The economic downturn has created more buzz than usual around the issue of encroachment in O&P. Now, more than ever, O&P practitioners find themselves fighting for fair reimbursement and trying to cut costs. Many feel that physical therapists and other allied health professionals are to blame.
Instead of engaging in a tug-of-war over corners of the allied health sandbox, perhaps O&P practitioners, physical therapists and others involved in allied health care should combine their efforts and get the most from their available resources.
O&P Business News spoke to O&P practitioners and physical therapists to learn from both sides.
Real threats
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To many in the O&P profession, the threat of encroachment is real, and it may come from any number of health care professionals. When health care professionals — physicians, orthopedic surgeons, physical therapists or O&P practitioners — without the proper education, credentials or experience in a discipline treat patients under the umbrella of that profession, they are infringing on that profession and risking the patients’ safety in the mean time.
But encroachment has many faces.
The biggest encroachment threat to the O&P industry, Carol Hentges, CO, principal owner of Custom Care Orthotics in Minneapolis, said, is that the Centers for Medicare & Medicaid Services (CMS) and other payers authorize — by way of reimbursements — these physicians and other allied health professionals to evaluate and fit orthotic and prosthetic patients.
“There is an immense pressure in all areas of health care right now to capture more revenue. I think, whether it be therapists or physicians, they see O&P as a revenue resource,” she told O&P Business News.
Because of this increased scrambling for revenue, the threat of encroachment lies in CMS and other payers not understanding that only practitioners with the proper credentialing and education are qualified to provide O&P services. Once payers stop paying, the allied health care practitioners will stop fitting.
Aaron J. Sorensen, CPO, LPO, owner of Restorative Health Services Inc. in Nashville, agrees, but has seen an even bigger issue arise with physician groups. He has found that physicians have begun expanding their service offerings into other disciplines, including physical therapy, occupational therapy, diagnostics and pharmaceuticals. Recently, he said, O&P professionals, experienced in not only clinical practices but also business practices, have begun joining with physicians to open O&P departments as part of health care groups. These groups are different from — and more dangerous to O&P than — physicians who dabble in O&P themselves because the new groups operate with guidance from the experienced O&P professionals. With physicians referring patients to O&P practitioners within their own practices, there are fewer opportunities for independent O&P practitioners.
“With that referral stream drying up, we are starting to see some of the smaller mom-and-pop shops start to hurt financially,” Sorensen said. “I think if the independents are not careful, and do not start to look to either expand into other regions geographically, or look to expand and diversify into other services or product offerings, then I think a lot of the independents, especially in the larger metropolitan areas, will not have a strong presence in 3 to 5 years.”
Jason Lalla, CP, certified prosthetist at Next Step Orthotics & Prosthetics Inc. in Manchester, N.H., worries most about nationalized health care because, from the payment standpoint, several effects of nationalizing health care, like single-payer systems, would threaten independent O&P practitioners, and make it difficult for private practices to operate at their current level.
“As O&P providers, our hands are tied,” he said. “We don’t control our prices, yet we are at the mercy of increased materials cost.”
From a profit standpoint, this causes a problem, but Lalla also emphasizes the effect of economic hardship on patient care. Ultimately, he said, the patient suffers the most.
Payer issues
An issue for Hentges is that O&P providers are one of the few — if not the only — health care providers who bill for products and devices, but not services. This is an unfortunate circumstance, given that fitting patients with O&P devices and following up to ensure proper fit require time and a specific skill set, she said.
“I think we have evolved from just filling the prescription that was mandated by the physician to truly having a part in determining that patient’s care,” she said.
Sorensen points to the differences in expenses for individual O&P practices versus for health care groups, which already have in place the physical building space, liability insurance, support staff and administrative tools.
“Adding a discipline, product or service is an incremental expense to these physicians, versus a certified prosthetist or orthotist who decides he or she is going to go out and try to build the company from scratch,” he said.
For this reason, Sorensen said that prohibiting physicians from building these “micro-monopolies” is not as important as encouraging CMS and other payers to re-evaluate the reimbursement amounts to reflect this discrepancy, which might then discourage physicians.
In addition, he feels that these health care groups — which can refer orthotic and prosthetic patients internally to their surgeons for amputations, their physical and occupational therapists for rehabilitation, their diagnostic centers, and their staff O&P practitioners — spend unnecessary health care dollars overprescribing their patients when compared to physician groups that do not refer internally.
Allied health partnerships
The main focus for orthotists and prosthetists should be patient care, Hentges said. However, O&P care cannot be provided by untrained allied health care practitioners. One major difference remains between a physical therapist’s ability to fit a patient with an off-the-shelf AFO and an orthotist’s ability to fit the same patient with that device, she said.
“Can you do just minimally adequate care, or can you give optimal care?”
