Reimbursement Page

Bracing for Impact

How will prior authorization, competitive bidding, and other trends affect your O&P business?

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ONE OF THE CHALLENGES in today’s fast-evolving business environment is understanding how changes that are happening today will impact your business in the future. This is especially true for O&P businesses, which have faced several significant changes in recent months.

Changes are not necessarily bad for business, but how you react and adjust to change will determine how successfully your business navigates change. This month’s Reimbursement Page reviews some of the changes and trends impacting the O&P business world and discusses how they may affect your facility in the future.

Prior Authorization

Medicare prior authorization is a relatively new program for O&P services and is currently limited to six lower-limb prosthesis codes, two spinal orthosis codes, and three knee orthosis codes. While the Medicare prior authorization program has gone very well for lower-limb prostheses, with almost all requests receiving affirmation upon the initial submission, prior authorization requests for spinal and knee orthoses have proven to be a bit more difficult.

Issues that have caused denials in the past, such as the lack of measurable objective joint laxity in osteoarthritic knees, are lowering the initial affirmation rates for orthoses that now require Medicare prior authorization as a condition of payment. While this situation can be frustrating, it also provides an opportunity to adjust your business practices based on the quickly emerging trend. If prior authorization requests are not receiving affirmations, then it may be time to provide additional education to your referral sources and adjust how you document in your own records.

At the moment, Medicare prior authorization for orthotics is limited to five orthosis codes, but it is likely the program will be expanded. Learning how to improve your chances for success with a limited number of impacted Healthcare Common Procedure Coding System codes will pay dividends as Medicare prior authorization expands to other areas.

Competitive Bidding

The Medicare competitive bidding program is viewed by many as a tremendously successful program—not only for O&P services, but for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) in general.

Currently, only off-the shelf (OTS) orthoses remain subject to Medicare competitive bidding. The most recent round of competitive bidding, also known as Round 2021, removed all of the DMEPOS categories that were previously subject to Medicare competitive bidding. The stated reason for this was that competitive bidding resulted in significant cost savings, and future rounds of competitive bidding would most likely not lead to additional savings to the Medicare program.

Removal of the durable medical equipment product categories from competitive bidding no longer restricted access for patients since they could once again receive services from any enrolled supplier, but competitive bidding had already resulted in reductions to the Medicare fee schedule.

While it is possible that future rounds of Medicare competitive bidding may expand the number of OTS orthoses subject to competitive bidding, the trend that we witnessed in durable medical equipment may result in the elimination of competitive bidding for OTS orthoses. This would no longer require O&P providers to participate in competitive bidding but would include the Medicare fee schedule reductions that have already been implemented for the OTS orthosis codes that are currently part of Competitive Bidding Round 2021.

PDAC Coding Verification

In another key O&P trend, the number of procedure codes that are subject to code verification by the Pricing, Data Analysis, and Coding (PDAC) contractor has been increasing. CMS and the durable medical equipment Medicare administrative contractors (DME MACs) may require, as a condition of claim payment, that the PDAC verify that certain products are correctly coded. PDAC verification was recently incorporated into the Medicare prior authorization process to help facilitate timely decisions by verifying correct coding in advance.

PDAC is currently using the physical attributes of products as the primary factor when performing code verifications. AOPA believes that product function also is a relevant factor that the PDAC should consider when performing code verification. Keep in mind that, in addition to PDAC code verifications being required for payment in specific situations, they also are binding on the supplier community—even if a product is submitted for PDAC review voluntarily.

While PDAC coding verification requirements can be frustrating, understanding what is required—and when—can be helpful in avoiding unnecessary claim denials.

Correct Coding Bulletins

The DME MACs and PDAC have increased the number of correct coding bulletins they are releasing. Correct coding bulletins are not considered medical policy and are therefore not subject to the same public notice and comment requirements that govern changes and updates to Local Coverage Determinations. Correct coding bulletins are designed to communicate the requirements that a product must meet to properly meet the language of a particular code descriptor.

Correct coding bulletins have become increasingly more specific in recent years. While technically not formal policy, correct coding bulletins are being used when making coverage decisions for individual claims. These bulletins, if not followed or understood, may result in unnecessary and costly claim denials.

RAC Audits

Dealing with recovery audit contractor (RAC) audits has become a standard part of O&P business operations—and there are lessons to be learned from the trends that they have created.

RAC auditors are the only Medicare contractors that are paid a percentage of the overpayments they identify—between 9% and 12%. This is a significant revenue opportunity for the RAC contractor, which is looking for the “low-hanging fruit” that will represent the biggest profit opportunity for their organization.

Two of the contractual requirements that RAC contractors must follow involve obtaining CMS approval for any new audit activities, and publishing their current approved issues on their website: www.performantcorp.com/cms-rac/ cms-rac-resources/region-5/default.aspx. Spending a few minutes on this website on a regular basis will help you ensure your documentation adequately supports the services that the RAC is likely to be looking at. While documentation practices should be consistent for all of the services you provide, having this information will certainly contribute to your success in RAC audit situations.

Stay Alert

The areas identified in this month’s Reimbursement Page comprise just a few of the trends you should be closely following to determine their potential impact on your O&P business.

Success often is created not by how reactive you are to what is happening— but by how proactive you are regarding what may happen in the future.

Joe McTernan is director of coding and reimbursement services, education, and programming at AOPA. Reach him at jmcternan@AOPAnet.org.

