October 2017 O&P Almanac by AOPA

The Magazine for the Orthotics & Prosthetics Profession

O CTO B E R 2017

New 'TPE' Audit Process Explained

This Just In: RAND and Dobson-DaVanzo Studies Demonstrate Efficacy of O&P Intervention P.20

P.18

Clinical Tips From Practitioners With Limb Loss P.28

Does Your Compliance Plan Measure Up? P.40

Guidance on Code A5513 P.68

A MORE

Flexible

MINDSET

HOW O&P PROFESSIONALS ARE ADAPTING THE LATEST MATERIALS AND RETHINKING FABRICATION TECHNIQUES P.22

E! QU IZ M EARN

BUSINESS CE

CREDITS

WWW.AOPANET.ORG

P.19 & 43

YOUR CONNECTION TO

EVERYTHING O&P

THE PR EM I ER M E E T IN G F OR ORT H OT IC, PROSTH ETIC, A N D PED ORTH IC PROFESSION A LS.

e c n e i r e p Ex

September 26-29, 2018

VANCOUVER Vancouver is easy to explore during your time at the downtown Vancouver Convention Centre as there are many top attractions within walking distance. • • • • • •

Capilano Suspension Bridge Vancouver Aquarium Forbidden Vancouver Stanley Park Horse-Drawn Tours Harbour Cruises & Events Flyover Canada

• Vancouver Lookout • Dr. Sun Yat-Sen Classical Chinese Garden • Vancouver Art Gallery • Science World • Grouse Mountain

Experience Beyond Vancouver’s unbeatable location makes it the perfect gateway to the rest of British Columbia and beyond, providing you with outstanding opportunities for pre- and post-conference travel. • Whistler • Okanagan Valley • Jasper • Victoria • Banff • Cruise to Alaska

AOPAnet.org

#AOPA2018

Experience all the AOPA National Assembly has to offer while visiting Vancouver.

contents

OCTOB E R 2017 | VOL. 66, NO. 10

22 | A More Flexible Mindset O&P materials have not changed significantly over the past few years, but advances in materials fabrication and prosthetic manufacturing techniques have led to new designs and advanced componentry. O&P professionals with expertise in this arena discuss the “rethinking” of materials and explain how patients are benefitting from the latest trends. By Christine Umbrell

20 | This Just In

New Studies Document O&P Value Proposition The presentation of brand-new research documenting the efficacy of O&P intervention was a highlight of this year’s AOPA World Congress. The RAND Corp.’s “Economic Value of Advanced Transfemoral Prosthetics” focuses on the clinical outcomes of microprocessor-controlled knees, and a Dobson-DaVanzo study explores the benefits of lower-extremity orthoses, spinal orthoses, and lower-extremity prostheses.

36 |

28 |

From Experience, With Empathy Clinicians who have dealt with limb loss have first-hand knowledge of what it’s like to be an O&P patient. Their experiences help guide their decisions as practitioners, and provide evidence that strategies such as realistic goalsetting and empathetic listening are key to optimal patient care. By Lia K. Dangelico

OCTOBER 2017 | O&P ALMANAC

Center-Stage Research

The repository of impactful O&P research expanded during the AOPA World Congress, when two research studies—focusing on microprocessor-controlled knee-ankle-foot orthoses and symmetry in lower-extremity amputees—were recognized with Thranhardt Awards. A third business-focused study was honored with a Hamontree Award. By Deborah Conn

PHOTO: Reach Orthotic and Prosthetic Services

COVER STORY

FEATURES

contents

SPECIAL SECTION

DEPARTMENTS

AOPA’S 100 ANNIVERSARY TH

Views From AOPA Leadership......... 4 Insights from AOPA Board Member Rick Riley

AND WORLD CONGRESS CONNECTION

AOPA Contacts.......................................... 6 How to reach staff

44 | Then & Now

Numbers......................................................... 8

O&P education progresses through the years

Happenings............................................... 10

At-a-glance statistics and data

Research, updates, and industry news

48 | Bridge to the Future Advances in prosthetic skin

50 | The Global Professional Meet a Portuguese practitioner

P.12 People & Places........................................14 Transitions in the profession

COLUMNS Reimbursement Page..........................18

The Medicare Audit Process How ‘Target, Probe, and Educate’ will affect your business

CE Opportunity to earn up to two CE credits by taking the online quiz.

CREDITS

Compliance Corner.............................. 40

AOPA News...............................................58 AOPA meetings, announcements, member benefits, and more

TARGET

TPE

PAC Update ............................................. 60

Program

PROBE

Welcome New Members ...................61 EDUCATION

P.18

Careers........................................................ 64

How Effective Is Your Plan?

Professional opportunities

Access metrics from OIG to evaluate your compliance plan

Calendar..................................................... 66

CE Opportunity to earn up to two CE credits CREDITS by taking the online quiz.

Upcoming meetings and events

Ad Index...................................................... 67

Member Spotlight................................. 54 n

American Prosthetic Components

Precision Orthotics & Prosthetics

Marketplace............................................. 62

Ask AOPA.................................................. 68 P.40

Deciphering the latest guidance on code A5513

O&P ALMANAC | OCTOBER 2017

VIEWS FROM AOPA LEADERSHIP

Investing In Government Relations

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

S IT WORTH YOUR time and money to invest in building relationships with elected officials? How do you gain access and start to create a relationship that someday, somehow, could benefit your business and the O&P industry? The first time I attended the AOPA Policy Forum, about eight years ago, I got a taste of what it is like to lobby on behalf of patients and O&P providers. With appointments made by AOPA staff, it was amazing to be “up on the Hill,” trying to meet with senators and members of Congress. It didn’t take long for me to skip past the words “on the” and realize getting face time with an elected official is an “up hill” challenge. Most often, lobbyists and constituents meet with a legislative aide. Through the years, I've come to realize it gets a lot easier to achieve actual face time with an elected official if you develop a relationship before you go to Washington. Attending local events where national and stateelected officials are speaking, and fundraisers for candidates, puts you into situations where you can develop relationships. Getting to know your city and county officials is a worthwhile Rick Riley and the California delegation at the 2015 Policy Forum investment, too. Some of these people have aspirations for higher office. In some communities, being a member of the Chamber of Commerce also gives you access to elected officials. I was fortunate to serve as the chair of the board for the Greater Bakersfield Chamber of Commerce, an organization with nearly 2,000 member businesses. Elected officials and candidates running for local, state, and national office recognize the benefits of being supported by their local Chamber and its business members. That’s how I first got to know Kevin McCarthy (R-California), California’s representative for the 23rd district, who now serves as the House majority leader. Kevin—who prefers that you call him Kevin, not Congressman McCarthy—would meet with the board's Executive Committee several times a year. I started to look for opportunities to say “hello” to him at local events, and several times we chatted while waiting for a flight at the airport. Eventually, I was able to get Kevin and his chief of staff, Vince Fong, to visit our company, Townsend Design, and tour the facility. It was an opportunity to introduce him to the O&P profession, our primary customers. When I first told AOPA Executive Director Thomas F. Fise, JD, that I thought I could get him face-to-face with Kevin during the Policy Forum, I don’t think he believed it was possible. Sure enough, Kevin met with us. And the next year, and the next year. Each time, we increased Kevin’s awareness of key issues and shared our perspectives about legislative bills that benefit patients and AOPA members. The reason we get 10 to 15 minutes of face time with Kevin is because of the local relationship. There is a core group of about 50 to 75 AOPA members who annually spend the time and money to make the trip to the AOPA Policy Forum. There are also firsttimers and others making a return visit. If you have never attended, you should. More members need to be actively engaging with government officials—and making annual donations to the AOPA PAC—to help continuously build awareness for our industry and the patients we serve.

Rick Riley is a member of AOPA’s Board of Directors.

