Self-Mutilation
Self-Mutilation is a common problem in many areas of life. We see it in teens and young adults that cut themselves, or in the mentally challenged as they might bite, or hit themselves. In America we have a habit or process of dealing with such disorders by hiding them, and hoping at they go away, or at least only inflict pain on themselves and not those around them. As we continue to hide the ills of our society and tell people that we “are okay” many of us do not realize that this self-mutilation is not going away, but instead it is growing!
We seldom think about self-mutilation, it is not a term that rolls off of your tongue in a conversation. When we consider the populations that are affected by the typical outbreak of this condition, why would we focus on it, unless we are a relative or we are personally involved in the practice ourselves? The reason that we need to focus on this condition is that it affects far more than the population that we label as sufferers. This condition affects families, businesses, as well as the people around you on a daily basis.
Self-mutilation is seen in many areas of life once you begin to see things as they truly are. We see it business, yet we choose to cover the wounds by calling it “competition.” let me explain, the industry that I am involved in provides Orthotic and Prosthetic devices to the community in which the practice is based in. The industry started through local companies that provided hands on care to their patient populations, much like the family physician. Our industry was seen as an extension of the physician’s practice. We offered non-invasive treatment options to help control pain, and skeletal malalignments for the patient. Our treatments were seen as noninvasive and offered care without side-effects.
Medicare and other insurance programs understood the value of our services and established a payment process for our services. Our industry did not see the ever reaching hand of Government when they started to cover our services. They established a fee schedule that laid out the amounts that we would be paid for our products, since this was established for physicians as well, we simply felt to be part of the medical community. During this process a big battle was lost that has still not been renewed or challenged with any success. As practitioners we were deprived of charging for our evaluations or our clinical opinions. We were reduced to “selling a product” this was not the intention of our industry and it began a process of self mutilation that has not stopped. See when the evaluation step of the process was no longer covered or respected, our industry, rather than following the path of a physician through continued learning and simply trying to find the best care o!
ptions for the patient, our then practitioners followed the way of the pharmacist and began simply “filling prescriptions.” The marks left from this behavior were not seen immediately either and life went on.
In that day and age your family physician did everything to include minor surgeries in his office. He knew Orthotics as well as medicine and he knew when to write the prescription as well as which Orthotic device he wanted the patient to receive. Orthotics at this time were part if the training that was provided through medical school and the military programs dating back to WWI and WWII. As time moved on and the allowed mutilation continued, it became self-mutilation by a lack luster appeal to fight for our position as professional practitioners. Today this cycle has become much worse! Today, our physicians are no longer trained on the basis of best over-all care, they are trained on specialty care. Though this is good, it is a flawed concept of ignorance. We have been convinced that we should not be expected to know everything and that it is okay to refer to someone else for a particular condition that they may see more than you do. On the surface there is nothing w!
rong with this except the fee schedule. Now we are paying three doctors to get the information that we used to receive through one. One example of referring too quickly would be the family physician not trying Orthotic intervention prior to referring the patient out to a surgeon. I have heard many family or Internal Medicine physicians say that bones are not their specialty. It amazes me that they consider surgeons to be “bone doctors.” Surgeons are surgeons, they get paid to operate and reconstruct joints and bones. Today surgeons have been reduced to seeing patients in clinic much like a family physician would in days passed. I have asked many Family and Internal Medicine doctors after they have referred patients with Osteoarthritis of the knee to an Orthopedic Surgeon, if the patient was a surgical candidate. Many times they know many co-morbidities that would prevent them from being a surgical candidate, things such as cardiac issues, blood pressure concerns, respira!
tory concerns, or simply the lack of will by the patient to have surge
ry. Why are these patients referred to a surgeon if they are not a candidate for that service? On the other hand, many of my surgeon friends (prior to this article) have shown their frustration in seeing unqualified patients. They feel that they have to see these patients due to the lack of accurate screening by other physicians as to who would be a good surgical candidate. This is a cycle of care that frustrates the patient as well, “why did you have me go to the Orthopedist and wait three hours, due to him having an emergency surgery, only to be told that I need surgery? I told you last visit that I did not want surgery, nor did I have the time at work to be off to recover!” So the patient is prescribed an Orthosis, if not provided with one, by the Orthopedist. I have heard this so many times!
