November December 2022 O&P Almanac

By Michael Coleman

30 | Diabetes and Future Foot Health

By Christine Umbrell

Glenn Klute, PhD

Changing of the Guards: Commitment Remains

GREETINGS. With this issue of the O&P Almanac spanning both of our terms as AOPA president, we wanted to write it jointly.

Every year on December 1, leadership on AOPA’s Board of Directors changes. Because of our bylaws and how the board functions, the change in leadership is seamless. The Board of Directors meets monthly and the Executive Committee meets bimonthly. These meetings offer robust discussions about how to best support our members because that is our focus: you and the patients you serve.

The board also works hard to make sure that its members are representative of all O&P voices. The Nominating Committee—this year, under the leadership of Past President Traci Dralle, CFm—worked hard to achieve this goal. We therefore want to quickly share the new additions to the 2022-2023 AOPA Board of Directors. We welcome Arlene Gillis, MEd, CP, LPO, as director-at-large. Gillis will bring a new perspective to the board with her experience working at an international institute and O&P school. In addition, Lesleigh Sisson, CFo, CFm, joins the board, representing our 1-5 Patient-Care Facilities members. Sisson has unique experience as both the owner of a small O&P business and having worked with many others in a professional capacity. Their diverse viewpoints will help AOPA continue to support all of its members.

Over the next 12 months, we will concentrate on making new connections and maintaining existing ones. We will continue to foster AOPA’s relationships with gov ernment agencies and contractors: CMS; the durable medical equipment Medicare administrative contractors; the Pricing, Data Analysis, and Coding contractor; and state Medicaid agencies. We also will work to develop stronger relationships with commercial health plans to increase our advocacy on your behalf in the private sector. And we will continue to fight for appropriate federal legislation supporting the O&P profession. The passage of the Medicare O&P Patient-Centered Care Act remains uncertain at the time of publication, but AOPA will continue to identify ways to advance our profession’s interests in the halls of Congress.

We will continue our work to support you at the state level. In 2022, we partnered with state-based organizations and achieved successful outcomes, including the following:

• New York: Obtained a Medicaid fee schedule increase

• North Carolina: Expanded access to cranial remolding orthoses

• Minnesota: Expanded Medicaid coverage of lower-limb prostheses

• Illinois: Addressed the Medicaid fee schedule increase

• Pennsylvania: Provided support regarding licensure challenges.

Finally, in 2023 we will continue to support and expand So Kids Can Move, a statebased initiative with the goal of expanding access to recreational prostheses and orthoses for children.

So, as 2022 comes to a close, we want to thank you for your continued support of AOPA and for entrusting us both with the responsibility of serving as president. As we face the challenges of a new year, please know that AOPA is here for you. On behalf of AOPA’s entire Board of Directors, we want to let you know we appreciate all you do for the patients you serve, and we look forward to working with you. With your help, in 2023 we will continue to move closer to our objective of realizing a world where O&P care transforms lives.

Wishing you the happiest of holidays.

Dave McGill ended his term as AOPA president Nov. 30, 2022.Teri Kuffel, JD, began her term as AOPA president Dec. 1, 2022.

Publisher

Eve Lee, MBA, CAE

Editorial Management Content Communicators LLC

Board of Directors

OFFICERS

President Teri Kuffel, JD Arise Orthotics & Prosthetics, Spring Lake Park, MN

Advertising Sales RH Media LLC Design & Production Marinoff Design LLC Printing Sheridan

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President-Elect

Mitchell Dobson, CPO, FAAOP Hanger Clinic, Austin, TX

Vice President Jeffrey M. Brandt, CPO Brandt Consulting, Exton, PA

Immediate Past President Dave McGill Össur Americas, Foothill Ranch, CA

O&P Almanac (ISSN: 1061-4621) is published monthly, except for combined issues in June/July and November/December, by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. To subscribe, contact 571/431-0876, fax 571/431-0899, or email info@aopanet.org. Yearly subscription rates: $59 domestic, $99 foreign. All foreign subscriptions must be prepaid in U.S. currency, and payment should come from a U.S. affiliate bank. A $35 processing fee must be added for non-affiliate bank checks. O&P Almanac does not issue refunds. Periodical postage paid at Alexandria, VA, and additional mailing offices.

Treasurer Rick Riley Xtremity, Denver, CO

ADDRESS CHANGES

POSTMASTER: Send address changes to: O&P Almanac, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314.

Executive Director/Secretary Eve Lee, MBA, CAE AOPA, Alexandria, VA

DIRECTORS

Arlene Gillis, MEd, CP, LPO International Institute of Orthotics and Prosthetics, Tampa, FL

Elizabeth Ginzel, MHA, CPO Össur, Fort Worth, TX

Kimberly Hanson, CPRH Ottobock, Austin, TX

John “Mo” Kenney, CPO, FAAOP Kenney Orthopedics, Lexington, KY

James Kingsley Hanger Clinic, Oakbrook Terrace, IL

Copyright © 2022 American Orthotic and Prosthetic Association. All rights reserved. This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of AOPA, nor does the association necessarily endorse products shown in the O&P Almanac. The O&P Almanac is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P Almanac may be edited for space and content. The magazine is meant to provide accurate, authoritative information about the subject matter covered. It is provided and disseminated with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice and/or expert assistance is required, a competent professional should be consulted.

Lesleigh Sisson, CFo, CFm Prosthetic Center of Excellence, Las Vegas, NV

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Linda Wise Fillauer Companies, Chattanooga, TN

Shane Wurdeman, MSPO, PhD, CP, FAAOP(D)

Research Chair Hanger Clinic, Houston Medical Center, Houston, TX

Reach out to AOPA’s membership and more than 11,400 subscribers. Engage the profession today. Contact Bob Heiman at 856/520-9632 or email bob.rhmedia@comcast.net Visit bit.ly/AOPAMedia2022 for advertising options!

Specialists in delivering superior treatments and outcomes to patients with limb loss and limb difference.

Our Mission Statement

A trusted partner, advocating for and serving the orthotic and prosthetic community by:

• Fostering relationships with decision makers to ensure equitable access

• Providing education that promotes professional excellence

• Supporting research that informs innovative care

• Advancing equality to strengthen the orthotic and prosthetic profession and improve the lives of patients.

Our Vision

A world where orthotic and prosthetic care transforms lives.

AMERICAN ORTHOTIC & PROSTHETIC ASSOCIATION (AOPA)

330 John Carlyle St., Ste. 200 Alexandria, VA 22314

AOPA Main Number: 571/431-0876 AOPA Fax: 571/431-0899 AOPAnet.org

EXECUTIVE OFFICES

Eve Lee, MBA, CAE, executive director, 571/431-0807, elee@AOPAnet.org

Akilah Williams, MBA, SHRM-CP, senior manager for finance, operations, and HR, 571/431-0819, awilliams@AOPAnet.org

HEALTH POLICY AND ADVOCACY

Joe McTernan, director of health policy and advocacy, 571/431-0811, jmcternan@AOPAnet.org

Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854, dbernard@AOPAnet.org

Sam Miller, manager, state and federal advocacy, 571/431-0814, smiller@AOPAnet.org

Susannah Engdahl, PhD, manager, health policy and research, 571/431-0843, sengdahl@AOPAnet.org

Reimbursement/Coding: 571/431-0833, LCodeSearch.com

MEETINGS & EDUCATION

Tina Carlson, CMP, senior director, education and meetings, 571/431-0808, tcarlson@AOPAnet.org

Kelly O’Neill, CEM, senior manager of meetings and exhibition, 571/431-0852, kelly.oneill@AOPAnet.org

Kristen Bean, digital meetings specialist, 571/431-0876, kbean@AOPAnet.org

MEMBERSHIP & COMMUNICATIONS

Joy Burwell, director of communications and membership, 571/431-0817, jburwell@AOPAnet.org

Betty Leppin, senior manager of member services, 571/431-0810, bleppin@AOPAnet.org

Nicole Ver Kuilen, manager of public engagement, 571/431-0836, nverkuilen@AOPAnet.org

Timishia Bannister, membership coordinator, 571/431-0835, tbannisterAOPAnet.org

AOPA Bookstore: 571/431-0876

O&P ALMANAC

Eve Lee, MBA, CAE, executive director/ publisher, 571/431-0807, elee@AOPAnet.org

Josephine Rossi, editor, 703/662-5828, jrossi@contentcommunicators.com

Catherine Marinoff, art director, 786/252-1667, catherine@marinoffdesign.com

Bob Heiman, director of sales, 856/520-9632, bob.rhmedia@comcast.net

Christine Umbrell, editorial/production associate and contributing writer, 703/6625828, cumbrell@contentcommunicators.com

Publisher

Eve Lee, MBA, CAE

Editorial Management Content Communicators LLC

Advertising Sales RH Media LLC Design & Production Marinoff Design LLC Printing Sheridan

SUBSCRIBE

O&P Almanac (ISSN: 1061-4621) is published monthly, except for combined issues in June/July and November/December, by the American Orthotic & Prosthetic Association, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314. To subscribe, contact 571/431-0876, fax 571/431-0899, or email info@aopanet.org. Yearly subscription rates: $59 domestic, $99 foreign. All foreign subscriptions must be prepaid in U.S. currency, and payment should come from a U.S. affiliate bank. A $35 processing fee must be added for non-affiliate bank checks. O&P Almanac does not issue refunds. Periodical postage paid at Alexandria, VA, and additional mailing offices.

ADDRESS CHANGES

POSTMASTER: Send address changes to: O&P Almanac, 330 John Carlyle St., Ste. 200, Alexandria, VA 22314.

Copyright © 2022 American Orthotic and Prosthetic Association. All rights reserved. This publication may not be copied in part or in whole without written permission from the publisher. The opinions expressed by authors do not necessarily reflect the official views of AOPA, nor does the association necessarily endorse products shown in the O&P Almanac. The O&P Almanac is not responsible for returning any unsolicited materials. All letters, press releases, announcements, and articles submitted to the O&P Almanac may be edited for space and content. The magazine is meant to provide accurate, authoritative information about the subject matter covered. It is provided and disseminated with the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice and/or expert assistance is required, a competent professional should be consulted.

Advertise With Us!

Reach out to AOPA’s membership and more than 10,694 subscribers. Engage the profession today. Contact Bob Heiman at 856/520-9632 or email bob.rhmedia@comcast.net Visit bit.ly/AOPAMedia2022 for advertising options!

Diabetes and Foot Ulcers

Americans with diabetes are at risk of developing ulcers and other complications Diabetes was the eighth leading cause of death in the United States in 2020. Adults 50 or older with diabetes die 4.6 years earlier, develop disability six to seven years earlier, and spend about one to two more years in a disabled state than adults without diabetes. —Diabetes Report Card 2021, CDC

SOURCE: “Diabetic Foot Ulcers and Their Recurrence,” New England Journal of Medicine, June 2017; Diabetes Report Card 2021, CDC; “Diabetic Foot Ulcer,” National Library of Medicine; Information provided by ABC and BOC.

Happenings

Medical Bills Burden Americans

One quarter of adults with healthcare debt owe more than $5,000

Approximately 1 in 5 with any amount of debt said they don’t expect to ever pay it off.

Regular Device Use Corresponds With Below-Elbow Prosthesis Functionality

Researchers from Austria and London teamed up to study the actual daily use of prostheses among individuals with below-elbow amputation. Their goal was to consider actual prosthetic dexterity, rather than study wear time, because some individuals wear upper-limb prostheses for aesthetic purposes only.

The researchers, led by Stefan Salminger, MD, PhD, from the Medical University of Vienna, worked with five unilateral patients with transradial amputations to record the number of grasping motions during objective and timed assessments, including the Southampton hand assessment procedure, the box-and-block test,

the action research arm test, and the clothespin-relocation test. They also examined patient-reported wear time and estimated number of prosthetic movements over a three-month period.

After studying the results of the assessments and the patient-reported feedback, Salminger’s team reported that neither high functionality nor long wear times necessitate the frequent use of a prosthesis in daily life. However, frequent daily motions correspond with good functional scores, “indicating that regular device use in different real-life settings relates to functionality.” The study was published in October in Prosthetics and Orthotics International.

Altering a Measurement Tool To Better Accommodate Women

Nearly half (48% of) eligible

or 28.4 million people out of 58.6 million, are enrolled in Medicare Advantage plans in 2022. The percentage choosing Part C plans has more than doubled since 2017.

