Challenges in Upper-limb Care

As part of our issue devoted to O&P care for upper-limb prosthesis users, Julie Alley, president of biodesigns, shares her perspective on some of the challenges facing business owners who provide care to this population. [caption id="attachment_239290" align="alignright" width="240"] Yakobchuk Olena/stock.adobe.com[/caption] I stumbled into O&P because of Randy Alley, CP, my then boyfriend, now husband. I remember one evening when he picked me up for a date from my ad agency job and I expressed frustration at having to work late to finalize an ad. Then I asked how his day was. “Great, my patient and her husband cried with joy when she opened and closed her hand for the first time,” he said. Wow, I thought, what a meaningful, life-changing event. It was at that moment I realized what an amazing field he was working in. I remember thinking it would be great to work together, which became a reality. Today, we run our own R&D facility and patient clinic and continue to feel passionate about the work we are doing and the profession. We have also faced many challenges and downright bad policies, yet I hope with attention from our industry and professionals, together we can improve policy, rework the business model, and focus on practices that will empower business owners while benefiting patients. It’s a Bad Business Model When certain situations or scenarios arise at the office that do not make much business sense, I often wind up saying, “It’s a bad business model.” I say this tongue in cheek, but much of the business structure in O&P seems to be a bad business model. So what do we do about it? I think the first step is to acknowledge some of the issues and challenges and then work together toward change. These are my observations, and my hope is to spark some further thought and dialog. An Outside Perspective Looking from the outside in, the first thing I noticed about O&P was a lack of payment for services. In my advertising career, everything was billed and quickly paid. I came from an environment where lawyers created iron-clad contracts that both parties agreed to, clients paid a retainer, projects were billed in addition to retainers, and on top of this, a percentage of the media buy was also collected by the ad agency. Nothing was done unless we knew we would be paid, and there was absolutely no negotiation after the fact. Nothing was left to chance. In O&P, however, the expense of socket production and devices is being carried by the facility because the services (and future services) are included in the device delivery, and business owners are not guaranteed payment because insurance companies say “authorization is not a guarantee of payment.” Medicare Model Let’s look at the Centers for Medicare & Medicaid (CMS). CMS policy changes have particularly impacted O&P lately, especially regarding advanced upper-limb prostheses. In addition to the audits and claw backs of the last several years, clinics are facing several issues, including removal of critical codes for upper-limb myoelectric prostheses/partial hands, the inability to bill miscellaneous codes for newer, more advanced systems, and the lack of payment for warranty work/repairs. In contrast to other business sectors, let’s highlight O&P’s warranty servicing process. As well as advertising, I also worked in the automotive field where car dealers would submit warranty work (usually parts and labor at a negotiated rate) to the manufacturer for payment. In my experience, local dealerships would bill the corporate entity. At no point was the local dealership put in the position to absorb these costs and time. It does not make sense that Medicare expects O&P clinics to support warranty work for free. Adding to the problem, manufacturers, especially bionic hand manufacturers, have added even longer warranties. Going from a one-year- to a two-year warranty for multiarticulating hands, for example, sounds like a good idea for all. But that means the clinic just signed up for providing service for two years without any reimbursement. Medicare believes because we are not actually performing the warranty repair that our time and resources to evaluate, troubleshoot, take components apart, test, request loaners, ship items, track, deliver, adjust settings/alignments, etc. is of no value. If Medicare is not going to pay for our time, then perhaps the manufacturers should, just like it is done in the automotive industry. What do you think? Sound reasonable? Minimizing the Role of the Prosthetist For me, many of these issues can be grouped under the umbrella of the diminishing role and/or lack of respect for the prosthetist or expert. I see examples all around where the prosthetist/clinic is expected to volunteer time and resources. A noted recent example is from the Challenged Athletes Foundation (CAF), which provides grants to athletes in need of adaptive equipment. While this is a great program, even CAF unintentionally minimizes the role of the prosthetist and the resources needed to fit a system and maintain an adaptive prosthesis for a grant recipient. “Please discuss with your prosthetist the ability to provide support to you before applying for an athletic prosthetic,” states the CAF website. When budgets and awards are being calculated, why is there no fee included for the facility/prosthetist’s time, labor, and overhead? Why is it that our time and overhead are not valued? Why are the components valued far more than those individuals treating the patients? I understand sponsorships and a company deciding to provide resources in the hopes of getting new customers, goodwill, or marketing, but realistically, how many facilities have the ability to provide these services at no cost? I posit there would be more clinics able to support aspiring athletes if there were a reduced hourly fee or project fee included in the grants. New Models Another interesting area for discussion is an emerging model that allows patients to order arm prostheses directly from a manufacturer without involving the prosthetist in the process. Recently there has been much discussion on this topic of direct-to-consumer delivery models. Many O&P professionals, as well as the organizations that comprise the O&P Alliance, stand in strong opposition to any direct-to-consumer delivery models that do not involve a trained and educated prosthetist to “ensure safety and effectiveness,” the Alliance said in an official position statement in April. However, if prosthetists are not delivering consistent outcomes, it cannot be assumed that their role will be preserved and defended from outside disruptors with new, possibly better models. It is important that we examine the issues of prosthetic outcomes, user acceptance rates, and accessibility that may be driving new models coming into the space. Either the profession must move and improve or others will push the prosthetist out of the rehabilitation chain. I liken it to some of the fabrication models being promoted now that merely require some measurements or a scan of the limb. Or some of the adjustable socket products being supplied that focus on speed of delivery or prosthetist convenience with regard to fitting precision and not necessarily functional outcomes. To be clear, I’m not saying these options