Leveraging Power:
How O&P Professionals Can—and Why They Should—Be Involved in Legislation

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"Politics ought to be the part-time profession of every citizen who would protect the rights and privileges of free people and who would preserve what is good and fruitful in our national heritage."

—Dwight Eisenhower

No matter who you are—patient, clinician, businessperson, or manufacturer—a major piece of healthcare policy or legislation came into play in the past year that could change your life. Whether it's the 2.3-percent excise tax on Class I medical devices that was shoehorned into the new national healthcare reform law, the budget cuts that could have eliminated O&P from California's Medicaid benefits, or local campaigns for state licensure initiatives, current O&P-related legislation may affect revenues, access to care, and innovation across the profession. Unfortunately, many in the field are daunted by the question of how to advance initiatives that they believe to be in the profession's best interest. Can a single person, one organization, or the relatively small constellation of businesses and professionals that make up O&P have any real effect on laws whose purveyors measure billions of dollars as pocket change? Is it worth taking time away from the demands of business and family to try? Experts and everyday citizen legislators say it is.

"Politics is the art of the possible," said 19th century Prussian/German statesman Otto von Bismarck, and the modern political artisan's toolbox includes habits and methods that can be both effective and accessible to anyone with a stake in O&P. Its more esoteric devices, the ones insiders use to leverage money and projects on a national scale, are also accessible to stakeholders who use cooperation, diligence, patience, and tenacity to control them.

Knowing Is Half the Battle

Kirk

According to Tom Kirk, PhD, president and CEO of Hanger Orthopedic Group, Bethesda, Maryland, the most important element of political effectiveness is awareness, and for O&P professionals, that starts with reading the information provided by trade and clinical associations. "From NAAOP to the Academy to AOPA, we're constantly flooding our profession with information about what's going on.... And if you have a question about what we've written, pick up the phone and call Tom Fise, Peter Rosenstein, or Kathy Dodson and ask, ‘What does this mean?'" [Editor's note: Fise is the executive director of the American Orthotic and Prosthetic Association (AOPA); Rosenstein is the executive director of the American Academy of Orthotists and Prosthetists (the Academy); and Dodson is a senior director at AOPA. George Breece is the executive director of the National Association for the Advancement of Prosthetics and Orthotics (NAAOP).]

In an interview from the halls of the 2010 AOPA Policy Forum, held March 26–27, Kirk ticked off the three issues that forum participants concluded the profession will be "stuck with" if it doesn't influence policy effectively. The first issue, he says, is declining reimbursement. "In the last 26 years or so, the Medicare fee schedule has only gone up 45 percent while the whole consumer price index urban has gone up over 145 percent." Part of the profession's policy work, he says, must be in teaching legislators how the economics of O&P work—that, for example, the price of many devices includes months of uncompensated patient care. If politicians don't understand this and cut fee schedules, Kirk says that less efficient businesses may close, leading to reduced access to patient care. In a worst-case scenario, a severe shortage of clinicians could lead to politicians ruling to reduce qualification standards for the field.

This leads to the second problem, Kirk says: governmental ignorance of the O&P professional's skill set. "People need to understand the unique skill sets required to deliver quality items, and by that I mean understanding accreditation, certification, and licensure and how they play out in patient care in order to get a good outcome." Without this understanding, he explains, legislators unwittingly accommodate fraudsters and those who provide substandard patient care for the sake of an easy buck. This, in turn, tarnishes the profession's reputation, diminishes integrity of care, and shrinks the pool of money available for reimbursing legitimate professionals.

The third issue, Kirk says, is limited clinical education. Few people on the Hill "appreciate the supply dynamics of our practitioners," Kirk says. Though the Academy has secured funding through its U.S. Department of Education grant and for its Paul E. Leimkuehler Online Learning Center (OLC), Kirk contends that the profession badly needs a steady stream of new professionals to care for aging Baby Boomers and new patients with diabetes while it increases ongoing education in new technologies.

