O&P: Who Are We?

Is there an identity crisis in O&P? What emerges in talking with various leaders in the field is that there really is no identity crisis among what the profession regards as its core - certified orthotists and prosthetists, supported by registered technicians, assistants, and fitters -whether credentialed by the American Board for Certification in Orthotics & Prosthetics (ABC) or the Board for Orthotist/ Prosthetist Certification (BOC). Where the identity crisis apparently lies, though, is in the eyes of payers: Medicare, private insurance companies, and others. A critical issue that hangs in the balance is just who, to Congress and the Centers for Medicare & Medicaid Services (CMS), is a "qualified provider?" What makes the O&P professional mainstream as we know it different from all the others who are now providing DMEPOS [Durable Medical Equipment, Prosthetics, Orthotics, and Supplies]? On the positive side, the O&P profession is awakening to the need to prove what differentiates - and elevates - the profession from the swarm of other providers of DMEPOS services. This awareness seems to be intensifying, driving several distinct but interrelated threads: O&P organizations are working more closely together to achieve common goals, as well as collaborating with healthcare organizations in other fields; The profession is increasingly recognizing the need for research and outcomes studies to prove the value of its services, as differentiated from lesser-trained providers, and is undertaking research initiatives; Linked closely with research and outcomes studies is an increased focus on complex, custom orthotic and prosthetic solutions, which require the education and expertise of the highly trained orthotist and prosthetist; Education is being promoted and advanced; and Strong efforts are underway to educate policymakers and to influence legislation and governmental regulation. Numbers Tell the Story First, let's take a look at the numbers, as well as the sheer logistics problem of patient access to O&P services. In 2004, total healthcare spending in the US was about $2 trillion, with Medicare, Medicaid, and other government payers accounting for about onethird of that, says healthcare attorney John Latsko of Schottenstein, Zox & Dunn, Columbus, Ohio, based on research by the law firm. Private payers and selfpay accounted for the other two-thirds. Of that total, DMEPOS spending was approximately $23.8 billion or 1.5 percent. Included in DMEPOS is home oxygen, wheelchairs, hospital beds, nebulizers and drugs, parental & enteral nutrition (PEN), ostomy supplies, eyeglasses and lenses, home dialysis equipment and supplies, and other similar equipment and supplies. Those items amount to approximately 90 percent of the total DMEPOS expenditures. O&P, which includes artificial limbs, braces, and spinal orthoses, is approximately 10 percent of the total spent by Medicare on DMEPOS, Latsko notes. With total spending for all DMEPOS in 2004 from all sources being about $3 billion, Medicare and other government payers spent an estimated $1 billion on O&P. Various experts estimate that the average O&P facility bills around 35-40 percent of its claims to government payers including Medicare and Medicaid, with about a third to a half on average being for customfabricated, custom-fitted, and customized devices. Commercial payers and self-pay account for most of the rest of the revenue. However, based on anecdotal information, it is estimated that the lion's share of work involves custom fabrication and fitting for a substantial number of O&P facilities, perhaps even most of them. The percentage of custom orthotic and prosthetic devices could decline drastically, with the number possibly dropping to 10-20 percent, due to new prefab devices now available, Latsko warns. The increase in off-the-shelf solutions also concerns O&P consultant John Michael, MEd, CPO, FAAOP, FISPO. Says Michael, "The proliferation of non-custom solutions and the ready reimbursement for them has drastically changed the complexion of the field. This is the most important specific development I've seen in the last 30 years." Michael feels that the O&P field may not be sufficiently aware of this trend and its implication for O&P companies and certified practitioners, since the ease and attractiveness of using and billing for non-custom devices is increasing the ability of less-qualified providers to take a larger share of the market. In turn this trend can impact the quality of patient care as well as the viability of mainstream O&P facilities, he points out. At least 110,000 DMEPOS suppliers had submitted Medicare claims in 2003, according to Walter Gorski, director of legislative and regulatory affairs for the American Orthotic & Prosthetic Association (AOPA). Alfred E. "Al" Kritter Jr., CPO, FAAOP, who is a member of AOPA's Coding Committee and a member of the Board of Directors for the National Association for the Advancement of Orthotics & Prosthetics (NAAOP), learned under the Freedom of Information Act that in 2004, about 148,000 Medicare supplier numbers for DMEPOS existed, and theoretically each, if they wish, could bill an L-Code, with about 28,000 of these stating on their application that they intend to provide orthotic and