Academy Society Spotlight: Policy Influence and Clinical Realities
January 2018 Issue
The Centers for Medicare and Medicaid Services (CMS) administers the provision of healthcare to beneficiaries in the United States. The goal of healthcare public policy is to balance needs with available and limited resources. Busy clinicians focus on the ability to maximize functional outcomes for patients while being good stewards of the resources and complying with policy. When treating a Medicare or Medicaid beneficiary, established policy must be a consideration from the initial patient encounter to final delivery, follow-up, and billing. The well-rounded O&P professional concerned with quality patient care must also stay abreast of the changing landscape of policy.
How do we connect policy with clinical care? Foremost, the patient has a right to expect quality service from competent professionals, and policies and proposals that support patient-centric goals are strongly supported by the O&P profession. Certification and accreditation standards are widely adopted, and the profession has united in support of those programs to assure professionalism. However, when CMS acts to delay or reduce payment for services, it challenges O&P professionals and their facilities, not only with regulatory compliance, but also to remain financially viable while providing optimal care. If you know what an L-Code is, are concerned with the possibility of an external audit, or worry about claim denials, then you are familiar with policy. If you practice in a state that requires licensure, you are affected by policy. Whether you acknowledge it or not, policy touches everything you do as a healthcare professional. Other, more numerous healthcare professionals you interact with have well-established methods to use their formidable collective lobbying force to affect policy in the direction of their interests; therefore, it remains a good idea to be well versed in the policies and proposals that affect your profession and your interests.
Legislative and policy efforts have proposed the qualifications necessary for O&P professionals, and to describe those who are qualified to receive reimbursement. Section 427 of the Benefits Improvement and Protection Act of 2000 (BIPA) addresses such qualifications. The certification and accreditation requirements of BIPA were opposed by groups that included therapists and physicians, which are larger and more resourceful than the O&P community. This resulted in therapists and physicians being exempted from O&P qualification requirements. Then, toward the end of the Obama administration, a proposed rule was released that, among other things, would have implemented the statutory requirements of Section 427 and established O&P as an autonomous and distinct profession, one that requires unique training. Although the various factions outside O&P came down on the opposing side of this issue, it afforded the O&P community the chance to advocate on behalf of their patients and defend the O&P professional as the provider of choice. Again, with pressure from organized opposition to O&P-specific certification and accreditation requirements, the proposed rule was withdrawn, maintaining the current exemption indefinitely. There was also realistic speculation that withdrawal of the proposed rule was a by-product of the Trump-era focus on regulatory reduction. However, it's apparent that O&P will only make progress in directions that other, larger influences will allow.
O&P professionals are faced with compromising on the issue of qualifications to advance other important initiatives. Of concern is a permanent exemption proposed in a bill before Congress, the Medicare Orthotics and Prosthetics Improvement Act of 2017 (www.congress.gov/bill/115th-congress/house-bill/2599/text). This strategy is meant to neutralize opposition with the goal of advancing other significant gains that enhance O&P professionalism and improve the policy climate for O&P patient care. This need not be a proposal that either permits full exemption or requires full certification of therapists and physicians. As stated by the American Academy of Orthotists and Prosthetists (the Academy) in its response to CMS regarding the BIPA proposed rule, "Physicians, occupational therapists, and physical therapists are vitally important to the evaluation, prescriptive, and follow-up processes surrounding the provision of custom orthotic and prosthetic care. Indeed, orthotists and prosthetists depend on prescriptions and evaluations from other professionals to initiate proper orthotic and prosthetic care, as diagnosis and prescription are not within the defined scope of practice of orthotists and prosthetists. This is an important distinction, and a division of responsibility that we believe enhances quality patient care." This acknowledges the important overlaps in responsibility that reflect a shared commitment between cooperating professionals for quality O&P patient care. It describes the unique contribution of all caregivers' knowledge and skillsets. In addition, subspecialists such as certified hand therapists have undertaken additional training and testing processes which are in place to ensure competency and patient safety. The Academy position is that it "does not wish to prevent these specialized therapists from continuing in this specific course of treatment.…" There is room for a compromise position that accommodates uniquely qualified contributions without continuing the sweeping exemption for therapists and physicians that their training does not justify. It is the "all or nothing" stance that has led to past misunderstanding and disagreement and prevented meaningful dialogue that could lead to impactful policy formation and passage. There is common ground and room for compromise, as long as there is communication.
Individual efforts for advocacy are important, but it is undeniable that coordinated and combined efforts of many individuals and organizations with similar objectives help influence the direction and speed of healthcare policy that directly impacts O&P care. Created in 2006, the O&P Alliance comprises five organizations: the Academy; the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC); the American Orthotic & Prosthetic Association (AOPA); the Board of Certification/Accreditation (BOC); and the National Association for the Advancement of Orthotics and Prosthetics (NAAOP). Since these organizations are representative of the scientific, research, professional, business, and quality aspects of O&P, they approach policy and advocacy from varying points of view. The Alliance is the vehicle for these organizations to speak together and explore their viewpoints prior to making public comment. They have much more in common than it may appear, and the goal is always to reach consensus and speak collectively. The Alliance was a major step forward in the profession's efforts to influence legislation and policy intended to improve the quality of patient care.