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NEED TO KNOW

• Most future-focused O&P facilities prioritize patient satisfaction and adaptability over time, and some of the most successful O&P businesses distinguish themselves by focusing on a specific goal. • Some clinics identify specific patient populations—for example, active limb loss patients, or limb salvage patients—and equip their clinics to best meet those patients’ needs. • Other facilities embrace a particular technology—such as 3D printing—and build a reputation as an innovator in that arena. • Still other businesses focus on patient experience and design their spaces to be welcoming, responsive, and technologically advanced. • Specialization is a trend that may help smaller O&P facilities remain profitable into the future.

HIGHLY SUCCESSFUL O&P facilities share several traits in common: They are willing to adapt; they focus on patient satisfaction; and they explore new technologies. Facilities that match these descriptions can be found throughout the country.

Among these high-performing facilities, a few state-of-the-art clinics have set themselves apart even further. These facilities have identified a special area of focus—be it a specific patient base, a specific technology, or a specific approach to patient care. How did they do it? Several successful owners share how they distinguish their facilities and offer inspiration for others looking to do the same.

FACILITY FOCUS:

Active Prosthetic Patients

Prosthetic and Orthotic Associates (POA) in Orlando is a one-of-a-kind facility for a niche patient population. There, clinicians specialize in active patients, seeing a high percentage of both elite-level athletes and less competitive—but highly mobile— individuals with amputation.

Owner Stan Patterson, CP, LP, launched POA about 25 years ago, working out of his garage. Today, the facility encompasses 23,000 square feet, including a full gym, a 40-meter indoor track area, and plenty of outdoor space. “When we started, I wanted to have a facility that concentrated on more active patients”—where his expertise lies—rather than on dysvascular and diabetic patients, he says. To cater to the more active population, POA’s current space is an open-concept design, which includes a fitting/training area with a fully equipped fitness center, plus lounge and kitchen areas where patients can socialize. A dedicated children’s corner features a rock-climbing wall, activity table, and toys. “We also have a fun-loving canine crew that provides entertainment for all,” Patterson says.

POA features an open-concept design, which includes training equipment plus lounge and kitchen areas.

Other features at POA include a socket fabrication area, laser posture equipment, and a OHM machine that creates drag as athletes run.

POA has an in-house silicone house for fabricating custom liners.

Patterson’s decision to allocate open space where patients can test prostheses, participate in physical therapy, and engage in athletic training was inspired by a visit to Walter Reed Army Medical Center more than 15 years ago. “I saw soldiers in the big physical therapy room [at Walter Reed], and I noticed they were building off each other in trying new things. It was almost like a big support group.” At POA today, “the camaraderie within the open space provides a sense of community and belonging, which is invaluable, no matter where you are in the recovery process,” says Patterson.

In addition to four sets of 20-foot parallel bars and two sets of smaller parallel bars, the open space boasts high-tech features that encourage patients to improve their walking or running techniques, including zerogravity treadmills, treadmills that measure stride length and pressure during walking/running, and a large golf simulation room. At the track, clinicians use digital timers and an OHM machine that creates drag as athletes run. To ensure proper alignment, “we use a lot of slow-motion videos, via drones that fly beside the person,” Patterson says. Cameras are clipped directly to athletes, “or you can just follow along and the camera steadies itself. We can get footage from overhead, or from the side; we can get whatever angle that we need” to help adjust devices to optimize mobility for patients.

Fabrication at POA is kept in-house, which “allows us to maintain control over the quality of the prosthesis from start to finish,” while minimizing fabrication times, says Patterson. Twelve technicians work in the fabrication lab. The facility also has a fully stocked machine shop and an in-house silicone house “so we can make custom liners in a day.”

POA’s expansive social media presence and word-of-mouth has boosted its reputation as a travel destination for active athletes. Videos and posts highlighting the facility’s specialization have garnered the attention of active individuals across the country and around the world. “Because we specialize” in prostheses for active patients and frequently treat difficult-to-fit patients—such as individuals with hip disarticulation and proximal femoral focal deficiency—a significant portion of patients travel from outside of Florida to be seen by Patterson and his staff.

FACILITY FOCUS:

Limb Salvage

A Hanger Clinic in Gig Harbor, Washington, is another high-tech spot designed to cater to a specific patient population: limb salvage patients. While the facility also sees prosthetic patients, a high percentage of patients visit the facility to use the ExoSym device, a hybrid prosthetic-orthotic device that is custom-made to ensure optimal alignment, position, off-loading, and control, says Ryan Blanck, CPO, LPO, ExoSym program director and national upper-limb specialist. “The majority of my patients travel here from across North America, Europe, Asia, and the Middle East and typically stay for one to two weeks of focused care at a time. The facility was specifically designed to support this model and deliver the highest level of care for a variety of needs and devices.”

The 13,000-square-foot facility was designed “based on my experiences at the Department of Defenseoperated Center for the Intrepid in San Antonio … with a large training space, including a gym, equipment, and systems to help both limb salvage patients and patients with limb loss or limb difference achieve their maximal functional abilities,” says Blanck.

The ExoSym Limb Salvage program involves custom-designing and fitting each device on-site, then typically working for several weeks with the individual patient to observe the functionality of the device in real time, according to Blanck. “In addition to patient rooms, a reception area, and other typical features of an O&P clinic, we have a fully capable, 5,000-square-foot gym and training space outfitted with workout and rehabilitative equipment for all needs and abilities, including treadmills, weights, sleds, stairs, ramps, and an ambulatory rail harness system.”