OCTOBER 2017 | O&P ALMANAC

Board of Directors OFFICERS President Michael Oros, CPO, LPO, FAAOP Scheck and Siress O&P Inc., Oakbrook Terrace, IL President-Elect Jim Weber, MBA Prosthetic & Orthotic Care Inc., St. Louis, MO Vice President Chris Nolan, LPO Ottobock North America, Austin, TX Immediate Past President James Campbell, PhD, CO, FAAOP Hanger Clinic, Austin, TX Treasurer Jeff Collins, CPA Cascade Orthopedic Supply Inc., Chico, CA Executive Director/Secretary Thomas F. Fise, JD AOPA, Alexandria, VA DIRECTORS David A. Boone, PhD, MPH Orthocare Innovations LLC, Edmonds, WA Traci Dralle, CFm Fillauer Companies Inc., Chattanooga, TN Teri Kuffel, JD Arise Orthotics & Prosthetics Inc., Blaine, MN Pam Lupo, CO Wright & Filippis and Carolina Orthotics & Prosthetics Board of Directors, Royal Oak, MI Jeffrey Lutz, CPO Hanger Clinic, Lafayette, LA Dave McGill Össur Americas, Foothill Ranch, CA Rick Riley Townsend Design, Bakersfield, CA Brad Ruhl Ottobock, Austin, TX

An ENDORSED MEMBER of AOPA

Before you renew, get a quick quote at bit.ly/cailorﬂemingOandP

BE READY for any kind of WEATHER. WE’RE NOT HERE TO JUST PROTECT YOUR BUSINESS. We’re here to provide a

CO MPLE TE PLA N with our insurance program specifically designed for the orthotics and prosthetics industry. We understand the risks and offer comprehensive protection that allows your business to succeed, whether it’s a patient care facility, central fabrication, manufacturer, or distributor. Practitioners trust us most because we know your business and we know insurance unlike any other program..

toll free 800-796-8495 | www.CAILORFLEMING.COM/OANDP.ASP PROFESSIONAL LIABILITY

GENERAL LIABILITY

PROPERTY

AUTO

UMBRELLA

WORKERS COMP & MORE

AOPA CONTACTS

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 www.AOPAnet.org

Editorial Management Content Communicators LLC

Our Mission Statement The mission of the American Orthotic & Prosthetic Association is to work for favorable treatment of the O&P business in laws, regulation, and services; to help members improve their management and marketing skills; and to raise awareness and understanding of the industry and the association.

Our Core Objectives AOPA has three core objectives—Protect, Promote, and Provide. These core objectives establish the foundation of the strategic business plan. AOPA encourages members to participate with our efforts to ensure these objectives are met.

EXECUTIVE OFFICES

REIMBURSEMENT SERVICES

Thomas F. Fise, JD, executive director, 571/431-0802, tfise@AOPAnet.org

Joe McTernan, director of coding and reimbursement services, education, and programming, 571/431-0811, jmcternan@AOPAnet.org

Don DeBolt, chief operating officer, 571/431-0814, ddebolt@AOPAnet.org MEMBERSHIP & MEETINGS Tina Carlson, CMP, senior director of membership operations and meetings, 571/431-0808, tcarlson@AOPAnet.org Kelly O’Neill, CEM, manager of membership and meetings, 571/431-0852, koneill@AOPAnet.org Lauren Anderson, manager of communications, policy, and strategic initiatives, 571/431-0843, landerson@AOPAnet.org Betty Leppin, manager of member services and operations, 571/431-0810, bleppin@AOPAnet.org

Devon Bernard, assistant director of coding and reimbursement services, education, and programming, 571/431-0854, dbernard@AOPAnet.org SPECIAL PROJECTS Ashlie White, MA, manager of projects, 571/431-0812, awhite@AOPAnet.org Reimbursement/Coding: 571/431-0833, www.LCodeSearch.com

O&P ALMANAC Thomas F. Fise, JD, publisher, 571/431-0802, tfise@AOPAnet.org

Yelena Mazur, membership and meetings coordinator, 571/431-0876, ymazur@AOPAnet.org

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

Ryan Gleeson, meetings coordinator, 571/431-0876, rgleeson@AOPAnet.org

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

AOPA Bookstore: 571/431-0865

Bob Heiman, director of sales, 856/673-4000, bob.rhmedia@comcast.net Christine Umbrell, editorial/production associate and contributing writer, 703/6625828, cumbrell@contentcommunicators.com

OCTOBER 2017 | O&P ALMANAC

Publisher Thomas F. Fise, JD

Advertising Sales RH Media LLC Design & Production Marinoff Design LLC Printing Sheridan SUBSCRIBE O&P Almanac (ISSN: 1061-4621) is published monthly 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 landerson@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 © 2017 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 12,500 subscribers. Engage the profession today. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac17 for advertising options!

NUMBERS

How Are Your Sales Trending? Smaller O&P companies see greatest gains in net sales

O&P facilities with sales of less than $1 million saw an increase of more than 15 percent in net sales/ billings in 2016 versus 2015. AOPA’s 2017 Operating Performance Report, based on 2016 data, captured the financial facts from 88 companies representing 350 full-time facilities and 77 part-time facilities.

REVENUES FOR FY2016

PERCENTAGE INCREASE IN NET SALES/BILLINGS IN 2016 vs. 2015

NET PROFIT BEFORE TAXES AS A PERCENTAGE OF TOTAL ASSSETS

$547,238

$176,915

Median revenue generated per nonowner practitioner, up from $510,836 in FY2015.

Median revenue generated per employee, compared to $162,987 in FY2015.

Net Sales/Billing Increases Over Previous Year

18.6 Percent

15.2%

Average return on assets for all respondents.

3.5% Companies with less than $1 million in sales.

Companies with $1 to $2 million in sales.

6.3%

Companies with $2 to $5 million in sales.

4% Other job titles 3% Practitioner assistants/extenders 3% Owner practitioners 4% Nonclinical owners/managers

4.1%

67.2 Percent

39% Office

administration/ marketing staff

14% Technicians

Average return on assets for profit leaders—top 25 percent of respondents.

Companies with more than $5 million in sales.

33% Nonowner practitioners

O&P Facility Net Profit Margins

Company Size

FY2015

FY2016

Up to $1 Million

9.1%

8.5%

$1 to $2 Million

9.3%

8.5%

$2 to $5 Million

4.8%

7.6%

Over $5 Million

7.0%

6.0%

OCTOBER 2017 | O&P ALMANAC

EMPLOYEE MAKEUP

Editor’s Note: The 2017 Operating Performance Report is now available through the AOPA bookstore. Visit www.aopanet.org.

PLUS PLASTER MATERIAL for CASTING and SPLINTING Say goodbye

to gloves, masks and special ventilation. Choose an alternative solution free from isocyanates and fiber glass. Protect our nature and avoid exposure to environmental and health risks!

Happenings ADVOCACY IN ACTION

Senator Visits Minnesota Facility

RESEARCH ROUNDUP

Universities Develop Bionic Suit for Individuals With Spinal Cord Injury

Dave Lewis, CO, of Minnesota Prosthetics & Orthotics, meets with Sen. Amy Klobuchar (D-Minnesota).

OCTOBER 2017 | O&P ALMANAC

Cynthia Ramirez in a current-model exoskeleton. The National Science Foundation has awarded an $8 million federal research grant to three colleges to develop a fully implantable brain-machine interface device that could restore the ability to walk and restore sensation to the lower body, allowing paraplegic users to “feel” while they walk. The brain-machine interface will be designed to transmit commands to a robotic exoskeleton for walking, which will then transmit sensory information back to the brain. Researchers from the University of Southern California’s (USC’s) Keck School of Medicine, the University of California—Irvine, and the California Institute of Technology will work to decode signals generated by the brain that trigger walking. These signals will be decoded to control a wearable robotic exoskeleton, with miniature electronics

than can be implanted into patients. It is hoped that artificial sensation will be generated from the bionic suit so users can experience the feeling of walking. “The restoration of walking is a very significant goal for patients after spinal cord injury,” said Charles Liu, MD, PhD, principal investigator at the Keck School and professor of clinical neurological surgery and neurology and director of the USC Neurorestoration Center. “New solutions are possible with the recent advances in neuroprosthetics and regenerative medicine. We’re at the point where we can create solutions similar in concept to Tony Stark’s Iron Man suit, which is neurally integrated with him. Tony Stark’s brain interacts with the suit, and the suit interacts with his brain. Everything the suit feels, his brain feels. That’s the idea.”

