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Physical Therapists: Colleagues or Combatants?
By Miki Fairley Almost universally, credentialed orthotists and
prosthetists acknowledge physical therapists as clinical colleagues
on the rehabilitation team and agree that the two professions are
complementary and integral to best patient care. However, that's as
individuals and fellow clinicians. From an organizational and
legislative perspective, it's another story.
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Terry Supan, CPO, FAAOP, FISPO |
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"The 'problem' is with the organization [the
American Physical Therapy Association], not with the therapists in
the trenches," Terry Supan, CPO, FAAOP, FISPO, says succinctly. And
Supan should know. He and colleague Mike Brncick, CPO, who also was
interviewed for this article, are battle-scarred veterans of the
failed Negotiated Rulemaking Committee Meetings (NRM, or "NegReg")
in 2003. The committee was formed to assist then Health & Human
Services (HHS) Secretary Tommy Thompson in implementing the
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection
Act of 2000 (BIPA), which includes provisions aimed at protecting
Medicare patients from receiving orthotic and prosthetic care from
unqualified providers.
Since, as Shakespeare noted, "the past is prologue," the
present-day legislative battlefront between physical therapists and
orthotists/prosthetists regarding Medicare physical therapy direct
access legislation and increased physical therapy scope-of-practice
provisions at the state level grew from BIPA and the NRM. The
controversy centers around the educational and experience
requirements for fitting prosthetic patients and the more complex
orthotic cases which require highly trained patient evaluation,
custom orthotic design for the specific patient, along with skilled
follow-up care and adjustments.
Most certified prosthetists and orthotists acknowledge that
physical therapists, as well as athletic trainers, physician
assistants, and other allied health professionals, have the skills
to fit many prefabricated orthoses, especially since many of these
have improved in quality. But caring for amputees and orthotic
patients with more complex conditions requires much more intense
education and training--and continuing education to keep up with
rapidly changing new technology and clinical research in O&P,
most credentialed O&P practitioners believe.
At NRM, "There was a Y2K disaster for our profession that we
still have not recovered from," says Supan. About 20 organizations
regarded as stakeholders participated in the NRM. Supan represented
state O&P licensure boards and Brncick, then NCOPE chair,
represented that organization.
Legislative Saga
The original language of legislation introduced by Senator Tom
Harkin (D-IA), which would later become BIPA 2000 was generic in
nature, not naming any certifying bodies, but requiring education
and examination of individuals, Supan notes.
Political maneuvering and pressures entered the arena. The saga
was described this way:
The National Orthotic Manufacturers Association (NOMA) wanted
to make certain its manufacturers' representatives could still
direct-market to physicians and other health personnel. During the
House and Senate conference, a senator from Maryland added the name
of the Board for Orthotist/Prosthetist Certification (BOC), and
then the American Orthotic & Prosthetic Association (AOPA)
brought the American Board for Certification in Orthotics and
Prosthetics (ABC) into the language. Physical and occupational
therapists were brought in also. In the view of some, this was
considered a means to increase the power base of NOMA, which
numbers physical and occupational therapists among its members'
customers. "So instead of restricting who could provide orthoses
and prostheses to those who had formal education in O&P as a
means of controlling fraud and abuse, any salesman, physician, or
therapist could get a supplier number and bill Medicare for
custom-made orthoses and prostheses," Supan says with
frustration.
The O&P organizations, including ABC, NCOPE, the American
Academy of Orthotists and Prosthetists (the Academy), and the
National Association for the Advancement of Orthotics and
Prosthetics (NAAOP) were not happy with the legislation, Supan
says, "But we were told at the time that it was the best we could
get, and we would have to accept it."
The O&P contingent pinned hopes on Section 427 of BIPA,
which required use of the negotiated rulemaking process by the
Centers for Medicare & Medicaid Services (CMS) and which stated
that the therapists had to be "qualified," that orthotists and
prosthetists had to be "educated," and that everyone had to have a
supplier number which required them to meet supplier standards. "No
one could have imagined that the NRM would fail based on those very
issues, and that the qualified provider' decision would be thrown
back in the lap of CMS," Supan says.
APTA Drops Bomb
The American Physical Therapy Association (APTA) dropped a bomb
on the O&P group by unexpectedly declaring that "qualified"
simply means "licensed" in the state in which physical therapists
practice. Specific education requirements in O&P aren't
relevant per se, but depend on what each individual state's
licensing requirements are relative to scope of practice, as APTA's
stand was understood.
"Prior to the beginning of the NRM process, the APTA led the ABC
to believe that they were on the same side as strong advocates of
education and credentialing," says Supan. "Before BIPA 2000, there
was never any claim by the APTA that a licensed therapist was
competent to provide custom orthoses or prostheses based solely on
their license." It came as a shock when both the APTA and the
American Occupational Therapy Association (AOTA) made that
assertion at the very first meeting of the NRM, Supan adds. "It
also came as a surprise to discover that several of the state PT
practice acts were changed after 2000 to include fabrication and
fitting of orthoses or prostheses as part of the responsibilities
of a physical therapist. Low-temperature upper-limb orthoses have
always been a therapy modality in OT, but this was new for PT."