prosthetic services. Of these, about 10,000 listed themselves as having certified orthotic and/or prosthetic professionals on staff. A breakdown on what credentials and credentialing entities are involved and their numbers were not available. Now we get to the numbers of "core" or "mainstream" certified O&P professionals: ABC currently has 8,910 credentialed professionals, including 5,107 certified practitioners, with the rest being registered technicians, orthotic fitters, O&P assistants, and mastectomy fitters. In addition, ABC has accredited 1,282 O&P facilities. BOC lists 1,925 certified orthotists and 951 prosthetists. Of these, 475 are certified in both disciplines. In addition, BOC lists 2,409 certified orthotic fitters and 1,082 certified mastectomy fitters, along with 217 accredited facilities. It must be noted that some of these numbers for ABC and BOC may include those certified by both, thus skewing the totals somewhat. Who Is a 'Qualified Provider'? This brings us to the conundrum Medicare and state governmental entities face in deciding who is a "qualified provider"? With a total of less than 8,000 ABC- and BOC-certified orthotists, prosthetists, and orthotists/prosthetists (excluding technicians, O&P assistants, and orthotic and mastectomy fitters), there are simply not enough to fill the need of the large and growing patient population. Who currently are the "professionals" included in the 10,000 Medicare supplier companies which say they have a professional(s) on staff? Who are the other 18,000 suppliers included in the 28,000 applying to provide O&P? AOPA has undertaken a study to show just what different categories of providers are billing L-Codes in Medicare claims. The majority are orthotists, prosthetists, physicians, DME companies, and pharmacists, explains Gorski. Levels of Expertise Required Peter Thomas, NAAOP general counsel Two questions arise: "Who really is qualified to provide O&P services?" And, "How can O&P services be provided to all who need them?" The answer may lie in a tiered or bifurcated set of qualifications for defined scopes of practice, suggests Michael and attorney Peter Thomas, NAAOP general counsel. O&P leaders generally acknowledge that providers with lesser qualifications can often appropriately care for patients with relatively simple needs and provide off-the-shelf devices; however, they assert that prosthetic patients and more complex, difficult orthotic cases require the expertise of a highly trained, well-educated O&P practitioner who is able to evaluate the patient and design and fabricate the needed custom device. And even providing a simpler prefabricated device may need the knowledge of a trained, experienced practitioner, who would know whether this really is the best solution for that particular patient. An inappropriate device would not yield desired treatment results and, worse, could actually harm the patient. They point out that, to provide the full range of orthotic and prosthetic services, practitioners need knowledge of kinetics, kinematics, physiology, biomechanics, and materials sciences, among others. Even though they may be experts in their primary fields, physicians, physical and occupational therapists, and other healthcare professionals simply don't have the in-depth knowledge and experience to produce good patient outcomes in complex cases, O&P experts assert. "I have a problem with persons who are highly trained in one field, then dabble in the orthotics and prosthetics field," says Michael. "When they cross over into our field without specialty training in O&P, I'm not comfortable with that, and I think this needs further study." Regarding physical therapists (PTs) and the proposed direct access legislation, by which PTs could treat Medicare patients without a physician's prescription, Gorski says, "AOPA doesn't think physical therapists have the ability to evaluate and diagnose all the medical conditions that a Medicare beneficiary could present. Medicare patients may have multiple co-morbidities, for instance, so we maintain that physicians should be the front line, the gatekeepers.... PTs don't have the education, training, or equipment to provide the full range of O&P services." Thomas concurs, "The real disagreement is the presumption that, just because they receive some courses in what constitutes orthotics and prosthetics, they equate that with the idea that physical therapists are thus qualified to provide the full complement of O&P services." This stand by the therapists and the countering stand by O&P organizations, led to the breakdown of the negotiated rulemaking process in 2003, Thomas noted. The negotiated rulemaking process was mandated by the Medicare, Medicaid, and SCHIP Benefits Improvement & Protection Act of 2000 (BIPA) to assist the Secretary of Health & Human Services (HHS) in developing rules and regulations to implement the law. An unfortunate consequence, however, of the negotiated rulemaking breakdown, is an impression that "the O&P field is very set in our way, not willing to compromise, and basically protecting our turf," says Thomas. "This is the only time the negotiated rulemaking process has ever ended without consensus, so it goes down as a failure in CMS books." He adds, "I think that made the field