License to Care

It is illegal to cut hair without a license or provide a professional massage. But for more than half the country, it is acceptable to provide a life-altering prosthetic device to an amputee – with no license required.

Many in the field of O&P believe that licensure – the process of “demanding minimum education and requirements to ensure high standards of care,” as defined by the American Academy of Orthotists and Prosthetists (AAOP) – could stop unqualified individuals from treating patients and bring validation to the profession.

Meanwhile, others believe the current licensure structure is broken and is forcing the profession in the wrong direction.

No national standards

Scott Williamson, MBA, CAE(Ret.), president of Quality Outcomes in Virginia, thinks the problem rests with inconsistent regulation. While licensure is meant to improve health care standards across the O&P profession in the United States, it is only currently active in 16 states. O&P licensure is simply not a government priority, Williamson told O&P News.

“To get a bill enacted requires a significant investment on the advocate’s part. Just to get a foot in the door is a political nightmare,” he said.

Budgetary concerns and other high priority matters have handcuffed states’ ability to spend, he said, bringing licensure talks to a standstill.

In states like Montana and Wyoming, with few O&P facilities, obtaining licensure is even more difficult because of the per-capita cost of drafting and implementing the necessary legislation, he said.

“Since [the profession] is so small, we have to lobby [and] hire folks to write the legislation. It is a lot to ask of a few people … and it is not a cheap deal,” he said.

Less dedicated manpower to support legislative initiatives means higher costs for practitioners, John Reynolds, CPO, past-president of the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) and owner of Reynolds Prosthetics & Orthotics in Tennessee, told O&P News.

“If you are in a state where you do not have a large population of prosthetists, the fees can be very expensive. Not every state is ready to make that commitment,” he said.

Lawmakers are asking practitioners to produce fiscally responsible bills that are self-sustaining and have zero effect on state budget, he said, adding that the fees do not go away after initial investment.

“It took 2 years to get Tennessee’s bill passed. We paid more than $40,000 over that period and almost 99% of that money came from individuals writing checks – small business owners.”

Not everyone contributes to the costs, Reynolds said, “which is just how it is.” Practitioners deeply rooted in the process could shoulder most of the financial burden, creating animosity toward those who are not.

But that is not the only concern with the process, he added. Various state issues prevent development of a national licensure standard, which would allow practitioners licensed in one state to automatically become licensed in another.

Since many O&P professionals were licensed through grandfathering, or absolved of new requirements by virtue of experience, the lack of reciprocity would restrict them from providing care in any other licensure states except their own.

“It tends to limit the free market, making it difficult for folks to move into a new state,” Williamson said, adding that the same law meant to offer high standards of care to patients could stop qualified practitioners from providing it.

Proponents argue that basing state laws on a national platform could eliminate reciprocity issues, but Dennis Clark, LCPO, president of the Orthotic and Prosthetic Group of America in Iowa, and Thomas F. Fise, JD, executive director of the American Orthotic and Prosthetic Association (AOPA), have different ideas about it.

“Each state has different requirements,” Clark told O&P News. “Look at fishing regulations or the bar exam, for instance. Texas, Illinois and Iowa – each state has certain nuances that a person may or may not fulfill.”

That makes reciprocity “a very big ask,” Fise added, and said practitioners should be required to measure up to each state’s unique standards. “If one state’s requirements are more stringent than another, maybe [a practitioner] should not have to start back at ground zero, but they should instead be allowed to show they meet those additional requirements.”

Facing opposition

This could partly solve the issue, he said, but even if a practitioner is properly licensed in a state, their ability to practice could be jeopardized. Providers in fields such as physical therapy could pose opposition to licensure standards that exclude them.

The American Physical Therapy Association (APTA) has practice acts in about 38 states, which overlap with current licensure states, according to AAOP’s comprehensive licensure guide.

While physical therapists possess some knowledge of O&P-specific care, these acts argue they are “fully competent, by education and training, to provide comprehensive prosthetic and orthotic services.”

Because advocates in other fields outnumber those in O&P, prosthetists and orthotists would not likely have their own licensing board and be forced to join a similar one. This could create a vacuum, Williamson said, causing the profession to become limited or defined by another profession.

“Almost always other parties come in and say that licensure is unnecessary or that they should be included, too. You groups like the APTA that come in and say, ‘You have to allow us to provide these services or we will oppose the bill,” Williams said.

“You cannot have that kind of major opposition…or by the time you write a good bill, it would be watered down by the political process.”

The National Orthotic Manufacturers Association (NOMA) also could pose opposition. NOMA says the education provided by prosthetic manufacturers is sufficient for sales representatives to provide off-the-shelf devices and care with little or no risk to the patient.

Many new devices can be custom fitted without needing modification, but experienced practitioners have concerns about patients being fit by those with no training.

“It is expected when you deliver an orthosis or prosthesis that you have the capacity to manage patient care, not just provide an item,” Clark said. “In cases where [providers] do not have offices, consistent hours or repair capabilities, you have the potential for patients to receive poor care … and for unqualified practitioners to receive reimbursement.”

Reynolds cited the Benefits Improvement and Protection Act of 2000, or BIPA: Section 427, which mandated all prosthetics and custom fabricated orthotics be provided by qualified personnel. Transmittal 656, of 2005, further mandated that CMS only reimburse services for Medicare beneficiaries from accredited practices or those that meet state licensure laws.

No steps have been taken to enforce either of those provisions, Reynolds said.

“The legislation was passed and never applied. We have been after Congress for a long time, but cannot get an answer as to why,” he said.