Articles have shown that physicians today receive the majority of their pharmacological training through drug company representatives. Here again on the surface, this does not alarm us, IT SHOULD. When physicians become dependent on representatives for their education it can be, and is, slanted information. Secondary, unlike the Orthotic professional that sees the patient and evaluates the physician’s understanding of the information that they have been provided, the drug representative never reviews if the patient is a good candidate for their treatment or not. Most representatives have no idea if the patient is appropriate even if they could review their cases. The Orthotic Professional (Orthotist) stands behind the information that is provided to the physician, and they stand beside the physician in the treatment of their patient! By the Orthotist not understanding their position of a true arm of the physician, and more importantly the patient’s care, we have engaged in!
the self mutilation cycle! We have mutilated our industry and our profession.
We have cut our industry into pieces and have given it away! We have mail order companies now mailing Orthotics into patients. The patient has no idea how to fit or use the device, and when their condition does not improve, the industry is viewed as flawed. The industry is damaged by the silence of the Orthotist that allow these companies to discredit our products and our profession. Our industry has non-certified people that are jumping into our industry without the educational back ground of anatomy, physiology, and kinematics needed to address the diagnoses that are presented. These people do more damage to our industry than any other. Many of them are nice people, they are consistent in their marketing efforts to the physicians, yet they do not know the effects that their products have on the patients. Most of these “representatives” only have one product line, despite the patient’s condition, they only have one Orthotic device to offer. Rather than refuse the comm!
ission from the sale, they treat the patient even if their product is not the best treatment option for that patient! If the rep actually knows enough to know that their product is not appropriate in the first place, many are simply filling a prescription.
Then we have the physician regulation called “doc fix” that stands as a 25-30% reduction in physician’s fees for treating Medicare beneficiaries. This has been hanging over the physician’s head for years, and at this writing it has just been delayed again until December 31, 2012. This financial uncertainty has led many physicians to search for additional revenue streams. I have already discussed that physicians today are not trained in Orthotics during medical school. In spite of their ignorance in this area many have started to provide Orthotic devices from their offices to diversify their revenue stream in defense of this proposed legislation. Without the proper education and the check of an Orthotist, many patients receive the product that the physician has on his/her shelf, not necessarily the product that would best serve their needs. This again discredits our industry, and makes the physician appear desperate.
Worse than the physician themselves fitting Orthotic devices, they hire someone to fit them. There is a law called the Stark Law that many physicians are regulated under. This law broadly states that the physician should not “self refer”, meaning they should not be able to write a prescription for a device, and then fill that prescription through their own stock or company that they can profit from on a per referral basis. This has led many physicians to hire an employee to fit their Orthotics with in their offices. The physician or physician’s group then does not claim a profit per referral for the Orthotic sell, but yet allows the revenue to be applied to the bottom line of the company, and this profit is dispersed as bonuses throughout the mid-year or year-end. This concept avoids the Stark law by not having a profit paid to the physician on a per referral basis. Secondly, the “fitter” of these items is not certified or licensed, they are typically a low paid employee !
that is categorized as an ancillary employee to the “true practice.” From the patient’s point of view there is a false sense of security in this person’s skills due to them being a employee of the physician. In the name of consumer protection, I feel that this is misleading.
The DMEPOS (durable medical equipment prosthetics and orthotic supplies) community is now viewed as a fraudulent industry rather than a professional one. In spite of this quick label that is thrown around in the publications and media, I have not seen one case where the individual was certified and licensed that has committed any wrong doing, despite these facts CMS will still shut the door on providers that are certified and licensed. Instead they approach this concern through Surety bonds and accreditation. Surety bonds are bonds that say if you do steal from us, we will have a bond to cash out for fifty thousand dollars to “protect the tax payer.” I have not seen CMS act once within a fifty thousand dollar window. The cases that read about on HHS or the OIG site are for millions of dollars in fraud, what did the fifty thousand dollar requirement really do?
