Shift of Focus

Shift of Focus
Image: © 2010

The present state of the economy, the dismal unemployment rates throughout the nation and the impending 2010 elections have shifted Congress’ attention away from massive health care reform legislation to focus on enacting bills to stimulate job growth and cut the deficit. President Barack Obama has proposed a 3-year freeze on federal funding not related to national security, a move that is read by many as a sign of the pressure on the administration to reign in the current budget deficit.

Obama’s budget

In early February, the administration released its federal budget for fiscal year 2011 which begins on Oct. 1. Obama included in his proposal to have Congress adopt stringent pay-as-you-go budget rules that would inhibit lawmakers from passing programs unless the costs of those programs are somehow offset by spending decreases elsewhere in the budget.

Obama also announced that he would create a bipartisan presidential commission to study and recommend to Congress where further reductions in spending were possible, primarily in the mandatory spending categories of Social Security, Medicare and Medicaid.

O&P agenda opportunities

While health care reform remains stalled in Congress without a clear path toward completion, ample opportunities still remain for the O&P field to advance items on its own agenda. There are expected to be a number of meaningful legislative opportunities throughout the coming year to advance the O&P profession’s priorities.

One of these strategies involves being included in a series of smaller health care bills that Congress is expected to focus on in the coming weeks and months.

Another possible opportunity for the field is to include current O&P Medicare priorities in a reconciliation bill. This would only require a simple majority in the Senate to pass, not a filibuster-proof 60 votes which the Senate Democrats no longer have due to the changeover over of party power in Massachusetts that took place in January.

Elimination of fraud and abuse in O&P

The current focus on the economy and the budget deficit also provides an opportunity for O&P advocates to make their case that O&P Medicare legislation can help eliminate fraud and abuse within the field while also improving the quality of care. Lawmakers continue to be interested in boosting accountability in a variety of health care settings and simultaneously saving money when possible. This focus would inevitably reach both goals.

At this time of political uncertainty, there is one thing we can all count on: the interest in improving quality while simultaneously decreasing spending will continue to be a priority for leaders on Capitol Hill and within the Obama administration.

Senator Wyden’s Medicare O&P amendment

Enter Senator Ron Wyden’s (D-OR) amendment on clinical laboratories which was accompanied by an important set of O&P provisions designed to offset the cost of the increased clinical laboratory payments.

The Wyden amendment was clearly in play during deliberations by the Senate Finance Committee late last year, but to date has not been adopted.

The Wyden amendment would link Medicare payments for O&P services and devices to the qualifications of providers and suppliers. These qualifications include education, training, certification and accreditation requirements, at varying levels of complexity of O&P care. While the framework for this long-standing goal of the O&P community is already in federal statute, it has never been completely implemented by the Centers for Medicare and Medicaid Services. The Wyden amendment, therefore, essentially seeks to put into action an existing law with the capability to benefit all providers of orthotic and prosthetics care and ultimately their patients.

Quality of care

It is clear that adopting a change such as this in policy would significantly reduce the provision of complex O&P care by unlicensed, uncertified and/or unqualified providers and suppliers. This, in turn, would drastically reduce fraud and abuse in the field and raise the standard of care for Medicare beneficiaries. The policy adoption would also have a positive impast on Medicare saving money in the long run.

At the same time, the failure to act on these issues will significantly induce demand for orthotic and prosthetic services from providers and suppliers who seek to bill the Medicare program for customized and complex O&P services without the proper facilities, education, training and/or experience to provide quality orthotic and prosthetic care to Medicare beneficiaries.

Federal O&P parity legislation

A complimentary piece of legislation is also currently pending in Congress but was similarly omitted in the House of Representatives and Senate health reform legislation.

The bill would provide orthotic and prosthetic “parity” in private insurance plans that otherwise cover O&P care. This federal effort is designed to capitalize on the already successful campaigns that have been going on at the state level for more than 10 years to enact state prosthetic parity legislation. One of the reasons the federal legislation has not been as quickly adopted as the state bills is due to the context of the overall health reform proposals.

The existing health care reform bill would have specifically included “orthotics and prosthetics” in the standard benefit package. In doing so, all private health plans participating in new health insurance “exchanges” would have had to cover orthotics and prosthetics to meet federal requirements.

In addition, there are a series of important protections against discriminatory treatment as the Department of Health and Human Services and various advisory committees expand upon the detail of what is covered under the category of O&P as well as other identified categories of covered benefits.

These two inclusions taken together would mark an enormous victory for the O&P field with regard to overall recognition and coverage of O&P patient care. But with the existing health care reform bill in a state of legislative limbo, the chances of securing these important benefit protections in federal law decrease with each passing day.

Mandate debate

If, in fact, health care reform does not get across the finish line this year, the importance of enacting a separate O&P parity law at the federal level becomes all the more important. The only downside is that the O&P field will quickly become subject to the claims of others who believe their particular health care benefit category ought to have the same level of parity protection as the O&P parity legislation would create. This argument is not an easy one to counter and would not be a new one to face.

Such a debate might quickly devolve into a discussion of which beneficiaries are more deserving of having their needs met by private insurance plans. For instance, would a $500 cap on power wheelchair coverage for a person with a spinal cord injury be any less offensive and inappropriate than a similar cap on prosthetic device? Would an exclusion for portable oxygen therapy be any less appropriate than an exclusion for microprocessor controlled prosthetic components?


In the end, whether you are a for or against health care reform, it is perhaps beyond debate that there are serious problems with the system of insurance coverage in this country that will ultimately have to be addressed. It took 15 years since the last crash of national health reform efforts for the frustration and fiscal threat to create the political will to take on health care reform. Whatever the fate of the current effort, it is unlikely that our country can ignore these pervasive problems for another decade and a half without enacting some significant reforms to the system.

For more information:

Peter Thomas

Peter W. Thomas, JD, is general counsel for the National
Association for the Advancement of Orthotics and Prosthetics.

Theresa Morgan

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