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O&P: Who Are We?
By Miki Fairley Is there an identity crisis in O&P? What emerges
in talking with various leaders in the field is that there really
is no identity crisis among what the profession regards as its core
- certified orthotists and prosthetists, supported by registered
technicians, assistants, and fitters -whether credentialed by the
American Board for Certification in Orthotics & Prosthetics
(ABC) or the Board for Orthotist/ Prosthetist Certification (BOC).
Where the identity crisis apparently lies, though, is in the eyes
of payers: Medicare, private insurance companies, and others. A
critical issue that hangs in the balance is just who, to Congress
and the Centers for Medicare & Medicaid Services (CMS), is a
"qualified provider?" What makes the O&P professional
mainstream as we know it different from all the others who are now
providing DMEPOS [Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies]?
On the positive side, the O&P profession is
awakening to the need to prove what differentiates - and elevates -
the profession from the swarm of other providers of DMEPOS
services. This awareness seems to be intensifying, driving several
distinct but interrelated threads:
- O&P organizations are working more closely together to
achieve common goals, as well as collaborating with healthcare
organizations in other fields;
- The profession is increasingly recognizing the need for
research and outcomes studies to prove the value of its services,
as differentiated from lesser-trained providers, and is undertaking
research initiatives;
- Linked closely with research and outcomes studies is an
increased focus on complex, custom orthotic and prosthetic
solutions, which require the education and expertise of the highly
trained orthotist and prosthetist;
- Education is being promoted and advanced; and
- Strong efforts are underway to educate policymakers and to
influence legislation and governmental regulation.
Numbers Tell the Story
First, let's take a look at the numbers, as well as the sheer
logistics problem of patient access to O&P services.
In 2004, total healthcare spending in the US was about $2
trillion, with Medicare, Medicaid, and other government payers
accounting for about onethird of that, says healthcare attorney
John Latsko of Schottenstein, Zox & Dunn, Columbus, Ohio, based
on research by the law firm. Private payers and selfpay accounted
for the other two-thirds. Of that total, DMEPOS spending was
approximately $23.8 billion or 1.5 percent. Included in DMEPOS is
home oxygen, wheelchairs, hospital beds, nebulizers and drugs,
parental & enteral nutrition (PEN), ostomy supplies, eyeglasses
and lenses, home dialysis equipment and supplies, and other similar
equipment and supplies. Those items amount to approximately 90
percent of the total DMEPOS expenditures.
O&P, which includes artificial limbs, braces, and spinal
orthoses, is approximately 10 percent of the total spent by
Medicare on DMEPOS, Latsko notes. With total spending for all
DMEPOS in 2004 from all sources being about $3 billion, Medicare
and other government payers spent an estimated $1 billion on
O&P.
Various experts estimate that the average O&P facility bills
around 35-40 percent of its claims to government payers including
Medicare and Medicaid, with about a third to a half on average
being for customfabricated, custom-fitted, and customized devices.
Commercial payers and self-pay account for most of the rest of the
revenue. However, based on anecdotal information, it is estimated
that the lion's share of work involves custom fabrication and
fitting for a substantial number of O&P facilities, perhaps
even most of them.
The percentage of custom orthotic and prosthetic devices could
decline drastically, with the number possibly dropping to 10-20
percent, due to new prefab devices now available, Latsko warns. The
increase in off-the-shelf solutions also concerns O&P
consultant John Michael, MEd, CPO, FAAOP, FISPO. Says Michael, "The
proliferation of non-custom solutions and the ready reimbursement
for them has drastically changed the complexion of the field. This
is the most important specific development I've seen in the last 30
years." Michael feels that the O&P field may not be
sufficiently aware of this trend and its implication for O&P
companies and certified practitioners, since the ease and
attractiveness of using and billing for non-custom devices is
increasing the ability of less-qualified providers to take a larger
share of the market. In turn this trend can impact the quality of
patient care as well as the viability of mainstream O&P
facilities, he points out.
At least 110,000 DMEPOS suppliers had submitted Medicare claims
in 2003, according to Walter Gorski, director of legislative and
regulatory affairs for the American Orthotic & Prosthetic
Association (AOPA).