There's a limit to how effective lobbying pressure can be from individual O&P practitioners, or even by those organizations representing professional points of view. Issues may be interpreted as self-serving, no matter how altruistic the intent to advocate on the patient's behalf. Ultimately, it is the patient who benefits from efforts to alter policy; and patients telling their stories are very compelling.
"When you get the patient involved, it makes a huge difference because it takes the conversation with the payer from a bill to a person's needs behind the claim," says Jack Richmond, president and CEO of the Amputee Coalition.
It is extremely effective to include patient advocates in any discussion or presentation to payers and policy makers. Patients can share their experiences resulting from their access to qualified professionals, including their concerns about an outright denial of service, or delays in treatment not caused by the O&P provider. "We have to remember and emphasize to payers that care delayed is care denied," Richmond says. "Who wants to put their life on hold for six months waiting to get what you need to get on with your life? The psychological and physiological consequences of waiting six months or more to get a limb or any device a patient needs to continue the rehabilitation process is devastating."
This translates to a call to action for all orthotists and prosthetists to identify and recruit patients who can be vocal participants in advocacy efforts at the local, state, and national levels. The Amputee Coalition and other regional advocacy groups can be helpful in this regard. Most practitioners know of patients who would welcome the opportunity to voice their concerns about policy that affects their care. One only needs to provide the invitation. The power of patient testimony was demonstrated in the successful passage of O&P licensure in Minnesota. As a patient protection measure, the state established that certified orthotists, prosthetists, and pedorthists are recognized and licensed providers. While professional testimony was important, it was vital that patients also shared their perspectives. There is no substitute for that first-person message of the impact that O&P care has.
The Amputee Coalition has launched a tool at www.amplifyyourself.org that allows patients to be their own advocates by contacting their insurers, with the assistance of a practitioner, in the event a claim denial stops or delays treatment. It can also be used to communicate with the patient's congressional representatives in Washington.
Policy Affects Patient Care
Imagine how your clinical care as a prosthetist would be different today if the Draft Local Coverage Determination (LCD) for Lower Limb Prostheses that caused a stir in 2015 were in effect. The draft is a great example of how involvement in policy issues requires communication and effort to ensure that stakeholders have a say. The O&P Alliance is still actively engaged in this issue, and at the time of publication the profession awaits results from the interagency workgroup tasked with re-examining the proposal following submission of comments. This is sure to receive ongoing attention.
Need more proof that policy influences your patient care? A recently released policy interpretation would disallow reimbursement for custom-made foot inserts using virtual modeling processes. The discussion has been limited to A-5513 and objection to the new policy interpretation of "molded to positive model." Custom-made is defined in the O&P policy language as "molded to positive model." However, with today's technology, the body shape and dimensions are captured digitally, electronically altered and manipulated, then used to produce a molded product of the desired qualities, shape, and size. The only model produced is the digital version. Antiquated language is being used to define—and restrict—technology that is currently being used in O&P design and manufacture. While the CAD/CAM revolution has been present in the profession since the early 1980s, it has been steadily advancing and replacing the techniques used to custom produce items conforming to the unique anthropometric qualities of the individual patient. Policy language must change and evolve with the processes that are now becoming common, and must be properly inclusive of future technology to design, produce, and deliver O&P services. The alternative to not addressing this policy challenge will result in plaster casts of feet piling up in your office—or worse, discontinuing the service and abandoning the patient.
Healthcare policy and related topics are usually not the stuff that leads to vigorous discussion among busy O&P clinicians. Yet, policy issued by government agencies can impact the degree or complexity of care delivered, who is qualified to deliver that care, and the level of reimbursement. Most continuing education content, research endeavors, and practitioner interests are directed to solving clinical challenges and offering improved services to those needing O&P care. Rightly so, as advancement of the art and science of O&P is the primary goal of professional commitment, dialogue, and interaction. However, public policy and patient care are intimately linked in a cause and effect relationship. All clinicians, regardless of experience, can be involved. It even helps for more experienced practitioners to mentor others.
"Role models were instrumental in encouraging me to step out of my comfort zone and involve myself with O&P policy," says Katelyn Ell, CP, a recent O&P graduate. "It took the reassurance from mentors to get me out the door and that is all that it took. Presently I don't feel like I am on the pulse as I was a year ago, but studying for certification exams will do that to a person.... My plan is to begin bolstering my policy enthusiasm once again; it gets in your blood [and] I don't think I can ignore it. I'd rather say I actively advocate for our patients rather than hoping someone else will pick up my slack."
Advocacy does take time. But the passion for involvement, like the issues themselves, can come and go in waves as do many other pressures in life. Some of us took nearly a whole career before we became engaged in matters of policy that has an influence on clinical care. Future efforts are yet to be chronicled by those who take our place to defend the quality of care through political and policy activism. One thing is easily proved; the need for vigilance and action will continue. It is never too late, nor too early, to start.
Richard W. Miller, CO, FAAOP, is the immediate past president of the American Academy of Orthotists and Prosthetists (the Academy) and a member of its Public Policy Committee and Behavioral Sciences Society. He is also a facility accreditation senior site surveyor for the American Board for Certification in Orthotics, Prosthetics and Pedorthics.
Academy Society Spotlight is a presentation of clinical content by the Societies of the Academy in partnership with The O&P EDGE.