Tomorrow's O&P: A Survival Guide Part 1: Trends to Track

When The O&P EDGE asked a dozen of the industry's leading experts to share their visions of tomorrow's O&P environment, we expected to receive a considerable variety of cautions and concerns. Far from being scattershot, however, the responses we received revealed a confident, universal consensus of opinion in several significant areas. Responses, which were both troubling and encouraging, identified trends that are expected to continue to impact O&P practitioners in the years to come:

Trend #1 Increased Demand for Evidence-Based Practice Every respondent identified this at or very near the top of their list of concerns.

Rogers Jim Rogers, CPO, FAAOP, president of the American Academy of Orthotists and Prosthetists (the Academy), points to the use of best practices, an evidence-based approach to care, as the biggest trend he envisions. "In the near future, we will not be paid for treatments and care plans that do not have documented success," he says. "This is perhaps our greatest challenge as a profession."

In 2003, with grant funding from the U.S. Department of Education, the Academy recognized the need to define the current state of the science on a number of topics; e.g., effective treatment of the neuropathic foot, orthotic treatment of cerebral palsy, immediate post-operative prosthetics, etc. Rogers explains, "The Academy's response was to conduct eight State of the Science Conferences (SSCs) from a list of over 30 relevant topics, identifying where the profession is in terms of the literature and current practice to support that care, and, when necessary, to pose the research questions that still need to be answered. That began...leading us down the road toward evidence-based practice."

Ruhl Brad Ruhl, immediate past president of the American Orthotic & Prosthetic Association (AOPA), refers to AOPA's Strategic Planning Initiatives, which were released on September 11, 2008. The initiatives were based on a December 2007 member survey which measured respondents' concerns about threats to the O&P field, and identified opportunities to improve future business. The third of the 11 initiatives, Ruhl says, is titled "Foster Research into Outcomes to Further Support Evidence-Based Practice Models."

"We need to be able to prove that what we're doing now makes a difference, and produces a higher level of functionality and/or greater patient satisfaction," Ruhl explains. "We're not terribly skilled at demonstrating that. One of the ways we will fight the reimbursement battle is through evidence. So my hope is that we will learn how to play that game and play it well."

Chris Hovorka, MS, CPO, LPO, FAAOP, Georgia Institute of Technology (Georgia Tech), agrees that physicians and other allied health scientists "are already being pressed to provide an evidence base or prediction of outcome before services are provided. That's going to continue," he says. "Some of the evidence is out there; it just hasn't been used properly."

Hovorka

Thomas

McGill

Janisse

Peter Thomas, general counsel, National Association for the Advancement of Orthotics and Prosthetics (NAAOP), also notes, "The quality debate will continue to drive healthcare coverage and payment, including in the field of orthotics and prosthetics. Many payers, including Medicare and Medicaid, will demand better evidence before continuing to cover relatively expensive technologies or cover new innovations."

David McGill, vice president, Legal Affairs, Ossur Americas, Aliso Viejo, California, agrees that the most important trend is the increased scrutiny by payers of the efficacy of the medical devices for which they're paying. "Medicare and private payers are increasingly moving away from a model of passive payer to active player in reimbursement," says McGill, who also serves on the boards of the Amputee Coalition of America (ACA) and NAAOP. "They want to determine the value of what it is they're paying for in objective, tangible terms. That's a significant development because it's going to require practitioners to document outcomes much more than they've ever had to in the past."

Dennis Janisse, CPed, president and CEO of National Pedorthic Services, points out the difficulties of developing evidence-based practice without a body of evidence available: "I'm a member of a foot-ankle society, along with orthopedic physicians. They'll spend a whole day arguing about bunion surgeries. They have done massive numbers of surgeries in which they've used different procedures. We don't have those kind of numbers and hence, little evidence to draw on."

Trend #2 Increased Documentation Carroll Kevin Carroll, MS, CP, FAAOP, observes that although "our practitioners are already totally snowed under with documentation and justification letters, we can only expect more of it.

Documentation is going to be very, very important as we justify what procedures we plan to do for the patient, especially the costlier high-tech solutions. The payers want to know what they're paying for. How the clinician addresses that will lead to their success or failure."

Thomas Kirk, PhD, CEO of Hanger Orthopedic Group, Bethesda, Maryland, agrees. "I think we'll see [requirements for intensified] documentation compliance in order to be reimbursed, and the regulatory world making sure that we're following good practice-we deal with that now. We will have to justify what we do with statistical outcomes, which means working very closely with the device manufacturers in the introduction of new products. We will also have to be concerned with the overall level of reimbursement and the structure of that reimbursement, and that clearly is going to have a major impact on our practitioners."

Kirk Janisse observes that while reimbursement is staying the same or going down, hours worked are increasing. "Government and insurance payers are requiring so much more documentation from us," he says, "that I am making less money per patient now than I was two years ago, largely because of all the extra paperwork that's [required]."