Alfred E. "Al" Kritter Jr., CPO, FAAOP, who is a member of
AOPA's Coding Committee and a member of the Board of Directors for
the National Association for the Advancement of Orthotics &
Prosthetics (NAAOP), learned under the Freedom of Information Act
that in 2004, about 148,000 Medicare supplier numbers for DMEPOS
existed, and theoretically each, if they wish, could bill an
L-Code, with about 28,000 of these stating on their application
that they intend to provide orthotic and prosthetic services. Of
these, about 10,000 listed themselves as having certified orthotic
and/or prosthetic professionals on staff. A breakdown on what
credentials and credentialing entities are involved and their
numbers were not available.
Now we get to the numbers of "core" or "mainstream" certified
O&P professionals: ABC currently has 8,910 credentialed
professionals, including 5,107 certified practitioners, with the
rest being registered technicians, orthotic fitters, O&P
assistants, and mastectomy fitters. In addition, ABC has accredited
1,282 O&P facilities. BOC lists 1,925 certified orthotists and
951 prosthetists. Of these, 475 are certified in both disciplines.
In addition, BOC lists 2,409 certified orthotic fitters and 1,082
certified mastectomy fitters, along with 217 accredited facilities.
It must be noted that some of these numbers for ABC and BOC may
include those certified by both, thus skewing the totals
somewhat.
Who Is a 'Qualified Provider'?
This brings us to the conundrum Medicare and state governmental
entities face in deciding who is a "qualified provider"? With a
total of less than 8,000 ABC- and BOC-certified orthotists,
prosthetists, and orthotists/prosthetists (excluding technicians,
O&P assistants, and orthotic and mastectomy fitters), there are
simply not enough to fill the need of the large and growing patient
population. Who currently are the "professionals" included in the
10,000 Medicare supplier companies which say they have a
professional(s) on staff? Who are the other 18,000 suppliers
included in the 28,000 applying to provide O&P?
AOPA has undertaken a study to show just what different
categories of providers are billing L-Codes in Medicare claims. The
majority are orthotists, prosthetists, physicians, DME companies,
and pharmacists, explains Gorski.
Levels of Expertise Required
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Peter Thomas, NAAOP general counsel |
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Two questions arise: "Who really is qualified to
provide O&P services?" And, "How can O&P services be
provided to all who need them?" The answer may lie in a tiered or
bifurcated set of qualifications for defined scopes of practice,
suggests Michael and attorney Peter Thomas, NAAOP general
counsel.
O&P leaders generally acknowledge that providers with lesser
qualifications can often appropriately care for patients with
relatively simple needs and provide off-the-shelf devices; however,
they assert that prosthetic patients and more complex, difficult
orthotic cases require the expertise of a highly trained,
well-educated O&P practitioner who is able to evaluate the
patient and design and fabricate the needed custom device. And even
providing a simpler prefabricated device may need the knowledge of
a trained, experienced practitioner, who would know whether this
really is the best solution for that particular patient. An
inappropriate device would not yield desired treatment results and,
worse, could actually harm the patient.
They point out that, to provide the full range of orthotic and
prosthetic services, practitioners need knowledge of kinetics,
kinematics, physiology, biomechanics, and materials sciences, among
others. Even though they may be experts in their primary fields,
physicians, physical and occupational therapists, and other
healthcare professionals simply don't have the in-depth knowledge
and experience to produce good patient outcomes in complex cases,
O&P experts assert.
"I have a problem with persons who are highly trained in one
field, then dabble in the orthotics and prosthetics field," says
Michael. "When they cross over into our field without specialty
training in O&P, I'm not comfortable with that, and I think
this needs further study."
Regarding physical therapists (PTs) and the proposed direct
access legislation, by which PTs could treat Medicare patients
without a physician's prescription, Gorski says, "AOPA doesn't
think physical therapists have the ability to evaluate and diagnose
all the medical conditions that a Medicare beneficiary could
present. Medicare patients may have multiple co-morbidities, for
instance, so we maintain that physicians should be the front line,
the gatekeepers.... PTs don't have the education, training, or
equipment to provide the full range of O&P services."
Thomas concurs, "The real disagreement is the presumption that,
just because they receive some courses in what constitutes
orthotics and prosthetics, they equate that with the idea that
physical therapists are thus qualified to provide the full
complement of O&P services." This stand by the therapists and
the countering stand by O&P organizations, led to the breakdown
of the negotiated rulemaking process in 2003, Thomas noted. The
negotiated rulemaking process was mandated by the Medicare,
Medicaid, and SCHIP Benefits Improvement & Protection Act of
2000 (BIPA) to assist the Secretary of Health & Human Services
(HHS) in developing rules and regulations to implement the law.
