O&P Ten Years Later: Where Are We Now?
January 2019 Issue
In January 2009, The O&P EDGE asked O&P experts to identify trends most likely to impact the profession during the next decade. In our 2019 follow-up, we find that nearly all their predictions were spot-on.
In revisiting the prognostications from 2009's "Survival Guide," we're able to look at not only where we've been, but what's likely to evolve during the next decade—what to watch for, and what to do about it.
Trending in 2009:
Trend 1: Increased Demand for Evidence-based Practice
Every 2009 respondent identified this trend at or very near the top of their list of concerns, and it's still considered the highest priority by most 2019 experts.
Brad Ruhl, past president of the American Orthotic and Prosthetic Association (AOPA) and managing director, Ottobock North America, headquartered in Austin, Texas, notes that "one of the major shifts that has occurred in the last ten years is the fact that we are starting to realize the true evidence-based practice model. There's been a lot of progress made within AOPA, specifically as it relates to sponsoring a research agenda.
"It has become incredibly obvious that the only way to establish new reimbursement, and to be credible with regard to justifying what you're getting paid, is that claims be evidence-based."
Supplementing progress through the American Academy of Orthotists and Prosthetists' (the Academy's) O&P Education Research Foundation with its own efforts through the Center for O&P Learning (COPL), AOPA issues requests for proposals for prosthetic and orthotic research, and funds projects annually, Ruhl says.
Dennis Janisse, CPed, president and CEO, National Pedorthic Services, headquartered in Brookfield, Wisconsin, notes that as president of the Pedorthic Foundation, he's also seen improvement in the development of new evidence-producing research. After a considerable dry spell that resulted from limited funding, he acquired funds provided by the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC), and the last five or six years have seen them supporting pedorthic-related research studies at Georgia Tech and Baylor University, and also taking over a California study handed off from the Pedorthic Footcare Association.
"It's taken time, but we are now getting some pedorthic research going. The more we can talk about research going on, the more interest we can attract for it," says Janisse.
Kevin Carroll, MS, CP, FAAOP(D), vice president of prosthetics, Hanger Clinic, headquartered in Austin, Texas, observes that "the entire O&P profession has begun to step up to the plate when it comes to evidence-based practice. Today we pride ourselves in how we have started incorporating evidence- and outcomes-based research to advance the care we provide to our patients. At Hanger Clinic, one of our new initiatives is the ME program, a smart, data-driven outcomes program that's designed to track and monitor the progress of lower-extremity prosthetic patients' individualized care in a way that empowers them to reach their highest personal goals."
The ME program's patient assessment and scoring system results in a custom scorecard for each patient, which is stored in Hanger Clinic's nationwide database, enabling future appointments with his or her clinician to include scorecard review and updates, goals tracking, and comparisons with others in similar circumstances.
"So far we are seeing patients react incredibly positively to this new outcomes-based tool that helps them achieve their mobility goals," Carroll notes.
Vinit Asar, CEO, Hanger Inc., points out that while O&P manufacturers are experienced at marketing their devices, it's important that they begin to conduct clinical trials that demonstrate the efficacy of their products—as manufacturers of hip and knee implants already do.
"In addition to our investments in other studies," he adds, "Hanger is working with manufacturing partners to design landmark clinical trials that will ultimately benefit our patients and our profession."
The body of evidence has increased over the last ten years, agrees Chris Hovorka, PhD, CPO/L, FAAOP, assistant professor, University of Pittsburgh, referencing a milestone double-blind study on orthotic spinal treatment of adolescent idiopathic scoliosis. But there's still a problem, he says. "The knowledge is there and easily accessible; the bigger limitation has been clinicians' knowledge and awareness of the information and where to find it—then, how to understand it and integrate it into their own clinical practice so that it can serve as an advantage in improving care and getting reimbursed."
One solution he offers is to better inform and train clinicians in what to do with the information available, beginning with the students currently in O&P educational programs. "They're starting to do that by providing coursework and curricula to train students, but it varies considerably how the training is done and at what level. It's not a clear requirement through NCOPE [the National Commission on Orthotic and Prosthetic Education], the accrediting body."
Schools should not only cover evidence-based practice, he says, but "they need to show the student how to formulate a question, how to read the information, and then how to integrate it into their plan of care."