Trend #3 Diminishing Reimbursement Thomas believes that reimbursement pressures will continue from "all payers, including Medicare, Medicaid, the Veterans Administration, as well as numerous health plans across the country. In addition, with respect to private plans, the trends of the past several years in reducing the breadth of orthotic and prosthetic coverage are likely to continue. This includes new and innovative technologies, especially those with significant reimbursement levels."

Despite recent state legislation mandating O&P coverage in insurance plans, Thomas notes, "It is likely that the trend in recent years of reduced coverage for O&P care will ultimately continue despite passage of these important new laws.

"Even before the recent economic crisis and the federal $700 billion rescue package, significant fiscal pressures foretold a budgetary showdown in 2009. In...2009, the State Children's Health Insurance Program will expire and require reauthorization. A set of harmful regulations will go into effect for Medicaid beneficiaries if Congress does not act to extend moratoria on these regulations so they will not go into effect. In addition, on the first day of 2010, the Medicare physician fee schedule will be reduced by 21 percent unless Congress acts to prevent this reimbursement cut. Offsetting the cost of this problem will put all [healthcare] providers at risk of having their Medicare reimbursement rates cut for several years to come. O&P providers are just as much at risk as any other provider group...."

Guth Thomas Guth, CP, president of NAAOP, concurs. "We're still going to have a lot of problems with reimbursement. CMS is still looking at competitive bidding for off-the-shelf orthotics, and Medicare is way over budget. If the 21 percent fee schedule cut for physicians is blocked in Congress, O&P and all other providers are going to get squeezed. We're just going to have to be watchdogs to see that O&P doesn't get stepped on."

Adds Kirk, "Theoretically, if we run the numbers, around the year 2017 or 2018, Medicare goes bankrupt. CMS may reduce the fees, they may change the deductibles, or, perhaps, introduce consumerism that offers people basic Volkswagen-level care, but if they want a Mercedes, they or their third-party payer will have to finance it. In 20 to 30 years, the growth of Medicare costs would consume the entire taxing capability of the U.S. government, with nothing left for social security, defense, or government administration. So something is going to happen, and those changes in healthcare are going to impact our reimbursement arena."

Ruhl agrees that the O&P profession will likely be facing "either a slowdown in the fee schedule increases, or a potential disastrous reduction in the fee schedule increase, and that will require businesses to find ways to cut their own costs and become more efficient in order to improve profitability so that they can survive. I think there are real threats facing the industry; those businesses that are willing to make sacrifices will remain viable, and those that aren't will not be in business."

Hovorka predicts a higher level of scrutiny when it comes to coding and reimbursement for high-tech devices. "We still have limited reimbursement and coding for some of these new technologies, and I think there will be more rigor and more skepticism by insurance companies when deciding whether to provide greater reimbursement for a fancy bells-and-whistles device, when the patient might get by on something less."

Trend #4 Increased Use of Pre-fabrication and Reliance on Central Fabrication James Wynne, CPO, FAAOP, Boston Brace, Avon, Massachusetts, notes that future practitioners will likely spend more time with their patients, evaluating, fitting, and recording objective outcomes, leaving less time for fabrication.

"We still need to be involved in the fabrication, but we may not be...hands-on as much. Time will be spent in reviewing the evidence that we have and measuring the outcomes of the patients, the level of the benefit, just to see how we're making a difference."

Striking a balance between patient care and fabrication becomes an economic issue, too, he points out. "We're a unique industry in that we are both a manufacturer and a clinical care provider.... If you can find a suitable central fab that has staff who understands the clinical aspects and knows exactly what you are trying to accomplish for the patient, you can be successful with fabricating off-site."

Trend #5 Continued Encroachment from Other Disciplines Rogers notes that this trend may vary by region. "My geographical area seems to place a premium on prosthetics over orthotics, perhaps because the margins are greater. This has led to an increase within orthotics toward prefabricated devices by many who provide orthotic care in an effort to improve margins. This marginalizes care in some respects and allows other, less qualified professionals to enter the orthotic care arena because they see a lack of customized care; it also decreases opportunities for talented orthotic providers who provide specialized care.

Kirk whimsically notes that competition is continuing to enter the O&P field Pac-Man style-little bites at a time. "Changes in design and materials are leading to a phenomenon that I call bifurcation," he explains, "where some simpler patient needs will fall into the off-the-shelf category and will be handled by fitters in a doctor's office, and some medium and all of the higher end custom needs would be dealt with in the classic O&P space."

