The O&P field holds a unique place in health care; somewhere between booming technology and dire restraints. There are many ideas about how to advance the profession, and moreover, what obstacles may lie ahead. Some concerns are overstated, leaders say. But others are real, and could damage the field if it does not take action.
In this Cover Story, O&P experts weigh in on the future of the profession.
‘Too much is a bad thing’
One looming concern is the threat of more patients. According to the CDC, one of every 11 Americans is affected by diabetes, with that number expected to reach one in three by 2050.
This has caught the attention of O&P leaders. “When you have 10,000 baby boomers turning 65 every day [who are susceptible to the disease], … you could see an onslaught of new amputees overwhelming the system,” Jeffrey M. Brandt, CPO, CEO of Ability Prosthetics & Orthotics, told O&P News.
The American Diabetes Association notes more than 60% of amputations occur because of the disease. Those aware of the issue are taking action to prevent it, and looking for ways to better serve the diabetic amputee community. Jon Shreter, CPO, executive director of Prosthetic & Orthotic Associates Management Corporation, is one of them.
“Our job is to serve patients … so they can get back to their way of life before the amputation,” he said.
With little reimbursement from insurance companies, that could be a tall order. Payers are cutting costs by paying for only minimum, basic devices, Shreter said.
“The profession is well-prepared [for a new wave of patients], but payers are restricting what could actually improve outcomes … in favor of the cheapest option available,” he said.
Saving funds at all costs
“From a clinical standpoint, it is causing us to second guess what to provide for patients,” Eric Shoemaker, MS, CPO, LPO, at Ability Prosthetics & Orthotics, said. “Do I provide what I think is the most appropriate … or do I provide a lesser device that I know Medicare is not going to put up a fight about?”
“It is a bit one-sided. [RAC auditors] are incentivized to find as many refunds as possible,” he said. “I do not know that there is necessarily pressure … you are not telling them to do something they should not, but this is unrestrained auditing against companies that [have typically] done nothing wrong.
For many small businesses, the answer has been the latter. The Recovery Audit Contractor (RAC) Initiative has placed providers in financial strain. RACs focus on fraud detection by identifying and recouping improper Medicare payments resulting from billing and coding errors. Shoemaker believes the system places emphasis on dollars.
“There is no accountability for contractors,” he added. “They look through records of something that has already been billed. If something is not done according to their guidelines, they take the money back. If they get it wrong, there are no repercussions for them.”
There are ways to appeal, however. CMS offers an opportunity to discuss improper payment determinations at five levels: Medicare redetermination by a CMS contractor; reconsideration by an independent contractor; hearing before an administrative law judge (ALJ); review by the HHS appeals council; and judicial review in U.S. District Court.
Even if a provider wins the appeal, Shoemaker said, “it is taking 3, 4, 5 years to get that payment back,” causing a cash flow issue in the profession.
“We are trying to carry over expenses while waiting for payment … but our suppliers are demanding money, our creditors are demanding money and our payment is being held up on the other end.”
It is getting expensive to stay in business, he added, and with a “guilty until proven innocent” approach to audits, “a lot of small facilities will not survive on these grounds.”
‘This land is your land’
Others have voiced concerns that physical therapists are encroaching on O&P. The American Physical Therapy Association (APTA) has practice acts in 38 states, according to the American Academy of Orthotists & Prosthetists (AAOP)’s comprehensive licensure guide.
Matthew Parente, MS, PT, CPO, O&P program director at the University of Hartford, believes there are physical therapists with a desire to provide O&P services, but says, “the courses available to them as continuing education are minimal compared to what orthotists and prosthetists go through.”
Still, certain items are accessible through outlets that bypass O&P. The National Orthotic Manufacturers Association argues that sales representatives are equipped to provide off-the-shelf devices and care with little or no risk to the patient.
“It is sort of like buying direct,” Parente said. “The sales rep may have training in business marketing, negotiations and everything else, but they may not have the skills needed to provide a custom orthosis.
“If the patient needs an adjustment or has a skin breakdown or something, the rep is then acting as a clinician…[and that] leads to a substandard of care because there is no real treatment plan.”
The Benefits Improvement and Protection Act of 2000, or BIPA: Section 427, mandates all prosthetics and custom fabricated orthotics be provided by qualified personnel. Transmittal 656, of 2005, further mandates that CMS only reimburse services for Medicare beneficiaries from accredited practices or those who meet state licensure laws.
To this point, no steps have been taken to enforce either mandate, sources say.