PHOTO: Ricardo Carrasco III, Keck School of Medicine of USC

Sen. Amy Klobuchar (D-Minnesota) recently visited Minnesota Prosthetics & Orthotics in Edina, Minnesota, to speak with practitioners, patients, and students about the Wounded Warrior Workforce Enhancement Act. The legislation would give grants to educational institutions for establishing and expanding training programs in prosthetics and orthotics. Klobuchar spoke with several patients who also are veterans while at the facility. Roger Wagner, CPO, from Century College, also took part in the visit.

HAPPENINGS

Researchers Compare Sockets Made Using CAD/CAM Versus Carver Technology A team of researchers at Dicle University in Diyarbakır, Turkey, studied 72 patients with transtibial amputations who tested prosthetic sockets made using either CAD/CAM technology or traditional carver technology. The team members collected data on the participants postrehabilitation, and studied several factors, including pain scores, walking distance, duration of use, and pain-free walking time. The results indicated the individuals in the CAD/CAM group adapted significantly more quickly to their

prostheses, walked farther, reported less pain with ambulation, and tended to have better scores on the Trinity Amputation and Prosthesis Experiences Scale. “Our study demonstrated that the sockets manufactured by CAD/CAM methods yield better outcomes in quality of life of patients with transtibial amputation than the sockets manufactured by the traditional methods,” reported the authors of the study. Findings were published in the American Journal of Physical Medicine & Rehabilitation.

ASU Scientists Begin Developing Smart Ankle Three Arizona State University (ASU) scientists have been awarded a $1 million grant from the National Science Foundation to develop and test a smart robotic ankle that allows amputees to more easily navigate uneven surfaces. The goal is to improve upon current designs of powered ankle prostheses, which can be problematic on more compliant surfaces.

“We want to create a robotic ankle that is powered but can identify differences on the walking-surface compliance, and adapt so that it can transition between surfaces,” said Panagiotis Artemiadis, PhD, assistant professor of mechanical and aerospace engineering at the School for Engineering of Matter, Transport, and Energy at ASU. “It’s a project that will have an impact out of the lab.”

Journal Features AOPA-Funded Research on Partial Foot Amputation A new article based on the research of Michael Dillon, PhD, has been published in Archives of Physical Medicine and Michael Dillon, PhD Rehabilitation, and is available via open access. The article “While Mortality Rates Differ After Dysvascular Partial Foot and Transtibial Amputation, Should They Influence the Choice of Amputation Level?” is a result of Dillon’s

research, which was funded in 2015 when AOPA awarded a grant for a systematic review on partial foot amputation. Earlier this year, an article stemming from this research was published in Biomed Central as an open access article titled, “Outcomes of Dysvascular Partial Foot Amputation and How These Compare to Transtibial Amputation: A Systematic Review for the Development of Shared Decision-Making Resources.”

DIABETES DOWNLOAD

California Sees Rise in Diabetes-Related Amputations Lower-limb amputations in California increased by more than 31 percent between 2010 and 2016, according to data compiled by inewsource and documented by state hospital data. The state data indicate that amputations of toes, ankles, and feet all increased. There is no clear explanation as to the rise in amputations in California. The Centers for Disease Control and Prevention’s Eric Gregg has suggested the increase may partly be due to the aging population. Other contributing factors may include inadequate attention to diagnosing and managing the disease.

ICYMI

Updated CMS-1500 Form Required Effective Aug. 30, 2017, any paper claims submitted to Medicare must be submitted using the current CMS-1500 form, version 02/12. To verify if you are using the correct form, double-check the version number on the top of the claim form and in the lower right-hand corner. The version number should be 02/12. Paper claims not submitted using the CMS-1500 form version 02/12 will be returned and not processed.

O&P ALMANAC | OCTOBER 2017

HAPPENINGS

MEDIA MADNESS

Stronger Premieres Across the Nation

OCTOBER 2017 | O&P ALMANAC

Exoskeleton Integrated With Amazon Echo Technology

A lower-body exoskeleton made by Bionik Laboratories has been integrated with Amazon Echo capabilities. The exoskeleton, called the ARKE, is designed for individuals who have spinal cord injuries or stroke-related mobility issues. In traditional exoskeleton devices, sensors in the feet and joints register changes in weight distribution and make inferences to initiate movement. The new technology enables users to offer verbal commands to take steps or sit. The developers of the new technology “had one goal in mind—to empower the user to take back their mobility and regain the ability to complete tasks that the rest of us deem normal, like walking to the refrigerator or going to get the mail,” said Michal Prywata, co-founder and chief operating officer of Bionik Laboratories. Integrating the latest technology into the exoskeleton “pushes the boundaries of what technology can do within the home health-care industry.” CYBERSECURITY

Study Finds More Health-Care Providers Reporting Cyber Attacks Forty-seven percent of health-care providers and health plans reported instances of security-related violations to the Health Insurance Portability & Accountability Act (HIPAA) or cyber attacks that compromised data, according to a recent survey by KPMG. Only 37 percent of respondents to a similar survey two years ago reported such violations. Over the past 12 months, healthcare providers have experienced several types of attacks, including phishing emails that resulted in a compromise (36 percent), singlesystem-based malware introduced via human error (54 percent), external hacking of a vulnerability (70 percent), an internal bad actor (20 percent), and third-party device

product or service (26 percent). KPMG also found that focus on cybersecurity as an agenda item declined at health-care companies over the past two years, and a smaller majority of these companies made investments in information protection. “Health-care payors and providers are on treacherous ground here, and some organizations are underestimating cybersecurity risks,” said Dion Sheidy, KPMG healthcare advisory leader. “There needs to be a higher degree of vigilance among boards and executive suites as attacks become much more sophisticated, especially as doctors need to share information to improve quality and as connected medical devices and wearables proliferate.”

PHOTO: Bionik Laboratories

The movie Stronger, the true story of Boston Marathon bombing victim Jeff Bauman, was released in theaters last month. Adapted from the autobiographical book of the same name, the movie depicts Jake Gyllenhaal as Bauman. Bauman is a Costco employee who was on the sidelines of the marathon to cheer on his girlfriend, and ended up losing his lower legs in the explosion. His first-hand account of seeing the bomber and his backpack prior to the explosion led police to the perpetrators. The movie focuses on the pain of the event, as well as the joy and hope Bauman experiences as an amputee. During its premiere weekend Sept. 22-24, Stronger came in ninth at the box office, grossing more than $1.7 million.

O&P INNOVATION

HAPPENINGS

O&P ATHLETICS

QUALITY CONTROL

Amputee Completes Extreme Triathlon

Standards To Address Exoskeletons

PHOTO: Courtesy of M. Lahna

Mohamed (Mo) Lahna is the first amputee athlete to complete the Isklar Norseman Xtreme Triathlon.

Team Össur member Mohamed (Mo) Lahna has completed the Isklar Norseman Xtreme Triathlon, a grueling international triathlon competition. Lahna, who was born with proximal femoral focal deficiency, swam 3.8 kilometers in Norway, biked over five mountain passes through 180 kilometers of rugged terrain, and completed the course’s 42.2-kilometer run, including 1,700 vertical meters up “Zombie Hill,” through rocky, mountainous terrain, becoming the first amputee in the contest’s history to reach the finish line at the summit of Mount Gaustatoppen. Lahna’s competition time of 15:52:45 placed him 156th, ranking him among the elite finishers from an initial field of more than 3,600 applicants and 260 selected competitors who vied for spots in the competition.

Pending approval from its board of directors, ASTM International has announced the launch of a new committee focused on developing technical standards for exoskeletons and exosuits. A group of industry representatives, associations, government agencies, and other stakeholders convened at ASTM International’s global headquarters in September to form a new committee, draft a scope, and establish leadership roles. The group initially plans to focus on standards development in five technical areas: design and manufacturing; human factors and ergonomics; task performance and environmental considerations; maintenance and disposal; and security and information technology. The committee will host its first official meeting in the coming months.

