What We Don’t Know About O&P: Can It Hurt Us?

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By Judith Philipps Otto

Ironically, in this Information Age, some believe that O&P is starved for information. Despite the online availability of more comprehensive and esoteric data than most brains can process, basic questions that arise about the people and businesses that practice orthotics and prosthetics in the US continue to go unanswered.

Surely basic statistical information could be of value to practitioners and to O&P business owners, helping them to better serve their patients, more successfully operate their practices, and make themselves a better asset overall to the O&P field: For instance, how many facilities are disappearing and at what rate? Who is practicing what-and where? What about revenues and reimbursements? Is anyone tracking this and similar information?

As we discussed the issue with various sources, new questions were raised, and the search for answers became a search for the reason answers weren't available.

Do other healthcare industries have this problem?

Not the American Medical Association (AMA), which expends considerable energy and effort to keep up with statistics pertinent to its field.

Every year since 1963, the AMA has compiled and published a book called Physician Characteristics and Distribution in the U.S., which is, as one might imagine, chock-full of statistical information on all physicians located in the US and its possessions, including the number of physicians, school graduated from, distribution by specialties, and analysis of professional activity by specialty and geographic region.

The AMA also funds ongoing opinion polls that gauge physician and patient attitudes toward healthcare-related issues such as Medicare payment reform. A current Gallup poll is also measuring public and physician perceptions of the AMA.

In an ideal world, with unlimited funds, perhaps the relatively tiny O&P field could pursue similar information. A fairer comparison, however, might be to another ancillary care field-occupational therapy.


Fred Somers, executive director of the American Occupational Therapy Association (AOTA), points out that AOTA also provides a variety of information to its members, and part of the challenge is keeping the information updated.

AOTA's Public Affairs Division provides Medicare-related data on its website ( www.aota.org ). An accrediting body accredits 300 college- and university-based occupational therapy education programs, sending out surveys every year to collect information on enrollments, average class sizes, and educational trends.

"We also do a periodic Work Force and Compensation Survey," says Somers, "which is a pretty comprehensive look at where people are practicing, what kinds of client populations they are working with, the hours that they are working, basic demographic data on the individuals as well as the compensation and benefits they have. That's a very rich body of data of great interest to our members."

Member surveys designed by AOTA are administered by an outside vendor approximately every other year. Of 5,000 persons contacted, between 1,500-2000 respond. Some results are posted on the AOTA website, and a detailed survey report is available for purchase.

"It all boils down to member expectations," Somers concludes. "As their professional association, we tailor our informational offerings to what our members want."


Interestingly enough, it seems inquisitive O&P professionals either aren't asking their questions loudly enough, or they aren't asking the right sources. Malissa Bennett, managing director of membership and communication for the American Orthotic & Prosthetic Association (AOPA), says that although she gets frequent questions from the media, she receives few from within the industry. "Almost never," she says. "My guess is that the average O&P business owner doesn't have an eye on that horizon. They're not looking out across the trends of the industry. They're paying attention to their business, their area, their market, and just focusing on being successful within their own region, where they're going to have a better handle on the trends."

Fortunately, industry leaders are keeping an eye on trends. They are also recognizing that trends are driven by these questions, which have more answers than one might think.


Ted Snell, CP, AOPA president-elect, says most of the answers are out there if you know where to look for them. "AOPA, as well as the other O&P associations, organizations, and the ACA [Amputee Coalition of America], have a lot of the answers. It's just a matter of people participating and reading enough in order to get that information." As more states add licensure, he believes even more demographics on O&P businesses will become available and easier to track.

"A tremendous amount of information of this nature is currently published in the AOPA Operating Performance and Compensation (OPC) Report," Snell says. "The last one was published in 2004, based on 2003 data; the next one will be released in 2008, based on 2007 data."

Meanwhile, he says, AOPA continues to recognize the importance of gathering more statistical information. "At our long-range planning meeting in summer of 2005, we came up with several initiatives, one of which we call Developing a Shared Vision.' To further this initiative, we invited individuals to participate in a meeting this November to discuss issues affecting the O&P field in the future. We'll use this to identify the questions that everybody has. Then, once those questions are identified, we need to determine methods to get them answered."


