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Licensure: Is your State Prepared?
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Is your state prepared? Lessons learned from the recent LCD situation

This special edition of the Licensure Corner focuses on the response of the O&P profession in the face of the drastic changes in patient care procedures and benefits proposed by the DME MAC Local Coverage Determination related to lower limb prosthetics. The article also highlights several issues that parallel concerns that are just as crucial occurring on a state level to sound the alert for state organizations to stay vigilant. Because of the importance of these issues and the need to keep some of this conversation amongst ourselves, this article is password protected and intended for Academy members only.

Many comments concerning the response from the profession (and others) to the LCD proposal carry superlatives not often associated with the typically mild-mannered O&P community. Descriptions of the O&P world's reaction included the remarks "unprecedented" and "inspiring" when talking about the collective voice raised in opposition to the proposal. The O&P Alliance (the Alliance), of which the Academy is a participating member, was the organization leading the collective groups. The other organizational members of the Alliance are the National Association for the Advancement of Orthotists and Prosthetists (NAAOP), the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC), the Amputee Coalition (AC), the American Orthotic and Prosthetic Association (AOPA) and the Board of Certification/Accreditation (BOC). It's important to note that, although these organizations haven't always spoken with one voice in the past, the efforts put forth in the LCD response were a collective victory. Herein lies the first advice to state organizations:

Use strengths collectively and put aside divisions that can derail your efforts before you start.


The Alliance incorporates a unique combination of professional, commercial, research, education, and patient interests. The Alliance has stated objectives to which all participants agree; the Alliance speaks with one O&P voice.


The key to being effective at producing desired results is to take prompt action through awareness and communication. This is possible to produce at the state level, but (as all will acknowledge) it takes clear and abundant communication. There can be a tendency for separate groups to wish to remain independent, wanting to stake their own claim in the process. This may establish bragging rights in the future, but can be counterproductive based on appearances. A large, well-coordinated organization with many moving and diverse parts will have a better showing at the policy table. In states with licensure, separate groups may have already come together to work collectively on behalf of O&P causes. Many times a state Academy chapter is involved, or a state O&P association has worked to initiate and maintain O&P licensure. Their efforts are most definitely enhanced by inclusion of patient groups or other allied health interests that are supportive of the effort.

Be vigilant and watch for proposals on the policy horizon.


The Alliance works full time to be alert for legislative and policy changes. Some policies that the Alliance offers comment on do not specifically mention or directly impact O&P care. But in cases where a proposed policy change could be used to affect future change in a more closely related manner, there is a need to draw those conclusions and make comment. Such was recently the case when the Alliance issued a position statement on the proposed bundling of benefits for post-acute care following total hip replacement surgery. A detailed response was issued to raise the concern. A full-time Washington, D.C. lobbyist and network of connected individuals keep watch on behalf of the O&P profession.


There is great value in having an individual to act as a "legislative monitor" on behalf of a state's O&P community. This individual is assigned the responsibility of watching for legislative bills or other proposals that may result in harmful consequences to the provision of O&P services and dispersing that information quickly with recommendations for a response. The value of being prepared and organized in advance to identify and respond quickly to an issue that is potentially detrimental to the O&P environment cannot be overstated.

States that have pursued and achieved licensure definitely have a head start if they find themselves faced with a legislative challenge. That doesn't mean it's easy; it does mean they've already joined forces to approach a task together. In some states a lobbyist or professional lobbying organization has been involved in the licensure process and whose services are retained beyond establishment of the licensing act. In that case the lobbyist continues to monitor bills or rule changes that could be adverse to the provision of high quality O&P care.

Recognizing the threat is step one; sounding the alarm, and coordinating the response are next. There are numerous examples of reduction of benefit proposals that were spotted in the early stages and successfully challenged and defeated. There are also examples of a state's O&P community being surprised by legislation that negatively impacts O&P care, resulting in much more time and energy needed to oppose and amend.

The proposal is offered; then what?


In mid-July 2015 the DME MAC proposed changes to the LCD template for Lower Limb Prosthetics. Details of the policy would result in severely restricted access to currently accepted practice, rehabilitation and technology. The 30-day public comment period ran through August. The Alliance first made sure that details of the suggested policy changes were distributed to all groups. The red flag was raised, as the initial reading of this vast policy gave cause for concern. As more time elapsed and Alliance organizations were given the chance to digest and interpret the policy, it became clear this was a policy that needed to be rescinded. When the LCD proposal went public, the response strategy was discussed among Alliance representatives and implemented. The deadlines imposed for comment required that the formidable policy be divided into manageable parts to be addressed by subject matter experts. There was frequent communication via email, conference calls, and numerous side conversations that were shared with the group to speed the process.