To address the issue for practicing clinicians, he suggests that O&P universities and O&P professional continuing education programs expand opportunities that help train practitioners in the process of evidence-based practice.
"We're in the days of accountable care," says Carroll, "which is good for medicine and good for healthcare. Today we pride ourselves on our ability to put together best practices based on data."
He points to Hanger Clinic's recently published Mobility Analysis of Amputees (MAAT I)* study—the largest of its kind to date—wherein Hanger Clinic's collected data and analysis demonstrate that higher quality of life and patient satisfaction are strongly related to higher mobility for patients with a lower-limb prosthesis. The second part of the study, MAAT II**, found that an individual's overall comorbid health has little impact on mobility with a lower-limb prosthesis, as patients with multiple comorbidities still benefit from a prosthetic device that provides meaningful mobility. Despite growing O&P research, Michelle Hall,MS, CPO, FAAOP(D), former Academy president, Gillette Children's Specialty Healthcare, St. Paul, Minnesota, finds it frustrating that what constitutes "adequate" evidence to the Centers for Medicare & Medicaid Services (CMS) appears arbitrary and inconsistent in some cases. "I feel that from a research standpoint there is a large enough body of evidence pointing to the effectiveness in safety and falls prevention to justify providing microprocessor-controlled knees to K2 individuals, for example. They've been around for 20 years, yet CMS still says it's ‘experimental' for that population. How do we acquire adequate evidence without either research funding or being able to fit it on patients and longitudinally record fewer falls, fewer hospitalizations over ten years? We can't collect evidence if the patient can't be fit with them.
"This has probably always been the case, but I feel like it's changing more in that direction."
*Prosthetics & Orthotics International, October 2017
**American Journal of Physical Medicine and Rehabilitation, November 2018
Trend 2: Increased Documentation
Although payers are not yet requiring evidence-based documentation, without evidence, claims are very easily challenged, says Ruhl. "If you don't have the outcomes, it's very hard to defend the claims."
David McGill, JD, vice president, reimbursement and compliance, Össur Americas, Foothill Ranch, California, says, "Everything changed in 2011 with the Dear Physician letter for lower-limb prosthetics. From that point forward, it has been a much harder road to get a claim either authorized and/or paid for as a result of significantly increased documentation requirements."
Companies that have succeeded despite this challenge have done so by documenting their care, the effect of that care, and why the care is needed—"much more effectively and comprehensively than O&Ps traditionally did in the past," he points out. "For the companies that have figured it out, it represents a huge competitive advantage. In fact, many of the companies that did not change their documentation model are no longer here, and those that do remain really struggle."
Janisse confirms that "for a couple of years there were a terrible number of audits based on [Medicare's] Therapeutic Shoe Bill, and a lot of people just threw in the towel and said they weren't going to do it; I think the increased documentation demands have forced some people out of practice."
An early adopter of electronic medical records, he believes the process has helped immensely with documentation accuracy. "OP&P has a lot more documentation than they had to do five years ago, but I think the people that are still doing that billing have gotten much better at securing the information and billing with it."
Jim Rogers,CPO, FAAOP, Academy past president, Pinnacle Orthotics and Prosthetics, Chattanooga, Tennessee, says that the Medicare-implemented documentation rules—specifically the requirements for physicians' notes—have not decreased fraud, but have angered physicians who are asked to do something that's not reimbursed. It has also delayed care and increased the cost of care. "I can't get a patient in for a diabetic shoe inside of four weeks, because physicians don't prioritize sending me their notes or writing them in a way Medicare deems acceptable."
Responding effectively to increased documentation demands may be a hard-earned lesson, but it may come with fringe benefits, says Scott Bretl, CPO, program director, Alabama State University. "Today's better informed patients arrive empowered with their own knowledge, and clinicians are challenged to be confident, informed, and transparent. Documentation is forcing us to be more explicit in what data we gather and how it's helping us make these clinical decisions on our patient's behalf. If we're already doing that for documentation purposes, it's a pretty easy step to just speak that out loud to the patient, too, and confirm that everybody's on the same page."