Athletes Earn Track and Field Medals in London

PHOTO: Getty Images/Dmytro Aksonov

Össur has announced that members of Team Össur and the Össur Ambassadors collected 15 medals at the global track and field World Para Athletics Championships in London. Three Team Össur members were multiple medalists: • Richard Whitehead of Great Britain, Gold medalist in both the men’s 200-meter and men’s long jump in the T42 category, and Bronze medalist in the men’s T42 100-meter • Markus Rehm of Germany, Gold medalist in both the men’s T44 long jump and as a member of the Gold medal-winning men’s 4 x 100 relay T42-47 team • Daniel Wagner Jorgensen of Denmark, Gold medalist in the men’s T42 long jump and Silver medalist in the men’s T42 100-meter. Other medal recipients included Stef Reid of Great Britain (Gold medalist in the Women’s T44 long jump), Helgi Sveinsson of Iceland (Silver medalist in the men’s T44 in the javelin), Toru Suzuki of Japan (Bronze medalist in the high jump in the men’s T44 category), and Jean-Baptiste Alaize of France (Bronze medalist in the men’s T44 long jump). O&P ALMANAC | OCTOBER 2017

PEOPLE & PLACES PROFESSIONALS ANNOUNCEMENTS AND TRANSITIONS

Kristin Carnahan, CPO, FAAOP, has joined Northwestern University ProstheticsOrthotics Center (NUPOC) as an instructor in the Department of Physical Medicine and Rehabilitation. Carnahan, Kristin Carnahan, who has nearly a decade of experience as CPO, FAAOP an O&P clinician in private practice, will use her clinical and instructional skills to teach MPO students and guide their clinical practicum as they learn to evaluate, fit, and fabricate O&P devices. Stefania Fatone, PhD, BPO (Hons), has been promoted to professor of physical medicine and rehabilitation, Feinberg School of Medicine, Northwestern University. She is principal investigator for multiple research Stefania Fatone, and development projects at NUPOC, where PhD, BPO (Hons) she also contributes to the MPO program. Fatone is one of a small cadre of qualified prosthetists and orthotists with a doctorate. She has clinical and teaching experience in prosthetics and orthotics, as well as experience in clinical gait analysis. She has published more than 65 peer-reviewed articles, editorials, and book chapters and mentored more than 60 graduate students, postdoctoral fellows, residents, and junior faculty.

THE LIGHTER SIDE

JoAnne Kanas, corporate director of orthotics and prosthetics for Shriners Hospitals for Children in Tampa, Florida, has been selected as the winner of the Orthotic Prosthetic Group of America’s (OPGA’s) inaugural O&P Woman of the Year Award. The award was presented Ryan Ball and JoAnne Kanas to Kanas at a ceremony held during OPGA’s member and supplier reception at the AOPA World Congress. Kanas was one of four finalists selected to travel to Las Vegas to attend the World Congress conference and OPGA’s award ceremony. The O&P Woman of the Year Award was open to all women who work in the O&P industry. A selection committee of five industry professionals reviewed the nominations and based their selection by considering the nominees’ contributions throughout their careers to patients, community, and the profession. Kanas has been in the O&P profession for more than 25 years. In addition to her role at Shriners, she serves on the board of directors of the American Academy of Orthotists and Prosthetists and on the board of OPAF, and she has presented at many state and national meetings and guest lectured for O&P and physical therapy programs. Kelly Millard has been promoted to the position of national sales manager at Allard USA. Millard will guide Kelly Millard Josh Baggett Mike Myslinski the company’s national sales team in continued education and promotion of Allard’s rehabilitation products. Josh Baggett will assume Millard’s previous position as Texas, Western Plains, district manager. In addition, Mike Myslinski has joined Allard as the company’s mid-Atlantic district manager. He will be responsible for the continued education and promotion of the Allard rehabilitation products to O&P partners within the mid-Atlantic district.

Steven Shade, BOCO

Don’t Get Caught in Dangerous Waters!

AOPA’s Health-Care Compliance & Ethics Week November 5-11, 2017 Visit bit.ly/aopaethics for more details. 14

OCTOBER 2017 | O&P ALMANAC

Steven Shade, BOCO, has joined Becker Orthopedic Patient Care at its Henry Ford Hospital location in Detroit, Michigan. Formerly employed with Nascott O&P/Hanger Clinic in Baltimore, Maryland, Shade has seven years of clinical experience as a certified orthotist.

The Perfect Pair Control your volume fluctuation with ALPS ENCP or ALPS Socks

www.easyliner.com | info@easyliner.com

PEOPLE & PLACES PROFESSIONALS IN MEMORIAM

ANNOUNCEMENTS AND TRANSITIONS

Vivian Smith

Ability Prosthetics & Orthotics has been named one of the Best Places To Work in Pennsylvania for 2017. Companies were evaluated on workplace policies, practices, philosophies, and systems, as well as an employee survey to measure the employee experience. “This is so exciting for our company, our staff, and our patients to know that we are among the best of the best in Pennsylvania,” said Jeffrey Brandt, CPO, founder and chief executive officer of Ability.

Vivian Smith (May 5, 1940-July 31, 2017) and her husband, Richard Smith, founded Oakland Orthopedic in 1971. She owned and operated Oakland Orthopedic until her death. She is survived by her husband, Vivian Smith Richard; her children, Debbie Williams, Timothy Smith, Roxane (Chuck) Hahn, Wonda (Jamey) Weirauch, Larry (Jodi) Smith, and Corey (Lesley) Smith; 17 grandchildren; 16 great-grandchildren; and siblings Marvin (Suzie) Yenglin, Doris (John) Seeley, and Neil Yenglin. Vivian's perseverance, dedication, and kindness were the keys to success in her personal life and in her role as co-owner of Oakland Orthopedic Appliances. She had strong faith in God, her husband, and her family. Like many successful entrepreneurs, she had no experience in growing a business. Through the course of 46 years as co-owner of Oakland Orthopedic Appliances, she grew her business into seven locations and 32 employees, now serving mid-Michigan and the thumb area of Michigan. Her passion and enthusiasm for the O&P industry showed every day in the office. She felt her employees were her biggest asset, and she cared about them both professionally and personally. She encouraged their education and maintained an opendoor policy to her office. She felt communication and listening are the keys to any successful relationship. Vivian felt that you rise by helping others. She supported several local charities, including the Bay Area Women’s Center, Good Samaritan, Covenant Kids, and Nathan Weidner Foundation. She was a member of St. Peter’s Lutheran Church. Vivian also owned an alpaca farm with her husband. She enjoyed spending time with her children, grandchildren, and great-grandchildren on the farm. She believed you had to have a balance between work and family, and she achieved this balance very well. Her leadership made others better as a result of her presence. Her absence will mark a lasting impression to the family she loved, the employees she led, the people she helped, and the company she co-founded.

BUSINESSES

OCTOBER 2017 | O&P ALMANAC

Hanger Inc. has given $10,000 to the American Red Cross to assist with Hurricane Harvey disaster relief efforts, and has donated $10,000 to assist those impacted by Hurricane Irma. Hanger also is encouraging others to donate by using its Red Cross microsite, and will match additional donations up to $10,000 through October 31. Össur has named Alexander Schwartz as the 2017 winner of its #MyWinningMoment online contest. Schwartz, a bilateral amputee who was born with fibular hemimelia, credits his job working on a TV show as helping him share his story and connect with others. Schwartz says that receiving his Cheetah running blades made the singular difference in his physical mobility as well as in his perspective on life. As the winner of this year’s contest, Schwartz and his guest will enjoy a four-day, three-night trip to Reykjavik, Iceland. Otto Bock HealthCare GmbH has acquired Freedom Innovations from its previous owner, private equity company Health Evolution Partners (HEP). Ottobock took over the company and all of its locations and employees on September 22, and the Freedom Innovations brand will continue to be used. “Together, Ottobock and Freedom Innovations will benefit from their combined sales power and portfolios. Integrating the company into the global Ottobock family offers significant advantages; we will be able to generate synergies and take Freedom Innovations to the next level thanks to the strength of our global sales network,” said Prof. Hans Georg Näder, president of Otto Bock HealthCare GmbH. “Users will benefit from an even broader spectrum of innovative systems in prosthetics and a full pipeline of new products, thanks to our combined development expertise.” “Ottobock is the ideal partner for us,” said Maynard C. Carkhuff, newly appointed chairman of Freedom Innovations. “No other company can offer users and employees anything comparable. We’re excited to be sharing our journey with Ottobock in the future.” Dave Reissfelder, who has headed the Ottobock subsidiary BionX in Boston to date, has been appointed as the new chief executive officer.

Edema control Adjustable sockets Corrects extension alignment FLO-TECH-TOR™ & UFOS™ Prep System Immediate post-op fitting and early weight bearing.