“If we surrender orthoses … we will see the line [between O&P and other providers] blurring,” Parente said. “As we look down the road, if we let those go, we will see our patient pool being conquered.”
Man or machine
Three-dimensional printing could also take part of the market, some fear. By creating custom objects from a digital model, 3-D printing is moving to a new level, while skipping the traditional fabrication process.
“The printers are getting faster, they are getting more accurate,” Brad Mattear, LO, CPA, territory and strategic account manager at Cascade Orthopedic Supply, told O&P News. “When we bring the strengths of 3-D into production, they are going to have an immediate and life-altering effect.”
One benefit is cost, he said. “When you look at a device in the traditional setting, you look at cost of materials, you look at fabrication. Whether you outsource or fabricate in-house … 3-D printing could reduce many factors that come into that equation.”
As prices decline, interest increases, Mattear added, pointing out that therapists can now purchase printers and create custom devices at low costs.
“[Some companies] will even let users print right from their homes,” Mattear said. “But what about when we start putting printers in shoe stores? What about when we put them in pharmacies or podiatry offices?
“Will that be a concern for the profession? Yes because never once did I mention that there would be an orthotist or pedorthist involved.”
To the chalkboard
One way to counter adversity is through education, sources said. But obstacles facing O&P schooling could pose unique challenges. Funding is a key issue, Ashley Mullen, MSAT, CPO, LPO, told O&P News. Mullen is an instructor for the Orthotics and Prosthetics Program at Baylor College of Medicine. As state budgets experience deficits, higher education has become costlier.
“I think it depends on the way each program is set up … but O&P education can be [more expensive] due to the equipment and materials that are required for fabrication,” she said.
Current projections show the supply of students in the profession may not meet the demand. “If you look the recent reports for patient care, by 2025 there will be a need that the number of graduates certainly does not fulfill,” Mullen said.
Medicare’s proposed health care provider credential – mandating amputees visit a licensed health care provider before the prosthetist – could also decrease the value of O&P-specific education, Brandt said.
“We have spent the last 20 years increasing and sanctifying our standards, and right as we are on the doorstep of churning out some well-trained students aligned with the medical model … we could take a giant step backward if Medicare invokes this requirement,” he said.
Mullen is taking an optimistic view. She says the challenges facing education could be overestimated.
“I think the [education system] is adequately preparing students for the real world … and I think the shift to the master’s degree emphasizes that,” she said. “In terms of patient outcomes, documentation, communication and technology … I think the shift to the master’s [degree] will mirror the shift in the field.”
When it comes to tuition, Mullen has not seen issues completing classes or filling seats.
“We are receiving more applicants than seats available,” she said. “I think when the potential earnings are weighed against expenses, students are saying, ‘This is acceptable, this is worth it, this system is sustainable.’”
The idea that patients with diabetes could outnumber O&P providers is also overstated, according to Shreter. He said while the disease is increasing, management is advancing and amputations have declined.
“I think we are going to see fewer amputations. Surgeons are coming up with better limb salvage techniques, and patients are more aware,” Shreter said.
Providers are acknowledging this as a major contributor to health care costs, he added, and assigning social workers, physicians and clinicians to patients.
“Even though more people may be impacted by diabetes, management is more integrated and it is being kept in better control,” he said.
If the profession did see a rapid increase in patients, “we would be well-prepared to handle it,” Shreter added. “We have all the tools we need, we already have the know-how. We just have to make sure we have the documentation to support what we do.”
As far as physical therapists encroaching on O&P, Parente said the situation is not as bad as it seems. In parts of the United States where orthotists are scant, physical therapists may use central fabricated or prefabricated orthoses. But their primary task is to increase patient mobility, not fabricate devices, he said.
“The fields are closely related … our biggest allies are therapists in a lot of ways. Yes, there is going to be some overlap, but that is not necessarily a bad thing.”
The goal is not to isolate physical therapists or push them out of the door, Parente said, “it is about respecting each other’s boundaries, having professional relationships and using our combined skills to benefit the patient.”
The same holds true for 3-D printing, Brandt said. Providers should focus on how it could help patients, as opposed to how it could hurt business.
“There are fabricators out there who have been doing things the same way for 60 years and that is going to change,” he said. “3-D printing will potentially be disruptive, but I think it will be disruptive in a good way.”
Some in the profession have not thought about like that, Brandt said.