Ed Neumann, PhD, PE, CP, director, Center for Disability and Applied Biomechanics at the University of Nevada, Las Vegas, contributed materially to expand our list of questions for which answers would be interesting and useful, if accessible. However, he points out that efforts to seek those answers might not be cost effective. Giving an example, he says, "One way to find out who is practicing that doesn't fall under the ABC [American Board for Certification in Orthotics and Prosthetics], BOC [Board for Orthotist/Prosthetist Certification], or AOPA umbrellas is to go through business licenses state by state and subtract out the places with at least one ABC or BOC person," Neumann begins. "This would be very labor intensive, and I doubt it would be productive, since it might not be possible to sort out the O&P firms. Going through the phone book for each major city and subtracting the ABC, BOC, and AOPA types would also be very labor intensive. Some of the states may have licensure, and the licensing bodies would certainly have data that would possibly be available on the Internet, but one would still have to sort out the ABC from non-affiliated firms by hand."

Like Snell, he believes that some of the needed data is available from ABC, AOPA, or BOC data files. The trick is locating it.

Tom Derrick, public relations, marketing, and professional discipline manager for ABC, estimates that 70-75 percent of O&P practices are independently or family owned. But when it comes to questions such as those concerning the number of practitioners or staff per facility, grouped by region and population area, ABC can only extrapolate from data available to it. "ABC maintains this information for all accredited facilities, which we estimate is approximately 50 percent of the total O&P patient care sites nationwide," says Derrick. This snapshot of the O&P profession has been used in the preparation of two major studies slated for publication by the end of 2006: ABC's Practice Analysis of the Disciplines of O&P and the manpower study titled, Issues Facing the Future Demand for Orthotics & Prosthetics, from the National Commission on Orthotic and Prosthetic Education (NCOPE). The latter study updates a 2002 study with the same name.

Also fresh in December was a new update on ABC's Practice Analysis of the Disciplines of O&P available online at www.abcop.org/Practice_Analysis.asp . (Editor's note: Watch future issues of The O&P EDGE for follow-up on these studies.) For other data, Derrick cites AOPA as a potential source.

Whom Do We Count?

Even when numbers are readily available, there are problems:

  • The major problem with studies, Bennett observes, is that no sooner is a study completed than it becomes outdated.
  • Numbers only represent the data provided by respondents, who may or may not necessarily comprise a representative cross section.
  • What about non-respondents as well as the non-credentialed, who practice their craft without a license, without certification, and sometimes without even an office? Do we count them? Should we?

Russ Hornfisher, a member of the AOPA Board of Directors, agrees that there are a significant number of people flying under the radar-people on whom no information is available. "A large portion of the estimated 70,000 podiatrists' offices in this country-maybe 10 percent-are doing some type of shoe orthotics, AFOs, walkers, etc.," he says. "There's no telling how many physician's offices have off-the-shelf orthotics and prosthetics and do some cast fitting."

The current crop of orthotic fitters includes not only certified orthotists, but also RNs, lab techs, physical therapists, and athletic trainers.

One possible way to count these people, suggests Brian Gustin, CP, a member of AOPA's Coding Committee, is through the National Supplier Clearinghouse (NSC). "The NSC is the agency that issues Medicare provider numbers. Usually, anybody who wants to get a contract with a private insurance company has to be a Medicare provider. By presenting a Freedom of Information Act request to the NSC, you could find out how many new applications they have received each year. That would help to identify those smaller players that set up in a podiatrist's or physician's office-or even in a roadside trailer."


Gustin points to AOPA's 2004 OPC Report, as the source of answers to many questions. "The survey hasn't addressed all of the statistical questions that may be out there, such as how many facilities go out of business. I'm not sure how we'd know that. But we certainly were able to track how many practitioners they had, how many technicians they had, how many administrative people they had. They looked at revenues, albeit self-reported. We can't know how accurate some of that information is, of course; it depends on the people who are answering."

Is it realistic to expect that answers to the list of posed questions will ever be answered? "Answered by whom?" Bennett counters. "I think the issue becomes a question of who has the data and how available it is. What happens to family-owned businesses, for example, is probably not a question that would be covered," Bennett continues. "If you look at it from the industry's perspective, I don't know why someone would have that information. How many go out of business annually? We have a sense of how many of our members don't renew, with the reason being that they are out of business. With AOPA's renewals well into the 90 percent range, we don't have a huge attrition; therefore, it's not something that we're tracking closely."

The conclusion is, then, that unless a statistic has immediate value, generally speaking, it is more expensive than it's worth to pursue it. Bennett agrees. "It's very expensive for AOPA to do these OPC reports," she stresses. "It costs much more to do than we make by selling copies of the report. We do them primarily as a service to our members and to the field."

She adds, "I believe the manufacturers have a good handle on some of the data, based on the market and whoever is out there and is buying. The number I keep hearing passed around is that there are about 2,600 viable facilities, and that syncs with our membership. We've got about 2000 of them-the lion's share-and we're working to get the remaining 600 or so into membership."

