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  • APTA to CMS: Proposed Orthotics and Prosthetics Rule Hurts Patients, PTs

    When it comes to a proposed rule from the Centers for Medicare and Medicaid Services (CMS) that would impose undue regulatory and financial burdens on physical therapists (PTs) who provide custom orthoses and prostheses, APTA isn't mincing any words, describing the proposed standards as a set of unnecessary requirements that will limit patient access to appropriate care.

    In a March 10 letter to CMS, APTA President Sharon L. Dunn, PT, PhD, lays out the case for CMS to back away from the proposed rule, which would require PTs to be "licensed by the state [as a qualified provider of prosthetics and custom orthotics], or … certified by the American Board for Certification in Orthotics and Prosthetics … or by the Board for Orthotist/Prosthetist Certification." APTA estimates that the additional administrative and financial burdens could affect thousands of PTs across the country.

    "Many physical therapists furnish and fabricate orthotics and prosthetics as appropriate," Dunn writes. "The standards that CMS is putting forth in the proposed rule are so restrictive that the effect will be to limit Medicare beneficiaries’ access to services that are safe and effective." The letter calls for CMS to maintain the provisions of a 2008 law that exempts PTs and other qualified providers from additional accreditation requirements in order to bill Medicare for the devices.

    In the letter, Dunn sets out 3 main arguments against the proposed rule: namely, that PT education and training already meet requirements supposedly upheld by the proposal; that the proposed rule would wind up costing PTs significant amounts of time and money; and that naming only 2 organizations as responsible for issuing accreditations is inadequate to meet the demand for approval, should the proposal be move ahead as-is.

    If enacted, Dunn writes, the real victims will be the Medicare beneficiaries themselves.

    "Prohibiting physical therapists without the proposed licensure or certification from performing interventions with orthotics and prosthetics would place an undue burden on patients by forcing them to see alternative providers," Dunn writes. "This would increase the cost to the patient and the amount of time spent using health care practitioners." Further, she writes, the proposal isn't even borne out by any state-level precedent, as "no US jurisdictions prohibit physical therapists from using orthotics and prosthetics as a component of physical therapist practice."

    The letter also urges CMS that should quality standards around this rule be developed in the future, the development process should be "established by consensus-based organizations that include all of the relevant providers." Although APTA was included in negotiated rulemaking around these issues in 2002, PT representatives—along with representatives of podiatrists, orthopedic surgeons, and physiatrist—have been largely excluded from quality standard development around orthotics and prosthetics.

    "Developing quality standards without consulting a large number of practitioners who furnish the services is problematic and will have a significant impact on beneficiaries who receive these supplies and services," Dunn writes. "Going forward, APTA wants to ensure that all relevant parties are consulted in updating any new quality standards."

    APTA is urging its members to educate themselves on the proposal, and then to provide their own comments to CMS about how the rule would hurt patient access and increase costs to PTs who are already qualified to provide custom devices. The association has created a fact sheet on the proposed rule, and offers a member-protected template letter that can be downloaded and shared with colleagues. Deadline for comments is March 13, 2017.


    • Physical therapists should not be required to get certified to be able to fabricate and bill for orthotics and prosthetics. It was part of their curriculum and they had extensive education while in school. They have previous experience with the application and they should not be obligated to take a new course to get paid for it. There would also be a decrease in productivity as well as detrimental consequences for the patient because it would require the patient to go back to their physician and get a referral to another specialist to get fitted for orthotics and prosthetics if their physical therapist is not certified. This may require patients to pay more and it will also delay the process of getting fit for their needs. When these patients get back from certified orthotists and prosthetists, they’d still need to be monitored by the PT on how they tolerate the devices with activities. If the orthotic or prosthetic device needs adjustment, the patient would have to go back to the specialist once again.

      Posted by Rochelle Anne Baes on 3/12/2017 11:38 PM

    • Please do not pass this bill. Many of our patients would not be able to order the equipment they need.