Opportunity Awaits

McCormack

However, the urgency to move policy forward isn't just about dodging bullets, Kirk and others emphasize. Doug McCormack, co-owner and CEO of Orthocare Innovations, Oklahoma City, Oklahoma, and a former lobbyist for the profession, points out that in particular, the war efforts in Iraq and Afghanistan have sparked opportunities. In the public eye, he says, "amputation…is a signature injury of the war effort," and has prompted "unprecedented spending through the DARPA Revolutionizing Prosthetics project and many, many other initiatives that have been funded by Congress and administered through the Department of Defense and Veterans Administration." He concludes that in the short time that public attention rests on these ideas, it is "essential that there be effective transition of the developments from those programs so that new products and technologies can actually be applied toward effective patient care, not only to improve the rehabilitation outcome of amputees but also to show a return on the government's investment."

Wall

For those on the coalface of patient care, R&D isn't the only place to effect change. The Massachusetts Society of Orthotics & Prosthetics (MSOP) has a committee that has worked for most of a decade with its state's Medicaid directors to make the program more just, modern, and efficient. John Wall, PT, CPO, FAAOP, has worked on the committee for more than five years to help update Mass Medicaid's archaic prescription requirements and remove antiquated procedures from its fee schedule. Because MSOP has offered numerous cost-saving suggestions to Mass Medicare, the two entities now have a mutual good-faith relationship.

"The people we work with at Mass Medicaid now appreciate us for our willingness to be honest with them," Wall says, recounting how the agency now sends e-mails to his committee members for their opinion on suspicious claims, trusting them to advise when something should be denied. MSOP's honesty makes the relationship "a two-way street," he says, giving the society more opportunities to "do the right thing for both Medicaid and for the industry."

Best Practices for Moving Policy

MSOP's integrity in its legislative relationships is an example of the kind of politicking that advances the profession. A variety of Beltway insiders interviewed for this article described this and other methods that O&P players both large and small can use to maximize political influence.

Among all the techniques mentioned, foremost was the art of cultivating relationships with individual legislators. In a time when budget constraints, overwhelming competition for funds, and the fierce scrutiny of public watchdogs push politicians to champion only sure, inoffensive requests such as those from municipalities and transportation agencies, the single best method for advancing O&P is to personally connect with those in power. First, find out who your legislators are by visiting www.usa.gov/contact/elected.shtml. Then, personally get to know those individuals, working patiently and, if possible, without making requests at first.

"You don't have to write huge checks to become an active participant at any Congressperson's events," McCormack says. "Volunteering in the community is a great way to get to know not only legislators but their local field representatives as well, and those can become very, very beneficial relationships over time. Those people handle issues on a day-to-day basis—they're the people legislators take their cues from." According to some lobbyists, town-hall meetings and low-cost fundraisers for politicians also offer great opportunities to simply shake your legislator's hand, introduce yourself, and thank him or her for something that touches the profession. Saying, "Thank you for supporting veterans—my name is Jane Smith, I own an O&P business, and I fit prosthetic limbs for a lot of vets," is likely to mean far more to a politician than will a faceless demand for support.

Participation like this can't happen just once a year, McCormack stresses. "It's consistent local engagement that really develops strong relationships and ultimately turns someone who might generally be interested in the field into a true champion of the various causes related to O&P."

Once you've connected with legislators, the next step is to help them to comprehend the reality of O&P practice and business. Bryce Docherty, executive director and legislative liaison at the California Orthotic & Prosthetic Association (COPA) says, "O&P has a great story to tell…. In my opinion, facility tours are hands-down the most effective way to get O&P's story out and to get people on our side." It may take a year or two of repeated invitations and reschedulings to get a Congressperson into your facility, lobbyists say, but it's well worth it.

"The former chair of our state health committee and the current chair of our subcommittee on health responsible for funding our Medi-Cal program toured a facility where we showed them a $55,000 prosthesis and then compared it to the components that Medi-Cal patients get," Docherty says. "It was an amazing visual." McCormack recommends inviting patients and employees to be part of the tour, and to make it "a very friendly place to talk about issues." Alternately, at certain times of the year, most legislators hold roundtable breakfasts with businesspeople to get a handle on various issues. At such a breakfast, you and a group of your colleagues can answer your legislator's questions about a variety of problems while making the legislator conscious of O&P.

