Tomorrow's O&P: A Survival Guide

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By Judith Phillips Otto

In this final chapter of our preview of the future of O&P as seen through the eyes of some of its leading experts, we offer a collective vision of what could be if we strive to achieve it-not pipe dreams, but practical possibilities from a dozen keen perspectives. We also take a look at the O&P professionals of the future, who will be instrumental in piloting us into a tomorrow that may exceed our most hopeful dreams.

When O&P Visionaries Dream

Janisse
Janisse

A hundred eventualities might and possibly should happen to the O&P profession within the next few years, but given a choice, which would do the most good? Which goals should the O&P field strive most mightily to gain-and how should the profession go about pursuing those goals?

Higher Standards to Protect Patients

Dennis Janisse, CPed, president and CEO of National Pedorthic Services, Milwaukee, Wisconsin, believes that holding practitioners and facilities to a higher standard should be a primary goal for the profession. "Mandatory standards like the accreditation legislation...are definitely needed. Nobody was really excited about having to go through that process, but it would have ensured that the people providing services were really qualified to do so, and that made sense to me. But at the eleventh hour, somebody amended the bill so it applies to very few people now."

Rogers
Rogers

Jim Rogers, CPO, FAAOP, president of the American Academy of Orthotists and Prosthetists (the Academy), feels that the answer to pursuing higher standards for the profession begins with licensure. "If I could simply accelerate those changes I see as [being] in the best interest of our patients, I would hope to see licensure as a reality in all 50 states. I would look for the Federal government and [the Centers for Medicare & Medicaid Services (CMS)] to recognize the specialized education and training required to provide orthotic and prosthetic care and to mandate that only professionals so educated and properly credentialed are qualified to provide that care. Lastly, I would hope for an infusion of money into the profession for orthotic and prosthetic research to answer the burning questions that are still unanswered with respect to the care we provide. Of course, there would be an adequate number of highly educated O&P researchers to carry out that research in partnership with other educated professionals."

Allen
Allen

Mike Allen, CPO, FAAOP, immediate past president of the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) board of directors, agrees that a standard that truly protects those who receive O&P care should be at the top of the list of goals for the profession. "ABC...is trying to look into the future of O&P in our strategic planning, trying to map how ABC will respond to changes in the future. So were trying to stay on the horizon in the future needs of not only the patient, but also the profession.

Patient Safeguards

Most of our experts agree that pushing higher standards will go a long way toward protecting patients and improving the standard of care, but some feel that additional protections should be put in place to adapt to the changing needs of specific patient populations.

Carroll
Carroll

Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics for Hanger Orthopedic Group, Bethesda, Maryland, is troubled by the emphasis on age when treating older patients and believes that a different approach to senior care is needed. "What difference does age make?" he asks. "It gives us preconceived ideas and limitations regarding our plans for their care. My hope would be that we could take a different approach to the management of our seniors, assessing their potential and how we can help them to reach it."

Thomas Guth, CP, president of the National Association for the Advancement of Orthotics & Prosthetics (NAAOP), is championing a bill that NAAOP helped to put before Congress: the Injured and Amputee Veterans' Bill of Rights, HR5730. The bill defines their rights to the latest technology, as well as their right to choose any certified practitioner, regardless of contract.

Guth
Guth

"We need a bill that will eliminate the parity problem, that prevents capitation insurance, and prevents insurers from eliminating O&P coverage completely," Guth says. "We really have to work on getting that passed. If I can get the veterans' bill through, then I can base a real bill for all amputees and all orthotic patients... on the veterans' bill and push it through."

Evidence-Based Practice

Though many O&P practitioners know that advanced prosthetic and orthotic devices can improve outcomes for some of their patients, ensuring access to that technology is not always easy. "As a profession, we must learn to demonstrate with statistical significance that new technology B is better than old technology A and become adept at research and evidence-based practice," says Brad Ruhl, immediate past president of the American Orthotic & Prosthetic Association (AOPA), referring to AOPAs recently-released list of strategic planning initiatives, which serves as a blueprint for their endeavors. AOPAs third initiative specifies a commitment to foster outcomes research to further support evidence-based practice models.

Ruhl
Ruhl

"My hope-and one of AOPA's goals-is that we become more talented, more focused on quality patient outcomes, and also far more skilled at demonstrating efficacy-at providing evidence that what we do makes a difference in producing a higher level of functionality and/or greater patient satisfaction."

