The O&P Alliance: An Update

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By Peter W. Thomas, Esq.

As the Orthotic and Prosthetic Alliance (O&P Alliance) continues into its third year, the advantages of active cooperation and coordination between like-minded organizations in a relatively small field are becoming more apparent. Not in recent memory has there been a time when O&P organizations have worked more closely and collectively to make progress on a consensus agenda.


Before the formation of the O&P Alliance, individual organizations worked for their memberships but rarely coordinated or communicated about consensus priorities for the O&P profession. In some cases, the individual efforts of the various associations became duplicative or, worse yet, at odds with one another. The O&P Alliance was formed to address this issue. In 2005, some of the primary O&P associations came together to see if a closer working relationship could be established while preserving the strengths of each individual organization.

Initial discussions during that first year turned into more substantive planning sessions, which ultimately culminated in an agreement to work in alliance with one another and to see if such a coalition could work. The fact that two and a half years after the inception of this agreement the Alliance is actively engaged on behalf of the O&P field is testimony to the success of the Alliance effort.

Structure of the Alliance

The O&P Alliance is not an independent entity. It is a coalition of four national O&P organizations: the American Academy of Orthotists and Prosthetists (the Academy); the American Board for Certification in Orthotics, Prosthetics & Pedorthics Inc. (ABC); the American Orthotic & Prosthetic Association (AOPA); and the National Association for the Advancement of Orthotics & Prosthetics (NAAOP). Together, the O&P Alliance represents the professional, scientific, research, business, and quality-improvement aspects within the O&P field. Each organization retains its long-standing mission.

This is not to say that the Alliance represents the entire field or every aspect of orthotics and prosthetics. Alliance members recognize that many other important organizations function in the O&P space and each plays a critical role in the betterment of the field. The Alliance is not intended to exclude any organization or point of view and routinely works in conjunction with other O&P-related organizations on an issue-by-issue basis. For instance, the Alliance often works with organizations involved in O&P education issues, groups that represent related aspects of O&P and the broader healthcare fields, as well as consumer/ disability organizations.

Each of the four Alliance member organizations are represented on a steering committee, and each organization has one equal vote. The Alliance functions under a consensus rule. If any one organization does not believe a particular issue should be subject to Alliance involvement, that issue is not dealt with as an Alliance priority. Activity on these issues would then fall to the organization(s) with an interest in pursuing them. Because only consensus agenda items are considered by the Alliance, each member of the Alliance is able to veto the agenda pursued by the collective group.

The Alliance steering committee meets by conference call every two weeks and in person twice a year. The steering committee makes all decisions, sets and implements the agenda, and serves the administrative functions of the coalition. Each of the four organizations provides in-kind contributions of their time, effort, and, in some cases, expenses to pursue priority objectives. In addition, the organizations provide a yearly stipend to the Alliance for the purposes of retaining legislative and regulatory counsel.

Because the Alliance is a coalition of existing organizations and is not an independent entity, it does not have its own website nor does it send out routine communications to the O&P field. While there may be instances where the Alliance chooses to communicate directly to the O&P community, communications on policy issues and related matters are functions of the individual organizations that comprise the Alliance. So while many in the O&P field may not have heard a great deal about the status and progress of the Alliance, there is a great deal occurring that will benefit the field for years to come.

O&P Policy Priorities

As a consensus-driven coalition, the first order of business of the O&P Alliance was to discuss and agree to a consensus agenda. In 2006, the Alliance debated and agreed to focus on the following three priority areas to advance the O&P field: (1) ) quality and qualifications; (2) coverage and reimbursement, and (3) education and research. These three priority areas became the pillars upon which the Alliance has built its agenda.

Quality and Qualifications

The Alliance is committed to assisting member organizations in advocating for federal and state policies aimed at ensuring that patients receive high-quality O&P services from appropriately trained and educated practitioners. Alliance goals under this priority include the following:

  1. Medicare should adopt appropriate quality standards for the provision of professional O&P care to ensure the quality of orthotic and prosthetic services for beneficiaries. Payment should only be made to those providers and suppliers who meet the quality standards.
  2. The O&P Alliance supports the development of qualifications for practitioners through O&P licensure at the state level and mandatory accreditation and certification initiatives at the federal level.
  3. The Alliance believes that ABC facility accreditation and its certification examinations are the gold standards that should be applied to measure quality and qualifications of O&P facilities, practitioners, and related personnel.
  4. Quality and qualification standards should apply to both prosthetics and orthotics and should differentiate between levels of care (i.e., custom fabricated, custom fit high, custom fit low, and off-the-shelf).
  5. The O&P Alliance opposes any legislative or regulatory scheme that provides Medicare beneficiaries with "direct access" (where a physician's prescription for therapy is not required) or self-referral by physical or occupational therapists because it is not in the interests of good patient care.

