While the need for O&P services is universal, the way in which care is delivered varies not only between countries with resource differences, but also between industrialized countries. The O&P EDGE contacted representatives from Canada, the United Kingdom, and Germany to learn more about their care models, and what insights the US O&P profession might glean.
Canada’s Compendium Protects Patient Care
In 2004, Canada’s O&P community was struggling with a system wherein “every insurance company, group policy, province, and social service—and two federal programs as well—[used] a different system of identifying reimbursable O&P services,” and the profession itself was not using a common language to describe its patient care functions (See “The Canadian Compendium: Reinventing O&P Coding North of the Border,” The O&P EDGE, February 2009).
Since then, when members of the Canadian Association for Prosthetics and Orthotics (now Orthotics-Prosthetics Canada (OPC)) first discussed the need for a unified national nomenclature for O&P and voted to create a document that would give a single voice to Canadian O&P, more than 30 Canadian O&P professionals put in countless volunteer hours to create the first iteration of the Compendium of Prosthetic and Orthotic Treatment (CPOT) presented in 2010.
“OPC volunteers had numerous meetings and working sessions cloistered together in various locations, sometimes for days on end,” say OPC President Linda Laakso, CO(c); OPC President Elect Scott Hedlund, CP(c); and Alberta Association of Orthotists and Prosthetists (AAOP) President and OPC Member Connor Pardy, CPO(C).
“The CPOT was approved and introduced as a reference document in 2011, and since then has been a key reference for OPC in updates of standards of practice, education, and other documentation, providing a qualitative rather than a quantitative description of practice,” they note.
The OPC representatives say much of its value lies in its use as a reference in providing data or measurement to outside stakeholders, or for internal uses like research. “It is a document that presents what we know in an organized and logical fashion, much like a dictionary, providing us with information to ensure that when we document, we use common terminology. This was especially useful when we conducted the practice analysis and for communications both within and outside the profession.”
“In Canada,” they explain, “prosthetic and orthotic care typically falls under provincial or territorial implementation. It is common for each province or territory to have its own fee schedule; therefore, standardization of pricing varies from region to region, and publicly funded programs likewise vary. Similar treatment options may or may not have public funding, depending on the province. With that in mind, the goal of the CPOT from the onset was to avoid funding and device-driven definitions and focus on prosthetic and orthotic treatment that remained the same from province to province. 
“The steps to providing a quality assessment should not vary across the country. The compendium was developed to define and outline all the steps involved in all prosthetic and orthotic treatments. Ironically, never once was reimbursement used for any of the processes,” the OPC group says.
Canadian O&P treatment processes are defined by regional funding. All provincial or territorial public funding agencies require a prescription that’s most often provided by a physician but may also come from regionally recognized sites, nurse practitioners, or podiatric surgeons. Subsequent O&P assessment identifies treatments required, for which O&P clinics submit public or private authorizations for pre-approval; work commences following approval or authorization.
Are insurance companies or payers altering their ideas regarding reimbursement due to a clearer understanding of patient conditions, treatments, methodologies, and devices—as described by the compendium?
“This is a slow ship to turn around,” the OPC members say. “In the decade that’s passed since the first iteration of the CPOT was completed, the Canadian O&P community has been using it as a reference for the ongoing updating and development of our professional and educational materials and resources. We have also been mindful of our verbiage when describing what we do. The word fit, for example, covers many specific actions. (Try not to use the word fit for a week!) This shift in our thinking helps payers understand the treatments we ask them to fund. We’ve been intentional about taking the focus off the AFO or prosthesis as a thing and putting it on the treatment we provide as professionals, but there is still a lot of work to be done.”
During the decade of its influence, how and where has the compendium had the greatest impact?
“By recognizing what goes into the provision of the treatment we provide, O&P professionals are more mindful of the goals, outcomes, and scope of our delivery of care; and by extension, the people we treat are more aware of what’s involved in the level of care they’ve always received—it’s not just about the device,” they observe.
“We’ve also better defined our scope of practice and our place in the healthcare team to those other healthcare professionals with whom we work cooperatively.”
But perhaps the most significant difference is where the CPOT helps professionals with documentation for patient notes and files, correspondence with allied healthcare teams, legal purposes, and funding. “We are using it for our next practice analysis and for all the documents for credentialing, accreditation, and education produced by OPC,” they agree.
Even insurance companies and payers regard the compendium favorably, the authors note, as it offers consistency to a wide variety of funding scenarios across the country by furthering their understanding of the treatments they’re paying for.