Source: “Medicare Advantage in 2022: Enrollment Update and Key

Recognizing that women with upper-arm amputa tion are more likely than men to dis continue prosthesis use, a research team led by Linda J. Resnik, PT, PhD, recently modified the Orthotics and Prosthetics User Survey (OPUS) Client Satisfaction With Device (CSD) instrument, an upperlimb prosthetic satisfaction survey, to render it more responsive to women. Members of the research team included scientists from the VA Providence Medical Center, Brown University, and Northwestern University. The team conducted a telephone

survey, calling 468 indi viduals in the United States with upperlimb amputation. The team identified three subscales, for comfort, appearance, and utility, with seven new items identified as important to women. The appearance and comfort subscales were found to have good reliability for group-level use in clinical and research applications, whereas the utility subscale was found to have poor to fair person reliability but excellent item reliability, according to the researchers. The study was published in June in Archives of Physical Medicine and Rehabilitation

SOURCE: “Healthcare Debt in the

Stiffness of Running Legs Impacts Intact Limbs

participants ran on a 15-meter runway at self-selected speeds using three different prosthetic stiffness conditions. The research team collected data for each participant at each stiffness condition to evaluate stance-phase center-ofmass velocity, contact time, and limb stiffness and joint/prosthesis work.

INSURANCE INSIGHTS

A new study examines how the stiffness of running-specific prostheses affects limb stiffness, running performance, and associated joint kinematics among individuals with unilateral belowknee loss. The research team, led by Cleveland Barnett, PhD, from the School of Science and Motion in the United Kingdom, collected kinematic and ground-reaction force data from eight males wearing running legs. The

The researchers found that as stiffness of the running prosthesis increased, participants experienced “acute increased mechanical demands” on their intact limbs. This finding reflects a reliance on the intact limb during running, according to Barnett’s team. “However, overall running was unaffected,” concluded the researchers, “suggesting participants acutely adapted to a running-specific prosthesis of a nonprescribed stiffness.” The study was published in October in Gait & Posture.

DIABETES DOWNLOAD

ADA Debuts Alliance To Address Amputation Inequities

The American Diabetes Association (ADA) announced the launch of the Amputation Prevention Alliance to focus on addressing communities facing disproportionately high rates of amputations and amputation mortality. “This Alliance, through the groundwork laid by the ADA’s Health Equity Now platform, will increase awareness among patients and healthcare professionals of risk factors for amputations and oppor tunities to avoid these procedures,” said Charles Henderson, CEO of ADA. “This initiative aims to advance needed policy changes to ensure that healthcare professionals have the tools necessary to prevent unnecessary procedures and save lives moving forward.”

ADA pointed to the high rates of amputation among people of color as a driving factor for the initiative, with Black Americans facing rates of

amputation up to four times higher than those of non-Hispanic white Americans, and high rates of amputation in both LatinX and Indigenous communities.

The Amputation Prevention Alliance has been designed as a three-year effort aiming to improve care for people living with diabetes and enhance access to quality care, technology, and inter ventions. “It is without question that diabetes-related amputations unfairly afflict communities of color at an alarming rate,” said Mike Griffiths, MD, president, CEO, and medical director at Advanced Oxygen Therapy Inc. and a founding partner of the Alliance. “When you consider that five-year mortality rates among those having a limb amputated due to diabetes are higher than most forms of cancer, then this situation is as dire as it is tragic.” Details are available on ADA’s website

Fewer PPOs, More Managed Care

Since 2014, preferred provider organization (PPO) health insurance plans have declined by 36% as a share of all plan type offerings. Managed care plans have grown steadily and now account for 82% of plan type offerings.

SOURCE : “ Insights Into the 2022 Individual Health Insurance Market ,” McKinsey & Co.

O&P LEADERSHIP

AOPA Leaders Embrace New Roles for 2023

AOPA leadership is preparing for a dynamic 2023, with many opportunities for advocacy, education, and research to sup port the O&P profession. The 2023 AOPA Board of Directors is excited to launch new programs and projects while continuing to focus on previously developed initiatives.

Teri Kuffel, JD, begins her term as AOPA president December 1 after being elected during the AOPA National Assembly in September. Kuffel will be supported by Mitchell Dobson, CPO, FAAOP, president-elect; Jeffrey M. Brandt, CPO, vice president; Rick Riley, treasurer; Eve Lee, MBA, CAE, secretary; and several additional board members. Dave McGill, who served as president for the 2021-2022 term, will continue serving the association as immediate past president.

Arlene Gillis, MEd, CP, LPO, and Lesleigh Sisson, CFo, CFm, are the newest members of the profession to join the AOPA board. Gillis, who is an O&P clinician and educator, is founder of the International Institute of Orthotics & Prosthetics. Sisson is president of Prosthetic Center of Excellence in Las Vegas and founding partner of consulting firm O&P Insight.

Traci Dralle, CFm, who served as immediate past president last year, and James Young Jr., CP, LP, FAAOP, con clude their board service at this time.

The board will carry out the functions of the AOPA mission statement, with goals of fostering relationships with decision makers to ensure equitable access; providing education that promotes professional excellence; supporting research that informs innovative care; and advancing equality to strengthen the O&P profession and improve the lives of patients. They are looking forward to meeting and discussing important O&P topics during the 2023 AOPA O&P Leadership Conference in January.

To the right is the full list of 20222023 AOPA Board of Directors members, who take office Dec. 1, 2022, and will serve through Nov. 30, 2023.

2023 AOPA Officers

Dave McGill Immediate Past President

Teri Kuffel, JD President

Rick Riley Treasurer

Mitchell Dobson, CPO, FAAOP President-Elect

Eve Lee, MBA, CAE Secretary (Nonvoting)

Jeffrey M. Brandt, CPO Vice President

Special Thanks, Retiring

New Board Members

James Kingsley

Linda Wise

James Young Jr., CP, LP, FAAOP

Traci Dralle, CFm

Elizabeth Ginzel, MHA, CPO

Shane Wurdeman, PhD, CP, FAAOP(D) Research Chair

Kimberly Hanson, CPRH

John “Mo” Kenney, CPO, FAAOP

Lesleigh Sisson, CFo, CFm

Arlene Gillis, MEd, CP, LPO

2023 AOPA Board Members

PROFESSIONALS

ANNOUNCEMENTS AND TRANSITIONS

Henry Christner joined UNYQ as vice president of global sales and marketing. Christner spent the last several years with ResMed focusing on strategy in its sleep, respiratory care, and digital business units.

At UNYQ, Christner will lead the global sales, marketing, and customer experience teams. He will focus on executing the organization’s business strategy, accelerating growth, and spreading the company’s vision to improve the lives of prosthetic patients and serving the prosthetics community.

The Board of Certification/Accreditation (BOC) Board of Directors has announced its 2023 Executive Committee: Wayne R. Rosen, BOCP, BOCO, LPO, CDME, FAAOP, chair of the committee; Cameron Stewart, BOCO, BOCP, vice chair; Abel Guevara III, DHA(c), MHIM, RHIA, CPHT, CDME, secretary; Daniel Griffis III, PharmD, treasurer; Rick Todd, COF, member at large; and Bradley “Brad” Watson, BOCO, BOCP, LPO, immediate past chair.

“BOC is grateful for the passionate, dedicated professionals serving on our Board of Directors,” said Rosen. “Their decades of experience and sound leadership support BOC’s continued

growth and ensure our credential-holders are backed by professionals who are truly committed to their success.”

Dixon LeGrande has been promoted to the role of president of Hanger Inc.’s products and services business segment. Coleson Chase has been promoted to vice president and general manager of SPS. In this expanded role, he will oversee the SPS business while reporting to LeGrande. These changes will take effect January 7. “I’m thrilled to fill these key roles with experienced Hanger leaders,” said Hanger Chief Operating Officer Pete Stoy. “I am confident these appointments will further solidify our products and services leadership structure, and prepare the team for long-term growth.”

LeGrande joined Hanger in 2010, holding leadership positions in sales and marketing for subsidiaries in both the products and services and patient-care business segments, including SPS and Hanger Clinic. Currently, he is the presi dent of Accelerated Care Plus (ACP), Hanger’s therapeutic solutions subsidiary. LeGrande will maintain his duties as ACP president while also supporting Chase as he leads SPS.

In Chase’s expanded role, he will oversee the SPS business, along with SureFit, including the customer service teams for both organizations. Chase joined SPS five years ago as the director of marketing, and most recently served as vice president of operations.

Henry Christner

Coleson Chase

Dixon LeGrande

BUSINESSES

ANNOUNCEMENTS AND TRANSITIONS

Allard USA has opened a new office in McKinney, Texas, to better serve customers and the people who benefit from the company’s products, according to CEO Dennis Williams. The McKinney office is staffed by Joey Saenz and Nicole Piazza, who will be managing inside sales. Saenz has more than 18 years of healthcare selling experience and a combined 30 years of business-to-business and direct-to-consumer/ patient sales. Piazza has eight years of client relationship management and customer service experience.

Amparo Prosthetics has announced a partnership with Empire Medical, a centralized purchasing department for the inde pendent U.S. O&P market. The new relationship will allow the member practices of the Empire Medical network to access the Amparo Confidence Socket products via unique Empire online purchasing tools. “Finding ways to support the indepen dent U.S. O&P practices is a key part of our efforts with the move of our corporate offices to Salt Lake City after our start in Germany,” said Wesley Teerlink, CEO of Amparo Prosthetics.

The Board of Certification/ Accreditation (BOC) has been awarded the Gold w3 Award for its recent web redesign and improvements for customer navigation. The w3 Awards are sanctioned and judged by the Academy of Interactive and Visual Arts. BOC’s newly redesigned website was honored for its user experience enhancements, including mobile-first design, user-friendly navigation, thoughtful menu categorization, and colorful, neatly displayed design elements.

Hanger Inc. has announced the completion of its transaction to acquire Surestep. The collaboration will provide Surestep with access to resources and is a continuation of Hanger’s investment in its recently launched pediatric specialty. The transaction also includes Surestep’s sister company, Transcend O&P, which includes 13 patient-care clinic locations in six states.

“We have long been admirers of the work of Surestep and Transcend, and we share their commitment to delivering high-quality clinical care, products, and services,” said Pete Stoy, Hanger chief operating officer. “There are a lot of simi larities in the cultures of our businesses and what drives us.” Surestep will be managed independent of Hanger Clinic, and

the business will maintain its brand, leadership, and team, led by Surestep CEO Bernie Veldman. “Our priority is fabricating quality products that provide life-changing outcomes, and this partnership will enable us to leverage the strengths of a national company to ultimately serve an even greater popula tion of children in need,” said Veldman. Transcend O&P and its employees will integrate into the Hanger Clinic business.

More than 150 participants traveled to Orlando to take part in Orthomerica’s 19th Annual STAR Summit in October. The STAR Summit brings together cranial clinicians who use Orthomerica’s cranial products and data acquisition technologies. Attendees participated in three days of multi disciplinary cranial lectures and workshops and heard from pediatric physicians and allied healthcare professionals. The event facilitates collaboration among cranial clinicians from across the world on a variety of topics, including deforma tional head shapes, craniosynostosis, new clinical studies, outcomes reporting, and best practices, according to Deanna Fish, CPO, clinical outreach manager for Orthomerica.

The University of Utah’s Bionic Engineering Lab, which developed the Utah Bionic Leg, has forged a partnership with Ottobock to license the technology behind the Utah Bionic Leg to bring the technology to individuals with lower-limb amputations. Ottobock “has committed to use the highest level of technol ogies available in robotics and artificial intelligence to bring this prosthetic leg to those who need it as soon as possible,” said Tommaso Lenzi, University of Utah mechanical engineering professor and lead researcher on the Utah Bionic Leg project.

The two organizations announced their partnership during a ceremony and press conference October 5. Attending the ribbon-cutting ceremony were Professor Hans Georg Näder, owner and chairman of the Board of Directors of Ottobock; Georgia Näder, Ottobock supervisory board member; Richard B. Brown, dean of the College of Engineering; and Lenzi.

VGM & Associates has released “VGM Playbook: Business Planning and Leadership,” which provides insight on how DMEPOS providers can enrich their business planning and leadership opportunities within their companies.