Over the past several years, Blanck has built important relationships with nearby referral sources and hospitals, which have been central to the facility’s success. “The center in Gig Harbor has excellent relationships with local trauma centers and the surgeons and rehab teams that support the limb salvage and amputation recovery process, as well as many trauma centers across the country,” he says.

The Hanger Clinic in Gig Harbor, Washington, has been designed to cater to limb salvage patients, with a high percentage of patients visiting the facility to use the ExoSym device at the 13,000-square-foot facility.

FACILITY FOCUS:

Additive Manufacturing and Mobile O&P

At EastPoint Prosthetics & Orthotics, with locations in North Carolina, Ohio, and Pennsylvania, owner Paul Sugg, MA, CPO, CPed, FAAOP, was an early adopter of additive manufacturing in both prosthetics and orthotics. He has invested in equipment to leverage new 3D printing technologies to meet patients’ rapidly evolving needs.

EastPoint staff leverage software programs to send modifications for 3D printing; the facility has invested in both fused deposition modeling printers and a hightech multi jet fusion printer.

“We have a willingness to try new materials, new design types, and new technologies—such as 3D printing—to advance the profession,” says Sugg, explaining that his facility merges a traditional O&P model with the digital model. While many facilities have begun to use additive manufacturing for simple prosthetic components, EastPoint is “pushing the envelope” with more advanced uses, including 3D-printed prosthetic components for patients with knee disarticulation, hip disarticulation, and partial feet, as well as orthotic components—an area that is newer to the 3D-printed space.

The fabrication area at EastPoint is a hybrid space that combines traditional fabrication with additive manufacturing. In addition to lower-cost, and more familiar, fused deposition modeling printers, Sugg has invested in a high-tech multi jet fusion printer—enabling clinicians to says Sugg. “By using state-of-the-art technologies and new materials, we’ll see the best quality outcomes.”

Sugg also has embraced a mobile model of patient care. The company’s two brick-and-mortar locations in North Carolina and its single-office locations in Ohio and Pennsylvania are supplemented by 14 fully equipped O&P mobile vans that travel to patients on a regular basis. The facility offered mobile services even before COVID, but has seen a surge in demand for mobile care since 2020—a trend that puts them on the cutting edge of O&P, according to Sugg. “We’re seeing the VA and larger national O&P companies starting to do mobile,” he says.

Housing a full fleet of mobile vans allows for specialization. “Each van

design more complicated components. Creating 3D-printed components, where appropriate, helps meet patient demand, according to Sugg. “Many patients—especially younger patients— are asking for lighter devices, and they want to be able to do more” with their componentry, he says.

An added benefit of the 3D printing process for EastPoint staff is a healthier lab. “My techs experience less carbon fiber dust from grinding, and laminating fumes also are reduced, so it’s safer,” Sugg says.

EastPoint also uses a hybrid scanning system, leveraging both digital imaging and traditional casting, depending on the purpose and the patient. “Our digital practice, combined with a mobile model, is meeting patients where they are,”

EastPoint clinicians provide mobile O&P care and can visit patients at their homes to adjust prostheses.

The Nashville location of Hanger Clinic encompasses 12,000 square feet spread over two floors and features separate adult and pediatric wings.

The facility features a 1,500-square-foot lab for on-site fabrication and offers a wide variety of casting/rendering styles for O&P devices.

is set up specifically for the patient population”—be it spinal, pediatric orthotic, geriatric, or another O&P subgroup, says Sugg. Components and equipment inside the van target the specific patient base.

Mobile visits give clinicians a better understanding of patients’ componentry needs and abilities, according to Sugg. They can meet with patients at therapist or doctor appointments, and in their own environments, which helps with compliance and provides a more accommodating experience, he says.

FACILITY FOCUS:

Aligning With Allied Healthcare

Some O&P businesses design their facilities to align with the needs of nearby hospitals and healthcare facilities—such is the case for the Hanger Clinic facility in Nashville. The Nashville location encompasses 12,000 square feet spread over two floors and is located in a medical center in Nashville’s Midtown neighborhood, known for its high concentration of world-class hospitals and healthcare systems, says Brett Parrish, MSPO, CPO, LPO, clinic manager of Hanger Clinic in Nashville and vice president of Tennessee Society of Orthotics and Prosthetics.

“The clinic is aligned with local healthcare systems so that patients can conveniently access all the services they need when, for example, recovering from an amputation, including physical and occupational therapy and postdischarge rehabilitation,” explains Parrish. The facility has separate adult and pediatric wings. The pediatric area is decorated to appeal to children and families, and supports cranial remolding and other custom pediatric care. There are 22 total patient evaluation rooms, says Parrish, including five in the pediatrics wing, seven orthotic patient rooms, six prosthetic gait rooms, and an upper-extremity evaluation room.

On-site fabrication takes place in a 1,500-square-foot lab, and “we implement every casting/rendering style available for O&P devices,” says Parrish, including hydrostatic casting and hand casting and carving, “which is catered to each patient based off their anatomical and functional needs.”

The clinic offers several tools for scanning orthoses and prostheses, including a Symphonie casting system. “We have patient-care rooms specifically dedicated to upperlimb patient training with different devices and TVs, so that the training can be streamed for family members and friends,” says Parrish. “We have multiple-terrain walkways that allow patients to experience how their lower-limb prosthesis or orthosis will interact with the variable landscape of their environments at home, and we partner with local therapists to allow for higher densities of therapy, including but not limited to, aquatic therapy with a device, dry needling for phantom pain, and manual therapy.”

Looking to the future, the Hanger Nashville site aims to grow its interdisciplinary team by partnering with more therapists to offer gait training on-site, “giving us the ability to make real-time adjustments without as many follow-up appointments being needed for the patient,” says Parrish.