“They see 3-D and think, ‘Oh no, everyone is going to lose their jobs because these printers are coming in. They automatically make the jump that a 3-D printed product is replacing electronics. But ask them how long [the device lasts], how sophisticated it is or how much torque it can handle.”
While 3-D devices may be seen as more cost-effective for lower functional needs, Brandt added, “you are not doing an apples-to-apples comparison” when it comes to traditional devices.
“Much of what you see right now is exo-skeletal in nature or the shell or covering of a product,” he said. “The electronic [components] of i-limbs are not being 3-D printed.”
Mattear believes 3-D printing could create jobs.
“We have youth coming in and the buzz is certainly there. Someone has to take on a different role, understand the mechanics and modify these molds virtually,” he said. “This is prime for new-school thinkers … this is for the generation who wants to get on that highway and drive.”
The road ahead
There are some legitimate concerns facing the profession, Shoemaker said, such as the barrage of RAC audits. “RACs have not improved over the years,” he said, “[and] as far as I know, they are not slowing down.”
In 2014, CMS extended its contract with RACs, including authority to audit claims for durable medical equipment, orthotics and prosthetics. Under the extension, audits will continue for the foreseeable future.
“It is freezing growth in the industry and preventing new jobs,” Shoemaker said. “I know companies would love to expand and open new offices … but all of our cash is tied up for years at a time.”
“We really cannot manage this,” Brandt added. “But we have to adapt to the changes by mining our data, understanding the monetary effects the LCD could have and take steps to prepare our practices.” He suggests facilities study coverage policies, maintain documentation and medical records, perform internal audits and have a reserve budget for unexpected expenses.
National organizations are fighting against restrictions, Shoemaker said.
“We are working to lobby Congress and Medicare. We are educating doctors and patients. But if CMS keeps doing more of the same, things will not any get better; they will only continue to get worse.”
A more recent concern is the Local Coverage Determination (LCD) for Lower Limb Prosthetics proposal released by the four Durable Medical Equipment, Medicare Administrative Contractors (DME MACs). The LCD draft could “create significant limitations to care…for roughly 2 million amputees,” according to an Amputee Coalition, American Orthotic and Prosthetic Association (AOPA) joint statement.
According to the proposal, amputees using assistive devices are considered to operate at low functional levels and would have limited options for prosthetic devices. Patients unable to attain an “appearance of a natural gait” or who have health issues, including high blood pressure could be denied a device altogether.
“Clearly there is some effort there to reduce overall spending,” Brandt said. “But some of these changes are so radical, it seems like they are aimed at commoditizing the profession or just completely wiping us out.”
O&P leaders are stepping up to the plate. The National Association for the Advancement of Orthotics and Prosthetics (NAAOP) spearheaded a White House petition and letter writing campaign. Most recently, stakeholders in the O&P community met with CMS in Linthicum, Md. and rallied in Washington, D.C., to protest the changes.
“Everybody is fighting [to make this better],” Brandt said. “The National Commission on Orthotic and Prosthetic Education, AAOP, NAAOP, the ACA … all of the professional organizations. “You have probably got six or seven governing bodies right now that are actively fighting this proposal. It has taken center stage for sure.”
One source said he would not recommend O&P as a profession for his children. Two others agreed they would steer their children toward a different path. However, others said differently. They expressed excitement when discussing the future of O&P, filled with amazing development and a blend of interests.
While some people may fear legislative challenges could curb strides, Steve Hill, BOCO, CO, owner of Delphi Ortho and vice president of the Orthotic & Prosthetic Technological Association, said there is reason to remain optimistic.
“We are made of creative, resilient and often brilliant individuals. We are in a field of endless possibilities,” Hill said. Although setbacks threaten to shatter recent victories, “we are made for making broken things whole again.” – by Shawn M. Carter
- Amputee Coalition. Available at www.amputee-coalition.org. Accessed Aug. 3, 2015.
- American Diabetes Association. Available at www.diabetes.org/?loc=bb-dorg. Accessed Aug. 4, 2015.
- American Orthotic & Prosthetic Association. Available at www.aopanet.org. Accessed Aug. 5, 2015.
- Centers for Disease Control and Prevention. Available at www.cdc.gov. Accessed Aug. 6, 2015.
- National Association for the Advancement of Orthotics and Prosthetics. Available at www.naaop.org. Accessed Aug. 7, 2015.
Disclosures: Parente is affiliated with Hanger Clinic. Brandt, Hill, Mattear, Mullen, Shoemaker and Shreter report no relevant financial disclosures.