Docherty notes that the ultimate way for individuals to move policy is to get elected themselves. "I'm still trying to find an O&P provider who could run for public office here in California," he says. "[Some] legislators are physicians, dentists, optometrists, psychologists—just various folks in healthcare professions who have made it part of their objective while being in office to further their profession. O&P providers should be encouraged to run for school boards, city council, and county government, and if they have political leanings one way or another, they should get involved in their local Democratic or Republican party."

Standing Together

No matter what, being involved in groups—even in non-O&P related groups, such as a chamber of commerce—makes you more interesting to legislators than you would be working as a lone gun; the more connections you have, the more influence you wield. Organizations that span regions touch the constituents of multiple legislators at one time and can also allow for hiring experts and coordinating with other groups to create even more powerful coalitions.

Calhoun

If you're just getting involved in politics at a time when urgent action is already needed, if you're crunched for time and money, or if you want to supplement your individual legislative efforts, your best vehicles for moving policy may be professional and consumer organizations.

"As citizens, we have an opportunity to have a voice in the legislative process, and usually that's best done cooperatively because it's hard to hear individual voices," says Kendra Calhoun, president and CEO of the Amputee Coalition of America (ACA). "When bringing coalitions together, we don't have the luxury to duplicate efforts, so we make written plans and goals, identify our strengths, and clarify objectives." She adds, "The ACA and trade associations like AOPA work to make individuals' efforts even more substantial."

Rosenstein

Peter Rosenstein, the Academy executive director, concurs. "The Academy tends to advance our governmental affairs on the federal level through the Alliance...," he says. "In most cases, the way the Alliance works is that for it to take a position on something, its four member organizations—NAAOP, ABC, the Academy, and AOPA—all have to agree on it.... It allows the profession to really try to speak with one voice and be more effective."

Rosenstein notes that the Alliance uses its substantial resources to advance the profession in myriad ways. "We provide information and education not only to Congress but also to federal agencies, including HHS and CMS, so a lot of the information that we provide to those agencies is again information that all the groups agree on."

Thomas

Peter W. Thomas, JD, general counsel for the NAAOP, says that one of the Alliance's top efforts is to ensure that O&P benefits are mandated in the basic benefit package used by every state and regional insurance exchange planned under the new healthcare law. Part of that effort is in developing a series of white papers that explain O&P's parameters, circumstances, and viewpoint to a variety of agencies. "We plan on sending this white paper to the National Association of Insurance Commissioners (NAIC) and to their panel of consumer representatives," Thomas explains. "We plan on distributing it widely across HHS and...Capitol Hill to make sure that the people who are working on O&P policy read it, understand it, and see where we're coming from."

Forum for Change

Another top collaborative effort of the profession this year was the AOPA Policy Forum. More than 100 members of the profession convened from 26 states for the event. Primary among their activities was cultivating relationships with the profession's strongest defenders in the District, holding fundraisers for Representatives William Cassidy (R-LA) and Jason Altmire (D-PA) and Senator Tom Harkin (D-IA). The relationship with Harkin has become an especially powerful one. Kirk quoted Harkin as saying to attendees, "I understand and support your cause. Don't worry…. I have a strong say when it comes to funding for HHS, and I will see that your message gets through."

AOPA leadership also met with power brokers including House Veterans Affairs Committee Chair Bob Filner (D-CA); CMS' Deputy Administrator of Program Integrity, Peter Budetti; and attendees at a meeting for consumer organizations including the ACA, the Brain Injury Association of America, and the National Multiple Sclerosis Society. O&P stakeholders hashed out questions and plans for dealing with many current and potential issues—"things we really need to keep our eyes on," Kirk says.

Avoiding destructive policy changes, creating alliances, and capitalizing on opportunities are all major reasons to use the tools that suit you to get—and stay—involved in legislation. Tyler Dunham, an MSPO student at the Georgia Institute of Technology (Georgia Tech), Atlanta, added a philosophical reason as well. "We have to extinguish apathy," he says. Of the professionals he interviewed for a 2010 academic project on O&P legislation, he says, "most of them were in their 50s or 60s and were so deeply passionate about these issues. They're never going to reap the rewards of the efforts that they're putting in. Even if they're wildly successful with their legislative endeavors, they're still probably going to be retiring in the next five or ten years. They're doing this for the next generation of practitioners...and if nothing else, I feel that we have a duty to them to at least understand what's going on."

Morgan Stanfield can be reached at

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