Trend 3: Diminishing Reimbursement
A 2009 respondent pointed out that at the current rate, the growth of Medicare costs would consume the entire taxing capability of the U.S. government within 20-30 years, which may be why recent O&P history has brought increased pressures from payers determined to reduce payouts:
"Payer pushback has been significant," says Ruhl, citing the Draft Local Coverage Determination (LCD) for Lower Limb Prostheses that CMS filed in 2015, the 2011 Dear Physician letter, and the dramatic 2012 upsurge in audits, notably by Medicare. "Conditions really put a huge stress on a lot of smaller businesses, forcing some consolidations and sales.
"It could get worse," he warns. "We're finding that it's almost impossible to go down a defined pathway to reimbursement for new technology. There's very little evidence in the last almost ten years of significant breakthroughs in getting new coding, new coverage, and new allowables set that are adequate. This was not the case 20 years ago, or 15, or even ten years ago."
"In pedorthics it's particularly bad," says Janisse. As a result, many of the people who specialize exclusively in pedorthics are changing their business model, as he has. "We're limiting our liability to the insurances and going to more of a self-pay system. With O&P, the insurance company can't discontinue orthotic and prosthetic care, for the most part. They can decrease their coverage, but they can't get rid of it."
With pedorthics, however, many insurance companies either discontinued coverage for foot orthotics, or dropped the reimbursement so drastically that providers lost money.
"Five or six years ago I was about 5 percent self-pay; today I'm up to about 40 percent self-pay. It's about the same for Medicare. I see a trend of coverage for foot orthotics going away entirely, with the exception of Medicare coverage of diabetic inserts."
Janisse sees that as a positive, rather than a negative direction.
"Seven or eight years ago, I had multiple offices; we were terribly busy, but we were losing money every day. Now I'm down to two offices, and we're breaking even. We're not making money, but the bills are paid," he says. "I'm hearing more and more people choosing that model. If their customers need something, they can afford it without insurance. A $300 or $400 foot orthotic is a lot different than a $20,000 prosthesis.
"I thought when we made the change, that we'd be more like a retail shoe store," he muses, "but we're not at all; we're still filling prescriptions—we're just not billing the insurance company."
Hovorka agrees that with a system that appears to be non-sustainable, the clinician of tomorrow cannot completely rely on a failing system of reduced reimbursements. "It appears that many clinicians are trying to find alternative sources for reimbursement, such as private pay, or other, more lucrative contracts, or perhaps seeking new opportunities through niche practices (i.e., O&P care of animals, etc.)."
McGill says that although reimbursements from commercial insurance companies have been shrinking, Medicare's fee schedule has remained comparatively stable.
"Ten years ago, you'd see commercial insurance plans with 80-20 coinsurance, and the deductibles were relatively low. You now see plans that are 70-30; 60-40; and even 50-50 with out-of-pocket exponentially higher than they were in 2008-09. Patients are having to bear a higher-than-ever cost of care relative to historical norms."
In contrast, in the wake of a 2 percent Medicare fee reduction which has since normalized, he observes, "…most years you see small but positive adjustments in the Medicare fee schedule. Relative to lots of other healthcare specialties, custom O&P has remained relatively untouched from a Medicare payment standpoint. While that‘s good news, we should be concerned about Medicare increasing its scrutiny of O&P payments and preparing for potential changes to the payment system in the coming years."
Despite previous predictions, Medicare has not gone bankrupt, Asar points out, "and I don't believe the American people would allow it. However, it is true that healthcare spending in the U.S. as a percentage of GDP is the highest in the world and has continued to climb. This is the part that is not sustainable. The pressure on healthcare to cut costs has been ongoing and we cannot expect it to stop. The healthcare industry does need to figure out ways to get more efficient. Those that are able to completely adopt the triple aim of healthcare will win: better health, better care for better value."
Hall reminds us that a decade ago, the O&P Alliance was just coming into its own—bringing together the Academy, AOPA, the National Association for the Advancement of Orthotics and Prosthetics (NAAOP), and ABC to accomplish shared goals for the O&P field. "Since then, BOC [the Board of Certification/Accreditation] has joined the conversation, and NCOPE is sometimes brought into the conversation, as well. The Alliance is now able to coordinate efforts across the profession even better than when they were first starting out, and that has led to some good pushes on the legislative effort and on the reimbursement aspect.