An unfortunate consequence, however, of the negotiated
rulemaking breakdown, is an impression that "the O&P field is
very set in our way, not willing to compromise, and basically
protecting our turf," says Thomas. "This is the only time the
negotiated rulemaking process has ever ended without consensus, so
it goes down as a failure in CMS books." He adds, "I think that
made the field look somewhat obstructionist, but frankly, I don't
think we were. I think the other groups were overreaching and
making unsubstantiated claims of their ability to provide all
orthotics and prosthetics regardless of complexity."
Despite a possible lingering negative perception of O&P at
CMS, Thomas feels that the agency seems to be leaning in the
direction of certification and accreditation as a standard of
quality. But what will this standard be? "If it is too low in order
to let enough people in to provide enough access for patients, what
is the incentive for ABC providers and students and practitioners
of the future to undergo the rigorous education and requirements to
meet top-level standards when they can simply qualify under this
separate track and get access to Medicare patients? This issue has
the potential to reduce quality dramatically across the board,
rather than improve quality."
And of course, Medicare standards and payments generally lead
the way for private insurers to follow.
A bifurcated system based on a credential's scope of practice
might be the solution, Thomas continues. "For instance, a provider
meeting ABC standards could provide everything; a provider with
less education and training could provide off-the shelf, but not
more complex care."
Michael sees a strong need for a high level of education and
expertise to design, fabricate, and fit complex prosthetic and
orthotic solutions - "defining the skill set as we traditionally
have." For relatively simple, non-custom solutions, "I think the
'orthotic fitter' credential is on the right track."
Recent Frauds 'Make the Case'
The recent fraud scandals in Florida dramatically
underscore the need for provider standards and credentialing,
O&P professionals point out. No certified practitioners,
ABC-accredited facilities, including members of the Florida Chapter
of the Academy (FAAOP) or Florida Association of Orthotists &
Prosthetists (FAOP) are involved, according to Paul E. Prusakowski,
CPO, FAAOP, president of the FAOP and incoming Academy president.
Also, as far as known at press time, no BOC-certified prosthetists
and/or orthotists and no BOC-credentialed facilities were involved
in fraud cases.
Although statistics were not available at press time,
indications are that the Medicare O&P fraud and abuse cases in
Florida have involved primarily DME providers or criminals outside
the O&P and DME fields who simply have made use of basically
nonexistent "straw" companies to defraud Medicare.
Working Together
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John Michael, MEd, CPO, FAAOP, FISPO |
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The various organizations representing the field -
who have not always presented a unified front to payers,
legislators, and others - are increasingly realizing the urgency of
working together for common goals. "I see more of a spirit of
cooperation than I think I've ever seen," says Michael, "and that's
encouraging." Other O&P leaders and observers echo this
thought.
"In the past, O&P organizations would sometimes collaborate,
and at other times, unfortunately, we went our separate ways," says
Thomas. "Now, some of the leadership in the O&P groups is open
to collaboration, and I think that is very positive."
Thomas continues, "In lobbying Congress or educating
policymakers, if we bring them different points of view in a very
specific area of healthcare that is barely on their radar screen to
start with, the first thing they'll do is put you on the bottom of
the stack. But if you approach policymakers with a unified position
across the field, with policies that make sense in the interests of
the program and patients, policymakers are much more willing to
listen and adopt your point of view."
The field needs to look beyond any infighting in order to
concentrate on sources threatening the future of O&P,
emphasizes AOPA President Michael Hamontree. "I am convinced that
each of [the O&P] organizations operates with the goal of
improving O&P.... We need to immediately circle the wagons and
recognize that it is the private insurers, managed care, Medicare
and Medicaid, and federal and state legislators who should be the
focus of our attention."
AOPA 'Represents O&P - No One Else'
Regarding concerns that have percolated at times throughout the
field that AOPA may be trying to serve the interests of
manufacturer and supplier members, Hamontree tackles the question
head-on. "At no time have we ever represented the interests of
manufacturer reps," he says emphatically. "While some of these
companies are AOPA members, they have independently formed a
lobbying group, the National Orthotic Manufacturers Association
(NOMA) that represents their interests on Capitol Hill and at CMS.
We have absolutely no relationship with NOMA, and we do not in any
way coordinate our activities with NOMA."
He continues, "You only need to look at the position AOPA took
with the rest of the organized field of O&P throughout the
negotiated rulemaking deliberations to see how directly opposed we
are to the position NOMA has taken on qualified provider standards.