State policy decisions can be made at the legislative or agency level. This information is public, but in some cases is not widely publicized. In other words, you won't hear about it unless you're looking for it. So as emphasized above, states should be organized and watchful. When the reaction is from panic mode the results are not always pretty.

Oppose the proposal using the agency's own words, methods, and rules. Know what the problem is, inside and out. Own it and set the record straight.


When the LCD Lower Limb Prosthetic proposal was released, the O&P community took swift action. The O&P Alliance sent a letter of opposition to the highest level within CMS. In addition, it is generally accepted that a bibliography accompanies policy releases such as this. In this case that didn't happen, and a bibliography and supporting documentation were requested. What came after the fact was something that was very general and outdated at best; the authors of some of the studies and papers quoted as supportive were willing to write letters requesting retraction of their documents. The definitions were attacked where they were weak, inaccurate, or flat out wrong. Where false assumptions were made the correct ones were pointed out, and were well supported. The Academy contributors focused on the dissection of documentation requirements in the LCD policy. The DME MACs were soundly criticized for issuing such wide-spread and impactful policy and for crossing the line of their authority and responsibility. The very action was pointed out as contrary to established policy and precedent. All the while, preparations were made to mount a massive public response within the prescribed 30-day period.


Again, speaking with a collective voice helps to clarify and emphasize the message. It's not that different groups don't have different perspectives; certainly patient advocate groups have viewpoints encompassing a paradigm unique from facility owners. The key is to zero in on the common issues that can be unifying to represent most people's viewpoints, creating the largest "bandwagon."

A coordinated "Public Outcry" can get press coverage and expand the message.


Fifty individuals gave testimony during a three-hour live hearing before the DME MAC medical directors. The venue and time allotted were changed to accommodate a much greater presence. Public demonstration in front of HHS generated nationwide press and TV news coverage. The website was created as a source for printable posters and postcards for facilities to use and distribute to patients. Hundreds of letters were submitted to CMS for formal comment on the LCD lower limb proposal.


Be prepared with your list of "patient champions." They must be individuals who have been or will be affected by the change. Know and publicize the talking points. Anyone who gets before a camera or writes an editorial should know the subject matter and stick to what they know. Energize the O&P facilities in your state to actively publicize the situation to patients and ask for their help. Use the resources of the national organizations for your efforts e.g., mailing lists, Action Alerts, etc.

Create political pressure to reverse bad policy.


Through gathered more than 100,000 signatures in 17 days to petition the White House to respond to the LCD issue. The website included a specific course of action to guide those seeking assistance to individually respond to the LCD. The website featured additional links and information including "white papers" and other aids to draft letters. Visitors to were urged to write a letter to the CMS Director and to their members of Congress.


Devise a plan to put political pressure on the decision-makers at the state level. This can include petitions, informative websites, etc. Make it easy for everyone to participate. Draft letter templates and make them available. Provide links to make contacting legislative offices easy. Invite all the participation you can, including allied healthcare providers, who are on your side of the issue. There will be some cost for this in terms of time and other resources. Work out a method to share the cost among the stakeholders.

Offer solutions based on correct interpretation of current available research and data.


A 139 page detailed response from the Alliance included a significant section authored by Academy representatives. Current research and data overlooked by the policy creators was brought to the discussion in the Alliance response. Specific "white papers" were created to refute inaccurate references within the LCD. The Academy and other Alliance-member organizations also issued their own response letters consistent with the issues brought forth by the Alliance.


Know the experts in your area and be prepared to cross lines of competitiveness to help each other out. This will take everyone's time and energy to accomplish, so share the load. Work for the common good. Collaborate!!

Draw realistic inferences and conclusions. Be gentle but firm when insisting a policy is misguided.


In its response to the LCD proposal, the Alliance avoided language that was emotional, exaggerated, or accusatory. Rather, all arguments were fact-based and well supported.


Once again the case can be made to be efficient and draw from the resources of organizations that may already exist in your state. The issue is not occurring in a vacuum, sit down and brainstorm a response, but be quick about it. In many instances, time is of the essence. It is important to focus on the content and intent of the policy. The authors of such policy may not have envisioned the unintended consequences that are obvious to those it affects. It is acceptable to project the effects of a policy into a future scenario in an attempt to draw conclusions and surmise potential outcomes. When doing so, be conservative in the approach and avoid exaggeration to make your story more plausible, and defensible.

A future edition of the "Licensure Corner" will include a second installment to expand on this topic. We will present a "scenario" of how a state can respond effectively to policy proposals that would result in lower standards of patient care or a reduction in benefits. Real examples of actual states' experiences will be incorporated to highlight the advantages of certain strategies. We will also explore the pitfalls that can result from being ill-prepared.


American Academy of Orthotists and Prosthetists
7910 Woodmont Avenue, Suite 760
Bethesda, MD 20814

(202) 380-3663