State by State: Licensing in O&P

On the heels of the Centers for Medicare & Medicaid Services’ (CMS) announcement that all orthotic, prosthetic and pedorthic facilities must obtain accreditation by Sept. 30, 2009, professionals across the United States are wondering if licensure also will become mandatory. O&P Business News explores this standard, its benefits and its practical applications.

Licensing by state

According to the American Academy of Orthotists and Prosthetists’ Orthotic & Prosthetic Licensure: A Comprehensive Guide, licensure benefits the patient through established criteria for education and experience.

“Licensure requirements are in the best interests of the profession in that they give official status to the practice of the profession, establish a recognized scope of practice for orthotists and prosthetists, and will be recognized by other health care practitioners in crossover of patient care responsibilities,” the Academy wrote in the Guide.

With initial costs ranging from $20,000 to $100,000, licensure has not been a state priority. In addition, ongoing costs can run between $100 and $800 for individual practitioners or for facilities, depending on if the facility owner decides to pay for each practitioner in the office.

A dozen states, however, have stepped forward to pave the way for the rest. Currently, O&P practitioners are required to be licensed in the following states: Alabama, Arkansas, Florida, Georgia, Illinois, New Jersey, Ohio, Oklahoma, Rhode Island, Texas and Washington. Tennessee became the 12th state to pass a licensure bill in 2006, and enacted the law this January; O&P members are working to finalize its provisions.

Tennessee: Completing the process

John Reynolds, CPO, of Reynolds Prosthetics & Orthotics Inc. in Maryville, was one of the active O&P practitioners involved in the licensure process in Tennessee. He spoke to O&P Business News about working to get the bill passed.

The first order of business for the O&P community was writing the bill, and practitioners found helpful information from a host of sources. As a foundation, the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) has a prototype available on its Web site for states interested in pursuing licensure. The Model Orthotics, Prosthetics and Pedorthics Practice Act offers a guideline for structuring the bill, defining terms, and enlisting help from “allies,” lobbyists and legislators.

The Tennessee practitioners reviewed this model, as well as bills from other already licensed states.

“We took the ABC prototype and ended up combining the Ohio and Illinois [bills] into ours to fit the Tennessee model for a bill,” Reynolds said.

The next step is finding a sponsor and hiring a lobbyist. A legislative sponsor will introduce the bill to the legislature, facilitate moving the bill through the committee, and will work to see that it gets passed and forwarded to the governor’s office. A good lobbyist’s job is to champion the cause and help procure funds. If members of a state’s O&P community are connected to those involved in the political process in that state, however, they may not need to enlist a lobbyist’s help.

Perhaps the most important component is fundraising, as each aspect of the process – from securing a lobbyist to submitting the application – requires funding. Tennessee received contributions from its state O&P organization, individual practitioners and business owners.

“Unfortunately, not everyone contributes, and that is true across the country,” Reynolds said. “It ultimately ends up where there are five or six business owners carrying the financial burden of getting this thing passed.”

Reynolds estimated that it takes an average of 2 years for the bill to make it through a number of committees and to the Senate and House of Representatives, and the O&P volunteers must be willing to make that time commitment.

“You have to have a group of practitioners who are available to go to the state capitol when the lobbyist says, ‘This is going to go through whatever health care committee. We need you there tomorrow.’” Reynolds said.

Reynolds remembers his position as “interpreter” at some of the hearings, explaining key terms to those reviewing the bill.

“These guys could not even pronounce ‘orthotist’ and ‘prosthetist.’ It became, ‘Oh that is the bill that nobody can pronounce the names of the people.’”

New Jersey: Two decades in the making

In 1982, Lou Haberman, CPO, set out to prevent unqualified, untrained and uneducated people from providing O&P care to patients.

Haberman believed that licensure was the vehicle that could “move the field from a structured, private organization into a true profession with state recognition.

“The national associations…could neither prevent such abuses nor offer any solutions,” he said. “It was clear that patients required greater protections that could only be offered by the licensing of the profession.”

Initially, Haberman collaborated with Mountainside Mayor Robert Viglianti and Linda Wilson to spread the word about the New Jersey licensure initiative. Wilson’s professional connection to U.S. Rep. William Pascrell, then a New Jersey assemblyman, proved useful to the cause. Pascrell agreed to sponsor the licensure bill, and became an ally in the state’s effort.

Although the first draft of the bill was patterned from the existing Physical Therapy Licensing Act, Haberman and Viglianti revised the content and language based on their years of O&P experience. Haberman then hired a lobbyist, and Viglianti helped to move the bill through the Legislature and to the governor’s office for his approval.