Sabolich Prosthetics & Research was an early adopter of outcomes-driven care and features an 11,000-square-foot full-capacity lab for quick repairs and one-day casting-to-fitting turnaround.

Prosthetic patients travel from outside of Oklahoma to be fit with a wide array of high-tech options.

FACILITY FOCUS

Outcomes-Driven Prosthetic Care

Scott Sabolich Prosthetics & Research in Oklahoma City was an early adopter of outcome measures, implementing a process to measure progress and quantify prosthetic patient outcomes before many other O&P facilities began doing so. Clinicians at the facility use the measures to determine the best possible outcome for prosthetic fitting, according to Jaime Perkins, the facility’s clinical liaison.

The facility’s mission is to provide the “Sabolich experience” for each patient who comes in the door, says Perkins. “Our entire staff is committed to the patient experience, from the very first phone call. The front office staff knows each patient by name—it’s like a family. We pride ourselves on the longevity of our staff.”

The main Sabolich facility is a 21,000-square-foot space in Oklahoma City, which includes an 11,000-square-foot full-capacity lab for quick repairs and one-day castingto-first fitting turnaround; the space includes a full built-in exhaust system. Fabrication is completed in-house, with casting done by hand. “It’s an open and transparent facility,” says Perkins. “Anyone can come in and take a tour.” The facility’s reputation has grown worldwide; a large percentage of the patients travel from outside of Oklahoma, according to Perkins.

Sabolich offers an array of hightech options for its prosthetic patients. “We have always combined intensive research efforts with daily clinical practice,” explains Kyle Wagner, CP, LP, chief prosthetist. “The prosthetics research and development industry is entering a groundbreaking and exciting era. Revolutionary technology promises to radically enhance the capabilities of our patients.” The facility is exploring artificial intelligence, environmental feedback, materials design, motorized articulation, and 3D printing, according to Wagner.

“We are creating designs that are radically different than conventional thinking by using advanced sensor technologies, smart control systems, and innovative computer modeling,” Wagner adds. “We understand the immense importance of research and development and the direct impact it has on our patients’ ability to get back to 100% functionality.”

FACILITY FOCUS:

Inviting Physical Spaces

Matt Bulow, CP, owner of Bulow Orthotic and Prosthetic Solutions, wanted patients to feel confident and comfortable at his facility, headquartered in Nashville. With that in mind, he created a high-tech space that is both comforting and clean. “Upkeep shows you take pride in your work,” he says.

While the facility originally focused specifically on prosthetic patients, it has grown to offer all types of O&P care. Some service offerings have been tailored for specific patient populations, including orthopedic/ trauma patients; vascular patients; and pediatric patients. The facility also partners with Vanderbilt Hospital’s Ingram Cancer Center in treating patients who have lost limbs due to cancer.

The facility strives to provide one-on-one-personal attention and “nurturing guidance,” according to Bulow. The headquarters building features an exposed ceiling, wide hallways, and a large waiting area with a coffee bar where patients often congregate. Two of the patient rooms are oversized, with permanent 24-foot parallel bars where patients can work privately with their clinician. High-end posters of patients—from high-end special ops military limb loss patients to everyday community ambulators, complete with signatures of the patients—decorate the walls. A separate “word wall” showcases 10 words, chosen by staff, that describe “the culture of our practice,” says Bulow.

Bulow O&P emphasizes the value of teamwork in its staffing, and encourages clinicians to collaborate with residents and technicians in finding solutions in complicated cases, says Bulow.

With several recently built satellite locations outside of Nashville, the facility is now structured in a “hub-and-spoke” model so patients don’t have to come into the city for O&P care, says Bulow. The lobby, lab, and gait room at Bulow Orthotic and Prosthetic Solutions have been intentionally designed to help patients feel comfortable as well as confident in their devices.

Tips for Small Facilities

Any facility can strive to be state of the art, regardless of size. Below are some tips for facilities seeking to optimize their patient-care experiences.

“Always make yourself available and tailor the care to each patient and their specific needs. Listen to their concerns, and be creative with the resources you have. Make the most of your situation. That goes farther and has more impact than just providing care in the most advanced center or facility available. In the end, when the patient knows you will stop at nothing to help them succeed, your facility will be excellent in the outcomes it provides.”

—Ryan Blanck, CPO, LPO

“Maintain as much communication with your local referral partners and therapists as possible, and continue to remain outcomesfocused. The future of healthcare will be completely driven by those that provide the best evidence of superior patient outcomes. In addition, never stop innovating and never stop educating your entire staff—both clinical and administrative. Stagnancy and complacency are the greatest detriments to any clinic.”

—Brett Parrish, MSPO, CPO, LPO

“Facility modernization goes beyond size; it can also include technology enhancements, staffing arrangements, increased use of digital technologies, functioning as part of a multidisciplinary team, and being local, available, and convenient to patients. Regardless of the size of their facility or available resources, clinicians can provide excellent care by prioritizing the patient experience and using functional outcomes to drive success and meet the patient’s goals.”

—James Campbell, PhD, Hanger senior vice president and chief clinical officer Keeping Patients Top-of-Mind

Not every facility can be “state of the art,” but every facility can make small changes to modernize and better meet the needs of its targeted patient base. For those facilities without big budgets, simply identifying a special area of focus, and committing to excel in that area, can result in expanded patient interest and recognition as a unique O&P provider.

Of course, any facility that seeks to prosper into the future should continue to explore new technologies and implement processes and procedures that improve the patient experience.