"We need to develop [a wider] evidence base and [additional] practical ways of measuring-coming up with models that are going to work within the confines of the clinic," agrees James Wynne, CPO, FAAOP, director of education and training, resident director, at Boston Brace, Avon, Massachusetts. "We have these sophisticated technologies, and we need to show the clinical benefit-particularly for third-party payers to be paying for these devices and providing them to the patients. We are not alone. Physicians and therapists are also lacking an evidence base, and their professions require it as well." The more the healthcare community can get done collaboratively, Wynne says, the more likely it is that these goals will be realized.

Hovorka
Hovorka

Guth also agrees that increasing the evidence base is a must. "We definitely need our research to support evidence-based practice, or there won't be a future. Today's method is to say, 'We had three people try it. They loved it. We can't prove why, but we think it's better.' That won't work any longer."

Improved Cooperation and Collaboration

In addition to increased collaboration among the various allied healthcare professions, Christopher Hovorka, MS, CPO, LPO, FAAOP, director of the master of science in prosthetics and orthotics (MSPO) program at the Georgia Institute of Technology (Georgia Tech), says that collaboration within the O&P profession is critical as well. "At a fundamental level, I would hope to see a change toward greater unification of the professions of P&O," Hovorka says. "Were already pretty small, and to exacerbate the situation, were fragmented. We've got ABC, BOC, the Academy, AOPA. I know we've grappled with this, but some type of unification would be ideal in order to consolidate the voice of our profession to lawmakers, third-party payers, and to the public."

McGill
McGill

Carroll hopes for better cooperation and teamwork not only between fellow clinicians and colleagues, but also with the new practitioners entering the field. "We have to be prepared for this new, educated group with high expectations," he says. "We don't want to stifle their enthusiasm or break it down. We have to look to one another as being on the same team. As a profession, we're tiny, but when we bring ourselves together to work as one, we have a huge opportunity to succeed...."

From his corporate perspective, David McGill, vice president, Legal Affairs, Ossur Americas, Aliso Viejo, California, looks for an increasingly symbiotic relationship between Ossur and the providers who are prescribing and fitting its products. "Empowering the practitioner through appropriate educational and clinical resources, in my view, is a key element to creating the kind of future that wed all like to have in this industry."

Willingness to Embrace Progress

Kirk
Kirk

Thomas Kirk, PhD, CEO of Hanger Orthopedic Group, Bethesda, Maryland, is concerned by the reluctance of some O&P professionals to embrace change. "There are pockets of people out there who'd like to continue doing things that have always worked for them before. We have to make sure the profession understands that to survive and prosper, they're going to have to realize it's time to move forward. And it's going to take a commitment and willingness to change."

Help Is on the Way!

The good news is that there's an army of prepared, skilled, and committed practitioners on the verge of completing their specialized training and poised to join the ranks of today's O&P professionals. Already, their efforts are propelling the industry toward the goals our visionaries identified as most important.

Says Ruhl, "As much doom and gloom as there is on the reimbursement front, and threats from the outside in terms of people who are encroaching within our traditional field, there are nonetheless a lot of really talented young people coming into the field with an incredible amount of technological skills. They are very open to advanced technology, and that's a good thing because patients can really benefit."

Even before starting an O&P curriculum, younger practitioners today are better educated than their predecessors, Ruhl points out, because high schools and colleges have improved their content and teaching tools and techniques. He points to another of AOPA's initiatives, which stresses the need for the industry to provide stronger input to O&P schools in the development of their curricula so that new O&P graduates will be prepared to hit the ground running as practitioners.

Graduates are already emerging better prepared, Wynne agrees. "New candidates for our residency programs are excellent consumers of research," he says. "They understand the evidence-based approach." These graduates understand the current lack of evidence base in O&P and are "looking forward to making an impact by developing objective measures for our service."

"Even in our own clinics," Wynne adds, "we notice that the residents are driving us to better charting, setting protocols for patient management, getting everything in place so that we can then go back and do a really objective measure of what we are doing."

Rogers is equally impressed by the caliber of students entering the field. "The young professionals currently in O&P schools now represent the most highly educated clinicians entering the profession in its history." To illustrate his point, Rogers points to the student social held during the Academy Annual Meeting and Scientific Symposium. "The energy and enthusiasm in that room is just phenomenal. But anyone who thinks it's all youthful exuberance had better bring their 'A' game," Rogers advises, "because the conversations I participated in showed incredible knowledge of the profession, the issues facing the profession, and the current controversies in care."

