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Idealism vs Realism: Balancing the Scales in O&P Practice
By Judith Philipps Otto We all want to make a difference in this world; most
of us want to leave it a better place than we found it. In our
youth, filled with confidence and high ideals, fired with
enthusiasm, we face a life of limitless
potential.
Unfortunately, with each passing moment, and with
each of the hundreds of choices we make every day, we limit
ourselves to a narrower and narrower path of opportunity and
accomplishment.
And somewhere during this process, our aging ideals are subtly
altered by reality. The "what could be" becomes "what is"; the
"what could happen" becomes "what did"!
So where are they now, those lofty ideals with which many came
to the O&P field? Has the hard reality of Medicare
cost-cutting, diminishing reimbursements, encroachment by
therapists and manufacturers, the breakdown of negotiated
rulemaking, internal bickering over American Board for
Certification in Orthotics & Prosthetics (ABC) and Board for
Orthotist/Prosthetist Certification (BOC) unification and more,
turned us into cynics? What is it that keeps O&P and other
healthcare providers in their beleaguered fields?
Justin Foster, CPO, was fresh out of
school and new to the profession when he raised questions on
OANDP-L, questioning, among other things, how O&P practitioners
could justify the high prices and accusing them of becoming fat
cats by feeding on patient needs.
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Justin Foster, CPO |
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Things have changed a lot since then. Foster
admits that, although he feels more motivated each day, the word
idealism' has taken on new meaning.
"I was very vocal about what I saw as serious faults in our
profession from the day I entered," he recalls. "What I have found
since publicly airing those concerns is a group of people that are
more dedicated than I had ever imagined to making a real difference
in the lives of people. I have been truly inspired by the time and
effort expended by members of our field in the pursuit of better
quality prosthetic and orthotic care.
"Several high-stature individuals took the time to guide
me--some with a firmer hand!--through what was a difficult time in
my young career, learning how to balance the ugly' side of business
with the ultimate goal of healthcare. As a resident fresh out of
school, it is not immediately apparent why a Flex-Foot® is so
expensive, or why you can't just waive a Medicare deductible.
"Motivation comes from the challenge of continuing to provide
quality prosthetic and orthotic care in spite of what is against
us, almost as if a call-to-arms is being broadcast! My new
idealism' is not to give away the farm, but rather to fit ALL of
the pieces together to be able make an AFO or prosthesis each time
it is needed by a member of our community."
Jan Stokosa, CP, Stokosa Prosthetic
Clinic, Okemos, Michigan, notes that he feels as motivated and
idealistic today as when he first entered the profession--probably
more so.
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Jan Stokosa, CP |
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"I think if a person gets into this field with the
intent to truly help somebody get back to their life, I don't see
how one could ever get exhausted in that attempt."
Stokosa uses a formula to assess a new patient:
- Objective physical capability;
- Quality and level of amputation;
- Relevant technology;
- Prosthetist's ability and willingness to innovate; and
- Amputee aspirations and will.
"Many prosthetists today have very little talent using their
hands," Stokosa says. "They can use a computer, and they can design
a prosthesis. But in complex cases, that utility becomes less
useful. You've got to be able to work with your hands, and you've
got to be able to innovate. If we can't solve a patient's issues
via conventional methods, then we come up with something; we may
have to make or redesign a component.
"So with this kind of challenge, and with all the new
technology, I don't see any prosthetist's senses being dulled with
respect to the ideal of allowing the person to get back to the most
comfortable, stable, functional life they can. With so many options
now available, no one really has the ability to predict what this
person is going to be successful with. All the suspension, all the
interface materials, all the foot, ankle, knee, hand, wrist, elbow
components--we simply don't know. So it requires us to be very
sharp, evaluate and test each person, and try to come up with the
best possible solution.
"I was using wood when I started in prosthetics. I saw plastics
appear in the 50s. The changes--the continuing progress--is
fascinating and exciting. I think anybody who has lost their sense
of idealism maybe is not meant to be in this field."
Michael Davidson, CPO, clinical
manager at Loma Linda University Orthopaedic & Rehabilitation
Institute, Loma Linda, California, says he feels even more
motivated and idealistic now than when he began his work in the
field 16 years ago. "Why? --I don't know why," he says. "Possibly
because I've had several patients that have done incredible things
physically, and they have challenged my definition of what
disabled' is. When somebody with a missing limb or paralysis can go
compete in a competitive sporting event that I have never dreamed
of doing, it makes me really question my sore knee and the excuses
that I can come up with!
"Helping people with physical disabilities has really challenged
my thinking since I've gotten into the field. So in a way, some of
the patients that I help, in turn, also help me confront my
challenges. When you think about it, we all have challenges in some
form, shape, or another, and we all have to confront
them&Confronting our challenges now helps prepare ourselves for
bad things that happen in life, and therefore makes us better as
people. So in a sense, I make my patients whole, and in turn they
make me whole."
