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US Certification Skirmish: ABC and BOC

Introduction:

To understand the surprising recent certification developments in the USA, several related topics must be summarized, including licensure, accreditation of training programs, the BIPA 2000 law, and Negotiated Rulemaking. One of the most critical tasks is to define the basic concept of certification. From this foundation, a rational discussion of some of the controversial issues that are currently being hotly debated can then follow.

Certification: A Voluntary Standard

The process of certification allows a field to establish specific standards for training, education, and experience judged to be appropriate and to recognize individuals who have met those standards. Unlike State licensure, certification does not restrict anyone from practicing since it is a voluntary standard. Certification is based on the assumption that the best performers in each field will choose to earn that voluntary credential, and that has certainly been the case with U.S. prosthetists and orthotists.

Proponents of certification argue that it is much less involved than legal standards such as licensure and can therefore be more readily implemented and upgraded as the field evolves over time. The costs of certification are also borne by certifees within the field rather than by all citizens who are taxpayers. This is one reason why both Federal and State governments actively discourage licensure. When first implemented, certification typically has limited practical impact, but it can develop more meaning over time as its value is more and more widely acknowledged.

American Board for Certification in Prosthetics and Orthotics

As many readers may already know, the United States was one of the first countries to implement professional certification for prosthetists and orthotists, more than half a century ago. The American Board for Certification in Prosthetics and Orthotics was established in 1949 by a group of visionary practitioners who recognized the need for established standards to gradually increase the level of knowledge in the field and to better serve patients with physical disabilities who require P&O devices. Initially, the primary qualification for certification was continuous full time experience in the field.

In the 1950s, optional formal training courses were implemented. Once the courses became well established, they formed a core curriculum to insure that all candidates had a uniform education. An examination process was developed, initially based on individual evaluation of each applicant by a volunteer corps of senior practitioners. Soon, a uniform written examination was instituted, and physicians specializing in orthopedic rehabilitation joined the CPOs in orally examining each candidate to independently verify the breadth of their knowledge of the field. Documented work experience under supervision of an ABC Certifee has been one of the fundamental requirements to sit for the ABC exam since the 50s.

By the 1960s, practitioner training had evolved into a formal academic process with New York University inaugurating the world's first [and at that time, only] Bachelor's degree in P&O while Northwestern University and the University of California at Los Angeles offered post-graduate certificate programs in P&O for students who had already completed their basic college course work elsewhere. Intensive short-term courses of approximately one month's duration were also offered so that the motivated student could remain employed full time and use vacation time to sequentially complete the same clinical specialty education over several years.

Initially, post-secondary academic education was offered but optional, but in each decade the entrance standards were gradually increased, first to a minimum of a two-year Associate degree and later to a four-year undergraduate degree. Curriculum standards were developed too and an accreditation process for P&O schools was implemented to insure that every student received a sound basic education in the fundamentals, based on necessary practice skills identified by successful ABC Certifees. By the 1980s, the minimum entry-level standard had become a four-year academic undergraduate degree including successful completion of specified course work in physics, anatomy, kinesiology, and similar core subjects. The short-term courses were gradually phased out, insuring that all new applicants for ABC certification had a uniform baseline academic background of at least a four-year college degree.

Once all new candidates could think, write, and reason at an undergraduate level, ABC could then make the examination process progressively more stringent as well as more objective, and the certification examination expanded to include written, oral, and practical components that were developed in consultation with testing experts. By the 1990s, the ABC exam included psychometrically validated written and clinical simulation segments and all new Certifees had a minimum of a Bachelors degree. The informal period of supervised work experience had evolved into a structured Residency with specific clinical experience requirements to insure exposure to a broad range of patients and pathologies.

By the dawning of the new Millennium, all new ABC Certifees had earned academic degrees that included specific core courses, completed a one-year Residency per discipline, and passed psychometrically valid national examinations.

Board for Orthotist Certification:

By the 1980s, it became clear that an increasing number of individuals who were successfully practicing full time had either not passed the ABC exams or would not be eligible under the current rules. For example, most of the military training programs have never been accredited so even very talented and experienced practitioners had to repeat their education at an accredited civilian program for ABC eligibility. The Veteran's Administration also had a "VA Qualified" program for many years that granted a credential that did not require passing a certification exam. Increasing demands for an alternative pathway to become and orthotist ultimately resulted in formation of the Board for Orthotist Certification.

Initially, proof of full-time work experience was the primary requirement for certification as an orthotist by the BOC but a written examination was soon implemented. In many ways, the evolution of the BOC examination has paralleled ABC's early history, with the scope and psychometric validity gradually increasing over the years. The BOC was the first to offer a Fitter credential for individuals specializing in providing prefabricated soft goods and later for those specializing in providing mastectomy restorations.

By the 1990s, the BOC had added certification as a prosthetist to their available credentials and a requirement for continuing education to maintain certification. Consistent with their slogan that "The difference is experience", the BOC has never required more than a high school diploma [or equivalent] for any of their credentials, arguing that passing a national examination is sufficient.