Aids against distal end breakdown Better anatomical shaping Access for wound care

VSCPS™ & UFOS™ Rehab System Early ambulation, when full knee movement is desired.

Distal pad set included with each system

FLO-TECH® Orthotic & Prosthetic Systems, Inc. P.O. Box 462 7325 Halseyville Road Trumansburg, NY 14886

Online: www.1800flo-tech.com Phone: 1-800-FLO-TECH (356-8324)

Hours: 8:30AM to 5:00PM EST

REIMBURSEMENT PAGE

By JOSEPH MCTERNAN

E! QU IZ M EARN

BUSINESS CE

CREDITS P.19

The Medicare Audit Process What ‘Target, Probe, and Educate’ means for your business

Editor’s Note—Readers of CREDITS Reimbursement Page are eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 19 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

TARGET

TPE

Program PROBE

N AUGUST 2017, CMS announced a major shift in audit strategy that would initially be utilized by a select number of Medicare administrative contractors (MACs), then eventually implemented across all MAC contractors. This initiative, titled, “Target, Probe, and Educate (TPE),” will have a significant impact on the volume of Medicare audits that providers will be exposed to, and it may have a significant impact on your business. To date, the TPE program has been implemented in two of the four durable medical equipment Medicare administrative contractor (DME MAC) jurisdictions, specifically Jurisdiction B and Jurisdiction D, but CMS has announced its intention to implement the program nationwide later this year. While the program may result in more frequent audits for certain providers, the overall number of Medicare prepayment reviews should be reduced significantly as contractors will focus their efforts on high-risk claims and providers.

EDUCATION

Traditional Medicare Prepayment Review

For years, Medicare contractors have followed a specific pathway when performing a prepayment claim review. They identify an area of risk, whether it be a product category, a particular health-care common procedure coding system (HCPCS) code or series of HCPCS codes, or a particular provider or provider type. They then initiate a limited, random, prepayment review, often called a “probe” review. Requests for additional documentation are sent to the providers subject to the probe review, 18

OCTOBER 2017 | O&P ALMANAC

and a prepayment audit takes place. Upon completion of the audit, if the results of the probe review show an unacceptable error rate, the Medicare contractor expands the probe review into a widespread medical review involving a much larger set of claims and providers. While this strategy has been effective, it often leads to an endless cycle of audits and has been criticized as overly aggressive and unfair. The term “throwing the baby out with the bathwater” has been used to describe the traditional prepayment review process.

How Is the TPE Program Different?

The primary difference between the traditional probe review/widespread review model and the TPE program is that the TPE program is much more focused, not only in identifying a much smaller pool of claims for review, but also in providing education for providers who do not pass the audit process in an effort to improve their compliance with Medicare policy requirements and regulations. The TPE program consists of three rounds of prepayment review. Each round involves 20-40 claims that have been identified for review through detailed statistical analysis that identifies specific areas of risk for the particular MAC contract area. Additional documentation requests are sent for each of these claims, and a standard prepayment review is performed. If the results of the first round of prepayment review are deemed acceptable or compliant, the provider receives a notice from the DME MAC that it will be removed from the audit pool for a period of one year. If, on the other hand,

REIMBURSEMENT PAGE

When Will the Program Be Implemented?

The TPE program was implemented in the Jurisdiction B and Jurisdiction D DME MACs as of July 2017. Jurisdictions B and D were included in a limited expansion of the TPE program to a total of four MAC contractors throughout the country. What this means is that Jurisdictions B and D have replaced their previous processes for prepayment review with the TPE program. CMS has announced that it intends to roll out the TPE program to all MAC contractors in the near future, as early as the end of 2017. Once implemented, MACs will no longer use traditional prepayment review methods; they will only utilize the TPE model for prepayment reviews.

PHOTO: Getty Images/Thomas Northcut

the results of the prepayment review are not acceptable, the provider is scheduled for a personalized education session with the MAC claims review department, where common errors and strategies to improve compliance are discussed. After the personalized education process is complete, a second round of prepayment review takes place, again consisting of 20-40 claims. If, after a second round of targeted review and education is complete, the prepayment review results are still not acceptable, a third round may take place. During each round of prepayment review, providers have the opportunity to be removed from the audit pool if their results are considered acceptable. The goal of the TPE program, as stated by CMS, is not to identify claim errors and punish providers but rather to assist providers in achieving better compliance when submitting claims to Medicare. While it is too early to measure the impact that the shift in Medicare audit philosophy will have on the overall number of claims subject to prepayment review, it appears that the TPE program will result in a smaller number of overall prepayment reviews but a higher level of scrutiny for claims selected for review through the new program.

What Does the TPE Program Not Do?

In general, the TPE program appears to be a positive development for Medicare providers, but it only replaces the MAC process for prepayment review. The implementation of the TPE program does not impact other contractor-based audits such as those performed by comprehensive error rate testing (CERT) contractors, recovery audit contractors, and zone program integrity contractors (ZPICs). These contractors will continue to perform the audits they have been using their in current processes. In fact, providers who do not reach an acceptable level of compliance after three rounds of claim review and education may be referred to other audit contractors such as the ZPIC for additional review and/or investigation.

How Will the Program Impact O&P Providers?

Unfortunately, the TPE program is relatively new so its specific impact on O&P providers remains to be seen. In general, O&P providers, like all providers, should see a significant reduction in the overall number of claims that are subject to prepayment review. This does not mean that compliance efforts should be reduced or ignored. The DME MACs and the pricing, data

analysis, and coding contractor are constantly performing data analysis that identifies trends in utilization as well as claim error rates. CERT contractors will remain active during the TPE program and will identify areas of risk where the DME MACs should focus their targeted audit activity.

The goal of the TPE program, as stated by CMS, is not to identify claim errors and punish providers but rather to assist providers in achieving better compliance when submitting claims to Medicare.

If anything, proper compliance is more important now than it ever has been. The ultimate goal is to avoid TPE reviews entirely through proper claim submission and compliant documentation practices. The TPE program appears to be a positive development in creating a reasonable and efficient Medicare audit process. AOPA will monitor the program carefully as it is expanded nationwide and will continue to provide guidance to its members on appropriate strategies for success. Joseph McTernan is director of reimbursement services at AOPA. Reach him at jmcternan@AOPAnet.org. 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:

www.bocusa.org

O&P ALMANAC | OCTOBER 2017

This Just In

New Studies Document O&P Value Proposition Recently released reports by the RAND Corp. and Dobson-DaVanzo take a deep dive into efficacy

HE BIG NEWS AT the recent

AOPA 2nd World Congress and Centennial Celebration was the presentation and release of the RAND Corp.’s “Economic Value of Advanced Transfemoral Prosthetics” research report and Dobson-DaVanzo’s updated “Medicare Services” data report. The 10-year value simulation RAND report, which was conducted by the RAND Corp. and commissioned by AOPA through the Prosthetics 2020 Project, analyzed the impact of drug and other medical costs plus earnings, related health risks (such as falls and osteoarthritis), and other

elements demonstrating the value of increased mobility experienced by amputees. To assist in building its simulation model, in addition to its own research efforts RAND drew on a comprehensive search of all available medical literature relating to advanced prosthetics, as well as the data developed through Dobson-DaVanzo’s cost-effectiveness research using Medicare’s own services data from 2011 to 2014, which also was presented in Las Vegas. This month’s This Just In offers a brief summary of the results of the RAND and Dobson-DaVanzo research.

RAND Report on Advanced Prostheses

Soeren Mattke, MD 20

OCTOBER 2017 | O&P ALMANAC

Soeren Mattke, MD, senior scientist at the RAND Corp., presented the company’s research and findings at the Sept. 8 General Session during the World Congress at the Mandalay Bay Resort and Casino in Las Vegas. Mattke also is a professor at the Pardee RAND Graduate School and managing director of RAND Health Advisory Services. “It is estimated that about 1.9 million individuals in the United States are living with the loss of a

limb. Of that number, 18.5 percent are transfemoral amputees. Due to recent advances in technology, prosthetic knees and feet allow for more dynamic movements and improved quality of life, but payors have recently started questioning their value for money. To answer this question, we developed a simulation model to assess the differential clinical outcomes and costs of microprocessor-controlled knees (MPKs) compared with non-MPKs (NMPKs),” Mattke told attendees. “We conducted a literature review of the clinical and economic impacts of prosthetic knees, convened technical expert panel meetings, compiled the input parameters required, and constructed and implemented a simulation model over a 10-year time period for unilateral transfemoral amputees with Medicare functional classification levels of 3 and 4. The results are summarized as an incremental cost-effectiveness ratio (ICER) from a societal perspective, i.e., the incremental cost of MPKs compared with NMPKs for each quality-adjusted life year gained.” All costs were adjusted to 2016 U.S. dollars and discounted using a 3 percent rate to the present time.