To continue the behavior of mutilation the O&P professional was exempted from the Surety bond requirement if you were locally owned and met different requirements. Again, this looks great on the surface, penalize the big companies, they can afford the twenty-five hundred per year cost for the bond. Regardless of what O&P facility (orthotic and prosthetic) was penalized through this act, there is no merit for it in the first place! It further knocked the overall appearance of our industry down in the eyes of the public as well as the medical community. This policy could have been avoided and our industry’s efforts promoted had CMS (center for Medicare, Medicaid Services) just recognized the difference certification and licensure makes in the quality of care and outcomes. Rewards actually produce better actions more times than punishment does. So, the Orthotic and Prosthetic community now has accreditation, licensure, certification, surety bonds, and educational requireme!
nts of a Master’s Degree, just to name a few, and yet the body of the industry continues to disappear. Where is it going? Let me tie this all together for you.
We have national companies that are selling all over the nation through unqualified people, out of the trunks of their cars. Some may meet the patient at the doctor’s office, or some reports say, on the side of the road. They fit fifteen patients in the morning and go play golf with the physician in the afternoon. These “providers” do not have to be certified, licensed, accredited, they do not hold Surety Bonds, many do not have general liability insurance. They are not required to have a facility and for that facility to meet ADA, and OSHA requirements, as well as all of the industry requirements of needed equipment, ventilation, inventory, blood borne pathogen control, just to name a few. These “providers” do not have any of these things, and they are not monitored by anyone! Does it really make sense to anyone that a company based in Oklahoma should be providing Orthotic devices in Montgomery, Alabama? Really? That the patient will not have a facility to return to if!
there is a problem with the device, that the billing service for these companies are not even in the jurisdiction that they are billing from. Does anyone else see a problem with this?
See the thing about self mutilation is that it is done in the dark, under the cover of silence and privacy. You will not walk out your door this morning and see your neighbor biting themselves, or cutting themselves. Just because we do not walk out and see it this morning as it occurs, we will see the scars tomorrow as we pass by the people that literally engage in such activities. Worse, they will see our scars through closed buildings, and unemployed practitioners. Worse than that, they will see the scars through increased surgical rates due to the incorrect spinal brace being applied, increased hospital stays due to incorrect knee braces being applied to otherwise healthy athletes that simply hurt their knee or tear their ACL. Increased therapy visits because a conducive environment for closed-chained function was never established by the use of an appropriate Orthosis. CMS did a study in 1996 that showed if a physician has a financial involvement in Orthotics, such a!
s a self owned inventory system, they write for 2/3 more Orthotics than the physicians who do not have a financial interest. Increases come without checks and balances, we know this throughout any area of life.
The only way that self mutilation continues is through the lack of attention and silence! I am sure there are many Orthotists that would love to use this article against me, to say that I am attacking the physician, so he/she should not use my services, some would say, the manufacturers should not sell to me, because I feel they are killing my industry by selling direct to physicians and national companies that use unqualified people, to you Orthotist I would like to say, I AM TALKING TO YOU! You are the one that is being quiet allowing this to happen! You are the one that sits in your office while the “provider” is taking your business. You are the one that will not call CMS, or your Congressman, because “you are too busy” just wait, help is on the way for your busyness my friend. You will soon have days without one patient interfering with your day, well you may have one or two that come in realizing that their “back support” does not fit correctly, and ask you to show !
them how to apply it correctly! If you perceive this article as just simply more rhetoric that is standing against hope and change, I would love to discuss the positive change that you have seen from the events that I have listed in this article. They cannot be refuted, they are true, and this is a very accurate quick view of their outcomes. I will gladly go deeper into any area of this article if need be. I am prayerfully hoping that a publication will stand up and print this article. Change is here, and I am okay with that, industries change all of the time, but when professionals are viewed as providers the outcomes will suffer! It is not fair to allow a young person eighteen years old to enter into a Master’s program at a cost of 100,000 dollars not to be viewed as a professional on the other side! It is also not fair for the O&P practitioner to be converted to a research scientist that cannot provide hands on care to a hurting patient! There must be balance in our a!
pproach to change, another reality that seems lost in our country toda
y!
Respectfully,
Carey Jinright, LO, ATP, MSM
Cross & 3
