Therapy Association (APTA) write or have a spokesperson be interviewed for an article presenting its perspective on these issues.
If such an article can be obtained, The O&P EDGE will publish it in a future issue.