I also want to point out that, while some of our members - both
patient care facilities and suppliers - provide durable medical
equipment, AOPA has never represented a DME interest. Ever! In
fact, we have done everything possible at every opportunity to
separate ourselves from DME interests. Again, DME has its own
stable of lobbyists. It is AOPA's job to represent O&P - no one
else."
Education Makes the Difference
AOPA, along with other O&P organizations, likewise wants to
see a high standard to define "qualified providers," according to
Hamontree. As does David F. Moretto, CP, FAAOP, outgoing Academy
president (Moretto turns the gavel over to Paul Prusakowski this
month), Thomas, and others, Hamontree points out that it is the
high level of education that differentiates the certified orthotist
and prosthetist from others providing O&P services. "It is our
education and training to provide O&P services as well as the
ability to adjust and repair devices that set us apart from other
providers, and regulations that govern payment should reflect
this."
Research and outcomes studies are underway and gaining momentum
to substantiate the value of the skill sets that certified
practitioners bring to the table, and to prove the importance of
custom devices, especially in complex cases involving several
factors to consider in design, fabrication, and adjustment.
Advancing education is a goal, as shown in the recent O&P
Education Summit in New Orleans, which involved educators,
researchers, practitioners, and others. The conference, conducted
as a collaborative effort of the National Commission on Orthotic
& Prosthetic Education (NCOPE) and the American Academy of
Orthotists & Prosthetists (the Academy), reached consensus that
a masters-level education is necessary for the delivery of quality
patient care, due to the dynamic base of knowledge and emerging
processes and technologies.
Future Looks Bright
On the education front, Michael sees two bright, promising
developments that should serendipitously dovetail in about ten
years or so: research and outcomes data that validate the value of
the clinical expertise and custom devices certified practitioners
bring to the table; and highly educated clinicians who can
effectively interpret and apply this research for best results.
Regarding research and outcomes studies, Michael says, "We are
beginning to develop some of these instruments, and they might go a
long way in showing the differences in the full scope of services
we provide and limited services [of other providers]."
One problem in research has been that principal investigators in
research projects have largely come from other disciplines, due to
the shortage of O&P professionals with advanced degrees.
However, the Academy's Project Quantum Leap is working toward
increasing the number of certified orthotists/prosthetists who are
PhDs by tenfold, Michael notes. "I think that within the next 12-24
months, we will have at least two PhD programs in the US; this will
be due in part to the Academy's Project Quantum Leap." Michael also
expects to see more masters programs develop.
"The time is right for us to have the credentials necessary to
hold our own in academic settings. We don't need a large number of
PhDs, but we need to push forward with this. I think in the next
ten years or so, we'll regularly have O&P PhDs obtaining grants
and being principal investigators in research studies."
Noting that the first graduating class of the masters-level
program at Georgia Technical Institute (Georgia Tech) is oriented
to clinical practice rather than research, Michael said, "I think
it's good that the MSPO graduates are clinicians. They'll then be
the frontline consumers of research; they'll be the first ones to
implement outcomes-based practices, because they'll have the
foundation to interpret research, sort out important research from
the unimportant, and translate that into clinical practice."
Michael sees masters-level and PhD clinicians as becoming the
O&P leaders of tomorrow and ready and able to implement
outcomes measurements and other research, if available by then.
Regarding clinicians with a high level of academic training,
Michael says, "You never lose your academic preparation; you just
become a seasoned clinician and thus better able to express your
academic preparation in a practical way that makes a difference for
your patients."
Michael sums up, "If things go well, in ten years we should have
a cadre of PhD clinicians or at least PhDs who have enough
understanding of clinical P&O that they can collaborate with
clinicians. We should have validated outcomes measures that are
fairly widely used and applied clinically. We can then demonstrate
the differences we believe we see in a well-made, well-designed
orthosis or prosthesis. We will then get respect from referral
sources, Medicare, and third-party payers, because we can
demonstrate in a tangible way the difference we make."
He adds, "If we continue to work diligently, I have every reason
to think we will succeed long-term."
The catch, according to Michael, is the need for the profession
to survive before all these efforts come to fruition, and he
praises the efforts of AOPA and NAAOP to meet the current
challenges. He also praises the Academy for its longer-term goals
of increasing academic preparation and building the infrastructure
of the field.
So to summarize: Apparently there's light at the end of the
tunnel - and it isn't a train - if the O&P profession can just
hang in there.
Table Of Contents - July 2005
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