Many concerns have been voiced regarding the merger of the American Board for Certification in Orthotics & Prosthetics (ABC) and the Board for Orthotist/Prosthetist Certification (BOC). Here are some ideas I would personally like to see implemented as new guidelines and standards are hammered out.
As we all know, infighting in the field of orthotics is nothing new. Encroachment from sales people, drug reps, and others is as old as our industry itself. O&P itself developed from orthopedics during World Wars I and II, becoming a full-fledged independent allied health profession. Credentialing organizations were established: ABC in 1948 and BOC in 1984.
Medicare Has Set the Guidelines
Our industry has grown and matured, but presently we are facing one of our most difficult times for reimbursement. The only way to stop encroachment and the reduction in payments--while still maintaining quality service--is to increase the number of providers. Medicare, with the Health Insurance Portability & Accountability Act (HIPAA), has set the guidelines for care. With ABC and BOC acting alone, it will be impossible to provide the services necessary for the booming number of beneficiaries over the next ten years.
Medicare has realized this for over a decade. In 1991, I had the privilege of attending a Town Hall Meeting. There it was stated that all orthotics and prosthetics would eventually become prefab-only. We are now 13 years forward and face the realization that Medicare WILL govern what can and cannot be done by us.
Ask a practice owner who has been randomly selected for a code audit about the justification and documentation guidelines that Medicare is moving toward. I have personally experienced such an audit. When a nurse practitioner in the review process asked why I did not provide an off-the-shelf brace for a Charcot joint patient, I had to justify and defend my selection process and services provided. Under the recently passed Medicare reform bill, competitive bidding for off-the-shelf orthotic devices and virtually all durable medical equipment (DME) is slated to begin in 2007.
A Tier System
An increase in the number of providers will not alone guarantee quality. We must look at potential practitioners who already are--or desire to be--providers of orthotics or DME. We then need to create a tiered system whereby these individuals can be trained within our industry. It's the only way to substantially increase our numbers while still guaranteeing quality and consistency. University programs can increase their number of students via those who do not want to take the necessary time to go through the experiential phases of this option.
As individuals work on the experiential phases, we need to ensure that their educational pathways are approved and accredited by the universities, so that if they want to receive college credit for on-the-job training or years of experience, they may do so and later transfer those credits into an accredited program. Perhaps the National Commission on Orthotic & Prosthetic Education (NCOPE) could examine this and develop an educational protocol which allows online or distance learning options. CEUs (Continuing Education Units) could be another way to receive college credit. If we move to this type of protocol, it would allow therapists a way to merge into our industry and thus expand our numbers of qualified practitioners.
Once ABC and BOC have set their merger, we need to consider bringing pedorthics and other similar professions into our ranks. If we close the door to those individuals who have the minimum skills and training presently required, then we will again be back in the same boat in which sales reps are fitting and providing devices.
We cannot stop the production and sale of over-the-counter products. Nor will free trade practices allow us to limit the practice abilities of individuals previously involved in fitting over-the-counter and custom devices. The only way to bring these fittings under control is to guarantee that there is one industry overseeing all forms of care and placing guidelines on that care.
Examples from Other Professions
In the nursing profession, there are certified nurse assistants, licensed practical nurses, registered nurses with associate and bachelor degrees, as well as nurse practitioners. Thus, there are many levels of nursing--each with a delineated level of care and supervision. My recommendation is that we set guidelines so people may practice independently with indirect supervision under a credentialed guideline. In this way we continue our growth and meet the needs of the increasing population, including Medicare beneficiaries.
At the Negotiated Rulemaking Committee (NegReg) meetings last year, I had the privilege of speaking with Dr. Hugh Hill of the Centers for Medicare & Medicaid Services (CMS). He informed me that the purpose of the meeting was for Medicare to come to a determination on unification of services provided through the professions and industries represented by such organizations as the National Orthotic Manufacturers Association (NOMA), American Occupational Therapy Association (AOTA), American Physical Therapy Association (APTA), the American Orthotic & Prosthetic Association (AOPA), the American Academy of Orthotists & Prosthetists (AAOP), and others. Due to our industries' inability to reach consensus on the qualifications of a practitioner, we lost a lot of ground. Now we are scrambling to regroup and repair the damage.
Unifying the Industry
In my humble estimation, the only way to do this is to bring about the unification of ABC and BOC, and then bring the Board for Certification in Pedorthics (BCP) into this group. Also, AOPA, AAOP, the Pedorthic Footwear Association (PFA), and NOMA should be unified. When this is accomplished, all manufacturers and providers of soft goods, orthotics and prosthetics, and industry sales reps will be able to negotiate with Medicare from a united front.
Physical and occupational therapists may want to consider combining their industries as Medicare continues to look for cuts. Since PTs are moving toward a doctorate program, it would behoove the physiatrists--all 900010,000 of them--to look at absorbing the rehab technologies into one industry.
If we explore a tier system and an educational process, then it would not be a large jump from a fitter to a doctorate level program over a 15-year period for those who choose to continue the educational process. We'd be able to obtain the highest level of rehab care through the continuing education process. By doing this, we will have unified the industry and given respect to our own program.
This is a large idea for a small industry, but large ideas move industries and society to a higher level. I recommend some form of this project be implemented during the unification of ABC and BOC. We, as an industry, desire to set the highest standards of quality care for our patients. We are all gravely concerned when unqualified individuals render services to patients. At this point, however, what is considered "qualified" and "non-qualified" is very vague. There is no unification within the industry to clearly set a guideline.
Until we are able to humble ourselves and realize that there is more than one way to obtain a level of acceptable proficiency within our industry, and then sit down and spell out those guidelines of proficiency, we will continue to have infighting and lack the respect of individuals in sister fields who are qualified and capable of providing the highest standard of care to patients.
I challenge the ABC and BOC boards which have been established to set forth new guidelines to consider the open process I propose. I urge them to consider supply and demand when they set guidelines for direct and indirect supervision. Under these guidelines, some flexibility for small practices is necessary. If flexibility is not allowed within small practices, services to small communities, rural areas, and to the aged and homebound may be jeopardized.
In closing, I would like to thank the boards for all their hard work and dedication to excellence during some tense and volatile times in our industry. I hope my thoughts and ideas will challenge each of us to think beyond the traditional and conventional and may result in new paths of entry being opened up to those who desire to enter our field.
Jeffrey M. Arnette, CO, LPO, has over 22 years of work experience in the O&P field. He obtained his O&P training in the US military and later used this training while serving in Operation Desert Storm. In 1995, he founded Progressive Orthotics and Prosthetic Services, headquartered in Claremore, Oklahoma, which comprises eight facilities. He currently serves as an Oklahoma representative to the National Small Business Advisory Council and as an industry advisor for Oklahoma State University. Readers are invited to send their comments and opinions to email@example.com or directly to Jeff Arnette through www.oklahomaoandp.com