“The field of healthcare is an everchanging professional landscape full of regular innovation that requires constant continuing education and adaptation so that the latest proven techniques can be used to provide superior care to our patients,” says Parrish. Keeping up with the latest trends will benefit both the facility and the patients its serves.

Patterson believes specialization is a trend that will help keep smaller O&P facilities relevant, even as the O&P field sees increased merger and acquisition activity. “Patients are searching out the particular type of care they need” by going online, and are willing to travel to be seen when they find the right fit, he says. He encourages O&P clinicians to consider opening their own small businesses, with a focus on the area of O&P at which they excel. “There is room in this space for independent practitioners,” he says. “Our prosthetic industry is getting better and better, with people specializing in arms, or lower limb, or orthotics or even cranial remolding,” Patterson says.

Patterson encourages small facilities to ask questions and visit other facilities for new ideas. “Sharing knowledge is very important in this field—and will help elevate the profession.”

Christine Umbrell is a contributing writer to O&P Almanac. Reach her at cumbrell@contentcommunicators.com.

Recruiting Gen Z

How stakeholders are drawing high school students to the profession

NEED TO KNOW:

• With a growing need for O&P services within the

United States and a recognition that employment of O&P professionals should grow by 18% by 2030, raising awareness of the profession among today’s students has become a priority. • To help attract students to the profession, ABC recently launched an initiative to promote the profession to Gen Z, and AOPA invited high school students to participate in some facets of next month’s Assembly in San Antonio. • Several universities and private practices have developed their own awareness initiatives and created internship opportunities for local students. • Some awareness programs focus on introducing the O&P profession to students of color, which may cultivate more diversity in the O&P profession. • O&P clinicians should consider becoming industry “ambassadors” to connect with students as part of ABC’s whatispop.org program.

IN THE SUMMER OF 2021, leaders at the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) started a conversation about the industry’s future, assessing where the next generation of O&P professionals would come from and how to attract students to pursue careers in O&P. The group quickly realized they had a lot of work to do.

After all, the U.S. Department of Education has declared O&P training a “national priority” because a shortage of practitioners can’t keep up with the surging demand for services as aging baby boomers become less mobile and national obesity and diabetes rates continue to rise. Providing costeffective, clinically appropriate O&P care to Americans in the years ahead will require a large pool of welleducated certified orthotists and prosthetists. Currently, there is no guarantee that need can be met.

“There is obviously going to be a huge need for more orthotists and prosthetists in the future, so we’re trying to help get people interested,” says Debbie Ayres, director of ABC’s

marketing and communications. “By the time that we have this great need [in the future], we’ll need to have people who are able and educated and certified to do it.”

The good news is that the O&P profession has a promising future to sell to career-seeking high school and college students. The U.S. Bureau of Labor Statistics has projected that employment of orthotists and prosthetists will grow by 18% from 2020 to 2030, much faster than the average for all occupations. About 1,000 openings for orthotists and prosthetists are projected each year, on average, during the current decade.

Drawing Gen Z to O&P

With extensive in-house research in hand, ABC leaders have developed a long-range plan for convincing students to consider careers in O&P. In June, ABC launched an interactive website, whatispop.org, and filled it with information about the profession, including ways to plug into educational opportunities, connect with accomplished practitioners, and learn about different O&P career paths.

ABC also created accounts on TikTok, Twitch, Instagram, and other social media platforms, advertising on each in an effort to meet Generation Z—anyone between 14 and 24—where they spend the most time online.

Ayres encourages O&P professionals who would like to serve as industry “ambassadors,” and who are willing to talk to young people about the profession or even serve as mentors, to contact ABC to join the current initiative. “Our research shows that [young people] want to hear from the people who are in the profession, and from people who are beneficiaries of the profession. We want as many people as possible who are willing to talk to students.”

Meanwhile, AOPA is doing its part to bring the O&P profession to the attention of young people. Next month, high school students from San Antonio will take part in the 2022 National Assembly. Joanna Kenton, MHA, CPO, LPO, FAAOP, co-chair of the AOPA Assembly Planning Committee, is leading the effort to welcome students from two local, health career and STEM-focused high schools to AOPA’s annual conference. Approximately 80 students will participate in a short presentation to learn about the O&P profession and glean insights from keynote speaker Mona Patel, executive director at the San Antonio Amputee Foundation. The students will break up into smaller groups to view the exhibits with tour guides, where they’ll learn about O&P products and technologies and how they can help patients improve their lives.

“This is a valuable opportunity to share about our amazing profession,” Kenton says. “To hear from us and our stakeholders will be a powerful introduction to explore a career in O&P.”

Localized Recruitment

National outreach efforts by AOPA and ABC are in some ways an outgrowth of more localized educational outreach that O&P practitioners across the United States have been doing for years. Paul Irving, CPO, who manages three clinical practices at the University of California, San Francisco (UCSF) Orthotic and Prosthetic Centers, became involved in high school outreach and mentoring through the Science and Health Education Partnership that connected UCSF and the Phillip and Sala Burton Academic High School in San Francisco. The partnership, established in 1987, helps students of color explore careers in the health sciences.

“We have learning sessions with these high school kids over the two or three weeks that they’re on campus,” Irving explains. “We’ll have them taking casts of each other and doing stuff that is really memorable, but it’s also about being able to put it in a context of careers in O&P.”

ABC recently launched the interactive website whatispop.org.