Hentges works with several physical therapists who respect her ability to work as an orthotist, while working with her to treat patients.
“They are not interested in doing my job, but I have lots of other colleagues who their biggest competitors are therapists,” she said.
Along the same lines, O&P practitioners complete training in the fields of orthotics and prosthetics, and would not do justice in providing physical therapy services, Sorensen said. Therefore, it is not that physical therapists cannot provide off-the-shelf orthoses; the issue is that they might not provide the best orthoses.
“Physical therapists can grab an AFO off the shelf, but maybe that off-the-shelf AFO, which is a posterior leaf spring, wouldn’t benefit that patient as well as an articulated ankle AFO with dorsiflexion assist and plantar flexion stop,” he said. “There may be some other things going on that we clinically understand and can address as orthotists.”
On top of the clinical argument lies the obvious business argument, which is that this practice takes away business from O&P practitioners, which is their livelihood. Sorensen also emphasizes the political standpoint, which is that, if allowed to continue fitting orthotic patients, physical therapists and other allied health professionals eventually will be able to prove to CMS that they have enough experience in O&P, and it should fall within their reimbursable services.
Next Step O&P maintains an open-door policy, not only with its patients, but with other allied health care professionals. The company holds in-services and gait training clinics — with speakers like Robert Gailey, PhD, PT — and invites physical therapists to its facility.
“I think it allows them opportunities to have more insight into the O&P business and have a little insight into the expertise and the skill set that it takes to do what we do,” Lalla said.
Because of the mutually beneficial relationships Next Step has with physical therapists and physicians, Lalla and his colleagues not only receive referrals for postoperative fittings, but occasionally for preoperative consultations where they are able to fully participate in the course of patient care. Lalla also serves as an example for patients facing amputation surgery since he has been a transfemoral amputee since 1989.
Although the company works with physical therapists who might use off-the-shelf orthoses without consultation, the practitioners at Next Step do not consider that encroachment.
“A lot of the strap-and-wrap, off-the-shelf orthoses that might be fit in a hospital … if you were so inclined, you could buy it and fit it yourself, as a patient,” Lalla said. “That is not a market that we are looking to be in. Generally, our time is better spent working on the highly customized prosthetics and highly customized orthotics.”
Physical therapist outlook
One facility Next Step works with is Catholic Medical Center’s Rehabilitation Medicine Unit (RMU) in Manchester, N.H. An acute facility located within a comprehensive regional medical center, the RMU provides patients with physical, occupational and speech therapy for as long as 30 days before they return home or transfer to a skilled nursing facility.
Prosthetic patients might be admitted to the RMU as soon as a week after amputation, and leave prior to receiving their definitive prostheses. Physical therapists there work with amputees on positioning, stretching and keeping a proper range of motion to ensure the proper prosthetic fit.
“Initially we do a lot of education so that they are better set up to be good prosthetic candidates later on,” Jennifer Walton, MSPT, one of RMU’s physical therapists, said.
Walton works with prosthetic patients to determine if they are ready for physician-recommended weight bearing on an adjustable postoperative prosthesis. If so, she calls in Next Step to do the job.
“A lot of times these temporary prostheses can be the difference between a patient going home versus a patient being unable to go home. Some of our older patients can’t hop around like the younger patients can,” she said. “When you give them this prosthesis, albeit temporary, it affords them a lot more protection for their wounds should they have a fall and offers them much earlier mobility.”
For orthotic patients, such as those suffering from foot drop, Walton and her colleagues will try off-the-shelf AFOs without consulting O&P practitioners. However, the physical therapists will consult with O&P if they have patients who will not benefit from an off-the-shelf AFO, because of poor sensation or poor off-the-shelf fit, or if the patients will continue to use AFOs permanently.
“My job is primarily increasing functional mobility and the evaluation and treatment of movement disorders, trying to help a patient get back to some level of functional independence. My job is not the evaluation and application of orthotics or prosthetics,” Walton said. “I’m going to let the experts in their field do what they do. There is no reason for me to step on their toes when they are the ones who have the background and education.”
Because of the way the RMU operates, Walton has no opportunity to follow up with her patients; this makes it difficult if she sends them home with off-the-shelf devices. If Next Step consults and fits those patients with custom orthoses, however, the company’s O&P practitioners will be available to help with their follow-up needs.
“The reason that it works so well for us is because of the good relationship we have with Next Step,” Walton said. “They are so good with their customer service and so involved with their patients that, if we have any questions, they will come right over.”
PT reimbursement
Kasey Cartwright Parsons, PT, owner of Elite Physical Therapy, which has offices in Spring Hill, Shelbyville and Franklin, Tenn., maintains a similar relationship with O&P practitioners in her area.
