Thoughts on O&P
Thomas Cutler
Description
Collection
Title:
Thoughts on O&P
Creator:
Thomas Cutler
Date:
11/25/2021
Text:
Hello Colleagues,
Last night I encountered a journal article written by educators about their role in crafting the future in O&P. And much as I respect our purveyors of normative education, I’m not sure that yet another outcome form designed by a non-clinical researcher and pushing for more 3D printing curriculum is our highest priority at the moment.
When I hesitantly gave my opinion to an AOPA staffer recently, I was impressed with the response. You see, it was 1975 when AOPA set us on our current trajectory. Since AAOP was still in its infancy (only founded in 1970), CMS went to the more established O&P association for input as to how they are to reimburse this profession known as orthotics and prosthetics. Today, CMS would have likely gone to something like the O&P alliance, but… that was also the decade of AMC Gremlins, shag carpeting, and polyester leisure suits.
While many sayings come to mind, the most insightful one is “My people perish for lack of vision.” You see, I believe that our ‘70s predecessors were craven in their failure to provide the thousands of Certified Prosthetists and Orthotists with the dignity of compensation for their clinical expertise. A billing code for an office visit. Careful about thinking too long on how those CMS conversations could have gone on for hours and yet nobody from the field of O&P suggested “Hey, if there’s an office visit, maybe they should get paid.” If you do, you are likely to become upset. Because we have two choices for this outcome: they were either morons or they knew that this would drive the profession to be beholden to manufacturers.
I told the AOPA person that it’s mind-boggling that the 1975 AOPA business committee only thought about the O&P profession as a dispensary, and not an infirmary. And to my surprise, they couldn’t agree more. I’m guessing that it’s because this person’s family doesn’t come from manufacturers, but from clinicians. And that’s why I would disagree with the educators about our most pressing need. I don’t believe that they sit down at the table for dinner and hear clinician family members discuss the actual issues affecting the many O&P clinics. Even lofty orthopedic and vascular surgeons get brought low by the uncle who remembers catching them peeing in the pool when they were 7. Talks at the dinner table can break through the hubris of the ivory tower. So, educators chat with us practitioners at an annual conference, but answer to the administrators at weekly staff meetings. And since smart people assume more firmly that their assumptions are correct, administrators are loathe to believe that a non-PhD orthotist has the insight that they overlooked. We don’t get the change we need, but that which an administrator “thinks we need”. It’s an echo chamber.
Having a billable office visit would change everything. When an insurance company asks for documentation, at least you aren’t already operating in the red. Spending time yet again to adjust a socket? Paid. What if O&P could get a mandatory consult from CMS prior to hospital discharge after amputation or stroke? That gives us an active part in the care plan. When research needs to be done, we can have a larger role. Did you know that of the VA’s 38 people in the top 4 levels of prosthetic research (CLIMB center), only one person has an ABC certification of any kind? And at the 4th level, no less. How can it be that we’ve allowed our profession to have so little voice in our own research? Even PTs and OTs have CPT codes 97760, 97761, and 97763 to bill for their time working in O&P (as opposed to a specious “repair code”). Go to their AOTA website and they even provide directions on how to bill for L-Codes. So, while all of these larger organizations are helping their members to succeed in encroaching into our profession, I’ve thrown my lot in with those who are focused more on making these targets more easily available? Living in the middle of California, I’ve seen that kind of focus before. It’s called a high speed rail from nowhere to nowhere, and it’s a distraction from the real problems in my beautiful, but poorly run, state. And the same distractions occur in our critical profession.
Mind you, consider it from the manufacturer’s perspective. Does their bottom line know if the check comes from a therapist or an O&P shop? To them it’s irrelevant, so we still have the principles of 1975 driving the world of 2021.
I’m certainly open to being wrong. My goal is better patient care, not loading my pockets with cash. And I feel like I need to step in as the adult when academics get twitterpated about “innovations” that are still emergent. Their residency sites want graduates with solid skills upon which they can build, not lofty thoughts that risk disdain and conflict with seasoned practitioners. Is that the profession I’ve thrown my lot in with?
You see folks, the textbooks and educators aren’t at the cutting edge of O&P innovation. That magic resides in your hands. The ability to modify an existing socket so that the patient’s pain goes from an 8 to a 2 doesn’t come from a career dedicated to the predetermined correct answer on a test in “transtibial prosthetics” in Spring Semester using deductive reasoning. It comes from abductive reasoning, an intelligence beyond the normative education of the textbook. It’s nuanced and heuristic, earned by the hard work of your residency and beyond. From the daily instant feedback of that “look” you get from a patient when it’s finally perfect. If there’s no incentive to go the extra mile to make that difference, then logic forces us to conclude that those who are content to not go the extra mile will be the most productive without a billable office visit code. They will generate the most revenue. They will select only the most lucrative interventions while your superior solution garners only a fifth of their profit. And eventually those resources will empower them to prevail. To prevail over the folks with magic in their hands and a heart for true patient care.