Ninety-eight percent of the students at Burton High School are minorities, and Irving says mentoring them is not only a way to show them a promising career path, but also an effort to cultivate more diversity in the O&P profession. “In many of the other medical disciplines, there’s very clear data that demonstrates when there is congruence between a patient’s racial identity and the clinician’s racial identity, outcomes are better,” Irving says. “Not only patient satisfaction—that’s certainly better— but actual medical outcomes.” create opportunities to spread the word about O&P; he suggests that O&P professionals determine how their contributions could fit in with school curricula and teachers’ lesson plans. “I think it’s critically important to create a partnership over time, and it’s really inappropriate to ask the school to suspend what they’re doing in order to meet our agenda,” he says. “Rather, we should ask how our [agenda] can meet their preexisting curriculum.”

After getting involved with the Burton high school student program, Irving began reaching out to other schools and nonprofit community organizations in the San Francisco Bay Area, and showing up at career fairs to proselytize about the promising prospect of a career in orthotics and prosthetics. That has led to more opportunities to establish relationships with school administrators, teachers, and students.

Irving encourages other O&P professionals to contact local schools to establish relationships that could Summer Study

Angela J. Bryl, CPO, MBA, clinical director at Dankmeyer Inc. in Maryland, helps run a summer program for a small number of high school students—usually two to four at a time—that allows them to shadow clinicians and learn about various aspects of the job. She says Dankmeyer sees a wide array of applicants to the program. Some are drawn to the engineering element of O&P, while more artistic students may be attracted to the molding and crafting of prosthetics. Still others are more inclined toward the scientific or medical side of the profession, or have an interest in working with patients directly to help them create better, more mobile lives. Bryl has noticed a significant number of applicants with an interest in STEM, but the program “appeals to a wide variety of kids,” she says.

Sometimes a brief high school or college internship results in a longstanding professional relationship, with the student coming back to Dankmeyer later as a resident and eventually becoming an in-house practitioner. In fact, Bryl took that path herself.

“I started out as an intern at Dankmeyer during my college days, came back as a resident, then stayed on as a practitioner and have been with Dankmeyer officially for 16 years,” she says. “We have other practitioners who followed a similar path with some shadowing, residency, and they are still on staff. Our current resident is someone we first met years back when he shadowed with us before he went to O&P school.

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“Getting to know high schoolers and college students who are interested in the field has increased our networking for potential future practitioners,” Bryl adds. “We have found it beneficial for us and would recommend it as a pathway for others as well, as long as you are willing to put the time and effort in up front.”

The internship process also benefits experienced practitioners, Bryl says. “We also learn from [the students]; they’ll bring in fresh ideas, things that we haven’t thought of. … Just being able to show and to teach helps you refine your own skills, too, because you have to explain it to someone else.”

Asked what advice she would give to leaders of other clinics who would like to establish relationships with local high schools or organizations that cater to young career-minded people, Bryl says to “start small” until they’re certain their O&P office can accommodate more than one or two students in the workspace while ensuring the experience is beneficial to both the student and the patient-care facility.

Tech Outreach

It’s not just those working on the clinical side of the profession who aim to convince high school students with the right aptitude to consider an O&P career path. Engineers and technicians on the manufacturing side are getting involved, too. And sometimes the high schools are the first to reach out.

In 2017, students in the Technology and Engineering Program at Wilson High School in West Lawn, Pennsylvania, decided to develop a prosthetic device that would be affordable and comfortable, both of which are challenges facing many individuals with limb loss. The students approached New York-based Curbell Plastics, and that’s when Jeff Wilson, senior business development manager in the O&P division, got involved. Wilson provided the students with technical expertise and a plastic material donation for the project. Wilson says he’s encouraged by the recent growth in technical education in the industry, noting, for example, that Kennesaw State University in Georgia

now offers a two-year, full-time applied science O&P curriculum that includes O&P engineering. “They’re starting a technician program—just for technicians,” Wilson says.

When talking to students, Wilson explains that entry into the O&P field doesn’t necessarily require a college degree, although most professionals in the field pursue certification. “There is a big shortage of skilled technicians at this time, and most of the larger labs will train someone that has no experience,” Wilson says. “For those who want to be a craftsman, who want to work with their hands—and you’ve got to want to get dirty because of all the plaster dust and stuff—there are some really good opportunities.”

Postsecondary Push

At the orthotics and prosthetics program at Baylor College of Medicine in Houston, Program Director Ashley Mullen, MSAT, CPO, LPO, has found success connecting with college students who haven’t declared majors by establishing a relationship with career advisers at college campuses.

“We’ve had a number of students who say, ‘You know, I was pre-med, or I was engineering, but I really didn’t know where I wanted to go.’ And then they sat down and talked to a career adviser, and they were excited when they were told about O&P. They didn’t even know this was a career. So, we’ve done a few presentations to a Texas network of academic advisers to try and make sure they’re well aware of the profession.”

Baylor officials even convinced leaders at the nearby University of Houston to add an O&P landing page to their website for students interested in medical careers. “That helped because it gives students at that institution direct information on the courses that you need to take to make the prerequisites for school,” Mullen says.

Mullen also taps into Baylor’s Center for Educational Outreach to connect with science teachers at area high schools. During summer camps or field trips during the school year, students learn about different medical programs offered at Baylor, including O&P.

“We’ve actually had a number of students that have decided to pursue O&P through a presentation that they saw their freshman year of college in one of those classes,” Mullen says. “So that’s been very effective.

“Ultimately, the students are looking for a career in healthcare because they want to make a difference in someone’s life. And we are able to show them a very concrete way they can have a career in which they’re doing that every day.”