“By no means is the CPOT a price list; but the treatments it describes can be the basis for nationally, and even internationally, accepted time studies that can then be combined with regionally established labor rates to determine remuneration,” they point out.
Designed to be reflective of O&P practice in Canada, the CPOT will never be complete, but is expected to evolve as technology and the profession evolve, with periodic updates to reflect contemporary practice.
Germany’s Five-part Compendium
The German compendium, Quality Standard for Lower Limb Prosthetics, was published in 2018. Following the Quality Standard for Upper Limb Prosthetics published in 2014, it is the second of five treatment pathways that are being developed by working groups of the DGIHV e. V. (German Association for the Interprofessional Supply of Medical Aids), the former advisory board for technical orthopedics.
It includes a unique traffic light color system that allows readers to see at a glance which measures are recommended (green) or possible (amber), as well as those which no longer comply with state-of-the-art treatment procedures (red).
Inauthor Michael Schafer’s introduction to the lower-limb quality standard, he writes that “over many years, a German expert committee comprised of physicians and O&P professionals drafted a quality standard reference for prosthetic treatment following lower-extremity amputations. While avoiding a technology-focused presentation, the aim was to place prosthetic treatment—based on the levels in the respective sections of treatment—in the context of a systematic treatment path for the first time.
“The comprehensive treatment approach consisting of 17 stages presents the chronologically necessary steps and framework conditions for successful prosthesis treatment.
At the same time, it conveys practical measures, recommendations, and approaches for the respective amputation situation, which ultimately enable quality-oriented and sustainable prosthesis treatment. Expert knowledge of amputation surgery among experienced physicians with regard to the respective types of amputation was incorporated into the study along with qualified experience from level-related, day-to-day prosthetic treatment.
Treatment recommendations and relative and absolute exclusion criteria within treatments also use the traffic light system. The reference offers valuable information about successful lower-extremity prosthetic treatment for both interested physicians and committed O&P professionals.”
Consultant Daniel Merbold, CPO, D Med Tech Consulting, notes that teams of specialists are already working on the remaining compendiums in the five-part O&P series, which will focus on orthotics (for lower and upper extremities) and neuro orthotics.
Such a compendium is helpful, he feels, in making quality measurable in the O&P profession.
“The work of a technician is not necessarily better because of it, but the compendium provides assistance with many topics surrounding the entire process of care. Even when selecting the fitting parts, attention is paid exclusively to functionalities and not to manufacturer specifications. This results in an objective, functional selection for the benefit of the user.
“Because the compendium objectively presents the entire process of care independent of manufacturers, it represents the state of the art regarding O&P patient care—and provides a standard for such care in our country,” he says.
Merbold points out that “although prosthetic technology changes rapidly, functionalities do not change that often. Therefore, I believe that the compendium will remain more up to date than if manufacturers and products had been included. And since the DGIHV e. V.
and the respective experts always compare the content of the compendium with new developments, when changes occur, new content can be added without revising the whole book.”
Has the compendium been recognized, accepted, and widely utilized by most German O&P practitioners?
“Interest in the compendium was there from the beginning,” Merbold recalls, and as a CPO who works as a consultant in the industry, he has seen firsthand how the compendium is being used every day at the companies and workshops he visits.
“From the point of view of orthopedic technology, the compendium offers so many applications for daily work, e.g., knowledge about amputation, assessment of residual limbs, the entire prosthetic fitting, and also aftercare. I have received only positive feedback and everyone who has the compendium uses it.”
Has it significantly impacted reimbursement from insurance companies?
“From the beginning, the compendium was understood to be a tool for orthopedic technicians, physicians, and also for health insurance companies,” Merbold notes. “One of its goals was to give the health insurance companies a better technical understanding of the fitting process. Although this certainly does not happen overnight, some important health insurance companies are now using this work to discuss their cost estimates with technicians and vice versa. In addition, the compendium is now often the basis for negotiations with health insurance companies about new service contracts. In other words, it is the basis for the remuneration of services and has had a positive impact on the reimbursement of aids described in the respective compendium.”
Merbold warns of many hurdles when implementing a quality standard such as the compendium beyond compiling the information.
“Since the book should be usable and useful for several professional groups, it assumes that the content is useful to them as well. The difficulty, however, was not to fill the compendium with content, but rather to introduce the respective interest groups to the work after its
publication, to make them familiar with it, and encourage its use in their everyday work. This is a process that has taken several years and is still ongoing. Above all, it needs people in the industry to support it and commit themselves to it.”
