[Untitled]

Levy, Charles

10/6/2003

Dear Friends,

I thought you might like to see the stand taken by the American Association
of Physical Medicine and Rehabilitation in regards to the recent Neg Reg
meetings.

Yours,

Charles E. Levy, MD






September 25, 2003



Mr. Robert Loyal, Director
Division of Provider Supplier
Centers for Medicare & Medicaid Services
7500 Security Blvd
Baltimore, MD 21244-1850

Dear Mr. Loyal:

I am writing on behalf of the American Academy of Physical Medicine and
Rehabilitation (AAPM&R) to inform you of the position of the AAPM&R
regarding the recently completed session of the Negotiated Rule Making
Committee for Special Payment Provisions for Prosthetics and Certain Custom
Fabricated Orthotics. In addition, this letter is intended as a direct
rebuttal to the letter written by Mr. Harley Thomas of the Paralyzed
Veterans of America, addressed to you on July 16, 2003.

The AAPM&R is the national medical specialty society of nearly 7,000
physical medicine and rehabilitation physicians, also called physiatrists.
Approximately 90% of all physiatrists practicing in the United States are
members of the AAPM&R. Physical medicine and rehabilitation, recognized as a
board-certified medical specialty in 1947, focuses on restoring function to
people with problems ranging from simple physical mobility issues to those
with complex cognitive involvement. Physiatrists also treat patients with
acute and chronic pain and musculoskeletal as well as neurological
disorders.

At the invitation of CMS, the AAPM&R participated in the negotiated
rulemaking process. In the view of the AAPM&R, there were two groups
present at the table during the process: those with a direct financial
stake in the process (representatives of various prosthetist/orthotist
organizations, manufacturers' representatives, and representatives of
physical therapy and occupational therapy professional organizations) and
those with a primary interest in the outcome for people in need of
prosthetic and orthotic services, but with no direct financial stake in the
outcome of the process (the American Association of Orthopedic Surgeons, the
American Academy of Physical Medicine and Rehabilitation, The Barr
Foundation, and the Paralyzed Veterans of America).



The AAPM&R sent a total of three representatives to the meetings. AAPM&R
representatives' collective experience includes more than 40 years of
working with amputees in a variety of settings including various academic
and privates practice settings as well as Veterans Administration Medical
Centers. The AAPM&Rrepresentatives included advocates for amputees, authors
of research articles and contributors to standard textbooks regarding
rehabilitation following amputations, an associate editor of the American
Journal of Rehabilitation, a chairman of a prestigious department of
physical medicine and rehabilitation, and a member who himself is an
amputee. One of the AAPM&R representatives is on the faculty of a department
of occupational therapy at a major university.

All three AAPM&R representatives participate in the instructional curriculum
of physical and occupational therapists. The members are clearly aware of
the general strengths of physical and occupational therapy degree programs.
However, the members are also quite aware of the specific and significant
inadequacy of such programs in regards to the practice of prosthetics and
orthotics. Simply put, these programs are not designed to deliver nor are
they delivering the complete education and experience necessary to prepare
their graduates to practice comprehensive prosthetic and orthotic services.

It is the AAPM&R's unequivocal position that the current standard
educational requirements for certification/registration/licensure for
occupational and physical therapy are insufficient to allow unrestricted
billing under the L codes for prosthetic and orthotic devices. The AAPM&R's
position is based on concern for patients. The field of physical medicine
and rehabilitation is dedicated to maintaining and improving the quality of
life for individuals with disabilities. Properly fabricated and fitted
orthoses and prostheses allow patients to walk, to run, to grasp, to dress,
in short to participate in life to the fullest. Unfortunately, poorly
constructed devices can limit mobility and self care and cause pain and skin
breakdown. This compromise of the skin can cause infection resulting in
further amputation and even death. Patients need and deserve the strongest
guarantees of competence. Allowing unrestricted access to prosthetic and
orthotic L codes to all physical and occupational therapists by virtue of
their diplomas/state licenses alone exposes patients to unnecessary dangers
and risks, and will undoubtedly lead to avoidable injury and mortality

It is the AAPM&R's opinion that many physician groups share our view. The
Barr Foundation and the Amputee Coalition of America have stated positions
endorsing the highest standards for prosthetists and orthotists, and reject
the concept that occupational and physical therapists should be regarded as
qualified by degree or licensure alone. In fact, the only consumer group
that seems willing to endorse physical therapists and occupational
therapists as qualified to have unrestricted access to construct all
prostheses and orthoses through current education/licensure alone appears to
be the Paralyzed Veterans of America.

A constructive solution to allow occupational therapists and physical
therapists to act as prosthetists and orthotists would be to require
additional certification for such practice. The AAPM&R would be happy to
work with American Occupational Therapy Association and the American
Physical Therapy Association and other appropriate organizations to set
proper standards.


Thank you for the opportunity to comment on the negotiated rulemaking
process. If you have any questions about these comments, please contact
Allison Waxler at the AAPM&R national office at 312/464-9700.


Sincerely,
 <<...OLE_Obj...>>
Daniel Dumitru, MD, PhD
President


cc: Alberto Esquenazi, MD
        Todd A. Kuiken, MD
        Charles E. Levy, MD
Ronald A. Henrichs, CAE, Executive Director
R. Dawn Brennaman, MPA, Director, Health Policy and Practice Services
        Allison Waxler, Policy Analyst, Practice Management