“Quality is now king in U.S. healthcare. This means that providing O&P care as you have always done will no longer be enough…. [Providers] will now have to demonstrate the value of the services they provide. And if you are able to do this, the benefits could be enormous.”
—Mahesh Mansukhani, president, Össur Americas, Foothill Ranch, California
Mansukhani delivered this message about the O&P profession's future last September to attendees of the American Orthotic and Prosthetic Association (AOPA) National Assembly. Mansukhani based his prediction on five trends that are already impacting the O&P field:
- Provider integration and consolidation within the medical field to such an extent that small, independent medical professionals increasingly find themselves working for large healthcare systems.
- New emphasis on cost-effectiveness in the face of evidence that countries and states that spend the most on healthcare seem, ironically, to deliver the poorest quality of care.
- A push toward improved quality because the U.S. marketplace demands it, and because the Affordable Care Act (ACA) emphasizes it repeatedly by rewarding provider performance, demanding quality and price transparency, and requiring health plans to report on quality.
- New healthcare provider options are arising in the form of retail clinics, such as Walgreens and CVS/pharmacy—which are already dabbling in the durable medical equipment (DME) market.
- The rise of the integrated provider network (IPN), which encourages collaboration (and a single consolidated claim for reimbursement) from the cooperating hospital, physician, imaging center, physical therapist, and O&P provider.
"In the absence of data showing the value of what you do," Mansukhani concludes, "payers will continue to make decisions based purely upon cost considerations, not what's best for the patient. And in that event, the technologies of yesterday will become the technologies of tomorrow. Put simply, the devices that hold so much promise today will become unavailable to you and your patients."
How Do You Prove Value?
Demonstrating quality (value) is as simple as tracking your patients' outcomes—but historically, this has not been a simple matter. The future pursuit of outcomes must increase to an extent never previously explored, Mansukhani says. He recommends tracking not only (A) traditional biomechanical or functional outcomes for each patient, but also (B) clinical, and (C) economic outcomes.
While functional outcomes (A) would include basics, such as the number of steps taken, average walking speed, patient weight, etc., clinical outcomes (B) would include metrics not typically linked to O&P care, such as measures that show how O&P treatment can mitigate the effects of diabetes; for example, glucose, blood pressure, and cholesterol levels.
Economic outcomes (C)—a long-term initiative—would collect data points that demonstrate the prevention of co-morbidities, the acceleration of the amputee rehabilitation process, and a reduction in the number of hospital visits.
This appears to be a tall order. Is it doable? Will O&P providers be willing to try?
Granted, this would mean significant additional work for the practitioners, points out Ryan Arbogast, president of WillowWood, Mt. Sterling, Ohio. "These are things that also question the decision making of the practitioner and require proof of need, proof of execution, and proof of improvements—and those are all things that, in an industry where the practitioner has been the end-all, be-all in decision making, certainly aren't going to be received too kindly."
Mansukhani finds that some people are embracing the idea, and some aren't. "I've encountered a few mature, successful practices that said they've tried this before, while other leaders are already integrating this new approach and finding it worthwhile."
"This has come up several times," Arbogast agrees, "and my opinion on why it failed is lack of commitment. The financial need to pursue outcomes just wasn't there. People could still get paid if they did their own thing, and as long as that situation existed, the kind of cooperation Mahesh talks about just wasn't going to happen because it means giving up trade secrets and trade information. But whether you like it or not, that's coming."
John Michael, MEd, CPO, LPO, FAAOP, FISPO, associate director of Northwestern University Prosthetics-Orthotics Center (NUPOC), Chicago, Illinois, agrees that O&P providers should be paying closer attention to outcomes and giving it more importance in their daily work. "I think the fundamental problem is that historically P&O has always measured short-term outcomes; for example, 'The item currently fits well, it presently improves the person's independence.' The only objective long-term outcomes we've ever measured historically are financial, so it shouldn't surprise anybody that external observers get the misperception that prosthetic-orthotic rehab is nothing but a numbers game."
Mansukhani's ideas are noteworthy, concurs Paul E. Prusakowski, CPO, FAAOP, CEO of OPIE Software, Gainesville, Florida; owner of Gainesville Prosthetics; and president of the National Association for the Advancement of Orthotics and Prosthetics (NAAOP). "It's definitely expanding our scope of how we're going to be approaching patient care, documentation, evaluation, and assessment. I agree that there is definitely a change on the horizon for us. I'm not certain to what depth and at which rate, but there's absolutely a need for us to have a much better understanding of what we're doing for a patient beyond just fulfilling a prescription. We need to be able to communicate and understand this level of impact that we're having on the patient and communicate that with the referral sources more than we can at this point. It may require a shift in our training and education."
Pursuing Functional, Clinical, and Economic Outcomes
Can O&P providers realistically access and acquire not only functional, but also the outcomes data Mansukhani characterizes as clinical and economic?
Dennis Clark, CPO, president of the Orthotic and Prosthetic Group of America (OPGA), Waterloo, Iowa, believes it is not only realistic and doable, but it is also an essential new direction that will move the profession forward to a wellness approach to care. "This is a large part of the future of healthcare, a prophylactic approach—avoiding and or delaying manageable co-morbidities."
It's a simple matter to escort patients to a treatment area by way of a weighing scale and a chair with digital blood pressure cuff, he suggests. "Weight information can be critical in determining the need for a new prosthesis based on weight change that affects socket fit; blood pressure that goes down and stays down after a successful prosthetic fitting is a positive indicator of the value of the prosthetic care."