Michael Coleman is a contributing writer to O&P Almanac.

Ferrier Coupler Options! Interchange or Disconnect

The Ferrier Coupler provides you with options never before possible:

Enables a complete disconnect immediately below the socket in seconds without the removal of garments. Can be used where only the upper (above the Coupler) or lower (below the Coupler) portion of limb needs to be changed. Also allows for temporary limb replacement. All aluminum couplers are hard coated for enhanced durability. All models are interchangeable.

Model A5

The A5 Standard Coupler is for use in all lower limb prostheses. The male and female portions of the coupler bolt to any standard 4-bolt pattern component.

The F5 Coupler with female pyramid receiver is for use in all lower limb prostheses. Male portion of the coupler features a built-in female pyramid receiver. Female portion bolts to any standard 4-bolt pattern component.

The Ferrier Coupler with an inverted pyramid built in. The male portion of the pyramid is built into the male portion of the coupler. Female portion bolts to any 4-bolt pattern component. NEW! The FA5 coupler with 4-bolt and female pyramid is for use in all lower limb prostheses. Male portion of coupler is standard 4-bolt pattern. Female portion of coupler accepts a pyramid.

NEW! The FF5 has a female pyramid receiver on both male and female portions of the coupler for easy connection to male pyramids.

NEW! The FP5 Coupler is for use in all lower limb prostheses. Male portion of coupler has a pyramid. The Female portion of coupler accepts a pyramid. The Trowbridge Terra-Round foot mounts directly inside a standard 30mm pylon. The center stem exes in any direction allowing the unit to conform to uneven terrain. It is also useful in the lab when tting the prototype limb. TheThe unitunit isis waterproof and has a traction base pad.

Model FA5

Model F5 Model FF5

Model P5 Model FP5 Model T5

Bestof Show

Preview this year’s award-winning Thranhardt presentations, featuring prosthetic and orthotic innovations

O&P STAKEHOLDERS WILL CONVENE in San Antonio to network, see new products and services, and experience in-person the latest in O&P education during the highly anticipated 2022 AOPA National Assembly, beginning September 28. Headlining a compelling and comprehensive mix of clinical education topics are this year’s Thranhardt Award presentations.

The Thranhardt lecture series, established through a gift from J.E. Hanger to recognize individuals committed to advancing O&P education and research, memorializes Howard R. Thranhardt, CPO, who made major contributions to the professionalization of prosthetics and orthotics. The award, one of the most coveted in the O&P profession, will be presented during the general session Friday, September 30, at 8 a.m., to Jennifer Johansson, MS, for her work with a bimodal run-walk prosthesis, and to Tiffany Graham, MSPO, CPO, LPO, FAAOP, for her work in predicting treatment duration with cranial remolding orthoses.

Read on to preview this year’s Thranhardt presentations and learn more about these important advancements.

Bimodal Run-Walk Prosthesis

Johansson will take part in the 2022 National Assembly to share her involvement in the development of a novel bimodal prosthetic foot design during her session, “Design and Testing of the Caesar Foot: A Bimodal Run-Walk Prosthesis.” The new design is a single device with optimized design, alignment, and biomechanics for both walking and running, according to Johansson.

A senior research engineer at Liberating Technologies Inc. (LTI), a Coapt R&D Co., Johansson says the study was sparked by reports that many individuals with limb loss cannot afford a running foot because their insurance does not deem it medically necessary. As a result, they are unable to participate in running-based activities or be as physically active as they wish. The team at LTI sought to develop a bimodal walking foot that would be covered by insurance but would offer excellent running capabilities as well.

“The goal of our research was to develop a walking foot that was as good in walking mode as any other walking foot, but also operate as a running foot that performs as well as a blade—in other words, to be fully optimized for each activity,” she explains. “As a walking foot, it would be covered by insurance—but because it has this second mode, it allows the user to be more active and reap the associated benefits, such as improving their health and social well-being.”

Johansson secured a Small Business Innovation Research grant from the Department of Defense to initiate the work in 2019. “People liked the concept,” she says. “To inform the design, we gathered input from several prosthetists who fit running blades, and we hosted multiple amputee focus groups that helped guide the design. For example, they wanted a sealed switching mechanism so nothing could get in and jam the works.”

Although the device is suitable for both above- and below-knee amputees, most early testers had below-knee amputations because Johansson’s team wanted to focus on the foot first, without potential interaction from the prosthetic knee.

LTI partnered with Deanna Gates, PhD, from the University of Michigan’s School of Kinesiology, for pilot testing of the Caesar foot. Each subject was tested under three conditions: using the bimodal Caesar foot, using a commercially available hybrid foot (AllPRo from Fillauer), and using the subject’s currently prescribed daily-use walking and running foot. The research team collected full-body kinematic and kinetic data as participants ran on a treadmill, walked overground at different speeds, and walked on stairs and slopes. The team also measured the rate of oxygen consumption during running or walking (for those who do not run) as a measure of metabolic effort. “While this effort is still ongoing, early results have been promising,” notes Johansson.

She is wrapping up the second phase of the project and applying for additional funding for the next iteration. She plans to use subjects at different activity levels, as well as in different weight classes and foot sizes. In addition, subjects will be able to test the feet at home, rather than confined to the lab. “We will be able to see how it behaves in the real world,” she says. “How will it hold up over time? How often will subjects switch between modes? How much will they actually use the foot every day?”

Johansson believes the bimodal foot is part of a trend toward creating hybrid devices, but notes that, unlike other devices, the Caesar foot is optimized in each mode. “This is something that can really get people out and more active,” she says. “It can have a profound effect on their quality of life.”

