Tomorrow's O&P: A Survival Guide Part 2: The Economics of Outcomes
February 2009 Issue
When, in the January issue, we began delving into what lay ahead for the O&P profession-soliciting insights from industry leaders, educators, and experts-we quickly discovered a great deal more than we expected. Prognostication is not a simple art, and the O&P profession is certainly not a simple subject upon which to practice it.
In the second part of this three-part series, we examine trends and indicators pertaining to O&P patient care: Is the current economic crisis likely to impact patient outcomes, either directly or indirectly? How can O&P practices survive while serving clients who can't afford their own care-nor the insurance to cover it?
Are Patient Outcomes at Risk?
"Patient outcomes are directly affected by the care people receive; in [O&P] practice, the economy really doesn't have a direct effect on patient outcomes," says Jim Rogers, CPO, FAAOP , president of the American Academy of Orthotists and Prosthetists (the Academy). Though he says he believes it is possible that "providers who are less qualified may look to cut corners, a professional would not do this."
If the Centers for Medicare & Medicaid Services (CMS) can decide who's qualified-recognizing the unique qualifications of orthotists and prosthetists and limiting others to their appropriate scope of practice, Rogers says, "that would go a long way toward preventing poor patient outcomes."
Like Rogers, Mike Allen, CPO, FAAOP , immediate past president of the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) Board of Directors, also believes that the nation's economic woes will not have a direct impact on O&P. However, he does say, "The economy has the potential of continuing to negatively impact the reimbursement issue, as insurance companies like AIG continue to be compromised. When the economy affects one aspect of an organization such as AIG, there are going to be inevitable ripple effects into the other segments of operation."
Most of us have already experienced those ripple effects as the economic downturn impacts not only housing and mortgages but also other essentials, such as transportation, food, and utilities. The federal government has injected billions of dollars into the U.S. economy through the controversial $700 billion Emergency Economic Stabilization Act of 2008-also known as the "bailout." But will it help O&P?
Peter Thomas , general counsel for the National Association for the Advancement of Orthotics and Prosthetics (NAAOP), notes that "the consequences of the economic rescue package will simply exacerbate the economic pressure to reduce the cost of entitlement programs such as Medicare and Medicaid and will likely reduce the scope of the children's health insurance reauthorization bill. It will also impact the expected debate on national health-system reform. The prospect of expanding coverage for a significant number of uninsured Americans becomes more difficult as the federal funding necessary to pay for such coverage expansions is far more difficult for the federal government to tolerate."
Thomas doesn't believe, however, that such changes will necessarily negate recent progress toward prosthetic parity. "This is not to say that prosthetic parity and mandated benefit laws will not continue to have some degree of success at the state level, as the case for prosthetic parity is compelling and credible. Whether this trend will lead to a federal law that applies this same parity concept to self-insured plans that fall under the ERISA [Employee Retirement Income Security Act] statute and are thus not subject to state insurance laws is not clear at this point. What is clear is that prosthetic-parity legislation will be in play this coming year as national health insurance reform receives significant attention and debate."
Thomas Guth, CP , president of NAAOP, points out that "CMS/Medicare codes say they cannot take away the service and benefits to patients, and they can't lessen the quality. So as long as we have good representation in Washington, patient care and outcomes should not be impacted. But we have to keep pushing that effort. The O&P profession is so small, and these patients need us so badly. We must continue to remind legislators that by cutting our patients' services, they save virtually nothing and do extreme-and costly-damage to these patients."
Economics may not have a direct effect on the quality of care and patient outcomes, but it certainly can affect it through reduced accessibility and funding. "Medicare spending will have to be reduced and taxes will have to go up," predicts Brad Ruhl, immediate past president of the American Orthotic & Prosthetic Association (AOPA). And it's only a question of how much will Medicare be reduced, offset by how much will taxes be increased.... That's a personal belief- not necessarily an AOPA belief."
Already David McGill , vice president of legal affairs for Ossur Americas, Aliso Viejo, California, and member of the Amputee Coalition of America (ACA) and NAAOP boards, has seen a movement toward increased utilization of consumer-driven healthcare, wherein high-deductible, high out-of-pocket health plans shift the costs from the insurance companies and employers to the patients. He identifies the continuation of such a drive as "the single biggest issue I would expect to see as a result of the economics of the last few months.
"The theory behind those plans is that they will encourage better decision-making at the beneficiary level, so the beneficiaries will choose their healthcare more wisely. Unfortunately, most of the objective data out there supports a slightly different conclusion." Instead of making smarter healthcare decisions, consumers stop making healthcare decisions entirely when confronted with these plans, McGill explains. They don't seek care because it's too costly.
"The use of consumer-driven health plans has risen over the last three years," he adds. "About 8 percent of employer health plans would now be considered high deductible, high out-of-pocket plans, up from 3 percent only two years ago. That trend is likely to continue simply because employers can't bear the cost."
The risk posed by consumer-driven healthcare is that patients who delay treatment until their condition has deteriorated significantly may ultimately require more extensive and expensive solutions. However, McGill points out that because of the relative newness of these kinds of health plans, the economic ramifications are still unclear.
Rogers agrees that a stressed economy may cause patients to put off care that they otherwise might seek in better economic times. "They may look at their insurance and realize that they'll have to pay 20 percent to get their prosthesis repaired or replaced, for example, so they decide to live with it the way it is. This results in more wear, ill-fitting devices secondary to anatomic changes, and can of course lead to reduced functional capacity."