After World War II, orthopedic surgeons and physiatrists became
vocal advocates of the clinic team model of rehabilitation, Supan
recalls. That was the beginning of bringing orthotists and
prosthetists into the medical arena. It was common for the PT to
have the administrative lead for these clinics, but even when
O&P was still largely simply a trade or craft, Supan recalls,
"Even the very experienced therapist knew to rely on the orthotist
or prosthetist and would never have had the audacity to think that
he or she could provide the orthoses or prostheses. It is even more
apparent today with the advanced education and clinical training
required of a CPO."
Clinical Colleagues
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Mike Brncick, CPO |
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At the moment, in the real world, the clinical
setting, scope-of-practice issues don't appear to be a problem. "In
a clinical setting, our professions are complementary," says
Brncick. "We respect each other's scope of practice and
expertise."
For instance, prosthetists are more able than PTs to consult
with orthopedic and vascular surgeons about levels of amputation
that would best enable the patient to use a prosthesis. (Of course,
in some trauma cases, the first necessity is saving the patient's
life, and deciding the best amputation level for prosthetic fitting
is not an option.) They can provide input on preprosthetic and
postoperative care and componentry options. Postoperatively, the
prosthetist can help reduce swelling and tissue trauma in the
residual limb. The prosthetist and physical therapist can work
together to help the amputee rehabilitate faster. Brncick also
cites the example of working with stroke patients: the physical
therapist can assess changes in patients' neurological abilities
and work together with the orthotist to provide optimum care.
Helping amputees cope with phantom pain is another area of
mutual cooperation. Both disciplines utilize modalities to reduce
phantom limb pain; physical therapists may use TENS (transcutaneous
electrical nerve stimulation) units; O&P students are likewise
taught various methods. Brncick recalls how he and a physical
therapist worked together to help reduce phantom limb pain for his
father, who was a bilateral transtibial amputee.
In Brncick's experience, the physical therapists don't want to
do O&P and will even say they are not qualified. Supan points
out that generally physical therapists have had to be trained by a
prosthetist in how to help their patients use an upper-limb
prosthesis or how to help amputees learn to walk with a prosthesis.
"And they continually come back to the prosthetist for more
consultations on how to train amputees with new technology that
comes out," he adds.
However, what the APTA is aiming for is that "licensed" equals
"qualified to practice the entire scope of orthotics and
prosthetics," according to Supan and Brncick. They reason logically
that how can a brief introductory, overview course in O&P that
perhaps a therapist may have had as long as 20 years ago, be
equivalent of the 490 to 565 clock hours of training and learning a
core curriculum of O&P? This is what's required in the
NCOPE/Commission on Accreditation of Allied Health Education
Programs (CAAHEP) schools--plus a one-year residency before being
able to sit for the ABC exam. One could ask, "Who would you rather
have providing prosthetic and complex orthotic care for someone in
your family?"
Reasonable Solutions?
A reasonable solution that has been proposed by some is that to
practice comprehensive O&P care, physical therapists should
take the core O&P curriculum at an NCOPE/CAAHEP-accredited
school, since, as Brncick observes, they do already have a good
background in health science courses such as anatomy and
physiology. He notes that there are some well-qualified physical
therapists that are now excellent orthotists and prosthetists.
These dual-credentialed individuals "did it the right way," says
Brncick. "They came through O&P programs and went on to become
certified."
Another possibility is a tiered system of qualifications
required to practice O&P at various levels, such as already
exists with ABC and BOC.
To maintain their certification status, certified prosthetists
and orthotists are required to earn a specified number of
continuing education credits. This reporter has been unable to find
out if any physical therapist licensing statute requires continuing
education credits specifically in O&P, a necessity to keep up
with the rapidly advancing technology and new clinical research and
efforts to establish practice guidelines in this constantly
evolving field.
Ironically, prosthetists and orthotists perform some of the
functions of physical therapists in gait training and teaching
patients use of the prosthesis--but they can't bill for it, since
the HCPCS L-Codes include the service component. However, PTs can
bill L-Codes for devices they provide, plus bill CPT codes for time
spent. To put the frosting on the cake, to payers and consumers,
the devices supplied by PTs may appear cheaper, since they may
overlook the skilled service aspect included in the global
L-Codes.
Analysis
In overall strategy, there often are linking objectives--a sort
of "connect-the-dots." The APTA is working hard to get the Direct
Access to Physical Therapy legislation passed. Thus, PTs could
treat Medicare patients without a physician's prescription,
providing whatever services they deem necessary and that are
allowed by the individual therapist's state practice act and
licensing requirements. Obviously, the more physical therapists can
enlarge their scope of practice in each state to include O&P,
or a higher level of O&P, the better.