Mind you, I’m not opposed to 3D printing and quantitative outcome measures. My point is that without the Certified Prosthetist and the Certified Orthotist getting paid for their clinical expertise, we don’t have a voice in the process. Instead, we get pedantic, ineffective “solutions” and get scolded if we have the temerity to ask questions. Maybe that could be a difference between the CP and the certified prosthetic assistant… the CPA can’t bill for time and the CP can. That way, the CP is brought into the research and the CPA has the incentive to get their master’s degree. The fact that a CP can bill for time warrants a higher salary to pay off school. If we get paid for an office visit, CMS can take that portion off the top of a post-op knee brace fee schedule amount (since we never see them anyway) and have the orthopod send them to us afterward for fitting and adjustment. I mean, have you honestly looked at one recently and said, “Wow, that fits great!”?
By the way, the same goes for the CPed. If they can do an “on-the-spot” fix with a small arch pad or whatnot, then having a payment pathway that’s recognized by insurers will create a better future for them. But ethical concerns preclude us from allowing a podiatrist to have this in addition to their existing codes. They have plenty. And it’s time for those other professions to finally figure out who’s the expert when it comes to designing devices to improve the lives of our patients. And for those who bristle at my claim that we’re the experts… if you disagree, then why did you become an O&P clinician? And if you bristled and you’re not a CP or a CO, then I would politely tell you that this doesn’t concern you. Please butt out.
To the various organizations and associations, have the courage of your convictions to effect real change and stop fooling yourself about things that feel good, but don’t DO good. Those ineffective programs are like dad’s favorite 12 year old tighty whitey underwear. Sure, they’re technically underwear, but come on… it’s time. And the same goes with programs that haven’t changed in decades. Make available the bandwidth to get O&P the billing code we deserve.
But for the moment, please forget all that and may you all enjoy a wonderful Thanksgiving.
Respectfully,
Tom Cutler, CPO, FAAOP
Sent from Mail< <URL Redacted> > for Windows
Last night I encountered a journal article written by educators about their role in crafting the future in O&P. And much as I respect our purveyors of normative education, I’m not sure that yet another outcome form designed by a non-clinical researcher and pushing for more 3D printing curriculum is our highest priority at the moment.
When I hesitantly gave my opinion to an AOPA staffer recently, I was impressed with the response. You see, it was 1975 when AOPA set us on our current trajectory. Since AAOP was still in its infancy (only founded in 1970), CMS went to the more established O&P association for input as to how they are to reimburse this profession known as orthotics and prosthetics. Today, CMS would have likely gone to something like the O&P alliance, but… that was also the decade of AMC Gremlins, shag carpeting, and polyester leisure suits.
While many sayings come to mind, the most insightful one is “My people perish for lack of vision.” You see, I believe that our ‘70s predecessors were craven in their failure to provide the thousands of Certified Prosthetists and Orthotists with the dignity of compensation for their clinical expertise. A billing code for an office visit. Careful about thinking too long on how those CMS conversations could have gone on for hours and yet nobody from the field of O&P suggested “Hey, if there’s an office visit, maybe they should get paid.” If you do, you are likely to become upset. Because we have two choices for this outcome: they were either morons or they knew that this would drive the profession to be beholden to manufacturers.
I told the AOPA person that it’s mind-boggling that the 1975 AOPA business committee only thought about the O&P profession as a dispensary, and not an infirmary. And to my surprise, they couldn’t agree more. I’m guessing that it’s because this person’s family doesn’t come from manufacturers, but from clinicians. And that’s why I would disagree with the educators about our most pressing need. I don’t believe that they sit down at the table for dinner and hear clinician family members discuss the actual issues affecting the many O&P clinics. Even lofty orthopedic and vascular surgeons get brought low by the uncle who remembers catching them peeing in the pool when they were 7. Talks at the dinner table can break through the hubris of the ivory tower. So, educators chat with us practitioners at an annual conference, but answer to the administrators at weekly staff meetings. And since smart people assume more firmly that their assumptions are correct, administrators are loathe to believe that a non-PhD orthotist has the insight that they overlooked. We don’t get the change we need, but that which an administrator “thinks we need”. It’s an echo chamber.