look somewhat obstructionist, but frankly, I don't think we were. I think the other groups were overreaching and making unsubstantiated claims of their ability to provide all orthotics and prosthetics regardless of complexity." Despite a possible lingering negative perception of O&P at CMS, Thomas feels that the agency seems to be leaning in the direction of certification and accreditation as a standard of quality. But what will this standard be? "If it is too low in order to let enough people in to provide enough access for patients, what is the incentive for ABC providers and students and practitioners of the future to undergo the rigorous education and requirements to meet top-level standards when they can simply qualify under this separate track and get access to Medicare patients? This issue has the potential to reduce quality dramatically across the board, rather than improve quality." And of course, Medicare standards and payments generally lead the way for private insurers to follow. A bifurcated system based on a credential's scope of practice might be the solution, Thomas continues. "For instance, a provider meeting ABC standards could provide everything; a provider with less education and training could provide off-the shelf, but not more complex care." Michael sees a strong need for a high level of education and expertise to design, fabricate, and fit complex prosthetic and orthotic solutions - "defining the skill set as we traditionally have." For relatively simple, non-custom solutions, "I think the 'orthotic fitter' credential is on the right track." Recent Frauds 'Make the Case' The recent fraud scandals in Florida dramatically underscore the need for provider standards and credentialing, O&P professionals point out. No certified practitioners, ABC-accredited facilities, including members of the Florida Chapter of the Academy (FAAOP) or Florida Association of Orthotists & Prosthetists (FAOP) are involved, according to Paul E. Prusakowski, CPO, FAAOP, president of the FAOP and incoming Academy president. Also, as far as known at press time, no BOC-certified prosthetists and/or orthotists and no BOC-credentialed facilities were involved in fraud cases. Although statistics were not available at press time, indications are that the Medicare O&P fraud and abuse cases in Florida have involved primarily DME providers or criminals outside the O&P and DME fields who simply have made use of basically nonexistent "straw" companies to defraud Medicare. Working Together John Michael, MEd, CPO, FAAOP, FISPO The various organizations representing the field - who have not always presented a unified front to payers, legislators, and others - are increasingly realizing the urgency of working together for common goals. "I see more of a spirit of cooperation than I think I've ever seen," says Michael, "and that's encouraging." Other O&P leaders and observers echo this thought. "In the past, O&P organizations would sometimes collaborate, and at other times, unfortunately, we went our separate ways," says Thomas. "Now, some of the leadership in the O&P groups is open to collaboration, and I think that is very positive." Thomas continues, "In lobbying Congress or educating policymakers, if we bring them different points of view in a very specific area of healthcare that is barely on their radar screen to start with, the first thing they'll do is put you on the bottom of the stack. But if you approach policymakers with a unified position across the field, with policies that make sense in the interests of the program and patients, policymakers are much more willing to listen and adopt your point of view." The field needs to look beyond any infighting in order to concentrate on sources threatening the future of O&P, emphasizes AOPA President Michael Hamontree. "I am convinced that each of [the O&P] organizations operates with the goal of improving O&P.... We need to immediately circle the wagons and recognize that it is the private insurers, managed care, Medicare and Medicaid, and federal and state legislators who should be the focus of our attention." AOPA 'Represents O&P - No One Else' Regarding concerns that have percolated at times throughout the field that AOPA may be trying to serve the interests of manufacturer and supplier members, Hamontree tackles the question head-on. "At no time have we ever represented the interests of manufacturer reps," he says emphatically. "While some of these companies are AOPA members, they have independently formed a lobbying group, the National Orthotic Manufacturers Association (NOMA) that represents their interests on Capitol Hill and at CMS. We have absolutely no relationship with NOMA, and we do not in any way coordinate our activities with NOMA." He continues, "You only need to look at the position AOPA took with the rest of the organized field of O&P throughout the negotiated rulemaking deliberations to see how directly opposed we are to the position NOMA has taken on qualified provider standards. I also want to point out that, while some of our members - both patient care facilities and suppliers - provide durable medical equipment, AOPA has never represented a DME interest. Ever! In fact, we have done everything possible at every opportunity to separate ourselves from DME