Then Gov. James Florio signed the bill into law in 1991, and nominated individual New Jersey practitioners to serve on the first board of examiners. In opposition to this legislation, however, other professional groups successfully delayed the approval of the final regulations, and thus the implementation of the bill, for 12 years, Haberman said.

“New Jersey practitioners requested and received the help of practitioners throughout the nation to aid them in their effort to preserve the integrity of the first O&P Licensing Act in the nation,” he said. “All realized the implications for the future of other state licensure initiatives if New Jersey’s bill was made impotent.”

It was not until 2003 that the process was completed and qualified practitioners were awarded their New Jersey licenses, more than 20 years after the initial thrust began.

Texas: Creating opportunity

Texas was another of the early states to apply for state licensure.

“The profession, although filled with many great professionals, was not formally regulated at the time,” said David Olvera, executive director of the Texas Board of Orthotics and Prosthetics. “In addition, the growing advances in orthotic and prosthetic technologies demand a need to maintain qualified practitioners and adequate continuing education.”

With the help of key players in the Texas O&P profession, including state Sen. Jerry Patterson, the Texas Legislature established licensure for O&P practitioners in 1997.

Olvera explained that Texas licensure combines both licensing and enforcement duties: the licensing aspect ensures a minimum level of competency through education, residency and examination, while regulation permits the state to penalize or remove practitioners through enforcement action.

Furthermore, Texas licensure allows for multiple points of entry.

“First, we monitor the progress of students by registering [them] after they conclude their degree programs, but before they begin their clinical residencies,” Olvera said. “This opportunity provides students and the Texas Board to become acquainted with each other in a relationship that will span their entire careers.”

Texas also welcomes practitioners from other states to complete the examination, and recently contracted with ABC to proctor exams on behalf of the state.

Other professionals within the health care industry, such as career technicians and assistants, may apply for licensure as well.

Kentucky: Overcoming rejection

Not every state moves easily through the political process.

In 2006, a group of practice owners in Kentucky – including John Kenney, CPO, FAAOP, owner/practitioner of Kenney Orthopedics in Lexington – met to consider the path of O&P in the state.

“We saw where the future was heading and that we wanted to regulate our issues at a local level rather than have it done for us by federal entities,” Kenney said.

Awareness of the situation came about through the state society, the Kentucky Orthotists and Prosthetists Association (KOPA). The networking and communication made possible at KOPA’s yearly meetings brought about the advent of state regulation. This, he said, prompted the formation of a licensure committee.

The committee followed the same course as the other states that passed before them: getting the bill recognized, hiring a lobbyist and raising money.

“That is what makes the world go around,” Kenney said. “We had to work at thinking of some type of fundraising projects, donations, anything we could do to help collect money for this cause.”

In 2007, the committee filed the bill and it passed unopposed through the Senate. When it reached the floor of the House of Representatives, however, it hit a roadblock.

“Another senator tried to attach one of his controversial bills to the back of our bill and then we got shut down,” Kenney said. “Not for any reason of O&P licensure, but everything had to do with the controversy of the attached bill. It was a levy tax bill that the senator was trying to get passed.”

The O&P community in Kentucky reaffirmed its efforts and now the bill is ready for another round in front of the Senate.

“We feel that we honestly lost our bill because of political circumstance that was out of our control,” Kenney said. “We feel confident this go-around, because we did not have any problems until we got to the last minute at the floor, that we can get this bill passed.”

If the bill passes, there will be a period of setting up regulations, allowing Kentucky practitioners a grace period of about 2 years before licensure would be enforced.

Benefits of mandatory licensure

To Reynolds, the benefits of licensure are obvious.

“We can police our own profession,” he said. “There are people out there who provide our services who should not be doing it. They are not qualified. State licensure is one way to police that.”

Olvera highlights the advantages for the practitioner.

“Practitioners benefit from an independent board that sets policy for the industry,” he said. “This allows orthotic and prosthetic professionals to regulate their own industry and use their expertise when discussing policy matters that require it.”

Despite not wanting to pursue licensure in her home state of Michigan, Anita Liberman-Lampear, MA, administrative director of University of Michigan Orthotics and Prosthetics Center in Ann Arbor, identifies certain advantages, including the ability to distinguish between qualified providers and those who are not.

“What [licensure] attempts to do is protect the consumer and make sure that they are being taken care of by people who should be doing this work,” she said.

She offers the example of Florida, where nonqualified individuals had billed CMS for a large amount of prostheses for patients who were not amputees, and had never received these services.

But not all incorrect billing is due to fraudulent activity. Liberman-Lampear also wants to clarify matters of miscommunication in the health care profession.