After conducting her initial patient evaluations, Parsons consults with an O&P practice when she has patients who need orthotic treatment, especially custom devices, or amputees who suffer from poor fit with their prosthetic devices.
For several years, Elite Physical Therapy offered its patients durable medical equipment — mostly limited to crutches, walkers and canes or off-the-shelf orthotic devices. At one point, Parsons even employed a clinician who enjoyed making orthotics, but she said that practice was short-lived because physical therapists do not receive reimbursement for O&P devices and because she does not feel that they receive the proper education to mold such devices. She eventually canceled her DME license to concentrate solely on physical therapy.
“I’m a physical therapist. I went to school for physical therapy,” Parsons said. “[O&P practitioners] went to school for [orthotics and prosthetics]. I don’t feel like we should encroach on that.”
The issue goes beyond the struggle between O&P and physical therapy, to include orthopedic physicians as well.
“I get a lot of patients who have had sports injuries and things of that nature, who are supplied with splinting and bracing from orthopedists,” Parsons said. “That is a sticky situation because they are orthopedists and they do know what they want, but at the same time, they are doctors. To what degree they actually learned in school about appropriate bracing like an O&P [practitioner], I don’t know.”
Additionally, if physical therapists are not reimbursed for providing orthoses, it seems logical that no provider be reimbursed for orthoses, except for qualified orthotists, she told O&P Business News. As more physician groups add physical therapy services to their practices, it becomes increasingly difficult for independent physical therapy companies to function.
Multidisciplinary approach
Overall the sources agree that the best approach to facing this issue is standing together as allied health professionals to offer optimal treatment to patients and to fight for proper reimbursement from CMS and other private payers. If all practitioners fought together — instead of against each other — the voice of allied health would be heard among the other health care professions.
“When we do in-services and when we talk to new potential referral sources, that is the approach we take: you be the best surgeon you can be, or the best physiatrist you can be, or the best therapist, and let us be the best at what we do, which is orthotics and prosthetics,” Sorensen said. “If we take a team approach, then patients are truly going to get the best quality of care they can get, and they are going to get the actual care of treatment that they need.”
At the RMU, Walton and her colleagues concern themselves with offering the highest level of treatment to the patient. They will issue off-the-shelf AFOs to patients who need a temporary fix to help them while at the RMU; often, patients are ready to give up the AFOs by the time they leave the facility.
“If that is what the patient needs, and that is what is going to help them, and that is going to get them home … I give the AFO if it is going to benefit the patient. It is of no benefit to me,” Walton said.
If a temporary, off-the-shelf device does not work, the physical therapists consult Next Step or another O&P facility. The therapists then attend the consultation and fitting to help Next Step work with the patient and continue open dialog about the patient’s care.
“To me, the patient’s safety and what is going to help them the best, what is going to get them the most independence, is what I have to do,” she said.
Qualified providers
Hentges, chair of both the Orthotic Exam Committee and the Professional Credentialing Committee for The American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC), said that proper education and credentialing are the only criteria available to O&P practitioners to prove to CMS and other payers that they are more qualified than other allied health professionals. ABC board members have been hard at work promoting facility accreditation and educating CMS about O&P.
ABC’s Orthotic Exam Committee is passionate about ensuring that the standards are set so that only qualified practitioners are providing care to patients. To then have to watch while unqualified providers treat O&P patients is discouraging to many people.
Additionally, it frustrates small business owners like Hentges that O&P practitioners only receive referrals regarding the difficult, custom patients.
“Sure we love to have the challenging patient, but yet we shouldn’t be losing all the other work out there just because they are not challenging,” she said.
This sentiment again points to proper payment for qualified providers.
“It still comes down to the basic thing, which is that, whether we like it or not, it is the payers that are determining who can provide care,” Hentges said. “I think that focus of educating the payers on what we do and why you need to be qualified to do it is the backbone of where we are in trying to maintain our ability to work.”
Patient care
Ultimately, O&P practitioners — of any education level and with any credential — must continue to treat patients to the best of their abilities, regardless of the obstacles and competitors.
“At the end of the day, I would hope that people got into this field for patient care and try to better somebody’s life the best way you can, or at least try to return them to a lifestyle that they once knew,” Lalla said.
Even if that means letting go of the reins and referring patients to another allied health professional.
“I think relationships with physical therapists, with physicians, with health care providers, are essential,” he said. “If you are referring people to certain groups, like physical therapists, hopefully you get return business and again, ultimately the end result is the patient’s outcome.”
More important is that patient providers do right by the patients. No degree of competition should make patients suffer.
“If you are doing reputable work, you have a reputation of doing good work, and people will find that. If you are doing subpar work, that eventually gets out and at some point it will catch up with you,” Lalla said. “We here at Next Step sleep a little better at night knowing that we are doing things that we find morally right and ethically right.” — by Stephanie Z. Pavlou