Office staff at Allard USA’s McKinney, Texas, location

Orthomerica’s 19th Annual STAR Summit

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Closing Out 2022

Review rules for holiday gift giving and Medicare participation status

Editor’s Note—Readers of Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 20 to take the Reimbursement Page quiz. Receive a score of at least 80%, and AOPA will transmit the information to the certifying boards.

ME!

gifts could be considered noncompliant and could land you in serious trouble. What should you keep in mind when shopping for gifts to patients? In 2002, the Office of Inspector General (OIG) for the Department of Health and Human Services published a special advisory bulletin, “Offering Gifts and Other Inducements to Beneficiaries.” This bulletin outlined three guidelines, still in effect, that must be followed in providing gifts to Medicare beneficiaries:

• Gifts cannot be cash or eligible for cash equivalents.

• Gifts must be inexpensive or of nominal value.

• You may not give gifts with the purpose of securing your services to a patient.

IT’S THE END OF the calendar year— the season for holiday gift giving, and time to review your facility’s Medicare participation status. This month’s Reim bursement Page provides a quick refresher on the rules for providing acceptable gifts and for updating Medicare participation.

Gift Giving

The giving of gifts to Medicare patients and referral sources is acceptable and allowed; however, some restrictions must be followed. These restrictions prevent your facility from providing a gift as an inducement to encourage patients to choose you, or to encourage referral sources to provide you with business. If these provisions are not followed, your

While gifts to patients of cash, or cash equivalents of any kind—including gift certificates or gift cards—are strictly prohibited, the use of nonmonetary gifts is acceptable as long as the gifts are of nominal value. OIG had originally stated that the value of gifts should not exceed $10 per gift, with a $50 aggre gate per calendar year. However, these values have been increased over time to $15 per gift, with a $75 aggregate per calendar year. You may offer patients a maximum of five gifts valued up to $15 each in any calendar year. In addi tion, there may not be terms or strings associated with a gift, according to the OIG report. For example, you cannot require that a patient come in for an

evaluation to receive their gift, or that they only receive the gift if they choose to receive a particular service or item.

Some of the same rules apply for gifts to referral sources. Gifts of cash or cash equivalents of any kind—gift certificates, gift cards, and free samples of products— are prohibited to referral sources, but nonmonetary gifts are allowed under very limited circumstances.

First, the value of the gift may not be tied to the volume of referrals received from a physician’s office. For example, you cannot provide a gift of higher value to your regular referral sources than you do to practices that only refer patients periodically. While you are not required to offer the same gift to all of your referral sources, you cannot base your decision on the number of referrals you receive.

Second, gifts may not be directly solicited by referral sources. If a referral requests a specific gift and you provide it, this could be construed as an inducement and a violation of federal antikickback statutes.

Third, there is a limit to the amount of money that may be spent on gifts to referral sources. This gift limit fluctuates from year to year and is adjusted according to the increase in the Consumer Pricing Index. For 2022, the aggregate limit is $452, so any gift or gifts provided to a referral source in 2022 may not exceed $452. Remember that the annual $452 aggregate is a limit, not an entitlement.

When dealing with gifts for patients and referral sources, consider consulting with an attorney, or OIG, if you have any doubts, as it can be very easy to go from an acceptable gift to a nonacceptable gift.

Participation Status

Before changing your participation status, make sure you understand what it means. The term “participating supplier” does not relate to whether you wish to be enrolled in the Medicare program or not—by the act of completing a Medicare enrollment application and obtaining a Medicare supplier number, you are part of the Medicare program.

Participation status instead relates to your agreement with Medicare to either automatically accept assignment for all Medicare claims or not to accept assign ment on claims; your decision to be a participating or a nonparticipating sup plier hinges primarily on how you wish to handle the assignment of Medicare claims, and the choice to accept assignment only relates to the amount of money you may collect from the patient and where Medicare will send its check.

When you elect to be a participating supplier, you agree to accept assignment on all Medicare claims; and by accepting assignment, you agree to accept the Medicare allowable for any given item or service as payment in full and you don’t have the ability to balance bill a patient. This means that Medicare will forward its payment, 80% of the approved allowed amount, directly to you, and you may then collect the remaining 20% coinsurance directly from the patient.

A nonparticipating supplier, on the other hand, is not automatically tied to accepting assignment and will have the ability to make a claim-byclaim decision on whether to accept assignment. The decision to accept or not accept assignment, however, must be on a claim-by-claim basis; you cannot accept assignment on one claim line and then not accept assignment on another claim line.

Also note that when a nonpartic ipating supplier elects not to accept assignment, the supplier has the ability to collect its usual and customary

charge from the patient, or balance bill the patient, and is not required to accept Medicare’s allowable as pay ment in full at the time of service.

When not accepting assignment, remember you must still submit the claim on the patient’s behalf, but Medicare will make its payment directly to the patient, and the patient is not obligated to use the Medicare payment to pay you.

Also remember that not accepting assignment, or becoming a nonpartic ipating supplier, does not relieve you from meeting Medicare policy criteria, including documentation require ments, or eliminate your financial liability should the claim be denied.

Your elected participation status with Medicare is valid for one year and may only be changed during the open enroll ment period, typically in mid-November. The contractors in charge of supplier enrollment and revalidations will send all Medicare-enrolled suppliers a letter reminding them of their current partic ipation status. The letter also informs each supplier that if they wish to change their current participation status, they must do so before December 31, the closing of the open enrollment period.

Prior to Nov. 6, 2022, there was only

one contractor handling all enrollments and revalidations for suppliers of durable, medical equipment, prosthetic, orthotic and supplies: Palmetto GBA or the National Supplier Clearinghouse. There are now two contractors, and each contractor will handle a different region.

Novitas Solutions will handle all suppliers in the eastern part of the United States, including Alabama, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, Mississippi, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, West Virginia, Wisconsin, District of Columbia, Puerto Rico, and U.S. Virgin Islands, and will be referred to as National Provider Enrollment (NPE) East. The Novitas Solutions website for NPE East is novitas-solutions.com/ webcenter/portal/DMEPOS.

Palmetto GBA will continue to handle all suppliers in the western part of the United States, including Alaska, Arizona, Arkansas, California, Colorado, Hawaii, Idaho, Iowa, Kansas, Louisiana, Minnesota, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Texas, Utah, Washington, Wyoming, American Samoa, Guam, and Northern Mariana Islands, and will be referred to as NPE West. You may still use the old National Supplier Clearinghouse website for Palmetto GBA to access information about NPE West, or you may use the new site, palmettogba.com/palmetto/npewest.nsf

If your organization has a current participation agreement in effect for 2022 and you wish to be nonpartic ipating for 2023, you must submit written notice to Palmetto or Novitas informing them that you no longer wish to be a participating provider. There is not a standard form to be used for this written notice; it is simply a letter from you to Palmetto/Novitas informing them of your desire to change your participation status. The letter must be on your official letterhead and signed by one of your company’s authorized

Not accepting assignment, or becoming a nonparticipating supplier, does not relieve you from meeting Medicare policy criteria.

•

•

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representatives. The authorized repre sentative must be the same person who is on file as an authorized individual— most likely a CEO, chief financial officer, president, or board member. If you are unsure who is on file as the authorized individual for your company review, your most recent Medicare enrollment application and the autho rized officials are listed in Section 15.

The letter must be received no later than Dec. 31, 2022; the letter may not be postmarked by December 31 and arrive at a later date.

If your company is currently enrolled as a nonparticipating provider and you wish to change your company’s status to participating, the process is a little bit more formal than simply mailing a request letter to the appro priate contractor. Your company must complete an official Medicare Participation Agreement for 2023, or the CMS-460 form. The CMS-460 is only one page in length and may be filled out by anyone; however, it must

be signed by an authorized individual. The completed form must be received by Dec. 31, 2022, or your participation status will remain nonparticipating for 2023. Visit cms.gov/Medicare/ CMS-Forms/CMS-Forms/downloads/ cms460.pdf to download the form.

calendar year. So, if you have several locations operating under the same tax ID, you may not have some locations be nonparticipating and other locations be participating; it is all or nothing. If you plan to make a change for 2023, be sure you understand how it may impact your front-office operations, and be sure all of your staff is aware of the change.

Devon Bernard is AOPA’s assistant director of coding and reimbursement services, educa tion, and programming. Reach him at dbernard@AOPAnet.org.

If you are happy with your current Medicare participation status and you do not wish to make any changes for 2023, simply do nothing and your status will remain the same.

One last thing to keep in mind: Your participation status is tied to your tax ID and not to the physical location of your facility, and any changes you make will not take effect until the start of the next

Take advantage of the opportunity to earn two CE credits today! Take the quiz by scanning the QR code or visit bit.ly/OPalmanacQuiz.

Earn CE credits accepted by certifying boards:

Your participation status is tied to your tax ID and not to the physical location of your facility.

Emergency RESPONSE

American O&P professionals answer calls for help in war-torn Ukraine

By MICHAEL COLEMAN

NEED TO KNOW

• Between 8,000 and 10,000 individuals in Ukraine—both soldiers and civilians—have lost limbs since February, when Russia first invaded the sovereign nation.

• Many O&P professionals and organizations have donated their time, services, and devices to help treat both new amputees and Ukrainians with preexisting amputation who are struggling to access care and componentry.

• Some U.S. clinicians and volunteers travel to Ukraine to treat patients at facilities or makeshift clinics using donated equipment and compo nentry; other groups arrange for Ukrainians to travel to the United States for prosthetic care and rehabilitation.

• Humanitarian groups, charitable organizations, and independent volun teers have been working collaboratively to provide aid, equipment, and care—complementing each other in a common purpose.

EARLY ON THE morning of November

15, Vira Hrabchuk, project manager at the newly launched Unbroken National Rehabilitation Center (Unbroken) in Lviv, Ukraine, sent an email via cellphone to O&P Almanac apologizing that she was unable to join a scheduled Zoom interview.

“Hello! Ukraine is currently under attack,” Hrabchuk wrote. An estimated 100 missiles rained down on Ukraine, including Lviv, as Russia’s brutal inva sion of the sovereign nation stretched into its 10th month. “I am sorry, we are currently without good Wi-Fi and electricity. We don’t know when it will be back, but we will reach out to you ASAP. Thank u!”

Fortunately, Hrabchuk, her colleagues, and their patients at Unbroken escaped injury and destruc tion that frightening day. Four days

later, Hrabchuk and her boss, Mariana Svirchuk, executive director of the Lviv Emergency Hospital and chief of Unbroken, explained how they are scrambling to provide prostheses and rehabilitation services to some of the estimated 8,000 to 10,000 Ukrainians who have lost limbs since the war began, and another 400,000 preexisting amputees who no longer can access routine care, because O&P clinics have been destroyed by bombing, according to estimates from the Limbs for Life Foundation.

“Right now, the Ministry of Health says that we still have 5,000 people— civilian and military—who need prostheses,” Svirchuk says. “We need money and equipment, but the main thing we need is technicians who can come to Ukraine for a month, or even two or three weeks, to help us.”

PHOTOS: Limbs for Life Foundation, Getty Images

Limbs for Life Foundation collecting thousands of donated prosthetic devices and componentry, assembling them into limbs, and shipping them to Poland

Called to Action

O&P professionals across the United States are answering the call, helping to provide equipment, training, and care across the sprawling nation of 43 million people that is roughly the size of Texas. American O&P clinicians and leaders of nonprofit relief agencies are taking part in a coordinated effort to assist Ukrainians with new ampu tations, including soldiers injured in battle as well as civilians whose limbs have been destroyed by land mines, crushed in bombed buildings, or irrep arably damaged by frostbite and sepsis.

Jeff Erenstone, CPO, founder of nonprofit Operation Namaste, traveled to Ukraine with his mobile limb lab and a group of clinicians in September to train Ukrainian O&P clinicians. U.S. nonprofit organizations Limbs for Life Foundation and Penta Medical Recycling are collecting thousands of donated prosthetic devices and compo nentry, assembling them into limbs, and shipping them to Poland, where they are being transported across the border into Ukraine. Yakov Gradinar, CPO, a Ukrainian-born orthopedic surgeon based in Minneapolis, helped launch

the Protez Foundation, a nonprofit that is arranging for war-wounded Ukrainians to travel the U.S. to be fitted with prostheses, rehabilitated, and, in some cases, returned to Ukraine at their request to rejoin the battle against Russia. Hanger Clinic sent several employees to Ukraine this year to help restore mobility to about 50 people who lost their limbs as a result of the ongoing war.