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Mike Allen, CPO, FAAOP |
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Michael J. Allen, CPO,
FAAOP, Allen O&P Inc., Midland, Texas, is a
second-generation practitioner in a 50-year-old practice, but
admits that he feels as idealistic now as he ever has. "Choosing
O&P as a profession was a choice made for a reason, and the
challenges faced today to provide a high level of care haven't
taken away the motivation--haven't affected that at all. It's still
fun to work with people.
"We're excited about our company's 50th anniversary celebration
this year, and we have many activities planned for the area
children and disabled community. I work with patients today that I
sat on the floor and played cars with many years ago. The sense of
continuity is very rewarding: Two years ago, I replaced bilateral
KAFOs for a post-polio patient who literally changed my diapers.
That's one of the joys of being second-generation."
Jim DeWees, CP, BOCP, Prosthetic
Center of Indiana at Bloomington, has had his own rocky road to
travel. A 39-year-old six-year amputee, DeWees had a series of
painful disappointments as a prosthetic patient which prompted him
to switch careers from pathology to prosthetics so he could make
his own legs as well as help others.
After completing the Cal State O&P program, he got a job
with a major O&P employer--and some unpleasant first-hand
experience with being required to sell the cheapest possible
components for the highest possible markup and to limit himself to
the same uncomfortable and inappropriate items as an example to his
patients.
DeWees switched jobs, but uncovered a situation where again,
sales and profits were more important than patient care, and salary
and bonuses were based on how much money he could generate.
"I was on the verge of switching back to a career in pathology,
when I decided to give prosthetics another chance, and opened my
own practice in Indiana about 15 months ago. It has been a lot of
work, but very rewarding and very successful.
"In January and February, I was really burned out and needed to
do something to remind me why I got into this field in the first
place. So I started a nonprofit organization to make prosthetic
limbs for amputees in the Dominican Republic, where I had lived
from 1984 to 1986, when I was 1921 years old. I speak Spanish
fluently and really love that country. There are so many amputees
there, being treated by 1940s1950s standards. If a bone is broken
and cannot be set and cast easily, they amputate the limb.
"So while I was there, I also met with a couple of men that have
an O&P practice there, and I made six limbs with materials they
had, and also brought five more casts back to my office in Indiana
to make the limbs here. I am going back to fit these five limbs,
and I will cast another 12 patients there, and bring the casts back
here, make them, return a few months later, etc. This will be an
ongoing adventure.
"This trip was so rewarding, and it was exactly what I needed to
give me that boost again to remind me why I am working in this
field. These people are so grateful and happy to get anything to
help them live a little better life.
"Being an amputee makes this profession more important to me; it
is a passion of mine, and not just a job. I know there are many
non-amputee prosthetists who also have a passion for it. But there
are many prosthetists--amputee and non-amputee--that have lost
sight of the patient and can only see the dollar signs now. That
really bothers me. But as long as there is a prosthetist in the
area that is passionate about quality and service, he will
hopefully take all the business away eventually from the greedy
practitioners/companies."
What helps you maintain focus in the face of abundant
negatives?
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Alberto Esquenazi, MD |
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Foster: "As long as
people keep coming to us for assistance in meeting their goals, we
are tasked with innovation, compassion, and completion of this
work. Part of my fun time' each day is coming up with creative
ideas to solve not only clinical concerns, but business and
logistical problems as well. Nothing feels better than a job well
done! That feeling is what keeps me coming back for more challenges
in all aspects of what we do."
Alberto Esquenazi, MD, chair,
Department of Physical Medicine & Rehabilitation at Albert
Einstein and MossRehab, and director, Amputee Rehabilitation
Center, MossRehab, Philadelphia, Pennsylvania, has been involved in
patient care for more than 20 years. What keeps Esquenazi focused?
"The patients--knowing that you can do something for them, and that
you are really providing them with an opportunity to return to the
kind of life that they deserve. You may have hundreds of
obligations throughout the day, and all it takes is one patient
saying, Thank you very much. You really made a difference.' In the
end, that is really what drives you."
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Charles Levy, MD |
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Charles Levy, MD, chief,
Physical Medicine & Rehabilitation, North Florida/South Georgia
Veterans Health System: "I think this boils down to whether you
have made the decision to try to do good in the world. If you have
decided that part of your existence is to be an advocate for those
in need, then you simply try to pursue that in your daily life.
"It's not really based on whether you are always successful or
whether you get nice fuzzy feelings back. You pursue it because
you're dedicated to betterment in the world, and this is how you
express that dedication. If you're not--if you're pursuing this
because you think it would be good for your business, that's not
necessarily a bad thing, but I don't think that's a very durable
motive--because maybe you'll decide you can make money
elsewhere&"
Allen: "I believe a lot of what keeps
me focused is the changing technology and the opportunities that it
allows us to enhance patient care."
Positive and Negative Influences
Foster: "I have had the most
difficulty adjusting to the fact that without money involved, there
would be less innovation, less invention, and less success in our
outcomes. It is certainly not unique to P&O; rather P&O is
captive to this system as a whole. Some of what we do on a regular
basis lends particularly well to questions of cost vs. efficacy,
but because of the relatively small number of consumers of our
products, it is a necessary evil.
