May 2021

O&P’s Need for Differentiation

By Eve Lee, MBA, CAE

Although orthotics and prosthetics (O&P) is a small part of healthcare, it provides critical clinical services for millions of Americans living with limb loss and limb impairment. Unfortunately, because of the way O&P services are reimbursed, O&P providers are often not compensated for all care provided to patients. In order to ensure adequate reimbursement and so that quality patient care can be maintained,  it’s vital that Congress take the long overdue step of distinguishing O&P from Durable Medical Equipment (DME).

Even though O&P includes a considerable amount of patient care and is decidedly more in-depth and personal than simply supplying a device, O&P clinicians are (at least statutorily) viewed as suppliers of DME. Yes, devices are involved, but that is only one aspect of the patient interaction. Most O&P devices are custom fabricated or custom fit, meaning they require the expertise of an orthotist or prosthetist who receives a Master of Science degree and residence training before becoming a certified practitioner. Additionally, the O&P clinician often spends time interacting with other parts of their patient’s care team. It all boils down to the fact that, currently the device is reimbursed but the in-depth and long term care provided by the clinician is not.

Differentiating O&P from DME will not only allow for more emphasis on care provision, it will get O&P to a place where its clinicians are universally considered part of the healthcare team ensuring an aging population gets the O&P care they need, when they need it.

The American Orthotic and Prosthetic Association, who’s over 2,000 members represent both the facilities that treat patients and the manufacturers of O&P devices, have been advocating for years for this differentiation. The bipartisan Medicare O&P Patient-Centered Care Act (H.R. 1990) would improve access to, and quality of O&P care received by Medicare beneficiaries. Specifically, it would:

  • Distinguish the clinical, service-oriented nature in which O&P is provided from the standard durable medical equipment benefit.
  • Restore congressional intent by revising the overly expansive regulatory interpretation of the meaning of “off-the-shelf” (OTS) orthotics to clarify that competitive bidding may only apply to orthoses that require minimal self-adjustment by patients themselves, without clinical expertise or intervention.
  • Reduce the likelihood of waste, fraud, and abuse in the Medicare program by prohibiting the practice of “drop shipping”  of orthotic braces that are not truly “off-the-shelf” (i.e., subject to minimal self-adjustment by the patient).
  • Exempt certified and/or licensed orthotists and prosthetists from the requirement to have a competitive bidding contract in order to provide OTS orthoses to their patients, much like the law treats therapists and physicians. These orthoses would be subject to the competitive bidding rate so this provision would increase patient convenience without increasing Medicare costs.

So, as our country seeks better solutions to cost, delivery, and coverage, the small but important sector of O&P needs to be distinct from DME. Passing the Medicare O&P Patient-Centered Care Act does this and ultimately protects O&P businesses and preserves patient access to quality care.

Eve Lee, MBA, CAE is Executive Director of the American Orthotic and Prosthetic Association.

The American Orthotic and Prosthetic Association (AOPA) needs your help to get support for this important legislation: Write your Representative and ask them to cosponsor the Medicare O&P Patient-Centered Care Act (H.R. 1990). To do this,  please visit http://www.aopavotes.org/. It will only take you a few minutes to send a message to them, and the more support we can garner for the bill, the more likely it is to pass. If you have any questions, please reach out to Ashlie White, AOPA’s Director of Strategic Alliances at awhite@AOPAnet.org.  Thank you for your efforts on behalf of the O&P profession.

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