Trend 4: Increased Use of Prefabrication and Reliance on Central Fabrication
The reliance on central fabrication and more automated commercially available designs will continue, Hovorka predicts. "I wouldn't be surprised to see more savvy designs, particularly in the area of orthotics, through a greater number of modular components that enable the clinician to customize fit using a wider range of interchangeable parts. This would potentially help clinicians customize device designs to meet their patient's functional needs."
Another potential trend in this arena, he believes, would be for on-site clinicians to use new 3D systems to print what they need in the desired size, shape, and method of attachment.
"Gone are the days of being able to set up a practice in any building, especially a medical building, and begin making orthotic and prosthetic devices," Carroll reflects.
EPA restrictions and landlords' objections to chemicals and noise, he explains, have forced many O&P clinics to move their labs off-site or to use a central fabrication facility. Many younger clinicians spend more time with their patients and less time in the labs—instead, using computers to design devices and sending the digital design to a central fabrication site. The finished device arrives back later for diagnostics and final fitting.
"Patients also appreciate having access to a clean, non-noisy facility," Carroll observes, "while retaining the expert in-person care of their orthotist or prosthetist."
James Wynne, CPO, FAAOP, Boston Orthotics & Prosthetics, Avon, Massachusetts, believes that increased use of central fabrication gives clinicians added time to develop the expertise with computer programs and scanning technology that today's technologically advanced profession demands. In an August 2018 O&P EDGE article, Wynne noted that "such advances have improved the patient experience and the quality of the device provided; the central fabrication facilities have highly skilled and trained technicians that know these programs and are efficient in their use."
Trend 5: Continued Encroachment From Other Disciplines
Many respondents agree that while encroachment is less of a concern than previously, it continues in certain areas. "Where we're seeing encroachment really taking place is directly through the physician channel," says Ruhl, "and much of that is aimed at off-the-shelf orthotics. That continues to become the primary channel for access to those kinds of devices."
Hovorka points to other allied healthcare professions such as physical therapy, occupational therapy, and athletic training that have been looking to add orthoses to an expanded scope of practice.
Those efforts are going to continue, he says. "I think these professions are looking to expand their capabilities to increase their chance of survival; this is their livelihood, and fitting orthotics is an economic strategy for them."
Rogers believes that encroachment has been facilitated as technology has advanced, while our regulatory environment has not—failing to distinguish between custom orthotic services, for example, and those that require no clinical expertise to fit an effectively made device that can be ispensed out of the box. This has led not only to encroachment, but misuse of codes, and CMS' subsequent misapprehension that the reimbursement is far too high for an off-the-shelf item and a one-visit episode of care.
"Orthotics and prosthetics have become commoditized," he explains. "We see a patient over an episode of care for multiple visits, but the only encounter that the payers recognize is the encounter where a device is delivered. And all they pay us for is that device during that encounter."
The numbers are weighted heavily—and not in our favor, says Hall, when it comes to competing for state licensure and scope of practice with other allied health professions. "In 2016 there were 239,800 physical therapists (PTs) in the country, and in 2017 there were 5,917 certified prosthetist/orthotists in the country. There's no question who has more clout—and gets more attention."
And although more licensure is progressing, "It's been a long haul to get as many licensure states as we have," Hall observes. "States like North Dakota will probably never be licensed because there are so few certified individuals. The cost to them would be astronomical."
McGill, however, excludes encroachment from the list of trends that still merit concern. "I won't pretend it doesn't exist," he says, "but the profession's concerns versus the objective reality aren't in sync. For example, the data does not bear out the claim that PTs are engaged in any material way in custom orthotic or prosthetic care. While there are instances cited of this kind of activity by some O&Ps, the data suggests it is the exception, not the rule, and I don't think it's ultimately a key threat to O&P long-term."
While some O&P practices are now physician-owned, McGill notes that this is not classic encroachment because the physicians are not actually providing the O&P care themselves and displacing O&P professionals: rather, they are hiring licensed or certified prosthetists and orthotists to deliver the care in the facilities that they own.
(In future issues, we'll apply 2019 perspectives as we revisit experts' 2009 concerns and expectations regarding the evolution of patient care and the economics of outcomes, as well as legislative and educational progress that advances the O&P profession.)
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.
To read a statement from the National Commission on the Orthotic and Prosthetic Education about its requirements for instruction on evidence-based practice visit NCOPE Letter.