Tying in with this is APTA's goal of an entry-level doctorate
degree (DPT) and its "Vision 2020." The APTA website ( www.apta.org) gives
this vision sentence and statement:
Vision Sentence: "By 2020, physical therapy
will be provided by physical therapists who are doctors of physical
therapy, recognized by consumers and other healthcare professionals
as practitioners of choice to whom consumers have direct access for
the diagnosis of, interventions for, and prevention of impairments,
functional limitations, and disabilities related to movement,
function, and health."
Vision Statement: "Physical therapy, by 2020,
will be provided by physical therapists who are doctors of physical
therapy and who may be board-certified specialists. Consumers will
have direct access to physical therapists in all environments for
patient/client management, prevention, and wellness services.
Physical therapists will be practitioners of choice in clients'
health networks and will hold all privileges of autonomous
practice&."
What is the rationale for having professional (entry-level) DPT
programs?
The APTA on its website ( www.apta.org) includes the answer in a list of
FAQs. Among reasons are:
- "Societal expectations that the fully autonomous healthcare
practitioner with a scope of practice consistent with the Guide
to Physical Therapist Practice be a clinical doctor; and
- "The realization of the profession's goals in the coming
decades, including direct access, physician status for
reimbursement purposes, and clinical competence consistent with the
preferred outcomes of evidence-based practice, will require that
practitioners possess the clinical doctorate (consistent with
medicine, osteopathy, dentistry, veterinary medicine, optometry,
and podiatry)
- "Many existing professional (entry-level) MPT programs already
meet the requirements for the clinical doctorate; in such cases,
the graduate of a professional (entry-level) MPT program is denied
the degree most appropriate to the program of study."
What's Next?
So, what's next? Effective October 2005, providers in states
that require O&P licensure must be registered with the National
Supplier Clearinghouse (NSC) as one of the specialties allowed to
bill for O&P, or they will no longer be reimbursed for
prosthetic and certain custom-fabricated orthoses. As of press
time, CMS is expected to soon implement nationwide the qualified
provider provisions set out in BIPA.
Under congressional authorization, CMS will soon mandate
orthotic and prosthetic quality standards for all O&P patient
care locations, notes ABC. "For our profession, the Medicare
requirements will effectively raise patient care standards to the
uniform standards of accreditation. This is an important milestone
in the evolution of O&P patient care, as the accreditation
standards measuring patient management, quality care, assessment,
evaluation, and safety will ensure a basic care level for all
Medicare patients. We can expect that the Medicare standards will
be adopted by other third-party payers."
Besides legislative efforts, what else can the O&P
profession do? Working to attain more public recognition of the
O&P profession is another avenue to increase awareness of the
value of the credentialed prosthetist and orthotist, Brncick points
out. The return of war-wounded soldiers and the high-tech,
visionary prosthetic research underway by the military are
capturing the public's attention. High-profile elite disabled
athletes likewise are garnering much more media attention. "We need
to let people know that we are the profession that takes care of
these people--not only military amputees and veterans, but also the
growing population of people with diabetes and other conditions who
need O&P care," says Brncick.
"The educated consumer of healthcare is a good consumer of
healthcare," he continues. "We need to make people aware that when
they or a family member needs orthotic or prosthetic care, to ask
questions of providers--for instance, 'Are you certified?' "
Editor's Note: The O&P EDGE has requested
that the American Physical Therapy Association (APTA) write or have
a spokesperson be interviewed for an article presenting its
perspective on these issues.
If such an article can be obtained, The O&P EDGE will
publish it in a future issue. 
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Arizona Couple Shows Patient Advantages of O&P, PT Partnership
- March 2006
Feature
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PT 'Direct Access' —Why Is It Considered a Threat?
- July 2005
Feature
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PT Direct Access: Threat to O&P?
- September 2003
Should physical therapists have “direct access” to patients—being able to provide physical therapy
services without a physician’s prescription?
With or without the passage of “direct access”
legislation, should physical therapists be allowed to provide orthotic and prosthetic services and devices, without additional education, training, licensing, and/or certification, as part of their scope of practice?
Feature
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It’s All About Education, Training, and Experience
- June 2003
Perspective
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Physical Therapists: Are They Encroaching on O&P?
- April 2003
Are the two disciplines complementary or competitive? How much do they overlap? Here, two physical therapists with wide experience in working with prosthetic and orthotic patients give their views.
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Prosthetists: A Physiotherapist’s Perspective
- March 2003
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Physical Therapists: Partners or Competitors?
- October 2002
Orthotists and prosthetists share their views on this controversial question. Next month, physical therapists and those who practice in both fields will get their say.
Feature
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Table Of Contents - March 2006
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