Licensure:

The United States does not have Federal licensure for any health care profession. Part of our heritage of decentralized government is the tradition that licensure must be implemented by individual States, based on their independent assessment of its value to their citizens. Of course, once all fifty States license a profession, in effect you have a national requirement. However, not every State sets licensure standards at the same level and therefore someone who is licensed in one jurisdiction may not be able to practice in nearby town just across the State line. The ideal is to have uniform licensure standards with reciprocity throughout the country, but it usually takes many decades to achieve this goal.

The first debates on licensure of prosthetists and orthotists that I recall occurred in Illinois during the late 1970s, when I was a fledgling Northwestern University graduate. The Illinois Legislature twice passed a bill mandating licensure to practice our profession that was widely [but not universally] supported by the practitioners of that era. Both times, the Governor vetoed the legislation, so it was never enacted and a recommendation from the Federal government to institute a moratorium on the licensing of new fields made it almost impossible to pursue the matter further at that time.

Interest in licensure was rekindled in the 1990s, although it remains a hotly debated topic. As of 2004, P&O licensure laws have been passed in approximately 20% of the States and legislation is pending or under active consideration in a number of others. Thus far, all States that have implemented licensure of CPOs have adopted the current ABC standards as the basic requirement. ABC has prepared model licensure law templates and actively cooperates in administering examinations or other support services for those States who have requested such assistance.

Under the US system, licensure cannot be used to restrict someone else's ability to earn a living. In effect, this means that every time a new field is licensed, the State will automatically grant a license to anyone who has been practicing full time, regardless of their other qualifications. Typically, at least two years of documented full-time employment is required to become "grandfathered" as a licensed practitioner.

The practical result is that all certifees and all non-certifees who apply automatically become licensed practitioners, so initially the status quo does not change. This is why both BOC and ABC certifees find themselves licensed under State law despite the differences in their certification requirements.

Over time, licensure has a much more powerful impact since the full standards take effect after the grandfathering period ends. Because licensure has the force of law behind it, serious violations carry stiff penalties including fines and jail time. [In contrast, although certification is generally revoked if a practitioner is convicted of a major crime, in States without licensure it is perfectly legal for non-certified individuals, including felons, to continue practicing.]

It has been said that certification standards open a door that one may choose to walk through, while licensure closes the door behind you, imposing standards on those who follow.

BIPA 2000:

Medicare is a Federal program that pays for an increasing percentage of prosthetic and orthotic care in the US, primarily for retired citizens. Historically, there have been no qualifications required to bill Medicare for P&O services. After the American Orthotic and Prosthetic Association documented repeated instances of questionable billing, such as a department store charging Medicare for custom-made prostheses including a carbon fiber dynamic response foot, Congress passed the "BIPA" law and ordered Medicare to develop standards to insure that only "qualified" individuals are paid for providing P&O services.

This was a momentous change, and one that generated much debate and many discussions since this was the first time a national law tried to restrict who can be paid for P&O care. The legislation specifically included both BOC and ABC certifees as "qualified" but instructed Medicare to convene a panel of stakeholders to try to reach consensus on who else should be considered "qualified". Unfortunately, after many months of long negotiations, this Negotiated Regulations [NegReg] rulemaking group adjourned without reaching universal agreement, so Medicare officials must now make this decision unilaterally.

Merger Mania?

One of the byproducts of the RegNeg discussions was that, for the first time, both ABC and BOC representatives found themselves discussing important issues about the future of the profession together on an ongoing basis. It became increasingly clear as the RegNeg meetings continued that having two difference certification standards for prosthetists and orthotists was confusing to the government and many other professionals, to say the least. In January, the BOC and ABC Boards amazed most of the country by announcing that they were undertaking serious discussions to see if they could merge into one comprehensive certification entity.

Not surprisingly, this possibility generated considerable anguish and argument within the field. Younger practitioners, particularly those who were about to start their formal training in P&O or who had recently done so, began wondering if it made sense to continue their education. This made the accredited P&O schools worry about a future decline in applicants. BOC practitioners were concerned that the alternative pathways that were easier to pursue while working full time might soon disappear. ABC practitioners felt that including those BOC certificants who had no formal education beyond the twelfth grade would lower the perceived value of their credential. Despite these serious questions, the two Boards had a series of meetings to look for some way to combine into one entity.

At the start of this month, a flurry of competing emails and press releases informed the field that the merger negotiations had broken off. As has traditionally been the case, BOC and ABC had different viewpoints on what had happened, and a series of conflicting memos and statements began to circulate. The interested reader can study both viewpoints by going to the BOC [www.bocusa.com] and ABC [www.abcop.org] sites.

Since the first of the month, my phone has been ringing off the hook and my In Box has been filled with a steady stream of email inquiries from colleagues across the country trying to sort out what has happened. In view of the concerted interest in this complex topic, I decided to hold off on posting the normal March Corner to develop this article instead.

The Latest Salvo:

This situation is still fluid, but as this article is being published, the following major developments have occurred:

1. ABC has offered all BOC credentialed individuals a time-limited opportunity to receive the equivalent ABC credential. In other words, a BOC orthotist would be grandfathered in as an ABC Certified Orthotist, a BOC Fitter as an ABC Registered Fitter, and so on.