This Just In

A further report on transtibial “We found that compared with amputee value proposition report is NMPKs, MPKs are associated with near completion. substantial improvement in physical In announcing the function and reductions in inciselection of RAND Corp. dences of falls and osteoarthritis,” in April 2016 to conduct said Mattke. “The effect on low-back the research, AOPA pain, depression, obesity, diabetes, and said, “Recognizing that cardiovascular disease could not be CMS has stated its commitment to a quantified due to the lack of data.” shift to ‘value-based purchasing,’ we Mattke reported that RAND’s simubelieve that this report may well be lation results showed the following landmark, first and foremost in using results when comparing MPKs with modeling and simulation to help define NMPKs over a 10-year time period: the economic value proposition for • For every 10,000 people, MPKs prosthetic care prospectively and in result in 82 fewer major injurious the broadest terms (going beyond falls and 62 fewer minor injurious the dramatic conclusions previously falls, and save 11 lives. established via the retrospective, • For every 10,000 people, MPKs Medicare-dollars-expended view of result in 1,630 fewer incidences of the Dobson-DaVanzo work, to also osteoarthritis. embrace implications as to employ• On a per-person-per-year basis, MPKs reduce direct health-care ment, and reduction or elimination costs by $3,676 and indirect costs by of patient reliance on social/safety $909, but increase device acquisinet programs), and potentially even pointing toward possible new reimtion and repair costs by $6,287 and total costs by $1,702. bursement approaches, pilot and • On a per-person basis, MPKs are demonstration-type projects that could associated with an incremental be pursued for O&P through the CMS total cost of $10,604. Innovation Office.” • On a per-person basis, MPKs increase the number of Expanded Findings life years by 0.11 and From Dobson-DaVanzo quality-adjusted life The latest results of the expanded Dobsonyears by 0.91. DaVanzo study were pre• MPKs have an ICER of $11,606 per quality-adsented by Allen Dobson, PhD, with discussant justed life year. commentary by AOPA • The economic benefits of President Michael Oros, MPKs are robust in various CPO, FAAOP, and AOPA sensitivity analyses. Board Member Jeffrey “Our study demonstrates Allen Dobson, PhD that advanced prosthetics for transfemoral amputees, specifically MPKs, are associated with improved clinical benefits compared with conventional prosthetic knees. Translated into economic benefits, MPKs are associated with reductions in direct health-care costs and indirect costs, and provide good value for the money using the standard criterion of $50,000 per quality-adjusted life year gained. The economic benefits of MPKs are similar to or even greater than those of other medical technologies currently reimbursed by U.S. payors.”

Lutz, CPO, at the Sept. 9 General Session. Their findings, summarized below, are further documentation of the value of O&P services. Lower-Extremity Orthoses (18-Month Episode): As compared to their nontreated counterparts, study group patients who receive lower-extremity orthoses had: • Fewer falls and fractures • Fewer emergency room admissions • Fewer inpatient admissions with shorter lengths of stay • Higher home-based care

• Lower mortality rate • Lower Part D drug spending • More rehabilitation. Medicare 18-month episode payments were $1,939 (or 8 percent) less than the comparison group. Spinal Orthoses (18-Month Episode): As compared to their nontreated counterparts, study group patients who receive spinal orthoses had: • The same prevalence of fractures and falls • Fewer emergency room admissions • Fewer inpatient admissions with shorter lengths of stay • Higher home-based care • Lower mortality rate • Lower Part D drug spending • More rehabilitation. Study group patients who received spinal orthoses had 18-month Medicare episode payments that were $2,094 (or 8 percent) lower than comparison group patients. Lower-Extremity Prostheses (15-Month Episode): As compared to their nontreated counterparts, study group patients who receive lowerextremity prostheses experienced: • Fewer inpatient admissions with shorter lengths of stay • Generally lower facility-based care • Higher home-based care • Similar rates of fractures and falls (perhaps due to increased mobility) • Similar number of emergency room admissions • Nominally lower Part D drug spending • More rehabilitation. Study and comparison group patients had similar total Medicare payments over a 15-month episode. The cost of the device was fully amortized by the end of 15 months. The comparison groups were demographically matched amputee patients similar to study group patients by diagnosis, age, and general health who did not receive O&P care. Access to both of these important research projects documenting the value of O&P services is available at http://bit.ly/randstudy. O&P ALMANAC | OCTOBER 2017

COVER STORY

A MORE MINDSET O&P professionals are adapting to the latest materials and fabrication processes to better accommodate patients By CHRISTINE UMBRELL

OCTOBER 2017 | O&P ALMANAC

COVER STORY

NEED TO KNOW • O&P materials have not changed significantly over the past few years, but advances in materials fabrication and manufacturing techniques have led to new designs and advanced componentry, resulting in more durable and flexible devices.

• Advances in 3-D printing increase the flexibility in material selection for inclusion in definitive devices, but experts say devices currently being made using this technology are not as durable as needed for most O&P patients.

• On the orthotics side, silicone is being used more frequently for ankle-foot orthoses, and very thin polypropylene is being used for total contact inner boots for lower-extremity orthoses.

• In the future, more biofriendly habits may emerge as the O&P community looks to identify material resources that are better for the environment, both from fabrication and waste standpoints.

• The prosthetics sector also has seen advancements in the use of silicone, as well as increased use of braided carbon tubing, which improves the ease of fabrication and consistency of wall thickness of socket walls. In addition, fiberglass is seeing new applications.

ECIDING WHICH DEVICES TO

fit on patients, and which materials to use to build those devices, are perhaps the most critical decisions when treating orthotic and prosthetic patients. Clinicians who want to ensure their patients are fit with the most appropriate solution must keep up not only with advances in technology but also with trends in materials and fabrication.

Matthew Major, PhD

Over the past 10 years, materials themselves have not changed dramatically, but tremendous advancement in materials fabrication and prosthetic manufacturing techniques has made it easier and more accessible to use certain materials, according to Michael Cavanaugh, CPO, and Matthew Major, PhD, who work in the Department of

Physical Medicine and Rehabilitation at Northwestern University’s Feinberg School of Medicine and ProstheticOrthotic Center. “Overall, these new methods provide us with greater flexibility in the types of materials we can incorporate into definitive devices,” says Major. Rachael Lavigne, MS, CPO, says that O&P has seen “an influx of attention over the past 10 years, due in part to the exponential increase in limb loss caused by diabetic manifestations.” Lavigne, a clinician with Hanger Clinic, also points to the advent of social media platforms, which have made it easier for people with limb loss or limb difference to share their stories globally, connect with one another, and develop online support networks. This attention, combined with interest in 3-D printing and other industries looking into more biomaterial usage, is positively influencing and improving the materials available to help meet patients’ needs. “The reality is, our industry is not very large, and we do rely on crossover industry

Rachael Lavigne, MS, CPO

development and media coverage to spur more interest for the R&D in our field specifically. “Overall, more materials are being introduced every day to help with the durability and flexibility of the devices we provide. Materials can make or break a device’s ability to suspend well, protect the limb adequately, and therefore allow someone to function optimally,” explains Lavigne. “I think we are learning in this field the careful balance of keeping devices easy to use and maintain, while also layering different types of materials in conjunction with new technologies to provide the most customized solutions for our patients’ needs.” Duffy Felmlee, MSPO, CPO, points to the example of thermoplastic sheet materials in O&P. While there have not been many changes from an end-user standpoint over the past few years, the consistency of manufacturer production of the stock sheet O&P ALMANAC | OCTOBER 2017

COVER STORY

Bringing Composites IN-HOUSE

OCTOBER 2017 | O&P ALMANAC

Trends in Orthotics

While no “transformational changes” in the use of materials for building orthotic devices have occurred, the practice of implementing different materials has become more common, say Major and Cavanaugh. Silicone is one example of a material that is making an impact in the orthotics side of the business. Felmlee identifies the silicone ankle-foot orthosis (AFO) as a more recent innovative and functional use of a material. “The ability to adjust specific areas to achieve a certain stiffness allows the clinician to tune a total contact orthosis,” he says. “Certain patients prefer the flexibility, thermal insulation, and profile of the silicone AFOs.” More silicone being used in a variety of durometers and applications, from custom sockets for both upper- and lower-extremity prosthetic devices, to custom AFO interfaces, according to Lavigne. “The standard use of silicone over the past 20 years continues to expand for prefabricated liners and orthotic skin protection/ suspension applications.” She also believes the science behind how the orientation of carbon layers affects the properties of AFOs “is being better explored by our prefabricated AFO manufacturers, which is going to improve both the integrity and function of the devices.”