Paramount, however, are the benefits it offers across the board: “The most significant advantage of a compendium is that all professional groups involved—physicians, CPOs, health insurance employees, and physiotherapists—have, for the first time, a common basis for discussion for their work and find it easier to talk to each other as equals.”
O&P Care in the United Kingdom
In the UK, O&P clinical services are either provided by the National Health Service (NHS) or private healthcare
services, explains Kameron Maxwell, CPO, an upper-limb prosthetist with prosthetics manufacturer and service provider Open Bionics, Bristol, England.
“To access NHS P&O services, patients are typically referred by their local general practitioner (GP) or other medical professional. Once patients have visited their P&O rehabilitation center, they will be able to arrange subsequent appointments directly with the multidisciplinary team, which could include prosthetists, physiotherapists, occupational therapists, psychologists, and consultants.
“Patients may also have an option to self-refer to a private clinic or alternate between private and public healthcare services,” Maxwell says. “For example, if a patient is undergoing rehabilitation post-amputation, they could rely on prosthetic services provided by an NHS multidisciplinary team, while also opting for a private prosthetist to fit an alternative prosthesis with components that are not currently offered by the NHS.”
There are limitations to the devices that can be prescribed by NHS medical professionals. “While technology has significantly advanced in the past few decades, for prosthetics and orthotics, there are two main barriers for the commissioning of new solutions within rehabilitation services. The most common is the cost new innovations pose on the NHS. Here at Open Bionics, we have designed our upper-limb prosthetic solution, the Hero Arm, to meet patients’ needs on a budget that NHS rehabilitation services can afford,” Maxwell says.
“The second most common barrier is the duration of time it takes for new technologies to be rigorously evaluated prior to successful NHS approval,” Maxwell continues. “As a company, we have undergone a series of clinical trials to support the adoption of multi-grip hands and advanced terminal devices for those with upper-limb absences. Some of these clinical trials are still ongoing, which shows the rate new innovations are offered to the general public.”
Rather than relying on a compendium of O&P care, or a recognized set of O&P guidelines or standards, “In the UK, medical professionals within the field of P&O deliver healthcare in accordance with evidence-based practice,” he notes. “This can be based on the outcome of appraised literature, internal within-service studies, consensus, and best-practice guidelines. This evidence often promotes changes and updates to the NHS policies which govern the P&O services provided. Prosthetists and orthotists are encouraged to advance their professional development and explore new evidence that informs clinical rationale both within the NHS and private healthcare providers.”
How does the reimbursement system differ for private and public care providers—and how do those differences in reimbursement affect best practices in general? Official figures indicate that only 10.5 percent of the UK population have voluntary private healthcare insurance, which means most healthcare costs are covered under the NHS.
“Here at Open Bionics, we have learned through patient feedback and published literature that abandonment rates are high for upper-limb prostheses currently provided by the NHS in the UK.” He says that patients often report rarely using their NHS prostheses because of the devices’ excessive weight, discomfort, limited functionality, and poor aesthetics. The patients also cited three- to six-month waiting times for an appointment to visit their local NHS prosthetics service.
Maxwell points out that “through technology automation and offering a blend of medical and technical expertise as part of a fitting process, we are able to manufacture the Hero Arm sometimes as soon as six weeks with a fit guarantee….”
What might we learn from the UK’s model of O&P care—considering its strengths and weaknesses alike?
“The greatest advantage of P&O clinical services in the UK is accessibility,” Maxwell says. “NHS P&O services are available to access, via GP or other medical professional referral, in most major cities and regions in the UK. Private healthcare providers are also available throughout the UK and can be accessed by self-referral.
“Despite the advantages of accessibility NHS P&O clinical services offers, limited resources within each rehabilitation center often result in increased waiting times, reduced appointment durations, and restrictions in the devices that can be routinely prescribed.”
Although the Open Bionics clinic is private, they hope to offer their services and advanced upper-limb solutions to the NHS in the future. “While the Hero Arm is available under the national health services in France and Australia, our mission is to ensure that it is accessible for all under private healthcare until the NHS offers multi-grip componentry as an option,” Maxwell says.
A Common Goal
In summary, it seems that with or without compendia—and whether dealing with professional colleagues, healthcare
teammates, patients, or funding sources—striving for the best quality O&P care is a common goal across
international boundaries. And it’s one that is best achieved through communication that allows us to inform, enlighten, share, learn, and arrive at better understanding that benefits all who speak O&P.
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.