2. The BOC has offered all ABC credentialed individuals the same opportunity for reciprocal recognition.



3. Both Boards have prepared public relations statements presenting their actions in the best possible light and highlighting differences between their certification program and that of the other group.



4. The Academy has temporarily suspended inducting new members and is trying to sort out all the ramifications of this situation.

What Does This All Mean?

No one can predict these Boards' next actions, so any assessment is only as accurate as the currently available information. With that caveat in mind, I will offer my thoughts on this matter.

Personally, I am disappointed that it was not possible to effect a friendly merger between the two entities. I realize how heartfelt the core issues were for both Boards, and congratulate them both on taking a long, hard look at "the unthinkable": That took a lot of courage.

I continue to believe strongly in the value of formal education and in progressively increasing our standards, to better prepare new graduates for the future in which they will be practicing. But, I think continuing to have two different certifying bodies is worse for the field in the long run than to temporarily lower the educational standards for certification to achieve unification.

If all certifees wind up holding the same ABC credentials, the net result will be the same as when the field is licensed in all fifty States: all BOC practitioners will have been grandfathered in and we will then have one certification standard. In essence, that would move us all closer to universal CPO licensure with reciprocity.

The New York Board Lesson:

As Yogi Berra is credited with saying, "This is deja' vue all over again!" I distinctly recall hearing virtually the same arguments, worries, fears, and commotion back in the 1980s when ABC reached a merger agreement with the NY Board, a body who granted an orthotist certification credential that was recognized locally but did not meet the ABC standards. At that time, I was vehemently opposed to granting ABC certification without passing the examination, and predicted dire consequences including lowering the perceived value of my CPO, and fully intended to allow my credential to lapse in bitter protest.

Fortunately, it was many months until the renewal date for certification and by then it had become crystal clear that my worries were grossly overblown. Much to my amazement, neither patients nor referral sources noticed any difference after that merger. Even though I was heartsick at how "unfair" it was, grandfathering several hundred successful practitioners into ABC was a non-event to the rest of the world.

The only lasting change was that ABC certification was no longer an absolute guarantee that the individual had been trained and tested in the full scope of practice principles. But, the solution to that dilemma as an employer was simply to request proof of graduation from an NCOPE accredited program in addition to ABC certification in good standing from all job applicants. So, I could still quickly identify those candidates with the combination of education, experience, and certification testing that I valued.

I had some vague worries that some of these newly grandfathered certifees might somehow divert attention from the importance of continuing education or otherwise have a profound negative effect on the profession. That too turned out to be unfounded. Many of the former NYB certifees were actually very good clinicians who had, indeed, learned a great deal from their mentors and who were enthusiastic supporters of lifetime education. They soon became cherished ABC [and Academy] colleagues.

There was a subset from the NYB group who did turn out to be uninterested or unable to benefit from continuing education, but they soon dropped from the ABC rolls when they failed to meet the recertification standards. Within a few years, all my concerns had proven to be futile. I suspect much of the current consternation will similarly dissipate over time, and I would certainly encourage everyone to avoid making any rash decisions in the heat of this current imbroglio.

Four Burning Questions:

This editorial will conclude with my responses to the four most common questions I have been hearing in recent weeks. I make no claims that my comments are correct or right for anyone else, but simply hope that they provide food for thought as my P&O colleagues struggle to find their own answers.

1. Why should I now spend the time/money/effort to complete my education at an NCOPE-accredited program?

For the same reasons that applied prior to March 2004. If you believe that comprehensive training and testing based on a curriculum developed from recommendations by successful practitioners will help you deliver better patient care, then you should complete an NCOPE-accredited program. No matter how this certification ruckus is resolved, the reasons for an academic education remain unchanged, and I predict that completion of an NCOPE level program will carry increasing value over the next decade.

2. What's the point of completing a formal residency now?

That too is unchanged by whether or not ABC grandfathers in other colleagues or not. P&O has adopted a structured residency format for the same reason as most other health care fields: that structure has been shown to be one of the most effective mechanisms to build the bridge between theoretical knowledge and applied clinical skills. When the residency has formal requirements, the new graduate is exposed to a wider range of important applications for academic concepts more quickly than generally occurs in an unstructured work experience. If you want to become a broadly skilled clinician as rapidly as possible, formal residency remains your best option.

3. Why should I bother with the ABC examination now?

Maybe you shouldn't. If you see ABC certification is an exclusive group like a private country club, then to have certifees with varying levels of academic training makes it a much less attractive accomplishment. On the other hand, if you want to measure yourself against a national yardstick established by your peers that has been systematically upgraded and validated over the past half-century, then it continues makes good sense to accomplish this goal.

4. Isn't it unfair if some people become ABC Certified without meeting the same standards as the rest of us?

Yup. Get over it: Life's not always fair. The more important consideration is what will be best for the future of the profession. I believe the value of a unified voice trumps any temporary unfairness and can accelerate the pace of nationwide licensure in the field.

So, from a long term perspective, I would encourage my fellow ABC certified practitioners to graciously welcome our BOC colleagues into the fold and to work with them to move the field forward. We face too many external challenges to continue devoting so much energy to internal bickering.