Survival Tips for Tomorrow's Model In the face of such ominous and daunting trends, the future O&P world may appear intimidating, but among the habits of successful people is the tendency to regard obstacles as opportunities and adversity as a challenge. To that end, our experts have these words of encouragement and coping strategies to share:

Hovorka believes that better cooperation is key. "There should be an enhanced awareness of the importance of working with others," he says. "If we don't look at the bigger picture of how other professionals manage the patient, we might lose some opportunities to market ourselves and to communicate with others for the benefit of the patient."

In order to retain business that could easily be lost to other disciplines, Janisse suggests that tomorrow's successful practitioner may have to be more mobile and more hospital-based, while Rogers advises that future clinical practitioners pursue licensure and "spend time researching the efficacy of what we do and how we provide our treatments before we choose an approach for a particular patient."

Rogers also anticipates that practice management software that interfaces all aspects of the delivery of care will become the norm as we strive to maximize efficiency and the transfer of information.

Carroll takes Rogers' prediction one step further, advising that tomorrow's O&P facility be totally paperless, with the record of clinical care-data captured from the patient's body-being digitally captured and stored along with billing information and other documentation. He believes that this will result in "greater precision all around and less opportunity for human error."

Kirk says, "We need to position ourselves for greater patient flow by incorporating cost and productivity improvements so we can survive no matter what." Using doctors and dentists as models, he suggests allowing the certified practitioner to serve patients by providing diagnosis, custom fitting, and consultation, and then leaving a practitioner assistant to execute the remainder of the treatment, with a final check by the practitioner.

"Fundamental business principles are going to become increasingly important," Ruhl believes, "things like improving efficiency and profitability, while reducing waste and costs. The ability of practitioners/owners to hone their business skills as well as their patient care skills is probably more important today than it's ever been in the past.

"There's a tremendous amount of threat," Ruhl concludes, "but within that threat, there are great opportunities for people who understand what it will take to be successful. Being more flexible, being more willing to look at some alternative delivery models of other aspects of healthcare than just the traditional O&P might very well be one of the key success factors."

Other Trends to Track: The Future of O&P Standards As the O&P profession moves into a shadowed and uncertain future, experts agree that standards will be more important than ever-and it's vital that a consensus be reached in this area.

Allen Mike Allen, CPO, FAAOP, immediate past president of the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) board of directors, identifies the mandatory requirement for accreditation of sites where orthotic, prosthetic, and pedorthic patient care services are rendered as one of the most significant trends affecting the industry's future.

"Although there's been a delay in the accreditation deadline, we are pleased that the legislation will provide protection for the public that receives OP&P care. One of the problems with accreditation is that there is, at this time, no consistent standard in the measure of competency of the providers." The Benefits Improvement and Protection Act of 2000 (BIPA)-refers to "qualified providers" who may provide orthotic and prosthetic services," says Cathy Carter, ABC's executive director. "BIPA doesn't define 'qualified provider,' but it does identify who is qualified to be paid for providing orthotics and prosthetics. We believe CMS [Centers for Medicare & Medicaid Services] is in the process of writing the regulation to define 'qualified provider.' We are hopeful those regulations will come out in early 2009."

Carter confirms that ABC will be monitoring the National Commission on Orthotic and Prosthetic Education (NCOPE) and Commission on Accreditation of Allied Health Education Programs (CAAHEP) change in the entry-level educational requirement from a bachelor's degree to a masters' degree, and "considering if changes in the ABC practitioner eligibility criteria are necessary and appropriate," she says. "I would expect that will be happening over the next several years.

"Accreditation requirements for facilities are likely to change if and when CMS not only makes changes to the quality standards but also requires changes of the deemed authorities-those ten organizations that CMS has deemed eligible to provide accreditation services for DMEPOS [durable medical equipment, prosthetics, orthotics, and supplies]," Carter adds. "ABC is on that list."

Allen says that ABC has been working with the O&P Alliance [a cooperative effort between ABC, the American Academy of Orthotists and Prosthetists (the Academy), American Orthotic & Prosthetic Association (AOPA), and the National Association for the Advancement of Orthotics and Prosthetics (NAAOP)] to develop "numerous recommendations to improve the quality standards. However, ABC continues to work with Medicare in establishing parameters to measure the competency of orthotists, prosthetists, and pedorthists. In October 2008, we provided CMS a comprehensive document identifying the education and clinical training requirements we believe are reasonable for the providers of OP&P care. I think the challenge is to continue the education process of our regulators and legislators."

The Board of Certification/Accreditation International (BOC), which also provides practitioner certification, was unable to provide input on this issue by our press date. However, the BOC perspective will be presented in the January 2009 online edition of The O&P EDGE . To read about how BOC envisions the future of O&P standards, visit www.oandp.com/edge

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.

Author's note: There's more to the preview of tomorrow's O&P arena than just trends and tips. Look for Part 2 of our Survival Guide in next month's edition of The O&P EDGE, where our experts will weigh in on the changing needs of tomorrow's O&P patients and consider the effect of economics on patient outcomes.

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