The 2004 report included information returned from 164 companies representing 893 full-time facilities and 171 part-time facilities, which equaled more than 20 percent of AOPA's membership-a survey response level Bennett describes as "very, very good," especially considering the time required for respondents to fill out the seven-page survey.

Are We Falling Behind in the Numbers Game?

If so, we're making up for it by developing solutions that require a better awareness of statistical information to begin with. As Bennett notes, "The data collected is only worthwhile if you use it. In any business, that's a challenge-putting data to good use and making it meaningful."

AOPA's Sunriver Initiatives, which include more than the Shared Vision program, are doing just that.

"We decided to create some business tools for anyone who might want to start his or her own O&P practice and to help existing practices grow," explains Gustin. (Editor's note: For more information on AOPA's Sunriver Initiatives, see "AOPA's Sunriver Initiatives Move Forward ," The O&P EDGE, October 2006.)

The result is the Business Optimization Processes & Tools Initiative, which relies on data from the 2004 AOPA OPC Report as well as from the AOPA O&P Profitability Guide and the AOPA Cost-Accounting Manual to set benchmarks in the templates being created for this initiative.


The committee chair for the initiative, Tom Kirk, was unavailable for interview before deadline for this issue, but committee member Rick Fleetwood provided an update. "The program aims to provide a set of business and practice management tools designed to help O&P companies and practitioners adapt to changing patient needs, competitive conditions, and payer requirements, and thereby improve their performance in the short term and optimize their business in the longer term in a cost-effective manner."

So far, says Fleetwood, at all levels of alpha and beta testing, every one of the subjects found value in the package and felt it would be a valuable tool to share with the O&P industry. The final product should be available early in 2007.

It is possible, adds Bennett, that the product's use may generate still more valuable and sought-after information. "As facilities start to use this set of spreadsheets, it is possible that we may hire a third party to collect the data from their spreadsheets in order to develop statistics."

Another Initiative in Pursuit of Numbers

Possibly the most important missing answers/numbers, and those of greatest value to O&P businesses and practitioners, however, could be the key to the industry's survival.

"Evidence-based care is the key-the big chunk that we're missing," says Bennett. "The board and the field are really gearing up behind getting this accomplished. AOPA is making a huge financial commitment, setting aside money from the budget in order to ensure that we get the evidence collected and that we are able to get data that supports the care that we know is needed because that's the trend in the industry. That's the direction in which the private payers and Medicare are going."


AOPA President and Evidence-Based Care Initiative Committee chair Walt Racette, CPO, says, "In 2005, we went through the process of identifying issues, trends, and challenges that we felt faced AOPA and the profession in the next 10-15 years. We have to be able to justify what we do and make decisions based on good research and the results of choices that we have made. It's certainly a trend that's going far beyond O&P, into every medical field. Paying for performance,' some people call it, or working based on good evidence.

"We felt that AOPA could contribute outcomes with the facility members that we have and really needed to be able to do that," Racette continues. "We have all this wonderful technology but need to prove why we want to use it and justify when we want to use it."

And, once again, the problem of discovering vital answers arises.

"We're at that stage that we don't really know what questions to ask, and I think you have to be very careful, or you may find that you don't like the answers," Racette warns. "It's somewhat daunting. The more we learn, the more we realize that we don't know what we need to know, and the bigger the project grows. My best estimate is that we're two to three years off actually producing papers or results or getting data collected."


Assistant Research Professor Stefania Fatone, PhD, Northwestern University Prosthetics Research Laboratory and Rehabilitation Engineering Research Program, Chicago, Illinois, notes that from a research point of view, everything should eventually be published in a journal, where completed research should also be publicly available. "The way that evidence-based practice is predicated is that you don't just take the findings of one study and base your whole practice on that. You take the findings of a number of studies that all support one outcome," she says. "One of the missing links for us isn't just the individual studies, but also the synthesis of those studies at the systematic review level."

Currently, however, Fatone notes, "There's an awareness that this is a problem and an enthusiasm to embrace the issue and try to find ways to address it. We didn't have that five to ten years ago." This trend is encouraging to many.

"AOPA's on the move right now, Snell adds. "It has a lot of things going that will benefit the industry overall. Under the good guidance and leadership of Walt Racette, and hopefully I can follow in his shoes, things are really starting to happen-not just meetings and talk, but productive follow through. Over the last 12-15 months, there has been tremendous effort on the part of all the organizations to work more closely together and become more of a clearinghouse to provide information. So hopefully we can soon provide a lot of answers for folks, and those that we don't have, we can make sure they know where to get them."

Judith Philipps Otto is a freelance writer who also has assisted with marketing and public relations for various O&P industry clients. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.