“I personally also think that the licensure has a benefit in terms of separating us from the [durable medical equipment] world,” she said. “God knows we’ve worked so hard to do that, and there’s no doubt in my mind that we’re succeeding.

In a perfect world, Reynolds believes that licensure would ensure that patients received the best possible care. At the least, he says, it provides a measure of competency.

“It does offer a measure of confidence that at least the patient is being seen by someone that has a credential that has been awarded by the state,” he said.

Because Texas requires licensure, patients needing orthotic and prosthetic services benefit from a higher level of confidence in their practitioners, Olvera said. In addition, they also “have a complaint process that allows them to address concerns regarding industry professionals.”

New Jersey regulations, too, demand the highest standards from its practitioners.

“It is a statutory imperative that the professional standards in the state…be equal to or exceed all other national requirements,” Haberman said.

These standards include college-level and post-graduate education and training, continuing education, and criminal monitoring, in the form of fingerprinting.

Michigan: To license, or not

In Michigan, O&P practitioners and third party payers work together to ensure the best treatment for patients, without the time and expense of setting up state monitoringAlternatively, the O&P community in some states, like Michigan, has chosen not to pursue licensure for various reasons, most dealing with the potential cost and effort.

Liberman-Lampear pointed out that most practices already pay for ABC certifications and registrations for those working in their facilities, including associates, fitters, techs, and orthotists, prosthetists and pedorthists.

“I do not think any of us are going to be willing to pay for both licensure- and accreditation-related certifications,” she said.

So Liberman-Lampear and others in the O&P profession in Michigan banded together to create a favorable situation for practitioners, patients and the state – minus all the red tape.

“We did such a good job of partnering and communicating with [third party payers] that they agreed that if you are ABC accredited, you would provide this certain level of services, which included custom, custom-fit and some off the shelf,” Liberman-Lampear said.

As such, practitioners and third party payers work together to ensure the best treatment for patients, without the time and expense of setting up state monitoring.

“At this moment, there is no plan to go for licensure, unless the federal government says that who can provide services has to be not only an ABC- and BOC-accredited facility, but you have to be licensed,” she said. “Then Michigan…won’t have a choice.”

But there is no harm in being prepared, Liberman-Lampear admits. Members of the Michigan Orthotics and Prosthetics Association have discussed outlining a plan for licensure in the state.

“What would it look like if we did go for licensure? What is it that we would need to do to make it happen if we choose to do it, or are forced to do it? And so that is probably going to be one of the things on [the Board’s agenda] in the coming years.”

Allies in allied health

Depending on the state and requirements at the time of applying for licensure, many O&P practitioners may find themselves working hand-in-hand with other allied health professionals – in some cases the professionals they sought to protect themselves against.

Practitioners in Kentucky “consulted with the other health professions, hoping to prevent some opposition,” Kenney said. “We approached the physical therapists and the podiatrists and the occupational therapists just to make sure that we weren’t stepping on any toes. We wanted to be polite about it and do it right the first time.”

Members of those professions were receptive to collaboration, he says, and the Kentucky O&P committee worked to revise the proposed bill to ensure its acceptance by all parties.

The O&P community in Tennessee worked together with podiatrists to create a Board of Podiatry in the state, which also encompasses O&P. This type of “piggybacking” aided in the bill’s passing, Reynolds said.

The benefit to podiatrists, Reynolds continued, is protection from nonpractitioners opening storefronts to diagnose and provide treatment without prescriptions. Licensure prevents that type of activity from taking place.

In addition to considering Michigan’s licensure, Liberman-Lampear and others in the O&P community have spent years ensuring the other allied health professions are not encroaching on O&P territory.

“Now [occupational therapists] are trying to get licensed, and we are not opposed to their license at all. What we are opposed to is their saying that they can provide O&P,” Liberman-Lampear said. “And they can’t. If you ask most of them, they say they were not trained in O&P.”

The professions should be able to work together, however, as colleagues and referring sources.

“I see wonderful examples across the state of occupational and physical therapists, and prosthetists, orthotists and pedorthists working together for the benefit of the patient,” she said. “We are…being collaborative and the patient wins.

Mandatory accreditation, optional licensure

The practitioners who spoke to O&P Business News agreed that mandatory licensure for each state remains unlikely, especially given the accreditation deadline announced earlier this year.

“Do we need both [licensure and accreditation]? It is expensive, and health care already costs us a fortune. Why would we want to increase that?” Liberman-Lampear said.

She expects that much of the conversation will be settled once decisions are made about competitive bidding, about who can provide care, and which organizations can regulate O&P practitioners and practices.