But some point out that even Mansukhani's type A functional outcomes have been elusive for the O&P industry to garner. "We're one of the only industries that I'm aware of that doesn't provide this information, and a lot of that is manufacturer-driven," Arbogast admits. "As manufacturers, we really need to be able and willing to provide that kind of information for the practitioners. How can they be expected to mechanically test every prosthesis [and] every orthosis that they fit? It's unreasonable. If there's enough demand—and I think it's coming or already here—I think it falls on the manufacturers to provide that…component. That can be as simple as printout PDFs or as complicated as integration into CAD systems. There are a lot of product-specific ways to get that information out there."
Even though the O&P field has been talking about outcomes for more than a decade, "We're still not measuring the biomechanical and functional outcomes effectively in our practices," Prusakowski agrees. "There aren't enough of us doing it, and it's not being done consistently. Actually, a major initiative of mine is to put this into daily practice in more clinics through establishing standards of practice among our OPIE Software users."
Organizing and managing the data is also a challenge, but as Prusakowski points out, the trend in healthcare overall is toward electronic medical records (EMR). Physicians, too, are using EMRs specifically to track those outcomes regarding how their total care process affects patients—especially in the diabetic area, and O&P is only one piece of that picture. "There are too many variables for us as O&P providers to point to the impact we may have had on the whole, but we are contributors and need to make sure that it's identified that O&P care is an integral part of that patient's well-being—justifying our role more than we have in the past."
While the need for O&P outcomes data is well-documented, the categorization of Mansukhani's three outcomes groups may confuse the issue of collecting and managing data, Michael says. "Mahesh talks about biomechanical or functional outcomes. I would suggest we talk about outcomes the way that other people in healthcare do. Outcome measures are often classified into at least five categories, one of which is healthcare economic impact—which parallels his part C." (Author's note: This and other categories tracked by the American Academy of Orthotists and Prosthetists (the Academy) 6th State of the Science Conference proceedings (2006), on lower-limb outcomes identified an extremely limited number of validated outcome measures.)
"No profession that I'm aware of has all of these outcome measures in abundance," Michael says. "They have just begun developing these in the last ten years, increasing in momentum only in the last five or six years. So, in many ways, we are on the front end of a curve; I think it would be a mistake for us to choose unvalidated outcomes as long as there are validated ones that are there to be clinically explored."
How important is the difference between validated and unvalidated outcomes?
"I think it's important to distinguish between clinical research on the one hand and what I think Mahesh was referring to more generically as outcome measures on the other," notes Dave McGill, JD, Össur Americas' vice president of legal affairs. "Clinical research is what you might see in a setting where you have partnered with a university or other research institution with a goal of publishing peer reviewed literature. That clearly has been lacking historically in the O&P profession and is something that manufacturers and prosthetists need to invest in and drive.
"The vision that Mahesh is presenting acknowledges the difficulty of just getting clients from our basic demographic—we're talking about one-half of one percent of the U.S. population, spread out across the country, most of whom live with mobility impairments—to repeatedly get to a research facility over an extended period of time. He's encouraging us to get outside the world of universities and research institutions and look at what we as prosthetists can do to back up the work that we're delivering every day—work that most of us know does provide enormous value to our patients."
Mansukhani points out that a large percentage of the O&P patient population has diabetes and vascular issues. "Their treatment within the healthcare system tries to focus on specific measures such as hemoglobin, insulin, blood pressure, cholesterol—these are the fundamental measures that hospital systems care about. We need to orient ourselves to the patient's broader wellness and start tracking those kinds of indicators within our own facilities. "The technology already exists for us to start basic step monitoring remotely. If we can, for example, demonstrate that a patient does 30 minutes of increased cadence walking, we've indirectly proven vascular improvement."
Perhaps a better way to collect certain data, however, is to request it from the physician, Michael suggests—which would also serve to promote a closer relationship with the referral source, and that could be advantageous—whether or not an integrated provider network is part of the future picture. "Asking if you could have updates every time the patient's glucose level or blood pressure is taken might get you added to the list of people who get a routine 'cc' for that information."
Whether or not these measurements and collected data actually prove anything, your practice will gain value as healthcare systems and insurance companies perceive your demonstrated willingness to track the same variables that they care about, Mansukhani stresses.
This Is Not a Drill…
The world is changing—but isn't it always? So what's the rush?
"The threat here is that the absence of data, when combined with current national efforts to contain healthcare costs, creates a perfect storm that within a few years could result in prosthetics looking much more like today's bracing business," Mansukhani warns. "And that would lead to an associated negative impact on patients' access to appropriate prosthetic care."
Could this mean a prosthetics Armageddon could happen within the next five years?
"That's a worst-case scenario—but it could happen!" Arbogast admits. "Another thing that we have to worry about is the unpredictability of government medical reimbursement. So if you look at the worst-case scenario, he's right on! It may be even less than five years."
"Mahesh's level of urgency is not overstated," Clark says. "Much of the orthotic side of our profession has become commoditized, all because little was done to show the value of having care provided by credentialed, trained, qualified providers. DME Armageddon is already here, with care and care providers based on lowest bid. We can still be part of the prosthetic solution—but the window is shrinking."
Prusakowski concurs. "I hate to be the 'sky is falling' guy—I don't think it's that drastic—but at one point all orthotists thought they were safe, too. The sophistication of componentry is reaching the point where it almost programs itself. Socket technology is the variable. I would think that if we're not careful, looking ahead and taking it seriously, there is a significant threat to our existence as we know it. We have the opportunity to set our own course, but we need to elevate ourselves and put ourselves in position before somebody else chooses it for us."
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.