Seth Mischo, a former airborne infantryman and biomedical engi neering student at Wake Forest University School of Medicine, helped coordinate relief efforts after traveling to the Ukrainian-Polish border on a medical aid mission early in the war. While there, Mischo connected with key logistical officials and witnessed firsthand the country’s urgent need for O&P care. After returning home to North Carolina, Mischo connected the aforementioned O&P industry profes sionals in hopes of getting urgently needed prosthetic and orthotic help to Ukrainians. Since then, the ad hoc relief team members have kept in touch and continue to coordinate their relief work.

“We slowly got the ball rolling on helping to get everyone who needed to be together, together to start the effort,” Mischo recalls, adding that an associate put him in touch with AOPA, which connected him with other players in the U.S. O&P industry.

The challenge of providing adequate O&P care to the massive number of new limb-loss patients in Ukraine is immense—not only due to the onslaught of new amputees into the state-run healthcare system, but also because the former Soviet nation’s O&P infrastructure is lacking, and professionally trained prosthetists are in short supply. The lack of clini cians is particularly glaring in eastern Ukraine, which has been plagued by strife in Russian separatist-controlled areas since 2014. Making matters worse, O&P care is not categorized as a healthcare profession by Ukraine’s Ministry of Health, meaning it receives less governmental funding than other healthcare disciplines. Instead, it is categorized as a social service under the umbrella of the Ministry of Social Policy, which oversees efforts as dispa rate as adoptions and labor relations.

Limited Capacity

As of 2018, there were just 216 tech nician-prosthetists in Ukraine—and no national strategy for upgrading the existing O&P workforce, according to a 2021 World Health Organization report. Some O&P clinicians in Ukraine have limited capabilities; many are quite adept at lower-extremity but less skilled in upper-extremity care, according to individuals with expe rience in Ukraine. Meanwhile, O&P clinics that are well stocked with plaster, thermoplastics, ovens, grinding tools, and other modern equipment are few and far between. In August, Ukraine’s Ministry of Health reported that 906 healthcare facilities of all kinds had been damaged by Russian attacks—and 123 completely destroyed.

First group of soldiers who received care at the Protez Foundation before departure back to Ukraine at Minneapolis-St. Paul airport

PHOTO: Protez

“There is a lot of disruption to existing O&P facilities in the eastern part of Ukraine, or even the middle part of Ukraine,” Erenstone says. One facility centrally located in Kharkiv was bombed, “and they had to dismantle it and kind of move it around.” To help provide equipment, Erenstone traveled to the Unbroken Rehabilitation Center in Lviv with his Limbkit, a compact mobile lab that folds up into a box and can be transported in a small truck or van to provide comprehensive trans tibial prosthetic care. “The front part of it comes off and turns into

(Far right) Jeff Erenstone, CPO, trav eled to the Unbroken Rehabilitation Center in Lviv with his Limbkit, a compact mobile lab that folds up into a box and can be transported in a small truck or van to provide comprehensive transtibial prosthetic care.

a table that goes next to it, and you add them together and it becomes a sort of workbench and tool storage,” Erenstone explains. “That’s what we deployed in Ukraine.”

Erenstone’s team fitted about 10 patients with prostheses during the trip—mostly soldiers and civilians with lower-extremity injuries sustained in bomb blasts, as well as a couple of civilians who had pre-existing limb loss resulting from diabetes. But their primary goal was to educate local prosthetic practitioners on how to use modern technologies, including 3D printing, to improve the care they provide. The group introduced and trained local clinicians on five types of technology: the Xtremity Socket, the Össur Direct Socket, the Operation Namaste Limbkit, 3D-printed sockets, and 3D-printed prosthetic covers. These technologies were chosen for their ability to provide care in less than one day. The team saw a variety of patients, including soldiers in the

rehabilitation hospital and civilians at Arol Plus, an orthopedic shoe retailer in Lviv. Some patients had traveled great distances to receive care and the normal multiweek process for receiving a device wasn’t feasible for them. During the trip, Todd Stone, CPO, Robert Gavin, and Jay Tew, CP, from the Hanger Foundation fit most of the patients and provided general prosthetic education while Erenstone focused on education for 3D printing prostheses.

Working with a Ukrainian techni cian, Erenstone designed and printed a cosmetic prosthetic leg cover with the now-famous image of a Ukrainian soldier “flipping the bird” at an imposing Russian warship in the waters off Snake Island. The design proved popular among Ukrainian soldiers.

“We took that image and put that on a cosmetic cover and showed it to the soldiers, and they [said], ‘Yeah, that’s what we want!’” Erenstone recalls. “Putin is trying to run a war of attrition where he breaks the will of the popula tion, and he is failing miserably. Their will is strong—nowhere near breaking.”

Continuing Challenges

Shelley Dutton, director of develop ment at Limbs for Life Foundation, says her organization has been helping to provide orthoses and prostheses to underdeveloped coun tries for 28 years, but the challenge in Ukraine is unique. “The volume [of new amputations] is exceptional, and it’s continuing,” she says. “It's not like it happened, and it stopped. We’re seeing more and more coming on a daily basis.”

The fact that so many O&P clinics are underequipped, are understaffed, or have been damaged by Russia’s bombing campaign increases the difficulty of providing care. “A reha bilitation clinic and physical therapy clinic we spoke to last week in southern Ukraine is right at the edge of the fighting, but they don’t have an in-house prosthetic lab there, so we aren’t able to send them anything because they don’t have the people

and the tools to do anything with it,” Dutton says. She notes there is a massive demand for high-quality prosthetic devices, and she encour ages the U.S. O&P community to donate whatever they can.

“We get request lists from some of the clinic locations with general sizes for feet and preferred items,” Dutton says. “There is not much of a pattern as they are seeing individuals of all ages, sizes, and activity levels with varied levels of limb loss,” including individuals with above-knee, belowknee, and upper-extremity loss. “Our best approach is to ask for donations of new and gently used limbs, prosthetic parts, and accessories [liners or socks that are not used], thus increasing our inventory availability when the requests come in.”

Another big hurdle to providing assistance to Ukrainians is the astro nomical cost of shipping into a war zone. Currently, Limbs for Life is coor dinating with a folkloric dance group in Poland that has a large warehouse on the border. The warehouse is now being utilized not only for colorful costumes and props, but also for prosthetic devices and componentry. Because the

organization cannot ship directly to Ukraine, it is sending items to the ware house, where they are picked up and taken by ground transportation across the border.

“They have become the destina tion site in Poland to ship to, because they have the capacity to accept it,” Dutton explains. “They have a great relationship with the border patrol and everybody else, and they can get it on track to go to the next [portion] of the journey. From there, it gets picked up again. And so, the shipping costs are exorbitant.”

Henry Iseman, co-founder and executive director of New York City-based Penta Medical Recycling, says his three-person organization— spawned in a dorm room at Yale University before the war began—has now shipped about 200 pieces of prosthetic and orthotic equipment to Ukraine. Mijamin Strong, Penta’s director of operations, says in the early days of the invasion, Penta sent a half-dozen boxes of orthotics, including ankle-foot orthoses and other types of braces, to assist with immediate trauma care. As the war dragged on, amputations became more

common, and requests for prosthetic components started flooding in. In September, Penta sent 10 boxes of prosthetic equipment to a major O&P clinic in Odessa.

The shipment included “every major component that makes up a prosthesis, except for the sockets,” Strong explains. “They have a nice clinic, and they are able to do the sockets and fitting, so we shipped them liners, adapters, pylons, clamps, feet, and lots and lots of socks.” Another shipment is bound for clinics in Lviv and Ternopil in mid-December.

Iseman says the components are being donated from sources across the United States. “We have our existing collection network of clinics, and there has been increased interest in donating this year,” he says. “We’ve had the opportunity to collect different equip ment than we usually do. There’s been a bigger demand for more advanced equipment that we don’t usually repur pose as much because in [less advanced countries], that technology hasn’t been used before. You can’t use a C-Leg if you don’t have a smartphone or electricity in your home to keep it charged.”

Iseman says shipping into a war zone is a new experience for Penta. “It’s been an interesting trial for us, but also made us realize that we can work in places where there is a more urgent need. It’s just a matter of getting around those barriers.” Iseman has been gratified to see competing O&P aid groups that might normally be jockeying for space or credit, working together to help Ukraine. “It’s been really nice to see more collaboration across the industry and space, where previously there might have been some competition across organizations that are kind of mission adjacent,” Iseman says. “We’ve seen a lot of groups coming together and complementing each other and using each other’s networks to advance each other’s missions. We’re hoping to come out of this with a more organized collective of groups working in the space that can work together outside of Ukraine and in other parts of the world where there’s obviously need, as well.”

Yakov Gradinar, CPO, fitting Ukrainian soldier Taranovets Vadym, who lost both limbs below the knee and spent 2.5 months in Russian captivity

PHOTO: Protez

Meaningful Work

In late October, Gradinar, the Ukrainian-born orthopedic surgeon and prosthetist who launched the Protez Foundation in Minneapolis, was overseeing the rehabilitation of soldiers who lost limbs in the war. One of the Ukrainians he treated lost his leg at the knee—but continues to work out on a weight machine in a “determined way,” according to Gradinar. The soldier “is not sitting around,” he emphasizes. “He’s trying to get a strong back and trying to walk. Most of [the injured soldiers] want to go back to the front line.”

In addition to the 22 Ukrainians receiving care at Protez in October, approximately 590 were registered for assistance with the Minnesota nonprofit as of mid-November. The group coor dinates with volunteers who help get the amputees out of Ukraine and into Poland, where more volunteers escort them to an airport, through customs, and onto an airplane. Then airport workers in the United States, also coordinated by Protez, greet the visitors and ferry them to Minnesota and the Protez offices. Minnesotans have provided free lodging and meals for the patients while they spend two or three months being fitted with prostheses and reha bilitated in the United States.

After receiving care at the Protez Foundation, Mykola Kobilnyk returned to Ukraine and went into training before rejoining the front line.

says. “We are very unbroken in our spirit. They can break our physical things, but not our state of mind.”

Gradinar, who previously worked with Limbs for Life, launched Protez and its current project, Prosthetics for Ukrainians, with another Ukrainian, Yury Aroshidze, to help provide Ukrainian children, soldiers, and civilians who have lost their limbs with free, high-quality prosthetic devices in the United States. In late October, Gradinar was working with 19 soldiers, two children, and one civilian adult. One of the children is 9-year-old Artem Fedorenko whose home was struck by a Russian bomb. During the attack, the child’s father gathered him and his 12-year-old brother and began running to a nearby shelter when another bomb struck. Fedorenko’s father and brother were killed—but because the boy was shielded by his father, he lived but lost an arm, according to Gradinar.

Gradinar, who also designs and builds prostheses, says it’s more effec tive for him to bring Ukrainians to the U.S., where he has appropriate tools and rehabilitation equipment, than for him to travel to Ukraine to help. Bringing injured Ukrainians to see a prosperous and functioning democracy has another unexpected benefit. “The thing that touched us a lot is that [they] say, ‘This is what we’re fighting for—we want Ukraine to look like the United States,’” Gradinar says.

The experience inspires him, as well. “This makes me feel that I’m contrib uting to the country that educated me and helping my own people,” he says.

Svirchuk, who runs the new Unbroken rehab center in Lviv, notes that Ukrainians who have experienced limb loss are deeply grateful to the U.S. for its assistance during the war, and that much more assistance is needed. She vows that the work of her organiza tion will not be in vain.