James Wynne, CPO, FAAOP , director of education and training, resident director, at Boston Brace International, Avon, Massachusetts, joins McGill and Rogers in their concern, and sees an added risk: Not only are patients likely to forego an appointment because of a co-payment, he notes, but O&P providers must also be concerned about insurance companies withholding payment a bit longer. "Although as practitioners we will still provide the quality care and service and product for our patients, from a business perspective, we need to be diligent about collecting the co-payments up front so that we are there in the future to continue providing service that patients are going to need. We all have to look at our cash flow a little bit closer now with the economic situation that we have."
Kevin Carroll, MS, CP, FAAOP , vice president of prosthetics for Hanger Orthopedic Group, Bethesda, Maryland, agrees that as money gets tighter for patients, their access to care may suffer. "A lot of our patients rely on healthcare insurance available through their employer. The economy is down, hence people are losing jobs and their health insurance along with them. As a result, more patients may have to go through Medicaid, which in a lot of states is strapped for dollars. Orthotic and prosthetic devices are often expensive items that people can't afford without the help of an insurance company or local or federal government support. Providing greater healthcare availability to all while maintaining high-quality care is a very tough task for the government to take on," Carroll says.
Is Government Control the Answer?
Does the solution lie in more government control-similar to the socialized medicine programs some other countries use?
"I practiced in Europe, where a lot of countries have socialized medicine," Carroll says. "The result of socialized medicine in Europe is long waiting lists. A person in need of a procedure is entitled to free care, but the reality is that they're waiting months, if not years. What good is free healthcare if you can't access it?"
The technologies available through such a system are older, rather than state-of-the-art, Carroll points out, placing patients at greater risk. Without an advanced knee that provides optimum stability, elderly patients might fall and sustain a hip fracture.
"Talk about saving dollars-what does it cost to rehab somebody if they need to replace a hip as the result of a fall?" Dennis Janisse, CPed , president and CEO of National Pedorthic Services, is also reluctant to advocate for a government-controlled system of guaranteed healthcare. He is working with Medicaid in Wisconsin to streamline documentation requirements that don't affect patient care in order to keep down the rising costs of doing business.
"I think the vast majority of practitioners care about their patients," he says. "Their goal is to help people. But we can't keep cutting back on care as reimbursement continues to decrease. "The Canadian and European government-provided healthcare systems sound good, but the care is not there," Janisse adds. "Many are forced to use the 'brown paper bag' method of getting care: paying a doctor under the table to have their surgery done quicker, or to get a better doctor, or to make sure they don't lose their place on the E.R. schedule and get bumped to the end of the line."
However, Christopher Hovorka, MS, CPO, LPO, FAAOP , director of the master of science in prosthetics and orthotics program at the Georgia Institute of Technology (Georgia Tech), feels that universal healthcare may offer some answers. "If you look at Canada's system, there are certainly advantages: All the costs of medical care are paid into the system by all wage earners. In the current American system, the millions of folks who are uninsured or underinsured create a dilemma. What happens to the quintessential person with obesity and comorbidities such as hypertension and the potential risks for stroke, diabetes, and arthritis?"
Hovorka also points out the philosophical aspect. "If we as a society don't consider a fundamental change in our attitudes and beliefs about caring for the sick and the elderly, who's going to do it? How will that neglect impact the fiscal and physical health of the community? To illustrate his point, he refers to an example in the Atlanta area. "The county hospital had been in a financial crisis," he says. "To address the situation, the Atlanta community realized if the hospital was not supported and failed, that other "for profit" hospitals would be impacted through a dramatic rise in uninsured and underinsured patient visits. As a result, the community stepped up and re-structured the community hospital administration and infused the needed capital to prevent its collapse. The community realized that if folks in need of basic healthcare today are not provided for, their health may deteriorate to the point that emergent or catastrophic care is required via treatment through the Emergency Department. The costs for emergent or catastrophic care exceeded the costs for preventive and maintenance care."
In a Nutshell
Thomas Kirk, PhD, CEO of Hanger Orthopedic Group sums up the issue. "In the short term, our biggest concern in this economic crisis is our patients. If they start losing their jobs, the natural fallout is that they lose their insurance and start neglecting and jeopardizing good healthcare. So the short-term influence of unemployment is that we may see some deterioration in the O&P business.
"In the long term, the country has set itself up for huge deficits that may result in tax increases in a couple of years. Higher taxes can put crimps in people's disposable income. And on top of that, insurance is very expensive."
Hovorka agrees that things are bound to get tougher. "In this down-turning economy, belt-tightening is one obvious answer, which will continue in healthcare. Healthcare policies will continue to restrict or reduce reimbursement on a greater number of services, particularly with regard to high-tech and very expensive treatments.
"We still have limited reimbursement and coding for some of the new O&P technologies, and I think there will be more...skepticism by the third-party payers when deciding whether to provide reimbursement for a fancy bells-and-whistles device, when the conventional knowledge or attitude may be that the patient's function may be optimal with something less. This is where evidence- based care will be critical in the rehabilitation and O&P professions. The O&P community has the opportunity to provide evidence to demonstrate that optimal patient outcomes may require more than the bare minimum in device design as part of a treatment plan.
Hovorka says that in order to deal with the trickle-down effects of reduced reimbursement and increased costs associated with the delivery of care, practitioners are going to have to streamline procedures and implement low-cost outcomes measures in the provision of O&P patient care.
Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.
Author's note: Our series concludes next month with part III of the O&P Survival Guide, "An Ideal O&P World-Can We Build One?" Some of our experts will explore their hopes, dreams, and schemes for the industry's future, and examine how the new blood entering the profession is already making an exciting difference in shaping that future.