The Future of Fitters: What’s in Store for Fitter Education and the Fitter Profession?

In August 2015, the National Commission on Orthotic and Prosthetic Education (NCOPE) announced that its board approved limiting its focus only to higher learning and education accreditation activities at the post-secondary level. For that reason, NCOPE decided to no longer accredit or approve orthotic fitter, therapeutic shoe fitter, and mastectomy fitter education courses since they fall outside the scope of post-secondary education. So what was behind this decision, and where does this leave certified fitters? The O&P EDGE spoke with NCOPE, the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC), the Board of Certification/Accreditation (BOC), the Pedorthic Footcare Association (PFA), and the American Association of Breast Care Professionals (AABCP) to gather perspectives. Making the Decision Understanding NCOPE's decision requires a bit of background information: NCOPE cooperates with the Commission on Accreditation of Allied Health Education Programs (CAAHEP), a post-secondary accrediting agency recognized by the Council for Higher Education Accreditation (CHEA), a national organization that promotes academic quality of post-secondary education through accreditation. CAAHEP's focus on post-secondary institutions, combined with its requirement that any CAAHEP-accredited education must be two semesters or longer, prompted NCOPE's change to its involvement in fitter education. "We were wanting to lend consistency to all of our accreditation activities for primary education...," explains Robin Seabrook, NCOPE executive director. "The fitter-level courses, which were a week or less depending on the fitter level, were outside this scope." "Our goal as an educational board is to educate the future clinicians of O&P at the highest level we possibly can," adds Charles Kuffel, MSM, CPO, FAAOP, chair of NCOPE's 2016 board of directors. "We back education. It's hard to say 'We back master's-level education, but if you have eight hours you can see patients as well.' It just doesn't make a lot of sense." He explains that NCOPE board members and staff examined several factors prior to making this decision. They considered best practice issues revealed by reports prepared by Dobson DaVanzo & Associates, Vienna, Virginia, and commissioned by NCOPE. They considered the fitter schools' responses, or lack thereof, to the federal government's Trade Adjustment Assistance Community College and Career Training (TAACCCT) grant program, which provides funds to educational and career training programs that can be completed in two years or less-only two fitter programs applied. NCOPE also saw that employment rates for newly certified fitters were low. The decision, though, was not made in a vacuum. "We had an educational meeting...and we had educators from all the schools, we had ABC representatives, we had BOC representatives, and one of the topics at hand was the fitter-level education," Kuffel says. However, "the icing on the cake was CAAHEP's nonrecognition of programs that are less than two semesters." Fitter Education Continues At first glance, NCOPE's announcement seemed to signal a void for orthotic, therapeutic shoe, and mastectomy fitter education. Seabrook emphasizes that was not the case. "ABC has already announced they will assume the role under the continuing education side for fitter-level approval," she says. "ABC accepted all NCOPE-approved programs as ABC [approved] and any new programs can now apply." The NCOPE courses ABC accepted were granted ABC course approval through December 31, 2017. "We were aware that they were considering making that move," confirms Stephen Fletcher, CPO/L, director, clinical resources for ABC. "ABC's leadership decided to create an immediate solution so that those wishing to be ABC-certified fitters still had an avenue." All of ABC's fitter credentials are accredited by the National Commission of Certifying Agencies (NCCA), and based on those accreditation rules and standards, ABC will approve new fitter courses through its continuing education department, he says. "Our continuing education staff, especially our director of continuing education, Heather Harris, already has well-established relationships with all of the course providers, so it is a fairly smooth transition for us to implement that process within our continuing education activities." BOC's certifications are also accredited by the NCCA. Individuals seeking new orthotic or mastectomy fitter certification through BOC are not affected by NCOPE's decision because BOC approves its own entry-level courses. Wendy Miller, BOCO/L, CDME, BOC's chief credentialing officer, explains, "We have our own process in which we approve the courses, our own evaluation criteria, and NCOPE was just not a part of that." She says BOC makes sure that its approved entry-level coursework covers the fitter scopes of practice so those seeking BOC fitter credentialing can provide the best care and take BOC's exams. "We have a scope of practice that defines what an orthotic fitter can do, the types of products that they can provide for their patients, and the courses submit their outline and they must include information from that scope of practice. That way we know the candidates are getting the best education toward their profession." The History of Fitters Orthotic fitters have been involved in patient care for several decades, and mastectomy fitters have provided patient care for many years, says Fletcher. Prior to the early 2000s, orthotic and mastectomy fitters were certificate holders, he explains. A person could take a course and the course provider would issue a certificate- much different from today's requirements of earning certification. "We are always looking