“We want to say that we are very strong, and we continue to fight for our independence and our land,” Svirchuk

EDITOR’S NOTE: The war in Ukraine has resulted in an immense need for O&P supplies, money, and clinical assistance. Reports from within the war-torn country suggest as many as 10,000 people have lost limbs since the invasion, and many of the country's 400,000 existing amputees cannot access care. AOPA thanks members and others in the O&P community who have donated supplies and their expertise to help those in need. Please contact the following organizations if you would like to help:

Limbs for Life: www.limbsforlife.org/ukraine

Operation Namaste: www.operationnamaste.org

Penta Medical Recycling: www.pentaprosthetics.org

Protez Foundation: www.protezfoundation.com

Unbroken National Rehabilitation Center: https://unbroken.org.ua

Michael Coleman is a contributing writer to O&P Almanac

First group of amputees who defended Ukraine and came to the Protez Foundation for prosthetic care with Artem Fedorenko

Diabetes and Future Foot Health

How trends in technologies, patient education, and access to care will affect treatment

NEED TO KNOW

• Pedorthists, along with orthotists and prosthetists, can play a key role in educating individuals with diabetes about the need for professional foot care, the benefits of properly fitting therapeutic shoes and insoles, signs of neuropathy and ulcers, and the importance of mobility.

• Many pedorthic practices already leverage digital technologies such as scanning, and some are considering how other innovations—including 3D printing and sensor-embedded socks and insoles—may improve patient care in the future.

• With a growing need among people who would benefit from diabetic shoes and inserts, O&P practices should consider adding pedorthic products and services to their offerings.

AS THE U.S. POPULATION continues to age, caring for the 37.3 million Americans—11.3% of the populace— who have diabetes will become increasingly important. Studies have shown that up to 34% of people with diabetes will develop diabetic foot ulcers, and up to 20% of people with moderate or severe diabetic foot infec tions will experience amputation.

Those numbers are expected to grow. “Many baby boomers are aging into the profile of people who develop full-blown diabetes,” says Seamus Kennedy, CPed, FAAOP(A), co-owner of Hersco Ortho Labs. “Among seniors—those 65 and older—the rate of diabetes is 29.2%. That’s almost one-third of seniors who are diabetic, and it continues to trend upward. This is an epidemic, and it will be a crisis for the healthcare system.” Studies have found the healthcare costs of treating people who have diabetes are 2.3 times higher than of those without diabetes, says Kennedy.

Pedorthists—the clinicians responsible for fitting foot orthoses

PHOTO: Getty Images

and therapeutic shoes, oftentimes for patients with diabetes—are an essential part of the healthcare team, says Dennis Janisse, CPed, founder of National Pedorthic Services and a longtime advocate for pedorthic care. “Pedorthic education is the only education specifically focused on the foot and ankle,” he explains. Pedorthists not only fit the proper shoes, but make the necessary modi fications—for example, adding rocker soles or flares, or adapting shoes for foot deformities. “The right shoe and shoe modification can enable people to improve mobility,” and, in some cases, dramatically improve walking distances and comfort, he says.

Preventative Care and Education

With diabetes predicted to be a signif icant healthcare burden in the coming years, patient education is essential, and pedorthists—along with ortho tists and prosthetists—can play an important role.

“The best practice for individuals with diabetes is to see a podiatrist at least every three months to check for any issues that could be developing, and to wear appropriate footwear,” says John Gurrieri, CPed, CFo, a pedorthist at Hanger Clinic. “Certain conditions within the foot may result in the podiatrist recommending and prescribing extra-depth diabetic shoes with accommodative insoles.”

Individuals with diabetes often experience some form of diabetic neuropathy, or poor sensation, “which is usually the start of problems in the feet,” explains Gurrieri. “When this compromised sensation is paired with poor blood circulation, patients can develop diabetic ulcers. Once these sores develop, these patients are at high risk of infection and face

the possibility of serious complica tions such as amputation. If they are managed appropriately, these wounds can often heal, but patients who have developed diabetic ulcers have a higher chance for them to recur.”

For this population to maintain a healthy lifestyle, preventative pedor thic care is extremely important, according to Gurrieri. “This care is the most effective way to stop ulcerations from occurring the first time, or reduce the likelihood of recurrence. Wearing properly fitted extra-depth diabetic shoes with the appropriate accommo dative insole and seeing a podiatrist every three months is a great way to ensure proper foot health throughout

Dennis Janisse, CPed

Seamus Kennedy, CPed, FAAOP(A)

an individual’s life.” He also recom mends updating diabetic footwear every six to 12 months, depending on the patient’s activity level.

Optimal patient care also requires an educational component—particu larly in the early stages of the disease, because many patients don’t access the health benefits available to them, according to Erick Janisse, CO, CPed, sales training manager for Enovis. Only 20% of individuals who are eligible for diabetic shoes through Medicare are actually getting these shoes, he says. “Even if they know about the shoes, many don’t realize how their feet prob lems relate to their diabetes.

and shear from developing. But good foot hygiene also matters, according to Kennedy. To prevent fungal infec tions, patients shouldn’t wear the same pair of shoes two days in a row—they should purchase at least two pairs and alternate wear. They also should have at least two pairs of insoles to switch out, to help prevent buildup of fungus and microbes. Paying attention to these details—and self-examining their feet on a regular basis to watch for red spots or signs of breakdown—can help prevent a cascade of events that can lead to amputation, he says.

Patients also benefit from under standing how mobility affects overall health. “Some studies show that people have a better quality of life when they walk,” says Kennedy. “If diabetes progresses and the patient ends up with an amputation, mobility may become limited. Less walking equates to a lower quality of life.”

turnaround is very important.”

Others cite advancements with integrated sensors that can monitor temperature and/or pressure and identify “hot spots” on the foot as potential revolutionary products. “Detecting temperature and pressure can help prevent diabetic foot ulcers,” says Brian Lane, CPed, director of education for Enovis. This is particu larly important because many patients with diabetes lose the ability to feel pain due to nerve damage, so small injuries can go unnoticed and develop into an ulcer that could lead to infec tion and amputation.

“Patients need to understand what an ulcer is, and that there is a risk,” Erick Janisse adds. Pedorthists, orthotists, and prosthetists should consider sharing the message by attending health fairs and other events to educate consumers that patients with diabetes can use Medicare’s ther apeutic shoe benefit when ordering special shoes.

For patients who do follow through with purchasing diabetic shoes, educa tion should continue, says Kennedy. “Many people don’t appreciate some of the problems associated with diabetes, like neuropathy, and don’t realize how serious it can be.” Pedorthists and other healthcare professionals can explain to patients why they should take their condition seriously and reconsider some of their exercise and nutrition behaviors, he says.

“If patients are educated, and get proper-fitting shoes and insoles, they will have less opportunities for ulcers to develop,” says Kennedy. The shoes can help prevent areas of pressure

Kennedy encourages patients with diabetes to use smartwatches and apps to measure step counts and distance walked. “The number of steps taken, regardless of inten sity, can impact long-term health,” he says. “As pedorthists, we’re here to dispense the shoes and insoles prescribed,” he adds, “but I also think it’s our job to try to change the course of the disease by educating patients.”

New Technologies, Future Options

Just as other healthcare special ties, pedorthic practices are looking to new innovations for improving current and future patient care protocols and options.

Many pedorthic practices already have embraced digital technologies, for example. “Directly scanning a patient’s feet with a 3D scanner can greatly reduce the turnaround time for individuals receiving footwear,” says Gurrieri. “Today, most manufacturers accept digital scans, which eliminates the need to ship casts and final prod ucts—resulting in a quicker delivery. Oftentimes there is a critical window to treat a diabetic ulcer, so a quick

Lane says some of these sensorembedded products are designed to alert the patient, and even a medical care provider, about a potential ulcer or infection. Meanwhile, sensors that measure temperature will make a difference because some studies have shown that a 4- to 5-degree temperature difference helps identify future ulceration sites or the beginning of Charcot, according to Dennis Janisse.

Some of the sensor-embedded technologies also provide vibratory sensation, according to Lane, which can be used to improve blood flow as well as aid in fall management. “There are some studies that show it’s benefi cial for neuropathy as well,” he adds.

For now, physicians and podiatrists are leveraging these technologies with their patients—but in the future, pedorthic and orthotic providers could be involved as well, according to Lane. While the costs of these tech nologies can be daunting, podiatrists can get reimbursed for CPT codes for remote monitoring of up to $150 per month, he says.

Brian Lane, CPed

Erick Janisse, CO, CPed

When sensor-embedded insoles come down in cost and rise in avail ability, then pedorthists may embrace the technologies, says Dennis Janisse. “Right now, the diagnostic billing is for physicians,” he says. “Down the road, there could be a cooperative effort between pedorthists and physi cians.” This could be advantageous for patients, many of whom visit their pedorthists more frequently than their physicians.

These technologies will be a “gamechanger” for patient care, predicts Lane. Pedorthists and orthotists will receive feedback confirming how often their patients actually wear the shoes and insoles they are fitting. “From a pedorthic standpoint, this will rein force if we are prescribing correctly, and if the patient is wearing them,” he says. “We can then aggregate data to show how helpful they are—which will get more patients on board” with wearing shoes and insoles.

Of course, some clinicians have expressed concern about the liability potential related to alerts for patients who experience hot spots while wearing new technologies and subse quently develop ulcers; these issues will need to be addressed as the tech nology takes hold. “Are you responsible if a patient gets an ulcer?” asks Lane. “There is some risk” in embracing these new technologies—“but the reward is worth the risk,” he says.

Another technology that is predicted to impact the pedorthic space is additive manufacturing. For now, “it’s a waiting game,” says Lane. “We’re waiting for costs to go down and printers to get faster.” But he believes these changes are imminent, and that most O&P and pedorthic facilities will integrate some form of 3D printing in the next few years. This will open the door to datadriven designs, of potentially lighter weight, made with greater accuracy and efficiency, according to Lane.

Erick Janisse is excited for a future where some orthotic insoles are 3D-printed because the process allows for unique geometric

structures and areas of different thicknesses. “Right now, it’s costprohibitive for pedorthists to print in-house,” he says, but he predicts it will become more economical.

“I haven’t seen many 3D-printed orthotics that I haven’t liked.”

Other innovations that will play a part in modernizing pedorthic care include “different materials, such as newer resins,” which are being used in new designs for diabetic footwear and inserts, according to Lane. And even virtual reality (VR) may play a role. Lane says he recently discovered “a large potential for the reduction of pain” using VR in patients with many types of health problems. In the future, he foresees an opportunity to leverage VR in pedorthics to distract from pain, in rehabilitation, and even in facilitating walking for patients who might not otherwise.

Access to Care

As we look to the future of pedor thic care, one important uncertainty involves the availability of pedorthic care givers to meet the needs of a growing patient population. Erick Janisse suggests that more O&P practices should add pedorthic prod ucts and services to their offerings.

Unfortunately, “O&P facilities are increasingly leaving the Medicare diabetic shoe program,” he says. “The number of people who access diabetic shoe services will decrease even further if there are no facilities that offer them.”

Diabetic shoes and insoles can be a revenue booster at O&P facili ties, notes Erick Janisse, as long as companies prioritize fitting patients correctly, understanding how shoes from different manufacturers fit, and learning proper documentation tech niques. “I would love to see all O&P facilities offering pedorthic services,” he says. Adding a pedorthist to staff to meet the footwear needs of diabetic patients can enhance an O&P practice, “and pedorthists can be privileged for AFOs” under the supervision of an orthotist, he adds.

Facilities may consider offering pedorthic products as self-pay, rather than via insurance, says Dennis Janisse. “There’s such a future for pedorthics,” he says. “Our numbers are going down due to retirements,” and insurance margins aren’t high, but “there’s a value in patients paying out of pocket” for all types of pedorthic services, he says. “Patients appreciate what pedorthists do, if you can show them how you can help them.”

Of course, expanding access to pedorthic care means more certified pedorthists will be needed—which may be a challenge going forward as there are currently no schools offering CAAHEP-approved pedorthic educa tional programs. Despite the lack of current programming, the need for skilled pedorthic services will continue.

“I don’t think the diabetes epidemic has crested yet,” says Kennedy, who fears that other health care practitioners—who don’t have the same skill and training—may step into the pedorthist’s role. “We need more pedorthic practitioners coming into the field.”

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

Christine

“The number of people who access diabetic shoe services will decrease even further if there are no facilities that offer them.”

—Erick Janisse, CO, CPed

PHOTO: Getty Images

O&P Almanac introduces individuals who have undertaken O&P-focused research projects. Here, you will get to know colleagues and healthcare professionals who have carried out studies and gathered quantitative and/ or qualitative data related to orthotics and prosthetics, and find out what it takes to become an O&P researcher.