PHOTOS: Reach Orthotic and Prosthetic Services

One of the most significant additions to the O&P materials mix over the years has been the introduction of prepreg composites—materials in which a reinforcement fiber is preimpregnated with a thermoplastic or thermoset resin matrix in a certain ratio. These materials are cured under high temperatures and pressures, and are generally known to be lightweight yet strong. Prepreg generally comes in sheets or rolls, and is now commonly used in both prostheses and orthoses. At Reach Orthotic and Prosthetic Services, headquartered in Newport News, Virginia, approximately 80 percent John Robb, CPO of lower-extremity orthoses are made of composite material. John Robb, CPO, owner of the facility, says the material offers several benefits to patients: “Composite materials are significantly more responsive for the patient, and we can allow motion in all three planes. We can create different directions in the fibers and composites.” Prepreg composites have become so essential to the work at Reach that the company—which has four patient-care clinics plus a fabrication facility that does work for all four clinics—has started manufacturing its own materials in-house. “A couple of years ago, we started using c-fab composite materials on the bracing side,” says Robb. “But now, we’ve made the investment to bring it in-house. We manufacture our own prepreg composites now.” Robb explains that the transition to bring all composite manufacturing in-house was a bit complicated, but worth the effort. “There is a learning curve to learn how to use [prepreg composites], and it can be a financial investment,” he says. “In order to bring it in-house, we did some significant training,” Robb explains. His team consulted with materials experts both inside and outside the O&P industry. “We also assigned one technician the responsibility of leading the initiative,” and he worked closely with one of the Reach clinicians to oversee the transition. “It took three to six months to really get it figured out and start doing it in-house,” Robb says. Now that the transition is complete, “we have more control over shapes, rigidities, and designs,” notes Robb. “We’ve had more success since bringing it in-house.”

material has improved, says Felmlee, who is assistant professor at the University of Hartford’s Department of Rehabilitation Services and chair of the Fabrication Sciences Society for the American Academy of Orthotists and Prosthetists. He notes that thermosetting (lamination) materials also have improved in machinability, and notes advances in the materials’ properties in terms of strength, stiffness, and durability. In general, the willingness of O&P professionals to think creatively about both the materials used for O&P and the fabrication processes themselves has led to several advances in O&P componentry and more flexible solutions to patients’ needs.

COVER STORY

Felmlee says that the use of very thin polypropylene for total contact inner boots for lower-extremity orthoses is an important trend to watch. “This isn’t exactly a material change, but more on the process management that manufacturers are becoming more aware of. Consistent sheet material quality and replicable fabrication techniques allow the utilization of a material in a greater variety of applications to improve patients’ proprioception and pressure distribution within an orthosis,” he says. He also contends that ProComp polypropylene composite—an “excited material” designed for the O&P profession—is becoming more commonly used. “Allowing for increased structural integrity for lower-extremity orthotics without an increase in material thickness is advantageous for the patient and clinician,” he says.

Duffy Felmlee, MSPO, CPO

PHOTO: Reach Orthotic and Prosthetic Services

One result of newer materials and innovative usages is improved flexibility in orthoses. Manufacturers are offering a variety of polymer blends that have more flexible characteristics, says Lavigne. She states that O&P professionals have been gaining a better understanding of how to utilize different layers of materials and bond more flexible polymer blends with rigid layers and foams. Flexible thermoplastics being used for AFO applications also may allow more patients to benefit from orthotic management, explains Lavigne. These constitute “another option for our patients to explore whether an AFO is the right solution for them,” she says, particularly for those patients who do not tolerate traditional rigid thermoform or thermoset devices. “Combining the flexible thermoplastics with the rigid support of other materials seems to be an excellent approach to AFO care,” she says. “We have also

A technician at Reach Orthotic and Prosthetic Services works with prepreg composites at the company's fabrication facility. seen excellent success in our area with AFO devices made from fully flexible materials, but oriented with features to create appropriate points of rigidity.”

Progress in Prosthetics

Like orthoses, prostheses have not seen any considerable developments in material design. However, advancements in fabrication and manufacturing techniques have led to quicker and less expensive production, allowing for increased flexibility in the selection of materials, according to Major and Cavanaugh. “We still tend to use composites, such as fiberglass and carbon fiber, as well as typical metal alloys, due to their high strength-to-weight ratio,” says Major. Just as silicone is being embraced for orthotics fabrication, Lavigne believes it is opening windows of opportunity in the prosthetics realm as well. “Silicone advancements are still coming as our manufacturers further explore different blends and durometers for a variety of applications within our field,” she says. “I look forward to

continuing to try to incorporate this material in both upper- and lowerextremity prosthetics, as well as AFOs.” In addition, the braiding of carbon fiber has allowed for improved multidirectional force distribution once fabrication is complete, says Felmlee. “Braided carbon tubing also improves the ease of fabrication and consistency of wall thickness of the socket walls.” Felmlee and Lavigne both note some new approaches related to fiberglass, which has been used within the profession for more than 20 years. But now, it is “being utilized in a very popular prosthetic foot,” says Felmlee. “Application of fiberglass allows for dynamic loading without the certain types of fatigue that is seen with carbon feet.” Lavigne also praises fiberglass as a new energy-storing material for prosthetic feet. “We all know and have seen how carbon fiber has improved our patients’ outcomes, and I hope that fiberglass feet are just the start of looking at other materials or combinations of materials to help restore our patients’ mobility.” O&P ALMANAC | OCTOBER 2017

COVER STORY

The Influence of 3-D Printing

SAFETY FIRST

When choosing which materials to use, it’s important to ensure safe fabrication practices are being followed at O&P facilities. “I think we are all aware of the potential hazards that the dust we create in our environments can pose,” says Rachael Lavigne, MS, CPO, a clinician with Hanger Clinic. “As we use a wider variety of materials, we should be more conscious that we could be potentially introducing new hazards. We need to continue using good practices in our own personal protection, and stay abreast of the studies OSHA [Occupational Safety and Health Administration] supports and what their findings recommend for our protection.” To ensure everyone involved in O&P fabrication and patient fitting is aware of safety issues, each manufacturer should be filing a Material Safety Data Sheet or similar standards for products that will be utilized in fabrication, says Duffy Felmlee, MSPO, CPO, assistant professor at the University of Hartford’s Department of Rehabilitation Services. “Clinicians and technicians should be aware of manufacturers’ recommendations for fire safety, personal protective equipment (PPE), and short- and longterm health considerations.” Clinicians and technicians should be mindful of how dust from grinding thermoplastics, foams, and thermosets can collect within the lungs, he says.

OCTOBER 2017 | O&P ALMANAC

One area where O&P professionals should be particularly careful is in the handling of isocyanates, which are compounds that react with other alcohol-containing compounds that are used to produce polyurethane polymers. Isocyanates are often used in synthetic fiberglass casting tapes and as a catalyst in foams and paints, but they pose a risk to clinicians, technicians, and patients if not handled properly, says Carlo A. Luetto, who is in charge of business development for the Americas for Allard USA. Isocyanates are powerful irritants and can sensitize workers, making them subject to severe asthma attacks and symptoms such as wheezing, tightness in the chest, and shortness of breath, explains Luetto, who spoke on this topic at AOPA's World Congress in September. He says O&P professionals may be exposed during casting because isocyanate quickly turns resin from liquid to solid. “Upon opening a casting tape pouch, the vapor inside the pouch is released into the work environment as isocyanate vapor,” he says. “Prolonged exposure over months or years may cause sensitization in the form of localized mild allergic reactions or occupational asthma.” To protect against isocyanate exposure, Luetto recommends monitoring exposure levels in the air and maintaining levels in compliance with OSHA (i.e., 0.02 PPM), managing the risk of sensitization by reducing contact, wearing protective clothing and respiratory protection, and undergoing protective training. He also suggests checking for state-specific guidelines, and, when possible, selecting materials that are isocyanate-free.