for that opportunity in the market to fill a need, and the fitter [certifications] came about from us seeing that there was a need for it and creating it," says Carrie Green, BOC marketing manager. "We knew of professionals who were providing prefabricated, custom-fitted devices but they were not able to sit for the orthotist exam, hence we created the COF, orthotic fitter certification," Miller adds. "Then we found that there were professionals out there that all they did was mastectomy fitting.... So it made sense to create a certification for mastectomy fitters." The first COF exam was given in 1999; the scope of practice and education for a BOC-certified orthotic fitter also includes fitting therapeutic shoes, so a separate certification is unnecessary. BOC's first mastectomy fitter (CMF) exam was in 2001. "BOC believes strongly that professionals need to be certified in order to demonstrate their competency to deliver qualified patient care," Miller emphasizes. In 2002, the ABC board of directors unanimously voted to create its own orthotic and mastectomy fitter credentialing programs; people who fulfilled ABC's requirements received registered fitter status (O&P technicians and assistants were also registered credentials through ABC at that time). Three years later, the ABC fitter credentialing program adopted the title "certified" for orthotic and mastectomy fitters (CFo and CFm, respectively, and CFom for those who are dually certified), with an examination requirement taking effect on January 1, 2006. The change from registered to certified was based on an assessment of what those terms meant and the perception of those terms to the profession, as well as on input ABC had received from its registered technicians, assistants, and fitters and their desire to obtain more recognition, Fletcher explains. "Because there is an educational requirement..., an experiential requirement (a certain number of experience hours that you have to meet), and an exam that has to be passed, ABC believes those three things represented certification rather than a registration." By 2006, ABC had also seen a need for certified therapeutic shoe fitters (CFts) so it created and added the program to its list of credentials. The driving force was the lack of standards for Medicare suppliers of non-custom diabetic footwear and inserts, Fletcher says. "Diabetic patients are a high-risk population, so the combination of no standards for providers of diabetic shoes to this group created a potential for harm to patients." The Future of Fitters As of January, BOC reported having 2,100 orthotic and mastectomy fitter designations; the actual number of people holding these designations is lower as some might be dually certified. Miller says the number of fitters has been increasing over the years. For the same period, ABC reported 2,699 certified fitters and 2,596 distinct individuals holding fitter credentials. Fletcher says that the numbers can be low at the beginning of the year because some ABC certificants may be late in renewing their certifications for the current year. Having said that, he admits the number of certified fitters-especially orthotic fitters- has decreased. He attributes this, in part, to a 2014 attempt by the Centers for Medicare & Medicaid Services (CMS) to no longer recognize certified orthotic fitters as providers who can independently bill Medicare for custom fitting a prefabricated orthosis. The proposed rule was challenged by the O&P Alliance, which includes ABC, BOC, and other O&P organizations. The rule was finalized without that language, he says. Fletcher believes the proposed rule had a chilling effect on the orthotic fitter profession. Individuals may be hesitant to seek that certification and practices may be concerned that in the future Medicare will not allow orthotic fitters to independently provide these services. "There is a gray area right now..., but we continue to work with Medicare to get clarification on that," Miller adds. "BOC believes, as we did when the fitter certifications were created, that it is better to have a certified professional providing patient care, and the fitters provide a valuable service to the Medicare beneficiary," she says. "Fitters have the option of asking a practitioner considered to have the specialized training under the quality standards to supervise and/or sign off on their work." Fletcher says that CMS' consideration of fitters is status quo. "We've been told by our contacts within CMS and Medicare that until they tell us something different, everything we're doing right now with accrediting businesses staffed by certified orthotic fitters is fine.... Nothing has changed." Fletcher says there continues to be demand for therapeutic shoe fitters given the high incidence of diabetes in the United States. He also sees a continuing role for orthotic fitters in O&P practices; it's a need that is driven by reimbursements and cost effectiveness. "If your practice provides a large percent of prefabricated orthotic devices... it makes economic sense to have a certified or licensed orthotic fitter do that work rather than have a certified or licensed orthotist do that work. The salary for the orthotic fitter is less than the orthotist, and the reimbursement is fixed no matter who provides the service. It is often not a highly complex clinical situation and is fairly straightforward. In those instances, an orthotic fitter is specifically educated, trained, and tested to provide those items and services." Kuffel concurs that the fitter versus clinician scenario Fletcher mentions is about dollars and sense. "It's the lowest common denominator. If a patient comes in for a pair of shoes or therapeutic inserts why is a certified orthotist/prosthetist seeing that instead of a [therapeutic shoe or orthotic] fitter? That's a bad allocation of talent at that point. So I think there is still an avenue for certified fitters in practice," Kuffel says. Rob Sobel, CPed, president of PFA, questions whether therapeutic shoe fitters belong in O&P rather than in durable medical equipment (DME) because, from his perspective, they may often work for pharmacies and DME companies. He says that therapeutic shoe fitters comprise 4 to 5 percent of PFA's membership. While he is unsure about the future of therapeutic shoe fitters, Sobel does know it's a tough way to make a living. "I know that the reimbursements on the therapeutic shoes for diabetics is not great." He's heard from many pedorthists who want to discontinue fitting and providing therapeutic shoes due to the low reimbursements, extensive paperwork, and audit nightmares they've encountered. "We would love to see [therapeutic shoe fitters] become pedorthists because at least that way it increases their scope of practice. To me, that's their best shot at a future in O&P." AABCP sees a positive and growing future for post-mastectomy services, including a return to mastectomy care by O&P practices, despite the difficult reimbursement climate and suboptimal reimbursement rate, says the organization's executive director Rhonda F. Turner, PhD, JD. "Mastectomy is a hybrid of both medically necessary services and retail products and has been for several decades. While many mastectomy fitters are struggling with documentation requirements, they have a firm and successful handle on the retail component of medical services. Additionally, there are state and federal mandates that require reimbursement of mastectomy products." She says, too, that with only a handful of products and reimbursement codes, knowledge and compliance is manageable. One of the issues AABCP addresses for mastectomy fitters is that of adequate education, she says. "The key component of mastectomy fitting is anatomical restoration; a return to symmetry," Turner explains. "If not done properly, there are physiological consequences. The other component of mastectomy fitter that is overlooked is that these women and men are breast cancer survivors. Mastectomy fitters in every appointment are required to marry these two types of knowledge to properly fit a patient." Kuffel asserts that despite the fitter education changes within NCOPE the profession will continue. "We want to still have some level of certification, but it's not the level of a certified CPO who spent three years on a master's degree and two years in residencies," he says. "I think there is absolutely a venue for fitter education, I just don't know if it's underneath the guise of orthotics and prosthetics." The Value of Fitters Todd Stone, CPO, CEO of Teter Orthotics & Prosthetics, Traverse City, Michigan, says it's "counterintuitive for [a certified practitioner] who is making a high salary to be fitting a pair of shoes or a small ticket item that doesn't [involve] a lot of difficulty." Teter O&P has 23 offices across Michigan, and 14 certified orthotic and/or mastectomy fitters. Due to the value the company receives from certified orthotic fitters, it has paid for lower-level employees to become certified. They are restricted to fitting off-the-shelf items, while performing some level of custom fitting "but only if they've demonstrated the abilities to handle such things and they still do it with supervision." To further contain costs, he prefers BOC certification for orthotic fitters because the credential also provides for the fitting of therapeutic shoes. He also had to limit the practice's mastectomy services to avoid losing money-despite knowing it is a valuable community service. David Sickles, CPO, CPed, COO of the Center for Orthotic & Prosthetic Care (COPC) of North Carolina, headquartered in Durham, is in charge of 16 offices, including a clinic on the Duke University Hospital campus and the hospital's breast center boutique, which COPC staffs with a mastectomy fitter. COPC has had fitters on staff for about eight years. The O&P clinic sees a substantial number of patients with diabetes who are in need of soft foot orthotics and therapeutic shoes. With diminishing reimbursements, he says, it's not financially feasible for COPC's certified practitioners to see these patients. This business model will continue "as long as we can do it this way and guarantee our patients are being taken care of." He emphasizes the fitters are well qualified and certified practitioners are available for more complex cases or to answer questions. "It is a great way to do it." Jeffrey Brandt, CPO, CEO and founder of Ability Prosthetics & Orthotics, headquartered in Exton, Pennsylvania, says, "Ability has always been predicated on providing comprehensive care that was focused on the crux of why we went to school and this whole effort to sanctify our educational requirements the last 15-20 years." He wants Ability's practitioners to think biomechanically while focusing on the care and quantitative outcomes of long-term users of O&P devices. However, with third-party payers utilizing the lowest fee schedule possible and beginning to attempt to commoditize wearers' custom needs, not valuing the prosthetists' or orthotists' clinical notes, coupled with increasing hospital contracting wherein the majority of the work is providing off-the-shelf devices requiring minimal adjustment, he is in the process of hiring a fitter at the time of this writing. "Make no mistake," he emphasizes. "At Ability we still want you to possess the highest credential out there for your level of training and job responsibilities."

The Future of Fitters: What’s in Store for Fitter Education and the Fitter Profession?

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