New Professional Standards To Enter O&P: A Plan
By Jeffery Arnette, CO 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.
Large Ideas
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 edge@oandp.com or directly to Jeff
Arnette through www.oklahomaoandp.com 
Table Of Contents - February 2004
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