Building a Better Lower Limb

Researcher Glenn Klute, PhD, left a career in aerospace engineering in favor of bioengineering—and O&P

This prototype, developed in collaboration with Charles King, CPO, expels perspiration from the skinliner interstitial space. The subject is about to step into a thermal chamber at 95°F to walk for 30 minutes.

GLENN KLUTE, PHD, STARTED his career not in O&P, but in aerospace engineering. He studied mechanical engineering as an undergraduate at the University of Washington (UW), and his first job out of college was designing cruise missile systems.

“While I believe in a strong national defense, I didn’t want to be the one making better bombs,” he says, explaining why he switched fields. “When no one would hire me to design medical devices, I went back to school to study bioengineering—first for a master’s degree at Pennsylvania State University and later for a doctorate at UW.” That path eventually led to robotic systems and technology that could be applied to help people move. “We’re still a long way from making an equal to the human limb, but that’s what makes the research interesting.”

Today, Klute is a research career scientist at the Department of Veterans Affairs (VA) and affiliate professor at UW. Specifically, he is associate director of the Center for Limb Loss and Mobility (CLiMB) at the Seattle VA, where he also conducts research to improve the mobility of individuals with lower-limb amputation. His responsibilities at UW include teaching occasional classes and supervising graduate students from

a variety of academic departments, including mechanical engineering, bioengineering, electrical and computer engineering, and rehabilitation medicine.

Groundbreaking Research

Klute’s research focus over the years has migrated to lower-limb pros thetics, rehabilitation engineering, and biomechanics. “Lower-limb prostheses are the application; devel oping them uses method from rehab engineering; and biomechanics are some of the metrics used to measure their performance,” he explains.

“Sometimes our research is focused on comparing different commercial products to see how well they work. Providers and payors appreciate these results—because why would you want to prescribe or pay for something that doesn’t work?” he says. “Other times, we’re developing something new because there isn’t anything out there meeting the need. Patients and manufacturers appreciate this work because it shines new light on what might be possible.”

Some of Klute’s early investigations related to socket technology. “Two decades ago, a university colleague was giving me a hard time about not working on problems related to sockets and suspensions. She was right

PHOTO: Glenn Klute, PhD

when she said it was one of the most important things we could be doing as researchers,” he recalls. “While ‘goodness of fit’ remains hard to mea sure, I started in on the easy things like skin temperature and perspiration. Manufacturers are now addressing these problems in earnest, and I like to think we helped get the ball rolling.”

Now, Klute is developing a novel device called the Pivot-Flex Foot. “Most people walk with a subtle little ‘hitch in their giddy-up.’ In clinical terms, the tibia and fibula rotate slightly in the transverse plane during the stance phase of gait while the foot rotates in the sagittal plane. Engineers call this simultaneous move ment ‘coupled motion,’ but currently available lower-limb prostheses don’t do this,” he says. Instead, most prostheses rely on spring-like behavior in the sagittal plane; some have it in the coronal and transverse planes, but “none provide coupled motion where one motion forces the other,” he explains. Klute’s

team has patented the technology, which is currently in the testing phase in the lab and in the community.

“What is exciting is how the O&P profession has raised the bar on adopting new products,” Klute says. “Every prosthetist we’ve talked to asks about evidence: ‘Show us how well it works.’ It really demonstrates how the O&P community has evolved and demands more than just marketing.”

Klute also is working on an “interesting problem” that involves leveraging machine learning methods to measure how a person walks, and quickly adapting the power output of a prototype-powered limb to respond appropriately. “When we first started this work, I felt behind on the technology because I had attended a national high school science fair in 2017, and it seemed like every other project involved machine learning,” he says. “These high school students were doing some inno vative work, and it was simply inspiring.

This prototype limb can invert and evert to conform to uneven terrain. Reflective markers (gray spheres), visible as bright spots in infrared light, reveal how a limb moves in response to changes in terrain.

PHOTO: Glenn Klute, PhD

Before prototypes are tested with volunteers, Glenn Klute, PhD, and his team conduct bench tests to improve designs and validate expected performance. Here, Klute makes an alignment adjustment before a laboratory proof load test.

You don’t have to be an early adopter, but you can catch up quickly. Working with new approaches like 3D printing can make your work more interesting and may lead to inno vations that help with your practice and meet your patients’ needs.”

Collaborations and Inspirations

Working at both CLiMB and UW means that Klute interacts with a wide range of colleagues, students, and O&P consumers who inspire his work.

“The University of Washington has been the source of many talented graduate students who have played key roles in my O&P research,” he

explains. “Their enthu siasm, dedication, and scholarship are inspiring.”

He also appreci ates the veterans with lower-limb loss who volunteer to participate in his studies. “Their willingness to try new technologies and provide meaningful feedback has been important,” he says. “Without people to give your ideas a try, you really don’t have much. The VA has played a key role in helping us reach out to these veterans.”

When he considers the future, he believes developing prostheses that improve mobility for users will continue to be key. “In the short term, providing comfortable and well-fitting socket and suspension systems has been and continues to be a challenge,” Klute

NOTABLE WORKS

explains. “In the long term, developing neural interfaces that can actuate prosthetic systems and provide proprio ceptive feedback is an exciting area.”

He predicts that wearables and data science will inform O&P researchers and will be essential to future investigations because these innovations “tell us so much more about what people do with their prostheses and where we need to improve,” he says. Together with patient interviews and survey responses, “we’ll have helpful tools that tell us where further development is needed.”

To ensure the future of O&P research, he notes the importance of funding. His own funding has led him to prioritize lower-limb mobility. “Since my funding comes mostly from the Department of Veterans Affairs and the Department of Defense, my target population is the adult capable of ambulation,” he says. “Across the spectrum of these individuals, whether you lost your lower limb from trauma or complications from diabetes/dysvascular disease, you really want your pre-amputation function back. If you’re capable of walking, we’re trying to help.”

Glenn Klute, PhD, has been involved in dozens of published studies, including the following:

• Segal, A.D., Kracht, R., Klute, G.K. “Does a Torsion Adapter Improve Functional Mobility, Pain, and Fatigue in Patients With Transtibial Amputation?” Clin Orthop Relat Res, 2014; 472(10):3085-92. doi: 10.1007/ s11999-014-3607-9. PMID: 24733445; PMCID: PMC4160517.

• Klute, G.K., Huff, E., Ledoux, W.R. “Does Activity Affect Residual Limb Skin Temperatures?” Clin Orthop Relat Res, 2014; 472, 3062–3067. doi.org/10.1007/ s11999-014-3741-4.

• Pew, C., Klute, G.K. “Design of Lower-Limb Prosthesis Transverse Plane Adapter With Variable Stiffness.” ASME J Med Devices, 2015; 9(3): 035001. doi. org/10.1115/1.4030505.

• Klute, G.K., Bates, K.J., Berge, J.S., Biggs, W., King, C. “Prosthesis Management of Residual Limb Perspiration With Subatmospheric Vacuum Pressure.” J Rehabil Res Dev, 2016; 53(6):721-728. doi: 10.1682/JRRD.2015.06.0121. PMID: 27997669.

• Srisuwan, B., Klute, G.K. “Locomotor Activities of Individuals With LowerLimb Amputation.” Prosthet Orthot Int, 2021; 45(3):191-197. doi: 10.1097/ PXR.0000000000000009. PMID: 33856151; PMCID: PMC8494105.

PHOTO: Glenn Klute, PhD

PUTTING YOUR BEST FOOT FORWARD

CUSTOM: FOOT ORTHOTICS • AFO’S • RICHIES

One size does not fit all. At Hersco, our team of professionals works to fabricate orthotics from your scans and casts to match your patients’ specific needs. Customer service is at the heart of everything we do and we work endlessly to help you be as effective and efficient as possible. When you want the job done quickly and accurately, Hersco is here to help.

O&P Consultancy

DALE BERRY, CP, LP, FAAOP, began his work in prosthetics in 1983, when he received certifica tion in Canada. In 1991, he gained his U.S. certification and began working for a practice that even tually became part of Hanger. He served as national vice president of clinical operations for his last 20 years with the company.

“And then I turned 60,” Berry says, “and even though I enjoyed working with Hanger immensely, I thought it was time to try something different. I had spent my career designing and fitting devices, but I also recognized that getting the prosthesis was the easier part; the hard part was getting proper reimbursement. So I decided to see what I could do to help patients get the devices they needed.”

Berry incorporated Prosthetic Xpert Consultation in 2019. His cli ents include patients, practitioners, attorneys, and workers’ compen sation and insurance companies.

For patients, Berry evaluates devices and offers guidance as to the most appropriate solution. “After an amputation, patients are in a whirlwind. They are looking for advice from someone who doesn’t have a financial interest in the choice of prosthesis,” he notes. “Sometimes the insurance compa nies pay me; sometimes the patient. I provide an unbiased opinion at a flat fee that is not influenced by the cost of the prosthesis.” During the pandemic, Berry began a tele health component to his business, providing consultations online.

Another service Berry provides is calculating prosthetic lifetime care projections. “I get hired by attor neys, insurers, and workers’ comp as an expert witness to estimate

the total cost of prosthetic care over the patient’s lifetime, to make sure they have the funds neces sary to get the care they need.”

Berry also reviews insurance claims for workers’ comp and insurance companies to ensure that a device is medically necessary, that the coding is accurate, and the price is at fair market value. “My first priority is the patient: Is this the right device? Second, I want to make sure that prosthetists are get ting fair compensation for creating a custom prosthesis. And finally, I want to ensure that the insurance company gets a reasonable price on the device.” He interacts with clinicians and patients to help create “a win-win solution in which the insurer has confidence that it is spending its money wisely.”

In addition to his business, Berry provides pro bono services to sev eral nonprofits that provide funding to patients without insurance. If a patient needs a device, Berry will help find a provider to work with them. He turns to his vast network of contacts within the medical and

insurance fields, aggregated over the course of his career. “I can help identify the best device and find someone to make it, and negotiate with them on pricing,” he says.

As prosthetic technology advances, Berry finds himself in an excellent position to help validate marketing claims. “I’m seeing where patients get certain products and then abandon them,” he says. “I see how often they are used and how often they have to be replaced.”

He is setting up databases to track products, noting how long a patient has used a device, how long it lasted, where it was obtained, and other pertinent information.

“The accepted wisdom in our profession is that a device will last three to five years. I’ve found that the overwhelming majority of devices last five years,” he notes.

“By developing these databases, I’m hoping to contribute to facts and statistics on how patients are actually using their devices.”

Berry continues to enjoy his profession, more and more each day, he says. “At the beginning of my career, I focused on making and fitting prostheses. Now I feel I can treat more patients and affect more outcomes through a different phase of prosthetic care.”

Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

Prosthetic Xpert Consultation added virtual appoint ments to its list of services during the pandemic and continues to assist some clients remotely.

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Legacy Care

AFTER W.T. HINNANT lost his leg in an auto accident in 1930, he found it difficult to locate a prosthetist in North Carolina. Hinnant had to travel out of state to obtain care, and every time he needed an adjustment or repair, he had to travel or do the work himself. He decided to enter the O&P field and became an apprentice with the Minneapolis Artificial Limb Company. In 1931, he launched his own prosthetic facility in Charlotte, North Carolina, where he and two technicians served amputees in both North and South Carolina.

Hinnant’s sons, John and Milton, worked for the facility and took it over after their father’s death in 1954; they were followed by Hinnant’s grandson. Jason Riffle, CP, purchased the business in 2018.

Riffle himself comes from an O&P background. “My grandfather and his three sons, including my father, who was a below-knee amputee, were practitioners, so I’m third generation in the field. My uncle also owned O&P practices as a certified prosthetist. I started professionally in 1991, and in 1995, my father and I opened a practice in Paris, Texas. We ran it until 2008, when my father retired.”

Riffle worked for other prac tices and then took over W.T. Hinnant O&P four years ago. The facility has nine employees and recently opened a new office in Camden, South Carolina, staffed by a full-time practitioner, Delisa Lawson, CPO. The facility recently became a residency site, and Riffle is looking forward to working with up-and-coming practitioners.