Reynolds does not see mandatory licensure becoming a reality, primarily because of states with a small population of O&P providers.

“States like Montana and Wyoming have such a small population [and] usually the general population kind of correlates with the populations of O&P providers,” he said. “It would be so expensive for those states to have licensure, so I do not think it is going to pass in every state.”

The main issue is whether or not complaints and misdemeanors are being properly handled and people are sanctioned accordingly, Liberman-Lampear said. ABC already has a system in place.

“I have heard from some of my colleagues that, on the licensure side, some of those issues are not being handled yet or very strongly,” Liberman-Lampear said. “So what is better? Right now, in my mind, ABC appears to be doing a better job on that than licensure.”

Haberman points out that ABC does not, and cannot, regulate the activities of a noncertified individual performing substandard care.

“Only state licensure can regulate the activities of people providing O&P services in a state – with or without a license,” he said.

Kenney believes that federally mandated accreditation and licensure likely would be regulated the same way.

“Both entities are designed to protect the patient and provide the best possible care,” Kenney said. “I think [practitioners would] be scrutinized more at a local level if the state licensure was involved.”

Reynolds likes the idea of accreditation, however, and believes that the two standards might work together.

“States may want to go back and have amendments done to their licensure bill and throw in the accreditation,” he said. “It’s more than just bricks and mortar – accreditation includes the person, the people providing the care.”

Olvera agrees that accreditation and licensure mutually benefit patients.

“Unfortunately, many unregulated industries experience a high level of bad actors. These types of operations often leave the public helpless to address their grievances,” he said. “Orthotic and prosthetic accreditation and licensure ensure consumer confidence and public safety much better than if the industry were unregulated.”

Education’s influence on legislation

As technology and development have raised the standards of O&P practice over time, they also have increased the need for higher education in the profession. Today’s O&P profession is quite advanced, demanding the highest quality, the newest technology and, therefore, the best educated individuals.

“Education is probably the backbone of proper regulation,” Kenney said.

He believes that ABC would be the most qualified organization to regulate licensure due to its breadth, longevity and standards.

“An organization that does not require education as a standard is not in the best interest of the consumer,” he said. “An agency that only accredits other agencies would not afford protection to the patient due to the fact that they do not credential the expertise of the practitioner.”

Education and licensure are “inexorably linked,” Haberman said.

“ABC can and should serve as a testing agency for new practitioners since it offers the highest national standards of competency,” he said.

On the contrary, Liberman-Lampear believes that licensure and education are unrelated entities. Educational requirements, she stresses, are an entirely separate conversation.

“When NCOPE began the discussion of making the terminal degree a master’s, I don’t think that licensure was part of that discussion,” she said. “We have two commissioners – Mark K. Taylor, CPO, MLS, FAAOP, and now a current commissioner, Alicia Davis, CPO, MPA, FAAOP – and never in any of our conversations has she brought or has he brought licensure to the table as a reason for moving education ahead.”

Advice from those on the front line

Because the collection of states with O&P licensure is small now, Reynolds feels that the current benefits are mostly hypothetical.

“If people want it, they have to be willing to work,” he said. “A lot of your own time has to go into it, and if it’s something you want to do, you have to be willing to participate.”

“Communication has been the biggest obstacle in this whole battle,” Kenney said. “We have had practices that have gotten upset because they felt that they weren’t informed or they weren’t aware of what was going on; the flip side is we have had some practices that just didn’t care.”

Kenney also suggests developing a close relationship with state societies, as the O&P committee in Kentucky did with KOPA.

“They are going to be helpful with some of the fundraising and the regulatory issues that are coming down the road,” he said.

Olvera also urges O&P professionals to rely on their national and state associations to voice to their state’s lawmakers the importance of passing legislation.

Competition aside

“The process of achieving state licensure can be daunting,” Haberman said. “A state considering licensure should be guided by the experience of other states that have obtained it [as well as have] the support of selected local state representatives, the governor and a political party.”

Haberman thinks state committee members should take it one step further, if possible, by becoming more politically astute and learning from the states who have already completed the process.

“The New Jersey experience was particularly challenging since it was essentially the first significant legislation in the United States for the licensing of orthotists and prosthetists,” he said. “States that borrowed from our experience benefited from it and often achieved their state licensure in 3 to 4 years.”

The idea that this type of collaboration is beneficial echoes across the states.

Liberman-Lampear agrees that O&P practitioners and others in allied health must work together for the benefit of the medical profession.

“You need to talk to the colleagues out there who are not in your field but who might think that they can do your work, like the physical therapists and occupational therapists. You want to bring everybody aboard with you, so…you are all working as a team,” she said.

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