      Posted by Erin Trudell on 3/13/2017 3:37 PM

    • Ms. Baes accurately summarized the issue. This rule will cost medicare more MONEY to achieve the same degree of accuracy, safety and benefit for the patient. It will also cost the patient more TIME to achieve the same benefit. The rule drains more taxpayer dollars, while slowing patient access to the intervention they need.

      Posted by Kevin McGovern on 3/15/2017 3:34 PM

    • Please do not pass this bill, as it just another example of how people have no idea just how much extensive education PT's receive in school.

      Posted by Jason Morrell, PT, DPT on 3/15/2017 3:50 PM

    • Many thanks to President Dunn for her response to CMS. Fabrication of orthoses constitutes about 90% of my practice and would have serious consequences for the medicare beneficiaries I serve, for myself as a qualified practitioner, for the physicians I work for and for the hospital I work in. It would also have serious consequences for those in rural areas where access to an orthotist or prosthetist may not even be an option.

      Posted by Cindy Armstrong on 3/15/2017 5:15 PM

    • As a licensed Physical Therapist in Michigan and an International missionary Physical Therapist, I have ordered and checked out multiple prosthetics and orthotics. I was trained very carefully to order and evaluate those who need such devises by Dr. Eugene Michaels at University of Pa. His training would be what Physical Therapists get in their Doctorate Program . There is no need to duplicate this training by requiring a separate certification. Please do not this waste of time to be required

      Posted by Lawrence Golin on 3/15/2017 5:36 PM

    • Several reasons why the proposed rule runs against the "better hope" for appropriate use of Prosthesis and Orthosis for patients management. A cardinal consideration that smacks on efficacy and efficiency, is tha, Prosthesis and orthosis, or other splints are applied for support and to assist mobility, including walking. Re-education of this important functional activity, and paramount disability/ handicap, is the primary premise for Physical Therapy, in almost its entirety. Bottle necking or hamstringing the Physical Therapist in the prompt recommendation, prescription, ordering, application, and regular reassessment of this "modality of treatment and essential treatment tool" is a misnomer to say it most subtly. When the PT is sidelined in ordering and application of Prosthesis and Orthosis, the fitting, modification and training of the "brace" is often limited, if not outright waste. Please do not pass this bill, would the reason be because the expertise of the Physical Therapist is being put to question, as a properly trained and licenced practitioner, imbibed with the high ethos' of beneficence service and protecting the public, whereas the PT is the unquestionable "gate-keeper" of the prescription, issuance, application and utility of Prosthesis and Orthosis. When a PT orders a brace, he takes responsibility for the appropriateness of its utilization, for the PT goals and patients goals. This practice inherently has efficiency - adequacy, timeliness and cost containment, as the hallmark.

      Posted by Popoola Adeola on 3/15/2017 6:47 PM

    • My practice has a specialty in gait aberrations. We design orthotics for on shoe wear to correct the gait. This very efficient for the patient and less expensive than involving another trip to the doctor and an orthotics.

      Posted by Joan Firra, PhD PT on 3/15/2017 6:47 PM

    • The use of orthotics and prosthetics are vital in the planning and preparation of gait analysis and positional support for the the biomechanics of the lower extremities. Physical therapists have teamed up with certified clinicians and practitioners to assist patients and clients with their return to functional gait activity and therapeutic exercise programs.

      Posted by Heidi harris on 3/16/2017 4:17 PM

    • PTs have been properly trained to make many forms a splints and adaptive equipment in our schools for many years. Patients have benefited by having the equipment immediately and changes can be made as indicated by the person who knows the patient best, his or her PT. Of course there are different levels of equipment and some, such as metal braces or prostheses, require the skill of a specialist in those higher forms of equipment. The PT is also trained to know when to refer to those providers for equipment outside the PTs skill and ability and to consult with them with medical knowledge. This suggested change will only hurt the patient! M

      Posted by Rex Nutt on 3/16/2017 11:20 PM

    • I would definitely suggest and in favor of PT to order limited prosthesis and orthotics for Patients benefits and if side bars orthotics or more complecated prosthesis or orthosis required then PT recommend to certified prosthetist or orthotist .

      Posted by MUZAFAR HUSSAIN on 12/28/2017 11:37 AM

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