"Everyone in every business is facing rising costs in this
country; the challenge is to remain viable while putting out a safe
and effective product. On the positive side, healthcare can't exist
without helping people. It is what we often take for granted, and
what many of us first and foremost want to do with our lives!"
Esquenazi: "Reimbursement is
definitely a negative factor--I think it's not so much the
reimbursement itself but the way we have deployed the resources
that we have. I don't know that we have a clear guidance on the
best way to deploy those resources. And not having the freedom to
utilize your budget in the most intelligent way for your patient is
something that is at times frustrating.
"I remember years back when the managed care company told me I
could prescribe one device for a patient--for his lifetime. Get
whatever you want for him--we'll pay for it--but it's one for the
lifetime.' It was ridiculous--this is a 17-year-old kid who was
hurt in an accident and lost his leg. It's like telling someone
they have a chance to get one pair of shoes for the rest of their
life. You pick the best shoes you can--but they're not going to
last--and you're eventually going to have to do something about
that.
"People just don't have a clear understanding, so in my opinion
the system is driven from a wrong perspective, one that is
appropriately looking at dollars and cents--but inappropriately
determining where to distribute them.
"Technology has been a very positive factor; but we have not
been able to take full advantage of that technology. We see a lot
of waste in medicine, and I think that if we were a bit smarter in
how to use technology, much of that waste would tend to disappear.
I'm talking about all perspectives, from who would administer the
care that we provide, how we sometimes repeat a procedure, from an
X-ray that gets lost--to always being able to access the film.
Technology will allow us to do some of that and help us choose in a
more intelligent manner what resources we need to use and how to
use them."
Stokosa: "Insurance companies more and
more are stepping in between the amputee and the physician and
prosthetist. We no longer have the ability to determine what's
going to be best for this person; as a function of cost, insurance
companies tend to say, If it's going to cost that much, let's go
with something cheaper.' The discouraging part is that
reimbursement will not meet the very heavy costs and overhead that
prosthetists have today. We must have more than just the typical
office space; we've got to have machining equipment, many different
fabricating materials, plastics fabricating equipment, and tools.
All this takes much more space than the typical professional
office.
"On the other hand, more and more prosthetists are using central
fabrication facilities to do the bulk of their work. I don't do
that, but I know many prosthetists do. This is a cost-saving
measure to offset the low reimbursement. Typically, when central
fabricating services are used, it tends to reduce the ability to
customize for each person--there's more of a generalized
approach.
"As for the positives, we have a new paradigm emerging in
improved surgical techniques--the Ertl procedure--though not as
fully recognized and appreciated as it should be. I believe it will
be scientifically proven to be superior to conventional techniques
we see so commonly today&More and more prosthetists are
witnessing the superior benefits of this surgical approach, which
in turn increases the quality of life for the amputee and
ultimately will reduce medical and rehabilitative costs
significantly per patient.
"And we've got better and more interested physicians. I'm
finding some younger physicians--both in the physical medicine and
rehabilitation areas as well as surgery--who are more interested in
providing the best possible care for the amputee and are working
together to do the best for the person, where before they could
almost care less."
Davidson: "The positive and negative
influences in O&P are the same: technology. It is positive in
that it's helping people; it's negative in that it is becoming more
cost-prohibitive. That's what makes us unique from other
industries. For example, when computers or cell phones get better,
they become less expensive; but when our components get better,
they become more expensive.
"Our ability to provide people with what they need is being
strained, definitely. Hopefully, more people will gain access to
clinically appropriate devices--and just by numbers, this will
lower the expenses of high-end components over time. "
Allen: "The most negative influence on
O&P today is the low reimbursement, relative to other segments
of healthcare. When you carefully examine the increases in
allowable fees for general medical care in the United States for
the past 20 years and parallel O&P with it, there is a dismal
comparison. O&P has simply not kept up with the inflation of
general healthcare. It is simply the result of the national trade
association not representing O&P in years past.
"I don't think the changes on the horizon--competitive bidding,
fee freezes, and qualified practitioner issues--are favorable,
either. I think it will require alterations in the way we provide
our expertise and various levels of patient care. The cost of
service is becoming more and more critical when you compare expense
to the reimbursement. That ratio isn't looking good for the
foreseeable future. Although it's going to require more creativity
from the business standpoint, I believe that there are other
alternatives that will allow us to continue versus compromising the
quality of patient care.
"One solution we have been implementing is allowing the majority
of our staff to take off Friday afternoons in weekly rotations, as
we shrink down to a skeleton crew for that half day--one office
staffer, one practitioner, one technician. We have also begun to
experiment with staff transitioning to a four-day work week versus
a five-day work week. Those are areas where we're looking at making
changes, because the historic salary increases we used to see a few
years ago are just not possible in today's economic climate." Judith Philipps Otto is a freelance writer who has also assisted with marketing and public relations for various O&P industry clients. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer. 
Table Of Contents - June 2004
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