W.T. Hinnant O&P started out as a prosthetics-only facility. Today,

up to 90% of patients are limb loss patients, although Riffle expects that ratio to change as the facility offers more orthotic services. “Insurance companies are asking us to do compression, shoes, and inserts, so we are trying to figure out a way to service the entire commu nity with orthotics and prosthetics,” he says. “Our prosthetic patients are a mix of legacy patients, who have been coming here for 40-plus years, and vascular and orthopedic referrals from the community.” The practice primarily sees adult and geriatric patients, as another facility in the area specializes in pediatrics. The company embraces such advanced technologies as microprocessors, myoelectric upper-extremity prostheses, and transtibial socket designs, as well as scanning and 3D printing. However, the facility will go “old school” for long-term patients who don’t want to change. “We still do quad sockets” for patients who have been seen at the facility for four decades, Riffle says. “We even do thigh lacers and leather waist belts and exoskeletal legs. … We want to accommodate our patients.”

One of Riffle’s success stories is that of a 36-year-old woman with a hip disarticulation and below-knee and above-elbow amputations. “She came to me because her prostheses were falling apart,” he says. She didn’t want an arm prosthesis, so Riffle fit her with the Helix hip and a C leg. Now, she can now climb stairs, exercise, work full-time, and drive. “She used to fall three or four times a day, and now she doesn’t fall at all. She is very independent!”

Another patient lost his leg below the knee in a motorcycle accident seven years ago and struggled with depression. Riffle worked with him and found him the help he needed, and today he is a peer visitor for the facility, who connects with new patients.

Riffle would like to expand in the future, both with new offices and improved services. “It’s hard to find help,” he notes, “but we want to attract good-quality practi tioners to the facility and continue to provide excellent outcomes for our patients and communities.”

Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

Longstanding facility offers both new and older technologies to wide range of patients

Deborah

Owner Jason Riffle, CP, works with a prosthetic patient.

The facility accommodates a significant percentage of prosthetic patients but is expanding its orthotics business as well.

Download the APP!

After creating your Co-OP account, download to your mobile device at aopanet.atlassian.net

AOPA’s Co-OP

The Compendium of O&P

A confluence of coding, billing, and policy information, the AOPA Co-OP provides a cooperative space for collaboration among O&P colleagues. This easily accessible, online resource enables your organization to be successful in today’s everchanging healthcare environment.

AOPAversity Webinars

JOIN AOPA EXPERTS

for the most up-to-date information on specific topics during these onehour webinars, held the second Wednesday of each month at 1 p.m. ET. One registration is all it takes to provide the most reliable business information and CE credits for your staff at a single office location. Visit AOPAnet.org/education/ monthly-webinars for details and registration information.

NEW MEMBERS

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UPCOMING WEBINARS

December 14 Year End Review & What Is Ahead

Join AOPA for the final AOPAversity webinar of 2022! As the year comes to an end, AOPA experts will highlight the updates and changes in policy, reimbursement, and coding from the previous 12 months and provide insights into potential changes in 2023.

Be on the lookout for AOPA’s 2023 webinars— coming soon!

DON’T

MISS VIRTUAL SESSIONS FROM THE 2022 NATIONAL ASSEMBLY

View the content you missed—or revisit a favorite session—starting October 18!

Educational content from the AOPA 2022 National Assembly in San Antonio will be available virtually from October 18 until December 18. View valuable, cutting-edge, clinical and business content—and earn CE credits. Visit AOPA’s website, aopanet.org, to find out how you can learn on your own schedule!

Welcome New AOPA Members

THE OFFICERS AND DIRECTORS of the American Orthotic & Prosthetic Association (AOPA) are pleased to present these applicants for membership. Each company will become an official member of AOPA if, within 30 days of publication, no objections are made regarding the company’s ability to meet the qualifications and requirements of membership.

Complete Prosthetics & Orthotics

130 W. River Heights Drive

Meridian, ID 83646 208/866-5177

Gunnar Harrison Maughan, CPO Patient-Care Facility

Martin Bionic Clinical Care OKC

214 E. Main Street Oklahoma City, OK 73104-4221 844/624-6642 martinbionics.com Jay Martin, CP, LP, FAAOP Patient-Care Facility

Promyse Prosthetic Orthotic Group/ dba Certified Limb & Brace 3227 Portland Avenue Shreveport, LA 71103 318/636-9145 certifiedlimbandbrace.com Henry Richter, CPO, LPO Supplier Category 1

Sign up now for expert guidance on hot topics—and start earning CE

O&P PAC Update

The O&P PAC Update provides information on the activi ties of the O&P PAC, including the names of individuals who have made recent donations to the O&P PAC and the names of candidates the O&P PAC has recently supported. The O&P PAC recently received donations from the following AOPA members*:

Curt Betram, CPO, FAAOP

Charles Kuffel, CPO, LPO, FAAOP

Teri Kuffel, JD

Martin McNab, CPO

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The purpose of the O&P PAC is to advocate for legislative or political interests at the federal level that have an impact on the orthotic and prosthetic community. The O&P PAC achieves this goal by working closely with members of the House and Senate and other officials running for office to educate them about the issues, and help elect those individ uals who support the orthotic and prosthetic community.

*To participate in, support, and receive additional infor mation about the O&P PAC, federal law mandates that eligible individuals must first sign an authorization form, which may be completed online: bit.ly/aopapac.

MARKETPLACE

AliMed® Open Heel and Open Forefoot Orthoses

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AliMed’s new Open Heel and Forefoot Orthoses help transfer weight off the heel or forefoot, offering effective pressure relief after surgery or trauma, or when wounds are present. Each lightweight orthosis features a soft, seam less inner lining that reduces irritation for greater patient comfort and allows for limited ambulation. XS-XL sizes.

• Open Heel Orthosis has a single bridge strap for easy application and a nonslip rubber outsole.

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Watch our video and learn more at AliMed.com/ wound-care-orthoses

ToeOFF® 2 ½ & BlueROCKER® 2 ½

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ALPS BioStep™, available in five different styles, is a break through innovation among dynamic response feet. ALPS BioStep™, powered with patented NRG™ technology, is based on a biomimetic design that enables dynamic patients to perform a wide range of activities with just one single foot. Active users can experience a high dynamic response combined with a fluid step and stability on all terrains.

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Children’s Foot Orthotics by Apis

Newly designed children’s foot orthotics feature a semirigid extended heel cup in UCBL style for extra ankle control and support. The orthotic is covered with an antimicrobial fabric top liner for effective moisture and odor control. They come in W width and sizes starting at T4-T13, Y1-Y6. Retail packaging and all sizes are in stock for immediate delivery. For free display samples, call 888/937-2747. Wholesale accounts only.

Becker GEO™ (Gait Evaluation Orthosis)

The Becker GEO™ is a prefabricated, carbon-composite evaluation orthosis used to assess the benefit of an anklefoot orthosis on ankle and knee stability. Please contact our customer service department today for more information.

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QSchool Is Our Orthotic and Prosthetic Online Education System

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Coyote has nine courses worth over 13.5 CE credits available. Choose from courses on products like “All Things Air-Lock,” or “Dynamic Strut AFO and its Fabrication,” and a number of other courses dealing with casting, basic fabrication, and materials like our “Alternatives to Carbon Fiber” course.

All of our online courses are free for the rest of 2022. Be sure to check www.opqschool.com for the credits you need.

For more free CE credits, go to www.coyote.us/events and register for our webinars.

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Silent air compressors are dependable, vibration free, and compact with noise levels as low as 30 dbA. These com pressors are energy-efficient, quiet-running rotary screw compressors designed to be customer friendly and easy to maintain and service. A number of models to choose from.

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The Original Preflexed Suspension Sleeve

ESP created the Flexi family of suspension sleeves as a comfortable, durable, and cost-effective alternative to traditional suspension sleeves. Preflexed at 43 degrees for maximum comfort and natural unrestricted movement.

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Hersco is delighted to offer HP’s advanced 3D-printing technology for custom orthotics. 3D printing has unique design capabilities not possible with other methods—reducing landfill waste by 90%! The accuracy of 3D is unparalleled, specs exceed direct-milled polypro, and manual plaster fabrication.

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Naked Prosthetics

It’s all about function. We are the manufacturers of durable prosthetic devices specifically for finger and partial-hand amputations. Our aim is to positively impact our wearers’ lives by providing high-quality finger prostheses. We offer four devices: MCPDriver (shown in rose gold), PIPDriver, ThumbDriver, and our newest device, the GripLock Finger. Our devices help to restore length, pinch, grasp, stability, and pro tection for sensitive residuum. Robust device engineering and their ability to withstand harsh environments help get people back to performing activities of daily living, and back to work. All are available in a dozen color coatings to match our wearers’ preferences and styles. To learn more, visit npdevices.com

Skeo Unique Custom Liner: The Right Solution Is Unique

Unique Liners from Ottobock are highly customized, so you can achieve innovative fitting results. The silicone Skeo Unique custom liner is recommended when high stability and durability are required.

This liner:

• Is appropriate for very conical or scarred residual limbs

• Stabilizes residual limbs, even those with significant soft tissue

• Skin-friendly silicone enables a superior connection with the residual limb

• Easy handling, easy cleaning.

Utilize the new Ottobock EasyScanner or the free Custom4U iPad app with a Structure scanner to digi tally capture the limb. STL files from any scanner can be uploaded into our iFab Customer Center (iCC) for easy digital ordering without shipping casts. Learn more at shop.ottobock.us.

RUSH ROGUE® 2

The newly redesigned, PDAC-verified RUSH ROGUE® 2 provides the most realistic and dynamic foot and ankle motion available. The Vertical Shock & Rotation (VSR) vertical shock offers relief up to 4.24 mm while offering +/- 15 degree torsion, allowing the user to push the foot and themselves to the limits. The RUSH ROGUE 2 is made of our advanced fiberglass composite, which is three times more flexible than conventional prosthetic feet. The roll-through characteristics of the foot provide exceptional energy return with no “dead spot.” The RUSH ROGUE 2 is also available in the PDACverified EVAQ8 elevated vacuum and H2O models.

For more information, visit shop.proteorusa.com.

Uneo Unique Liner: There’s No One-SizeFits-All When It Comes to Liners

Unique Liners from Ottobock are highly customized, so you can achieve innovative fitting results. The urethane Uneo Unique custom liner achieves an exact and comfortable fit thanks to the extraordinary flow characteristics.

Other qualities include:

• Polyurethane gel to cushion highly sensitive or scarred residual limbs

• Good pressure distribution within the socket

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• Skinguard antibacterial or fresh scent options available.

Utilize the new Ottobock EasyScanner or the free Custom4U iPad app with a Structure scanner to digi tally capture the limb. STL files from any scanner can be uploaded into our iFab Customer Center (iCC) for easy digital ordering without shipping casts. Learn more at shop.ottobock.us.

ProComp® Carbon-Infused Polypropylene Composite

The Xtern Summit, A Step Up for Foot Drop By Turbomed Orthotics

Composite Material Science = Improved Fabrication Processing = Enhanced Clinical Performance

ProComp® is produced in a high-pressure laminating process that infuses discontinuous carbon fiber into homopolymer propylene.

The patented prepreg composite sheeting is compatible with standard drape-encapsulation or bubble vacuum thermoforming.

Finishing techniques are standard. Four standard gauges are available for both orthotic and prosthetic applications. Eligible for double L2755 application in thermoplastic AFOs and appropriate prosthetic addition codes.

For more information, visit fabwithprocomp.com. Contact Gary G. Bedard, CO, FAAOP(D), managing principal, Rhode 401 LLC, at 650/773-3730 or email garyb@fabwithprocomp.com

Are you making countless adjustments to braces? Seeing the same unhappy patients over and over? Casting legs? Losing money? You may be ready for the Xtern. Your patients are ready. This revolutionary brace, specifically designed for people suffering from foot drop, is entering its sixth generation: the Xtern Summit. The Xtern line sits entirely outside the shoe, and is so flexible that it allows maximal range of motion and calf muscle strength. It combines extraordinary lightness with proven comfort. You’ll barely notice it’s there. Turbomed’s Xtern Classic, Xtern Summit, and Xtern Frontier are designed in Quebec, Canada, sold in more than 30 countries around the world, and distributed by Cascade in the United States. Visit turbomedusa.com, and think outside the shoe! The Xtern Summit launches October 15, and will replace the Xtern Classic in the U.S.