are good or bad; I’m just saying if the prosthetist’s role is reduced to merely placing a preconfigured item on the limb and turning a few screws, then there will be little use for a highly trained and skilled prosthetist. And the question will not be if prosthetists will be replaced, but when will they be replaced? Outcomes, Baby! For our profession, everything comes down to outcomes and showing continued improvement in the users’ lives and their ability to perform their activities of daily living. If the myoelectric prosthesis remains in the closet because the user says it feels too heavy, or if the microprocessor knee is leaning against the wall because the socket is too uncomfortable, then we all lose. As a company, our focus has always been on outcomes and not purely on delivery. The thought that we are in some gray area under durable [caption id="attachment_239289" align="alignleft" width="300"] Yakobchuk Olena/stock.adobe.com[/caption] medical equipment and are only there to provide a prosthesis is probably one of the most damaging notions the profession faces. To improve O&P reimbursement and authority and influence in the rehabilitation team hierarchy, we must continue to push back against a misguided and misunderstood perception of our role. And if we as a profession don’t truly understand the significance of our role, then who will? Next Steps These are not easy challenges to overcome, and I do not have any magic answers to combat these long-standing issues, but our practice has experienced success with the following: ■ Focus on the interface. Anyone can order a component and attach some parts, but our skill is realized with the interface. Customer service, the staff, the environment, the ability to listen, proper documentation, etc. are all essential parts of our business, but the key, in our opinion, is creating an interface platform that is founded in biomechanics, science, performance, and outcomes with the goal not of device toleration, but rather device embodiment. As the profession continues to evolve, outcome measures will eventually drive reimbursement. In our clinic, we utilize several different systems for capturing outcome measures and are now integrating this process with all of our patients. The role of the prosthetist will not be minimized if we have data to prove what we are doing is having a positive impact. ■ Appeal denials. Part of our day-to-day business is the appeal process, especially with upper-limb systems. While appeals take more time and effort pushing back on an appropriate system that was denied, we feel it is necessary. We have been extremely successful over the years appealing systems and making the case for why something is medically necessary, but we also recognize it can be time consuming and our efforts should be valued. To offset some of this added time, as a company, we are now considering charging the patient an appeal fee. Insurance companies and manufacturers are not the only ones that minimize the prosthetist’s role, many patients/users simply do not realize all the time and resources that go into the many aspects of their care. ■ Talk about it. Expressing an opinion, even if not popular, is also necessary if the goal is change. National tradeshows are a good time to connect, but there should be a committee that is focused exclusively on improving the O&P business model. ■ Find a good attorney. We have been able to work with great attorneys as either expert witnesses or via class action lawsuits to help support and defend patients. When other strategies are explored but fall short, sometimes a good attorney is needed to help in the fight. Our company has participated in two class action lawsuits brought against national insurance companies that were denying appropriate systems for our patients or that had policies that did not operate in good faith. This is not an easy or quick road to success, but policies can change subsequent to winning cases, which benefits both patients and the profession as a whole. All of us working in O&P hold the keys to its future, and our fate will be decided in the next few years. We can either sit back and see what happens or we can put the wheels in motion to help solidify our place and improve the business model. I vote for the latter. Perspectives From the Field “The prosthetics industry has a credibility issue with payers. For example, when comparing 20 claims from 20 different prosthetic providers, the retail pricing for a specific myoelectric hand ranged from $38,000 to $126,500…for the exact same prosthetic component.” – Dale Berry, CP/L, FAAOP “The biggest challenges facing the upper-limb prosthetics community today is related to reimbursement. While manufacturers are innovating and producing impactful technology, the coding and reimbursement to enable provision of these devices is not keeping up. We rely on outdated codes that were created before much of today’s technology existed. We are constantly battling nonissuance of new codes or even reduction in existing codes. All of this results in reduced patient outcomes and clinical care.” – Levin Sliker, CEO and cofounder, Point Designs, Lafayette, Colorado “As a manufacturer, the industry pain points we hear and see are slightly different. From the field we hear from our customers that their days are spent pushing papers more than fitting patients, not something they thought they were signing up to do. However, from a manufacturing perspective, we have been subject to some of the supply chain issues plaguing the entire country. As a human machine interface company, we’ve had to be very resourceful to make sure we have product on our shelves when the orders come in, a challenge I don’t think we predicted facing.” – Erica Karlson, director of sales, Coapt Engineering, Chicago “The biggest challenge I see is the varying skill of prosthetists fitting upper-limb prostheses. It is a constant frustration, especially as a therapist, to have prosthetists [who are] not trained and experienced fitting upper-limb patients attempting to do so. This inevitably will cause a system to be rejected, and the patient will suffer. I am in favor of an [upper-limb] certification program. I know many are interested in developing this program, and I am hoping to see traction on this topic that has been batted around the industry since at least 2012.” – Shawn Johnson, OTR/L, executive director, Enhancing Skills for Life “O&P has completely failed at implementing outcome measures in the clinical setting. A majority of the industry only becomes interested in outcome measures after experiencing an audit. Proving necessity of new prosthetics through a validated battery of ADL performance measure tests (i.e., improvement in symmetry, base of support, ROM, and comorbidities) is a must.” – Chris Cooper, CEO/cofounder, Anatomical Engineering, maker of GaitKeeper, Bethel, Delaware Julie Alley is president of biodesigns, Westlake Village, California. She can be contacted at jalley@biodesigns.com .

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Medicare Advantage Plans Are Robbing Us… Again

On the Job With an Upper-limb Prosthesis

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O&P JOBS

Certified Prosthetist/Orthotist (CPO)

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