September 2005 • Vol. 1, No. 3
	Advancing Orthotic and Prosthetic Care Through Knowledge

Watershed Moments

by Jim Rogers, CPO, FAAOP
Treasurer and Professional Issues Council Chair, American Academy of Orthotists and Prosthetists

Hopefully each of us has experienced or read of those times we commonly refer to as epiphanies or watershed moments. Often they involve our parents, spouses, children, spiritual experiences, or times when we connect with humanity in ways distinct from our daily existence. Regardless of the setting or those involved, these times share a common trait: they touch us deeply, they change us profoundly, and we are better for it. For many, an epiphany motivates us in ways no series of events can. We are moved, inspired. Our perspective changes, and we are never the same again.

Orthotists and prosthetists enjoy a unique sense of personal satisfaction. More frequently than the average vocation provides, we experience those extraordinary moments. Those of us devoted to voluntary leadership, and the staffs we work with, share a bond and a very tangible sense of belonging in both our accomplishments and our failures. Our efforts can yield deeply emotional experiences with our colleagues, but these usually fall far short of epic proportion. In our professional experiences, it’s not often that a gathering of our peers provides the environment for a watershed event. If you didn’t attend the O&P Policy Forum in Washington, DC, June 20–22, you missed out on one of the more extraordinary occurrences for our profession in quite some time, a watershed moment for O&P. I know, because I was there. I experienced it, and I spoke with many of our peers who were energized and moved in ways sadly foreign to our recent professional experiences.

O&P has experienced turbulent times of late. Our scope of practice is no longer exclusive to our profession, the effect of 30 years of expansion by other providers, most not as qualified as we are. The advance of technology has caught our profession unprepared for the ease with which once complex and entirely custom designs can sometimes not only be manufactured, but also be provided to patients with consistent success. We must look in the mirror and face the reality of a small largely unlicensed profession, just 0.3 percent of total Medicare expenditures, that is poorly financed when compared to our competitors and often appears disproportionately concerned with business and clinical issues compared to legislative and government relations. We are in the throes of growing pains, trying to increase our numbers without compromising our educational base and backgrounds. Consolidation still punctuates our existence as we strive to answer increasing regulation and budget concerns. Despite these issues, we march on and continue to make measurable improvements in the function of our nation’s disabled.

The Gathering

For three days, O&P professionals from 31 states gathered in Washington, DC, to learn about the pressing issues facing our industry. We heard from our congressional leaders and met with our representatives to discuss and influence their perspectives. In my 30-plus years in this profession, I have never witnessed a more focused and cohesive effort on behalf of O&P. The American Orthotic & Prosthetic Association (AOPA) staff and leadership organized and hosted a remarkable event. Representatives from the American Board for Certification in Orthotics and Prosthetics (ABC), The Academy, and the National Association for the Advancement of Orthotics and Prosthetics (NAAOP), along with more than 130 orthotists and prosthetists, joined them. Perhaps the most remarkable thing, however, was that despite our various affiliations, we were first and foremost passionate advocates for our beloved profession. I’m truly sorry you missed it. But I hope you are inspired by the highlights that follow and will plan to become involved and participate in the future. Failure to do so will only deprive you of one of the most rewarding experiences available to you outside of patient care, and deprive our profession of your much-needed support.

We arrived on Monday and were briefed late that afternoon by members of the AOPA and NAAOP staffs on state issues that impact the O&P profession. A sense of the energy in the air was immediately evident when the room proved too small for the attendees, and we had to open a sliding wall and add 30 chairs. The discussion was lively, passionate and focused. A social hour followed, and the discussion of the issues and how to present them did not subside.

That evening, the “G-4,” a group comprising the four main O&P organizations concerned with government and legislative issues (AOPA, The ABC, NAAOP and The Academy) met formally for the second time to discuss coordinated and proactive responses to issues on the horizon for O&P. This group emerged after the Orlando Academy Meeting when the APTA (American Physical Therapy Association) Direct Access Legislation issue brought to the forefront the need for coordination and communication in our profession. Our profession is blessed with many intelligent and dedicated individuals and this was only reinforced as I sat at this table and reflected on the work ahead.