interests. Again, DME has its own stable of lobbyists. It is AOPA's job to represent O&P - no one else." Education Makes the Difference AOPA, along with other O&P organizations, likewise wants to see a high standard to define "qualified providers," according to Hamontree. As does David F. Moretto, CP, FAAOP, outgoing Academy president (Moretto turns the gavel over to Paul Prusakowski this month), Thomas, and others, Hamontree points out that it is the high level of education that differentiates the certified orthotist and prosthetist from others providing O&P services. "It is our education and training to provide O&P services as well as the ability to adjust and repair devices that set us apart from other providers, and regulations that govern payment should reflect this." Research and outcomes studies are underway and gaining momentum to substantiate the value of the skill sets that certified practitioners bring to the table, and to prove the importance of custom devices, especially in complex cases involving several factors to consider in design, fabrication, and adjustment. Advancing education is a goal, as shown in the recent O&P Education Summit in New Orleans, which involved educators, researchers, practitioners, and others. The conference, conducted as a collaborative effort of the National Commission on Orthotic & Prosthetic Education (NCOPE) and the American Academy of Orthotists & Prosthetists (the Academy), reached consensus that a masters-level education is necessary for the delivery of quality patient care, due to the dynamic base of knowledge and emerging processes and technologies. Future Looks Bright On the education front, Michael sees two bright, promising developments that should serendipitously dovetail in about ten years or so: research and outcomes data that validate the value of the clinical expertise and custom devices certified practitioners bring to the table; and highly educated clinicians who can effectively interpret and apply this research for best results. Regarding research and outcomes studies, Michael says, "We are beginning to develop some of these instruments, and they might go a long way in showing the differences in the full scope of services we provide and limited services [of other providers]." One problem in research has been that principal investigators in research projects have largely come from other disciplines, due to the shortage of O&P professionals with advanced degrees. However, the Academy's Project Quantum Leap is working toward increasing the number of certified orthotists/prosthetists who are PhDs by tenfold, Michael notes. "I think that within the next 12-24 months, we will have at least two PhD programs in the US; this will be due in part to the Academy's Project Quantum Leap." Michael also expects to see more masters programs develop. "The time is right for us to have the credentials necessary to hold our own in academic settings. We don't need a large number of PhDs, but we need to push forward with this. I think in the next ten years or so, we'll regularly have O&P PhDs obtaining grants and being principal investigators in research studies." Noting that the first graduating class of the masters-level program at Georgia Technical Institute (Georgia Tech) is oriented to clinical practice rather than research, Michael said, "I think it's good that the MSPO graduates are clinicians. They'll then be the frontline consumers of research; they'll be the first ones to implement outcomes-based practices, because they'll have the foundation to interpret research, sort out important research from the unimportant, and translate that into clinical practice." Michael sees masters-level and PhD clinicians as becoming the O&P leaders of tomorrow and ready and able to implement outcomes measurements and other research, if available by then. Regarding clinicians with a high level of academic training, Michael says, "You never lose your academic preparation; you just become a seasoned clinician and thus better able to express your academic preparation in a practical way that makes a difference for your patients." Michael sums up, "If things go well, in ten years we should have a cadre of PhD clinicians or at least PhDs who have enough understanding of clinical P&O that they can collaborate with clinicians. We should have validated outcomes measures that are fairly widely used and applied clinically. We can then demonstrate the differences we believe we see in a well-made, well-designed orthosis or prosthesis. We will then get respect from referral sources, Medicare, and third-party payers, because we can demonstrate in a tangible way the difference we make." He adds, "If we continue to work diligently, I have every reason to think we will succeed long-term." The catch, according to Michael, is the need for the profession to survive before all these efforts come to fruition, and he praises the efforts of AOPA and NAAOP to meet the current challenges. He also praises the Academy for its longer-term goals of increasing academic preparation and building the infrastructure of the field. So to summarize: Apparently there's light at the end of the tunnel - and it isn't a train - if the O&P profession can just hang in there.

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