Statement of Ownership, Management and Circulation (required by U.S.P.S. Form 3526)

1. Publication Title: O&P Almanac 2. Publi cation No.: 1061-4621 3. Filing Date: 9/26/22

4. Issue Frequency: Monthly, except for com bined issues printed June/July and Novem ber/December 5. No. of Issues Published Annually: 10 6. Annual Subscription Price: $59 domestic/$99 foreign 7. Complete Mailing Address of Known Office of Pub lication (Not Printer): American Orthotic & Prosthetic Association, 330 John Carlyle St., Suite 200, Alexandria, VA 22314 8. Com plete Mailing Address of Headquarters or General Business Office of Publisher (Not Printer): Same as #7 9. Full Names and Complete Mailing Addresses of Publisher, Editor, and Managing Editor: Publisher: Eve Lee, address same as #7. Editor: Josephine Rossi, Content Communicators LLC, PO Box 938, Purcellville, VA 20132. 10. Owner (Full Name and Complete Mailing Address): American Orthotic & Prosthetic Associa tion, same as #7 11. Known Bondholders, Mortgagees, and Other Security Holders Owning 1 Percent or More of Total Amount of Bonds, Mortgages, or Other Securities: None. 12. The purpose, function, and nonprofit status of this organization and the exempt status for federal income tax purposes: Has Not Changed During the Preceding 12 Months. 13. Publication Name: O&P Almanac 14. Issue Date for Circulation Data Below: August 2022

15. Extent and Nature of Circulation:

a. Total number of Copies (Net Press Run) 10,990 10,923 b. Paid and/or Requested Circulation

(1) Paid or Requested Outside-County Mail Subscriptions 10,690 10,678

(2) Paid In-County Subscriptions 0 0 (3) Sales Through Dealers and Carriers, Street Vendors, 0 0 Counter Sales, and other non-USPS Paid Distribution (4) Other Classes Mailed through the USPS 4 4 c. Total Paid and/or Requested Circulation 10,694 10,682 d. Free Distribution by Mail

(1) Outside-County as Stated on Form 3541 0 0 (2) In-County as Stated on Form 3541 0 0 (3) Other Classes Mailed through the USPS 0 0 (4) Free or Nominal Rate Distribution Outside the Mail 13 0

Total Free or Nominal Rate Distribution 13 0

Total Distribution 10,707 10,682

Copies not Distributed 89 134

Total 10,796 10,816

Percent Paid and/or Requested Circulation 100% 100% 16. Electronic Copy Circulation: a. Paid Electronic Copies 0 0 b. Total Paid Print Copies (Line 15c) + Paid Electronic Copies (Line 16a) 10,694 10,682 c. Total Print Distribution (Line 15f) + Paid Electronic Copies (Line 16a) 10,707 10,682

(Both Print & Electronic Copies) (16b divided by 16c x 100) 100% 100%

“I designed this composite to allow you to transition from plastic to composite thermoforming.”

GARY G. BEDARD, CO, FAAOP(D)

Opportunities for O&P Professionals

Job Location Key:

-

North Central

Hire employees and promote services by placing your classified ad in the O&P Almanac. Include your company logo with your listing free of charge.

Refer to AOPAnet.org for content deadlines. Ads can be posted and updated any time online on the O&P Job Board at jobs.AOPAnet.org No orders or cancellations are taken by phone. Send classified ad and payment to: O&P Almanac, Calendar, P.O. Box 34711, Alexandria, VA 22334-0711 or email jburwell@AOPAnet.org along with VISA or MasterCard number, cardholder name, and expiration date. Make checks payable in U.S. currency to AOPA. Note: AOPA reserves the right to edit calendar listings for space and style considerations.

O&P Almanac Careers Rates

Color Ad Special Member Nonmember

1/4 Page ad $482 $678 1/2 Page ad $634 $830

Listing Word Count Member Nonmember 50 or less $140 $280 51-75 $190 $380 76-120 $260 $520 121+ $2.25 per word $5 per word ONLINE:

Inter-Mountain

Prosthetic Journeys

Begin Here

Prosthetist or Prosthetist-Orthotist Dalllas, Texas Kai Davis Prosthetics is an independent, family-owned, prosthetic provider, servicing patients across the Dallas Metroplex. We are seeking an ABC-certified prosthetist or prosthetist-orthotist to partner with us in our mis sion of providing patient first prosthetic care through tailor-made solutions that restore people’s lives.

Responsibilities:

• Visit surrounding hospitals in Dallas Metroplex for pre- and postoperative care

• Evaluate amputees and develop a treatment plan with supporting documentation

• Cast, measure, modify, and fit custom prosthetic devices.

Qualifications:

• Three years of experience preferred

• Texas licensed or eligible

• ABC-certified.

To apply, visit www.kaidavisprosthetics.com

WANTED!

SUBSCRIBE

A large number of O&P Almanac readers view the digital issue— If you’re missing out, visit issuu.com/americanoandp to view your trusted source of everything O&P.

A few good businesses for sale. Lloyds Capital Inc. has sold over 150 practices in the last 26 years.

If you want to sell your business or just need to know its worth, please contact me in confidence.

Barry Smith

Telephone: (O) 323/722-4880 • (C) 213/379-2397 Email: loyds@ix.netcom.com

2022December 1–31

ABC: Application Deadlines, Exams Dates, O&P Conferences, and More! Check out ABC’s Calendar of Events at ABCop.org/calendar for the latest dates and event details, so you can plan ahead and be in the know. Questions? Contact us at info@abcop.org or visit ABCop.org/contact-us

Monthly Webinar December 14 Year-End Review and What Is Ahead. 1 PM ET. Register at aopanet.org

2023

May

19–20

Orthotic & Prosthetic Innovative Technologies Conference. Minneapolis, MN. For updates, check our website at optech.ucsf.edu. Email cme@gillettechildrens.com to be added to conference mailing list

June 23–24

PrimeFare East. Nashville Renaissance Hotel and Conference Center. In-Person Meeting. Contact Cathie Pruitt at 901/359-3936, pruittprimecare@gmail.com; or Jane Edwards at 901/487-6770, jledwards88@att.net. For more information, visit primecareop.com

September 6–8

AOPA National Assembly. Indianapolis, IN For more information, visit aopanet.org

Calendar Rates

Phone numbers, email addresses, and websites are counted as single words. Refer to aopanet.org for content deadlines. Send announce ment and payment to: O&P Almanac, Calendar, P.O. Box 34711, Alexandria, VA 22334-0711 or email jburwell@AOPAnet.org along with VISA or MasterCard number, cardholder name, and expira tion date. Make checks payable in U.S. currency to AOPA. Note: AOPA reserves the right to edit calendar listings for space and style considerations.

Advertisers Index

Company Page Phone Website

AliMed Inc.

1 781/329-2900 www.alimed.com

Allard USA 7 866/678-6548 www.allardusa.com

ALPS South LLC 3 800/574-5426 www.easyliner.com

Amfit 17 800/356-3668 www.amfit.com

Apis Footwear Company 20 888/937-2747 www.apisfootwear.com

Becker Orthopedic 35 800/521-2192 www.beckerorthopedic.com

Cailor Fleming Insurance 19 800/796-8495 www.cailorfleming.com

Coyote Prosthetics & Orthotics 25 , 27 800/819-5980 www.coyote.us

ESP LLC 5 888/WEAR-ESP www.wearesp.com

Ferrier Coupler Inc. 37 810/688-4292 www.ferrier.coupler.com

Flo-Tech O&P Systems Inc. 13 800/356-8324 www.1800flo-tech.com

Hersco 39 800/301-8275 www.hersco.com

Naked Prosthetics 33 888/977-6693 www.npdevices.com

Ottobock C4 800/328-4058 www.professionals.ottobockus.com

Proteor USA 9 855/450-7300 www.proteorusa.com

TurboMed Orthotics 21 888/778-8726 www.turbomedorthotics.com

Xtremity 15 970/429-4203 www.xtremity.com

O&P State Policy Wins

Updates to Medicaid and other legislative changes from 2022

smiller@AOPAnet.org

Each month, State By State features news from O&P professionals about the most important state and local issues affecting their businesses and the patients they serve. This section includes information about medical policy updates, fee schedule adjust ments, state association announce ments, and more. These reports are accurate at press time, but constantly evolve. For up-to-date information about what is happening in your state, visit the Co-OP at AOPAnet.org/resources/co-op.

Illinois

Fifty-eight L codes were added to the Illinois Medicaid fee schedule in April, thanks to a proposal by the Illinois Society of Orthotists and Prosthetists. Reimbursement for these new codes, which include myoelectric and other high-tech components, is set at 2022 Medicare minus 6%.

Minnesota

As a result of advocacy efforts from a group of providers in the state, Minnesota Medicaid’s Lower-Limb Policy was updated in July to align K levels with Medicare, adjust coverage for several codes to include more K levels, and add a number of previously unlisted codes to the fee schedule. The group hopes to do the same with Minnesota Medicaid’s Upper-Limb Policy soon.

patients over the course of their life times, HF 2411, was signed into law. Previously, workers’ comp patients were only entitled to one replacement device. Under the new law, the portion of a settlement identified as the estimated lifetime cost of repair and replacement will be placed under control of the state treasurer in a separate fund to be dispensed as medically necessary.

Maine

THIS YEAR SAW IMPRESSIVE GAINS

in state-level O&P coverage and reimbursement. As 2022 comes to a close, it’s important to acknowledge the policy wins that have taken place across the country.

MEDICAID FEE SCHEDULE UPDATES

Arkansas

After discussions with pro viders in the state, Arkansas Medicaid has proposed a reimbursement rate increase to 90% of 2023 Medicare. For unlisted codes, reimbursement will be set at 80% of the 2023 Arkansas BlueCross BlueShield rate, or manually priced. Medicaid reim bursement rates were last set in 2006.

New York

In May, a coalition of O&P providers in the state success fully pushed for a New York Medicaid fee schedule increase to 80% of 2020 Medicare for 29 existing codes, as well as the addition of 35 codes that were previously missing from the fee schedule. These changes took effect June 1, and deliberations for the FY 2023 budget cycle are now underway.

ENACTED LEGISLATION

Iowa

In June, a bill allowing for mul tiple replacement prostheses for workers’ compensation

Maine enacted LD 1003 in May, which mandates that state insurance plans cover, for enrollees under 18, an additional prosthesis intended for physical activity, including running, swimming, biking, or maximizing upper-limb function. AOPA’s newest state policy initiative aiming to increase children’s access to physical activity devices, So Kids Can Move, is based on the provisions outlined in LD 1003.

Virginia

HB 925 and SB 405, com panion bills mandating prosthetic coverage in state insurance plans, took effect starting in July. Coverage includes myoelectric, biomechanical, and microprocessorcontrolled devices and repeals the existing requirement that coverage only be offered and made available.

For more information on these and other state developments, visit the AOPA Co-OP or contact Sam Miller at SMiller@AOPAnet.org.

Become an AOPA State Rep. If you are interested in participating in the AOPA State Reps network, email

Trust, Move, Live.

Since the introduction of C-Leg and its groundbreaking control technology, Ottobock has never stopped inventing new ways to take your patients as far as they want to go. With a portfolio including the Kenevo, Genium, X3, and now the latest iteration of C-Leg 4, every microprocessor knee supports a journey toward a limitless future.

Scan the QR code to learn more!

Kenevo C-Leg 4 Genium X3

IP 22 IP 67 IP 67 IP 68

The Kenevo is designed specifically for users with mobility limitations who need a high level of stability. State-of-the-art technology allows users to feel safer and more independent in their everyday life.

An IP 22 rating protects from dripping water or dust.

The C-Leg 4 provides exceptional reliability and dynamically adapts to a wide variety of everyday situations. The legacy lives on with the new C-Leg 4 Update with over 10 new features including supported descent on ramps and stairs. The C-Leg 4 is easier and more intuitive than ever before.

An IP 67 rating provides protection from damage due to casual contact or temporary submersion in fresh water up to 1 meter for 30 minutes.

The Genium provides the highest degree of intuitive function to individuals who need to adapt to changing environments, move quickly over short distances, or require more than 2 days of battery life.

An IP 67 rating provides protection from damage due to casual contact or temporary submersion in fresh water up to 1 meter for 30 minutes.

The Genium X3 is the most durable, intuitive and technologically advanced microprocessor knee available. With features that support activities like running, swimming and ascending stairs step-overstep, X3 supports individuals who push the boundaries of mobility.

With an IP 68 rating, Genium also offers the highest level of water protection offered in a microprocessor knee.