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Jennifer Johansson, MS

Predictive Methodology for CRO Treatment

Graham will head to San Antonio next month to present her latest research—a progression of her previous studies with cranial remolding orthoses (CROs). This year marks the third time Graham, an assistant professor at the University of Texas Southwestern (UTSW) Medical Center, has been honored with a Thranhardt Award. Her previous presentations focused on the significant factors that influenced outcomes among infants using CROs; her 2022 work, called "Development and Validation of a Prediction Model for the Treatment Time of Deformational Head Shapes Using a Cranial Remolding Orthosis,” is targeted toward developing a predictive methodology for the duration of treatment.

“Once a parent or caregiver finds out their child will be pursuing orthotic treatment, the next question is almost always, ‘How long will it take?’” says Graham. “Right now, experienced clinicians can give very good estimates, but pediatricians or less experienced orthotists may find it difficult to answer this question. Our goal is to develop a scientific calculation that will predict treatment time.”

Several factors influence the amount of treatment time needed in a CRO, notes Graham, including starting age of treatment and head shape severity. In addition, infants with torticollis seem to have extended treatment times compared to those without.

Graham performed a retrospective study of 1,250 subjects with different head shapes to see how much time was needed for CRO treatment. To develop the prediction models, Graham and her colleagues reviewed charts from Level 4 Prosthetics & Orthotics (Restore POC) in Addison, Texas, and from two locations in San Antonio. The three offices used the same methods to evaluate patients and fabricate orthoses, and they trained their clinicians in the same manner. All offices used the STARband brand CRO from Orthomerica, and subjects began CRO treatment between 3 and 18 months of gestational age.

The input for the models included the gestational age of the infant at start of treatment; presence or absence of torticollis and prematurity; initial Cephalic Index (CI), or the width-tolength ratio of the head; initial Cranial Vault Asymmetry Index (CVAI), or proportion of deformity compared to the overall size of the head; and level of CVAI desired by the practitioner at the end of treatment.

Graham worked with a biostatistician to figure out how long treatment lasted among the subjects and applied that information to a separate data set of 210 infants treated by the University of Texas Health Science Center, San Antonio.

When the prediction model’s output was rounded up to the nearest month for deformational plagiocephaly, actual treatment time was less than or equal to predicted treatment time in 85.19% of cases; when this was done for deformational brachycephaly, it was accurate in 56.67% of cases, and for asymmetrical brachycephaly, in 75.40% of cases.

“We had moderate accuracy and were pleased with the first round,” Graham says. “When the calculation was not accurate, it was fairly close. … It did overestimate times, which was intentional, as it’s better to end treatment earlier than caregivers expect than later.”

Graham is already involved in the second round of the derivation equation, adding in the second set of 210 infants to increase accuracy.

She notes that the equations should be used as a tool to educate caregivers of probable treatment time, assuming their infant started treatment at their current age and with their current head shape. If caregivers decide to wait to start treatment, changes in the shape of the head over time could significantly affect overall treatment time. If the infant’s information or the practitioner’s treatment goals change, it would change the estimate. It’s important to note that the models apply only if the infant wears the CRO 23 hours a day.

Graham discussed commercialization of the predictive model with her department at the UTSW Medical Center, perhaps as a cellphone app, but they decided to offer it to the public for free. Plans are underway to make the model available through the MDCalc website, which helps medical professionals do calculations, process algorithms and scores, and assess risks. The more people who use the

Tiffany Graham, MSPO, CPO, LPO, FAAOP

predictive model, the more accurate it will become, says Graham. “I’m curious to see what the feedback will be.”

She plans further studies with larger sample sizes and says future investigations should compare infants at several different treatment centers, and those who use different brands of cranial orthoses.

Ultimately, an accurate prediction of treatment time can contribute to the success of the intervention, Graham says. Parents and caretakers have a significant impact on the course and success of treatment by properly donning the CRO, ensuring it stays on 23 hours a day, inspecting the infant’s skin, and attending regular follow-up visits for adjustments. “A prediction model will allow practitioners to more accurately answer caregivers’ questions, thus improving their perception of treatment.”

Deborah Conn is a contributing writer to O&P Almanac.

Attend the Hamontree Presentations—and

Optimize Your Business Practices

The Hamontree Business Education Award, established in honor of Sam E. Hamontree, (CP), is a business-themed counterpart to the clinical Thranhardt Award. This year, three nominees will share presentations geared toward improving O&P business practices during the 2022 National Assembly. Attendees will have the opportunity to vote for the best Hamontree presentation in San Antonio.

Plan now to attend the Hamontree presentations, which will begin at 2 p.m. on Thursday, September 29: “The Three Things You Have Control Over To Speed Up Your Cash Flow” by Stacy Toner, CBCS “Survey of Emotional Burnout and Its Effects on Innovation in O&P,” by Gerald Stark, MSEM, PhD, CPO, LPO, FAAOP(D) “Using Outcome Measures To Justify Medical Necessity, Reimbursement, and Business Development in RealLife Settings,” by Jason Kahle, MSMS, CPO, LPO, FAAOP

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SMO AFO INDY 2 STAGE

This exceptional “orthosis within an orthosis” allows for the SMO to be locked into the AFO, or it can be easily removed to be used independently. This allows children to work through a variety of transitional skills without impeding normal muscle function.

See the difference the Indy 2 Stage can make!

Watch the progress one patient made utilizing the versatility offered by the Indy 2 Stage.