“CMS just never took action on it,” Fise said. “So, a substantial percentage of people being paid to provide O&P services today are either not licensed or not accredited…and that is a problem.”

CMS assures they are looking into ways regulate licensure and eliminate payments to unqualified parties, but “in states without licensure statues, who do you complain to?’” Clark asked.

“Who do you go to and say, ‘Hey, here is what just happened while my mother was being treated?’ If there is no oversight, then other government agencies are going to instill oversight on their own,” Clark said.

Williamson wonders if that will ever happen. “It is different from walking into a surgery suite and performing open heart surgery without a medical license,” he said. “But who is going to stop an unqualified person from putting an AFO on a patient with diabetes? This is the fight we have right now.”

Protecting credibility

To protect O&P’s credibility in the health care arena, the fight is worth it, Williamson added. Many in the O&P profession agree.

“There is a huge misunderstanding about what O&P is and what O&P does,” he said. “Our challenge is to educate bother payers and other medical professionals so they understand O&P is not about device sales, but rather a legitimate allied health care profession.

“Licensure can help with that. When third-party payers find out we are licensed, it changes the conversation – the door is not slammed immediately.”

As for the states without licensure statutes, “the difference is not as dramatic as you might expect,” Claudia Zacharias, MBA, CAE, president and chief executive officer for the Board of Certification/Accreditation (BOC), told O&P News.

She said regardless of what an individual state might require, often in order to be paid by Medicare, prosthetists and facilities must be certified or accredited by ABC or BOC.

“These are very stringent and rigorous processes,” she said. “To earn certification, candidates must possess what are known as KSAs – the knowledge, skills and abilities that demonstrate competency in the profession.”

Candidates for certification must have earned a Commission on Accreditation of Allied Health Education Programs-approved master’s degree and complete a National Commission on Orthotic and Prosthetic Education (NCOPE)-approved residency, Zacharias added.

“You do not just get certified once and you are done for life. You cannot just pass the exams, sit back and say, ‘Oh, I am all set forever.’ There are continuing education requirements that that all certificants must fulfill,” she said.

Certification examinations are standardized nationwide and include written and hands-on portions that assess clinical aptitude, problem-solving, patient and practice management. They also assess technical criteria, device recommendation, implementation and follow-up protocol.

Williamson thinks ABC and BOC have done a good job with the qualifying programs, and “they are a good way of honing and promoting standards of care and educating practitioners about professionally documenting and communicating the care they are providing.

“They define the qualifications of people who should provide O&P care,” he said. “This is a unique field in that we are providing both physical medicine and mechanical devices. There is limited group of people who competently perform those services.”

Reynolds added while physical therapists can provide a certain level of O&P care, licensure prevents it from becoming a large problem. There are different protocols based on the complexity of each case, he said, but at some point, the knowledge required to provide custom devices demands an O&P-specific education.

Working together

Licensure goes beyond education, Clark added.

“It is not only for the protection of the payers, but also for the protection of the patients involved,” he said.

Whether it actually improves care of those patients is yet to be seen, the sources agreed. While licensure is meant to offer high quality care through increased education, it is an ongoing process, Fise said.

“I think you can generally expect that having licensed personnel will result in better patient care. But that is not to say you cannot have licensed personnel [who] might provide substandard care.”

It seems that either way, licensure will likely become a staple, he added, and instead of fighting against it, the O&P profession should work to improve it.

Government agencies are taking steps toward that. Clark noted that CMS is implementing a prior authorization program, which would ensure patients receive care from qualified providers and speed up the process in which those providers are reimbursed.

O&P organizations are also involved, Zacharias said. The National Association for the Advancement of Orthotics and Prosthetics, ABC, BOC, AAOP and AOPA work together as members of the O&P Alliance. This is the O&P profession’s primary vehicle to track regulation and legislation and to advocate for what is best for the profession. The AAOP’s Licensure Task Force is currently gathering representatives from each licensure state to combine knowledge into one universal, accessible resource.

“There are outlets available to help [those in states without licensure] get started,” Clark said. “There are outlets for shortening the amount of time and money it takes to get through the process.”

He observed the profession would be better served if licensure became national, but for now, it remains a state-by-state issue.

“Why that is, it is hard to say,” Clark said. “But there is tremendous differentiation in terms of regulatory activity. Each state can put their own rules or requirements in place.”

That is why it is important for professionals to know what is happening on their own turf, Williamson said.

“A big part of our challenge is education. The greater level of practitioner education, the greater our ability to communicate at a different level than we have in the past,” he said.

“The more we understand the governments’ side and the payers’ side, the more we can start to speak their language – because it is a different language.”

He suggested O&P professionals network with advocacy groups, policymakers and lobbyists who can support their initiative and keep them apprised of any changes in legislation. A licensure initiative requires preparation, planning and a clear understanding of the process, he added, and said the future of O&P hinges on “those with their feet on the ground.”

“Whether this profession is able to survive will depend on if we can educate, network and demonstrate our value in the larger health care world,” he said. “That will be our biggest challenge.”

Taking the first step will indeed be a challenge and licensure will require hard work and careful maintenance, Fise said. But, he added, the sooner O&P professionals realize its importance, the sooner those steps can be taken.

“That is the starting point,” Fise said. – by Shawn M. Carter

References:

American Board for Certification in Orthotics, Prosthetic and Pedorthics. Available at www.abcop.org. Accessed Feb. 23, 2015.

American Orthotic Prosthetic Association. Available at www.aopanet.org. Accessed Feb. 25, 2015.

BOC | Board of Certification/Accreditation. Available at www.bocusa.org. Accessed Feb. 27, 2015.