Having a billable office visit would change everything. When an insurance company asks for documentation, at least you aren’t already operating in the red. Spending time yet again to adjust a socket? Paid. What if O&P could get a mandatory consult from CMS prior to hospital discharge after amputation or stroke? That gives us an active part in the care plan. When research needs to be done, we can have a larger role. Did you know that of the VA’s 38 people in the top 4 levels of prosthetic research (CLIMB center), only one person has an ABC certification of any kind? And at the 4th level, no less. How can it be that we’ve allowed our profession to have so little voice in our own research? Even PTs and OTs have CPT codes 97760, 97761, and 97763 to bill for their time working in O&P (as opposed to a specious “repair code”). Go to their AOTA website and they even provide directions on how to bill for L-Codes. So, while all of these larger organizations are helping their members to succeed in encroaching into our profession, I’ve thrown my lot in with those who are focused more on making these targets more easily available? Living in the middle of California, I’ve seen that kind of focus before. It’s called a high speed rail from nowhere to nowhere, and it’s a distraction from the real problems in my beautiful, but poorly run, state. And the same distractions occur in our critical profession.
Mind you, consider it from the manufacturer’s perspective. Does their bottom line know if the check comes from a therapist or an O&P shop? To them it’s irrelevant, so we still have the principles of 1975 driving the world of 2021.
I’m certainly open to being wrong. My goal is better patient care, not loading my pockets with cash. And I feel like I need to step in as the adult when academics get twitterpated about “innovations” that are still emergent. Their residency sites want graduates with solid skills upon which they can build, not lofty thoughts that risk disdain and conflict with seasoned practitioners. Is that the profession I’ve thrown my lot in with?
You see folks, the textbooks and educators aren’t at the cutting edge of O&P innovation. That magic resides in your hands. The ability to modify an existing socket so that the patient’s pain goes from an 8 to a 2 doesn’t come from a career dedicated to the predetermined correct answer on a test in “transtibial prosthetics” in Spring Semester using deductive reasoning. It comes from abductive reasoning, an intelligence beyond the normative education of the textbook. It’s nuanced and heuristic, earned by the hard work of your residency and beyond. From the daily instant feedback of that “look” you get from a patient when it’s finally perfect. If there’s no incentive to go the extra mile to make that difference, then logic forces us to conclude that those who are content to not go the extra mile will be the most productive without a billable office visit code. They will generate the most revenue. They will select only the most lucrative interventions while your superior solution garners only a fifth of their profit. And eventually those resources will empower them to prevail. To prevail over the folks with magic in their hands and a heart for true patient care.
Mind you, I’m not opposed to 3D printing and quantitative outcome measures. My point is that without the Certified Prosthetist and the Certified Orthotist getting paid for their clinical expertise, we don’t have a voice in the process. Instead, we get pedantic, ineffective “solutions” and get scolded if we have the temerity to ask questions. Maybe that could be a difference between the CP and the certified prosthetic assistant… the CPA can’t bill for time and the CP can. That way, the CP is brought into the research and the CPA has the incentive to get their master’s degree. The fact that a CP can bill for time warrants a higher salary to pay off school. If we get paid for an office visit, CMS can take that portion off the top of a post-op knee brace fee schedule amount (since we never see them anyway) and have the orthopod send them to us afterward for fitting and adjustment. I mean, have you honestly looked at one recently and said, “Wow, that fits great!”?
By the way, the same goes for the CPed. If they can do an “on-the-spot” fix with a small arch pad or whatnot, then having a payment pathway that’s recognized by insurers will create a better future for them. But ethical concerns preclude us from allowing a podiatrist to have this in addition to their existing codes. They have plenty. And it’s time for those other professions to finally figure out who’s the expert when it comes to designing devices to improve the lives of our patients. And for those who bristle at my claim that we’re the experts… if you disagree, then why did you become an O&P clinician? And if you bristled and you’re not a CP or a CO, then I would politely tell you that this doesn’t concern you. Please butt out.
To the various organizations and associations, have the courage of your convictions to effect real change and stop fooling yourself about things that feel good, but don’t DO good. Those ineffective programs are like dad’s favorite 12 year old tighty whitey underwear. Sure, they’re technically underwear, but come on… it’s time. And the same goes with programs that haven’t changed in decades. Make available the bandwidth to get O&P the billing code we deserve.
But for the moment, please forget all that and may you all enjoy a wonderful Thanksgiving.
Respectfully,
Tom Cutler, CPO, FAAOP
Sent from Mail< <URL Redacted> > for Windows
Citation
Thomas Cutler, “Thoughts on O&P,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/255704.