Coverage and Reimbursement

The Alliance is dedicated to advocating for fair and equitable coverage and reimbursement policies so that patients have access to technology and can continue to receive high-quality orthotic and prosthetic services to meet their daily needs and life goals. The goals of the O&P Alliance under this priority include the following:

  1. The Alliance supports all efforts to ensure that Medicare reimburses O&P services and devices at reasonable levels, including support for:
    • Separate and distinct classification from durable medical equipment (DME).
    • Annual inflation updates to the Medicare O&P fee schedule.
    • Exemption from competitive bidding for orthotics and prosthetics.
    • Due process for changes to O&P coding and reimbursement that are imposed without notice or comment by the Centers for Medicare & Medicaid Services (CMS) and its contractors.
    • Prompt and accurate payment of O&P claims from Medicare contractors.
  2. The Alliance seeks to maintain and promote the broadest coverage possible of professional O&P care under all healthcare programs and payers, including Medicare, Medicaid, and private insurance. This includes the following:
    • Improvements in Medicare's O&P medical policies, including the promotion of new technologies.
    • An exclusion of orthotics from Medicare's skilled nursing facility prospective-payment system.
    • State efforts to defend against Medicaid restrictions in O&P coverage.
    • State efforts to enact prosthetic and orthotic parity legislation (e.g., mandated insurance coverage of orthotics and prosthetics) and other favorable private-insurance-coverage efforts at the state and federal levels.

Education and Research

The O&P Alliance is focused on advocating for policies that enhance O&P education and promote a broad range of research opportunities. Inclusive in that is research that demonstrates the efficacy and cost-effectiveness of O&P services. The goals of the O&P Alliance under this priority include the following:

  1. Helping to secure the fifth year of funding for the Academy's U.S. Department of Education grant through both the legislative and regulatory processes as part of a broader goal of enhancing funding for O&P education and related programs.
  2. Actively supporting efforts to increase funding for research and to increase the profile of orthotics and prosthetics in order to further develop reliable outcome measures, evidence of clinical efficacy, and advancements in O&P technology.
  3. Striving to increase awareness and support for the advancement of orthotics and prosthetics.

2007 Strategic Planning

In 2007, the O&P Alliance actively worked to implement strategies and tactics to achieve progress on the goals encompassed by the three pillars discussed above. The Alliance focused its efforts on prompting CMS to improve the O&P accreditation requirement and the related O&P quality standards. Attention was also focused on Capitol Hill to ensure that the annual update to the O&P fee schedule was not decreased and to ensure that the Academy's Project Quantum Leap grant was fully funded. (Editor's note: Project Quantum Leap (PQL) is a long-term initiative of the Academy to advance the profession through updated research, an expanded body of knowledge, and a movement toward evidence-based practice.) There were many complementary efforts and successes on a variety of the priorities encompassed by the consensus agenda.

The steering committee also engaged in a lengthy strategic planning process throughout 2007 to examine the challenges to the O&P field over the long term and define a policy roadmap for success of the profession and the field as a whole. A series of overarching goals were debated and prioritized, and subgroups were formed to address specific objectives. Due to this strategic planning and efforts of individual organizations, the Alliance was able to meet a number of these goals.

Accomplishments and the Future

One of the most recent substantive accomplishments of the Alliance builds on the exclusion by statute of all prosthetics and custom-fabricated orthotics from Medicare competitive bidding. "Off-the-shelf" orthoses are included in the competitive bidding program by law, but CMS decided to not include off-the-shelf orthoses in the first and second rounds of competitive bidding. This has given the Alliance organizations some latitude in attempting to improve the accreditation requirement for O&P providers and to offer improved language for inclusion in the separate quality standards for O&P care. The Alliance has met with CMS on several occasions to discuss these issues and has submitted comments to various regulatory proposals over the course of the past two years.

This dialogue appears to be improving CMS policies. When publishing quality standards for accreditation, CMS published a separate "Appendix C" for prosthetics as well as custom-fabricated and custom-fitted orthoses, thus treating orthotics and prosthetics separately from DME. Due, in part, to suggestions from the Alliance, CMS released in February 2008 a new draft of the quality standards, which includes changes to Appendix C that are favorable to the O&P field. As one of the Alliances top consensus priorities, these favorable developments demonstrate that the Alliance structure is working.

The collective work of the O&P Alliance over the last two years has resulted in significant policy accomplishments. More important, the Alliance structure has created a routine and open communication mechanism among four of the national O&P organizations so that policy developments and coordinated responses to those developments occur efficiently and routinely. This is tremendously valuable to a field that is considered relatively small and highly specialized by any metric. The more coordinated, consistent, and focused the O&P field's message is, the better the chances that successful policy outcomes will result.

The O&P Alliance will continue to work to improve public policies for the benefit of O&P patients and the providers who serve them.

Peter W. Thomas, Esq., Powers Pyles Sutter & Verville, PC, is the legislative counsel for the O&P Alliance and general counsel for the NAAOP.