Today's students also seem to have a broader view and a clearer picture of their role in the overall patient care continuum, Kirk finds.

"If we go back to the roots of O&P, it was much like a craft industry, and so you became an expert in your craft. If you were a bricklayer, you laid bricks. If they were building a building around you, all you worried about was laying your bricks. Twenty years ago, that's what characterized success in O&P-make the best leg you can.

"People today have a more holistic view," Kirk says. "And while they want to be experts in their profession, they also want to be part of a continuum of care and understand how the process, procedures, and technologies they're using to treat a patient will integrate with what the doctor wants, with the patient's state of mind, and with the physical therapists' rehab program.

"The ability to parallel process and collaborate with other healthcare professions to get a better outcome is a goal that I know some of these young professionals have, and its being taught in some of the academic institutions as well."

Guth, who serves as a guest lecturer at California State University, Dominguez Hills (CSUDH), agrees that today's students reach and complete O&P training programs better prepared than ever. "The new students are...highly educated, highly motivated, they're the future of the industry." Within two years, Guth predicts that all O&P education programs will introduce a master's level program and confer appropriate degrees. He points to Tennessee State University's plan to put eight doctoral graduates in the field within the next three years. "This is terrific because we can't get research grants or get the [U.S. Department of Defense] (DOD) or [Veterans Administration] (VA) to even look at us because we don't have PhDs."

Allen agrees. "With the move toward a master's degree program, the educational threshold has been raised," he says, "and as a result of that we will see better educated and clinically trained individuals entering the profession."

Carroll also visits universities, where he has the opportunity to teach and work with clinicians during the early stages of their careers. "I'm finding that it's a very excited group of individuals, who look to O&P as a very rewarding career for themselves-a good career for supporting a family, and personally rewarding for themselves. They see a bright future-and I agree with them."

There is a danger, however. "The big problem is that if we don't solve the economic problems, these guys are going to enter the field, and the pay's going to be lousy, and they'll leave," Guth says. "So we have to protect these new practitioners coming in. They're going to do a wonderful job."

From his insider perspective as an educator for Georgia Tech's MSPO program, Hovorka confirms that the younger generation is embracing technology with more confidence and enthusiasm than previous generations, and the desire to help those who are physically challenged continues to be as strong a motivator as ever.

"Today...devices that include micro-electronic and computer-driven technology are of [great] interest to the younger generation because it's very familiar to them."

"What differentiates the younger and upcoming practitioners," agrees Carroll, "is their willingness to embrace change-change in the healthcare delivery system, in technological advancements. They love the concept of computerized orthotics and prosthetics and progressive rehabilitation concepts. They're very advanced in their thinking process. They really love technologies like the WalkAide®-and that's where the future is going to be."

Kirk agrees that the up-and-coming professionals are "supercharged" with energy, motivation, and a greater aptitude for technology. "They've grown up using computers. In some cases today, we're still trying to figure out what carrots we can give to entice senior members of our profession onto the computer. The new students' technology curiosity levels are much higher, and I think we're going to see a real transition from an occupation to a holistic profession."

Not only is the academic quality of incoming practitioners on the rise, but the quantity of the fresh talent is also increasing. Allen says that ABC has seen an increase in the number of applications to sit for the ABC credentialing exams, and Wynne has also noted an influx, pointing to specific growth in the number of students with engineering backgrounds entering the field.

Kirk interacted with several such students from Georgia Tech, whose bachelor's degrees are in mechanical engineering or computer science. "They're really looking at this from the perspective of pushing the frontier of science in the profession and marrying it up with good clinical care," he says. "In discussing their desire to find a meaty research subject for their dissertation, one of them said, 'Where do you think the real juice would be? What's the problem that needs to be solved?' They'd love to tackle that, and they're really engaged."

Along with the rising interest in the field comes a measurable change in enrollment demographics. Hovorka notes a larger influx of women coming into the profession and reports that since 2007, more women have entered the Georgia Tech program than men.

Other U.S. schools report a similar gender shift. Publications reporting university admissions nationally note that the gender shift is evident and rising, Hovorka says, with women enrolling in increasing numbers in a variety of disciplines and, in some instances, outperforming men. "This may be related to the continuing trend of breaking down barriers and an increase of females taking on the pursuit of science and engineering careers," Hovorka speculates.