Impressive Lineup

Tuesday began early. Judge John J. Farley III introduced the keynote speaker, Senator Charles Grassley (R-IA), Chair of the Senate Finance committee. Judge Farley is a long-time advocate for the disabled. He serves as an instructor for disabled skiing and recently retired from the United States Court of Veterans Appeals. He is a decorated veteran, wounded in combat in Vietnam. His long career in the legal profession is punctuated with numerous publications and educational positions. He presented Senator Grassley as an intelligent and steady force for fairness and quality within the CMS (Centers for Medicare and Medicaid Services). Senator Grassley addressed us on the process that led to competitive bidding proposals for CMS and issues of quality care. He displayed a keen understanding of these issues and made the case that CMS pays the same for poor care as it does for quality care. He punctuated these remarks by pointing out that the state with the highest percapita medical expenditures (Louisiana) also ranked 50th in total quality of care to beneficiaries. He ended his speech by pledging the cooperation of his legislative assistants for health care policy and investigation, mentioning them by name.

If Senator Grassley wasn’t enough of a coup, the gentleman that followed provided attendees with a glimpse of the inner workings of CMS and where we are heading in terms of qualified provider definition, coding reform, and competitive bidding. Mr. Herb Kuhn is currently director of the Center for Medicare Management at CMS. He quickly pointed out that if Part B physician’s claims continued to grow at their current rate, Medicare would double in size in ten years, and he described the Medicare Modernization Act (MMA) and how it will limit competitive bidding in orthotics to only off-the-shelf items. He announced new coding reforms with a goal of streamlining the process, the expansion of public meetings, and a generally more transparent decision process with preliminary decisions posted on the CMS website. He predicted the application process for new codes would be less burdensome. With respect to the Benefits Improvement and Payment Act (BIPA) and section 427 regarding “qualified practitioners,” he indicated that we should expect the comment period sometime this fall. Perhaps the strongest comment, and one which garnered rousing applause, was regarding Change Request 3607 (CR 3607, issued June 20, 2005) which will limit CMS billing for O&P services in those states that currently have O&P licensure on the books to only licensed practitioners! The momentum was beginning to build.

Next up was Don Muse, founder of Muse and Associates. Don has more than 30 years of experience in directing studies in healthcare costs and cost-effectiveness in both private and government programs. A prolific writer, Don holds a PhD in statistics and sociology from Florida State University (FSU), and his firm is one of the most respected policy analysts in Washington when commenting on Medicare and Medicaid program data. He is a former employee of HCFA (Health Care Financing Administration) and the actuary for the Congressional Budget Office. In short, he knows the ins and outs of the programs and their expenditures. What Don had to say about O&P expenditures in the Medicare program was music to the ears of practitioners weary of CMS reimbursement changes aimed at curbing the “increased utilization in O&P.”

He mentioned that it was commonly thought on Capitol Hill and in the CMS that O&P expenditures were increasing at a rapid pace because of over-utilization of services. We’ve heard it before: “Practitioners provide Mercedes components when a Chevrolet will do.” “The nation’s geriatrics are ‘running’ around with Flex-Foot® and C-Leg® prostheses.” Well Don had another story to tell, and he had the figures to back it up. From 1999 to 2002, CMS beneficiaries who required O&P services increased 40 percent, while O&P utilization grew only 7.1 percent! But wait, there’s more. For the same time period, Medicare services grew 18 percent; the O&P portion of Medicare services grew at a whopping 55 percent. Remove the 40 percent of increased beneficiaries requiring O&P services and we grew only 15 percent; adjusted real O&P growth was only 11.2 percent compared with 18 percent for the entire program.

I thought that was enough to counter the claims of rampant over-utilization in O&P, but Don wasn’t done. The idea that we “load up” geriatrics with high-technology devices is popular with cost-cutting administrators, but when we look at the age distribution of CMS beneficiaries receiving O&P services, the facts tell a far different story. More than 56 percent of O&P expenditures were for persons under age 65; 37 percent were for those between the ages of 80–84. The implication is clear: the majority of O&P services were for the youngest Medicare population, those on disability, and those who presumably would have the highest functional levels. Furthermore, if we look at overall cost growth in expenditures by type (that is, for O&P patients’ versus the entire Medicare patient profile) the typical beneficiary’s costs grew 20.8 percent where the typical O&P patient’s costs grew only 18.2 percent. This despite two very important facts: O&P patients are generally more medically complex, and average care costs for O&P patients are almost double that of the average beneficiary ($12,201 vs. $6,354).