In addition to this demographic shift in O&P, Janisse says he is delighted to see a trend toward encouraging younger people to enter the pedorthic profession as well. "As we tighten up the educational requirements, we're going to get better and better pedorthists. As time goes on, I think we'll see more people who are not taking on pedorthics as an add-on profession, as many have done in the past. Their focus will be on becoming certified pedorthists, and they won't be distracted by other demands on their professional time-and that will enhance the profession overall."

McGill is hopeful that the curricula offered by educational institutions that prepare young O&P professionals, as well as the focus of the bodies that certify them, will continue to evolve to meet the needs of the marketplace. "The need for a sophisticated approach from both a reimbursement perspective and on the operational end should be recognized," McGill says. "If that happens, the young blood coming in will stand a good chance of being able to take advantage of the opportunities that this field offers them."

Tomorrow's O&P leaders, the lifeblood of the profession and its future, are unlike any we've known before-grounded in today's technology, eager to embrace, promote, research, and solve. Our hope for the future rests in them-and things have never looked better!

Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.


O&P Gains a More Unified Voice

In December, the Board for Certification/Accreditation, International (BOC) and the O&P Alliance organizations (the American Academy of Orthotists & Prosthetists, the National Association for the Advancement of Orthotics and Prosthetics, the American Orthotic & Prosthetic Association, and the American Board for Certification in Orthotics, Prosthetics, & Pedorthics) came together to sign a consensus agreement on the minimum education and training requirement for providers of custom O&P care. The O&P EDGE asked Greg Safko, BOC president; Preston Madler, BOCO, chair of the BOC board of directors; and John Kenney, BOCO, secretary of the BOC board, to comment on the change and its impact on the O&P profession.

The O&P EDGE:  What was the impetus behind the BOC changing its minimum education requirements for O&P?

Kenney: There's a changing landscape in our industry, and the impetus that brought the O&P Alliance and the BOC together to discuss this topic was BIPA 427 [Benefits Improvement and Protection Act of 2000].... Beyond BIPA, though, access was key to our consideration in moving forward with the agreement. Are there enough baccalaureate programs in O&P to meet the needs of an aging population? We're hopeful that by 2013, when the minimum requirement for all certifying bodies is a baccalaureate degree, we will have that availability. It is that hope and that confidence that basically led to the agreement.

Safko: Medicare was one motivator to establish a unified front, but it's important to remember that the experience part of the equation is currently and will always be paramount-even beyond the four-year requirement. There are still residencies required with the supervision of candidates under duly certified practitioners. That doesn't go away.

The O&P EDGE: How will this change impact the O&P profession? How will it impact BOC certificants?

Safko: It doesn't change anything for BOC certificants through the end of 2009, and then in 2010 there will be a transition toward the baccalaureate requirement. If you don't pursue a bachelor's degree or an associate degree in O&P, which have always been avenues for BOC candidates, there will be some post-secondary courses required. Beginning in 2010, the requirements that will be in place until 2013 will include the completion of fundamental coursework, such as anatomy, kinesiology, health and disease, as well as algebra, psychology, and English, in addition to the experiential requirements.

Madler: Let me clarify one point. This change will only affect new certificants. Our current certificants will have a seamless transition. They're not going to have new standards put upon them.

The O&P EDGE: Will this change affect the legislative landscape? Will O&P have a stronger voice in Washington?

Madler: The BOC is becoming more vocal and is more hand-in-hand with the other major O&P players so that we can present a unified front and try to separate ourselves from the DME side of the house, which is rife with fraud.

Safko: I agree. I think we're going to have a lot more strength, have a louder voice, and be taken more seriously in Washington DC.

The O&P EDGE: Will there be future collaborations between the BOC and the O&P Alliance organizations?

Madler: Why not? Anything that helps the patient. The bottom line is taking care of the patient. You can't put it any other way than that. That's the whole reason certifying bodies exist.

Kenney: Having been in the negotiations with the O&P Alliance to get a consensus, I would like to applaud all organizations that were involved. Every person who was involved in the conversation came from a place where they were thinking in terms of what is best for those in the industry, those potentially to enter the industry, and, most importantly, the patients we serve.

For more information on the consensus agreement, visit www.oandp.com/edge/issues/articles/news_2008-12-18_02.asp