The conclusions are irrefutable: O&P practitioners care for some of the sickest of the Medicare population and do so at a rate slower than the average growth of the program. Our nominal rate of growth is driven by a significant increase in the patient population, and is certainly not proportional. We are a cost-effective part of the program. This was certainly good news, now we have to tell the story!

All This and It’s Only Lunch Time!

After an inspiring introduction by Lt. Col. Andrew Lourake, Representative J.D. Hayworth (R-AZ) provided the lunch address. Lt. Col. Lourake is a transfemoral amputee and the first individual to regain Air Force flight status with a prosthesis. His story is one of courage and determination and served as the backdrop for the animated Representative Hayworth.In an often humorous and self-effacing address, Hayworth reminded us of his roots in television sports casting. A conservative Republican with the dubious distinction of being a regular guest on the popular New York radio show “Imus in the Morning,” Hayworth is perhaps remembered most for his deft work on the powerful Ways and Means Committee where he spearheaded the effort to repeal a proposed tax on Indian gambling operations. Despite this and his sponsorship of the $500-per-child tax credit, he was voted the winner in the “no rocket scientist” category by The Washingtonian Magazine. He also scored high in the “biggest windbag” category.

During a 35-minute entertaining speech, Hayworth offered encouragement to the profession in between his frequent references to his dubious past. So with a full stomach and a measure of entertainment under our belts, we returned to the auditorium for the afternoon’s coverage of the issues facing O&P and a helpful series of role-playing representing the typical encounters we could expect with legislative aids and congressmen and senators.

Speakers included Sarah Walter from Venn Strategies in Washington and Peter Thomas of NAAOP, among others. Sarah provided invaluable insights on the people we would be meeting, how the congressional offices operated, and what our approaches should be. Peter discussed the Direct Access Legislation and focused the issue for the audience so that the threats posed to O&P by this legislation were clear and understood. Walt Gorski and Kathy Dodson, senior director of government affairs for AOPA, presented the balance of the issues in a clear and concise manner. The issues were many: the Medicare payments freeze, stricter qualified provider regulations, the APTA’s pending Direct Access Legislation, and orthotic inclusion in the skilled care Prospective Payment System. Each issue had to be considered not only in light of a particular legislator’s party affiliation and his/her voting tendencies, but also in light of looming budget deficits, huge projected cost overruns in the new Medicare Drug Benefit, recent fraud in Florida and the mood on Capitol Hill for relief to our beleaguered profession. AOPA did a great job of providing the appropriate information and encouraging each group of constituents to determine which two issues to focus on, based on their representative’s perceived receptiveness. We recessed for dinner, some attending the O&P PAC fundraiser.

Being Heard

Wednesday loomed warm and humid as we gathered early that morning for breakfast and last-minute instructions and strategy planning in the Dirksen Building adjacent to the Hart Senate Office Building. This was to be our “staging area.” AOPA again displayed its organizational capacity by providing each state with a team roster of representatives and senators to visit, including a timetable with appointments and room numbers, along with a detailed map of the various office building locations.

Washington is a special place. Whether you are a history buff, enjoy being near the seat of power, or simply wish to rekindle your pride as an American, the experience will not leave you wanting. Understanding that our government works for us and our profession instills a measure of calm. We have a story to tell. No one is going to tell it for us. Fortunately, more than 130 dedicated O&P professionals prioritized their schedules and overcame whatever fears they harbored and presented our profession and its concerns to a group of legislators and assistants who listened intently. If my personal experience is any barometer, the Policy Forum was a smashing success.

O&P has momentum in the right direction; the issues are out in the open and the solutions have been thoughtfully crafted. We still need to let our legislators know we are here, and our concerns must echo in the halls, for those who would oppose us also exercise their right to voice their concerns. Nothing less than the future of our profession as we know it hangs in the balance. If you missed the Policy Forum and the feelings of solidarity and purpose that marked it, don’t worry. There will be another. Now, right now, we need each one of you, our fellow practitioners, to educate yourself on the issues, their impact and solutions, and contact your legislators and their health care policy assistants to amplify our voice. As you read this, decisions are being made regarding accreditation for O&P providers as mandated by MMA. By this fall a ruling on who is qualified to provide O&P care will be issued by CMS. If you don’t speak for your profession, who will? As any great competitive sports team understands, the time to push, the time to put your best effort forward is when you have the momentum. The O&P Policy Forum created that momentum; let’s not snatch defeat from the hands of victory.