Some O&P professionals are exploring how advances in 3-D printing can offer new solutions. Major and Cavanaugh note that it is now possible to produce 3-D printed components quicker and for lower cost, making them more accessible. The ability to print in metal and multiple materials within a single part also may lead to new opportunities. “These changes will, of course, increase the flexibility in material selection for inclusion in definitive devices,” says Major. “However … there are many features inherent to the printing process that will affect the structural integrity and durability of the printed components that need to be considered by practitioners when implementing 3-D-printed components.” Concerning current thermoplastic printing, for example, structural integrity can be affected not only by the selected material but also by printing orientation, layer height, and infill density, as well as inclusion of color pigments. “Even if two components are printed from the same material, their definitive mechanical properties in one or more directions may differ due to the process by which they were printed,” explains Major. Lavigne believes advances in 3-D printing will provide a streamlined approach to combining materials and layering of materials more effectively—but for now, devices made using this technology are not as durable as needed for O&P patients. “Clinicians may have seen articles showing that this technology is proving to be useful in applications requiring tight timeframes and low-cost options, especially for upper-extremity patients,” she says. “However, materials being used thus far are not as robust. The claims at this time are that since the current 3-D-printed options are so low-cost, it is OK to simply make another when a device wears out, but I do not think that is an appropriate long-term solution to offer our patients. I think it will take time before we see materials being printed that have comparable integrity to what we currently use in our field.”

COVER STORY

Changes on the Horizon

PHOTO: Getty Images/demaerre

As we look to the future, fabrication techniques are likely to advance, allowing more materials to become accessible for integration into O&P devices. Major and Cavanaugh predict that novel materials with improved properties will be embraced, as will new ways to incorporate those materials into O&P fabrication and manufacturing.

In addition, new trends will emerge as studies are undertaken regarding the efficacy of devices of different compositions. “We are beginning to witness an increase in research studying the effects of these devices on user outcomes,” Major says. Lavigne believes that 3-D printing may play a bigger role in O&P, “both for positive mold generation and final device fabrication,” she says.

Ferrier Coupler Options!

“Materials used for positive models I think will continue to expand as we use more digital tools to help streamline our care and create a better experience for those we care for. I also think molding materials for traditional casts are evolving, as I have seen early stages of working with sand molds.” Lavigne also hopes to see some more biofriendly habits emerge. “In the near future, our field will need to find other material resources that are better for our environment, from both fabrication and waste standpoints. Use of biomaterials will hopefully advance and become cost-effective.” She expects the industry to look for additional ways to reduce waste. “Hopefully, we can adopt technologies that are cost-effective and can reduce this negative in our material usage in O&P,” she says. Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com.

Interchange or Disconnect

The Ferrier Coupler provides you with options never before possible:

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

Model A5

Model F5

Model P5

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

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

Model FA5

Model FF5

Model FP5

NEW! The FA5 coupler with 4-bolt and female pyramid is for use in all lower limb prostheses. Male portion of coupler is standard 4-bolt pattern. Female portion of coupler accepts a pyramid.

Model T5

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

NEW! The FP5 Coupler is for use in all lower limb prostheses. Male portion of coupler has a pyramid. The Female portion of coupler accepts a pyramid.

The Trowbridge Terra-Round foot mounts directly inside a standard 30mm pylon. The center stem exes in any direction allowing the unit to conform to uneven terrain. It is also useful in the lab when tting the prototype limb. The unit is waterproof and has a traction base pad.

O&P ALMANAC | OCTOBER 2017

By LIA K. DANGELICO

From Experience,

Empathy

WHAT CAN WE LEARN FROM O&P CLINICIANS WHO ARE PATIENTS THEMSELVES?

NEED TO KNOW • Clinicians who have experienced limb loss are uniquely positioned to share their insights on the O&P patient-care experience and offer suggestions on being an effective practitioner. • By demonstrating their ability to ambulate and perform their job duties using prostheses, amputee clinicians can serve as role models and offer hope to patients— especially those who have only recently experienced amputation.

OCTOBER 2017 | O&P ALMANAC

• Clinicians who also are patients say that the facility itself plays a part in how comfortable patients feel with their health-care experience. Offices with pleasant waiting areas and easy-to-navigate hallways may increase patients’ comfort level and help put them at ease. • The job of the O&P practitioner can be mentally and physically challenging, so clinicians who are patients themselves must take extra care to prioritize their own self-care and maintain healthy habits.

PHOTO: Getty Images/ThitareeSarmkasat

• Amputee clinicians emphasize the importance of “empathetic listening” when interacting with patients. Listening to patients’ questions and making decisions and adjustments based on their input is key to fostering acceptance and encouraging use of O&P devices.

• All practitioners—including those with limb loss—should be able to recognize if something’s not clicking with a particular patient, or if a certain patient would benefit from switching to a different clinician with particular expertise.

S THE ADAGE GOES: To best understand someone, walk a mile in his or her shoes. And we know for some O&P patients, especially those with limb loss, walking a mile is no easy feat. When first experiencing amputation or understanding their ability limitations as children, a variety of emotions is common. The Amputee Coalition outlines the “psychological aspects of amputation,” which include the five stages of grief: denial, anger, bargaining, depression, and acceptance and hope, along with other compounding factors, such as stress, physical pain, and body perception. Amputees born with congenital defects may struggle to understand why they can’t run and play like the other children. Amputees resulting from trauma may face guilt and anger, wondering how things could have gone differently. O&P clinicians often meet their patients for the first time at these critical junctures, when patients are experiencing feelings of confusion and powerlessness. In those moments of vulnerability and fear, they need clinicians to see the whole patient as a person in need of compassion and support. Few are better equipped to understand the complexities that O&P patients face—both physical and emotional—than O&P professionals who have experienced limb loss themselves. While most admit being an amputee doesn’t make them a better practitioner or designer, each has unique insights on how to be a more empathetic, effective, and healthy practitioner.

PHOTO: Getty Images/FangXiaNuo

tumor as a teenager, Garrison’s foot was amputated through the ankle just after he graduated high school. At that time, there weren’t support groups for patients, and psychological intervention was not integrated into prosthetic care. “I just wanted to feel normal again,” he says. Because he couldn’t, he got angry, and carried that with him for more than 10 years. He eventually wrote his autobiography, It’s Just a Matter of Balance—You Can’t Put a Straight Leg on a Crooked Man, which he says is the guidebook he wished had been available to him after his amputation. His experience taught him how to approach patients, even those who seem “fine.” “In very few cases, in my opinion, [the patient has] truly accepted it,” he says. “They talk like they do … they pretend like everything’s okay … Working Toward and maybe they are. But Acceptance in most cases, they’re not, Clinicians who have weathbecause it takes time.” ered the early days of limb Garrison relishes the loss know that navigating the road to acceptance is key, Kevin Garrison, CP, LP opportunity to bring some hope for patients, espebut also know how difficult those early days can be. Take, for cially during the dark early days. He example, Kevin Garrison, CP, LP, often visits patients in rehab centers owner and founder of Garrison’s or hospitals shortly after their ampuProsthetic Services in Florida. After tation, when they’re still heavily being diagnosed with a cancerous medicated and somewhat out of it.

“I say, ‘By the way, I’m an amputee myself and I just walked in here on a prosthesis,’” he says. “All of a sudden, they’re out of that stupor and they’re focused and they’re looking. And they go, ‘What? You’re an amputee?’ And I go, ‘Yeah, watch.’” Garrison walks for them and does what he calls his “little twirl and spinning,” showing he has complete control of his leg. “They’re in awe,” he says, “and they’re ready to jump out of that bed, and they’re going, ‘When can I get a leg? I want to walk just like you.’” He emphasizes to patients how important it is to get your strength back. “I tell them it’s like a mathematical formula,” he says. “The first thing you have to do is start developing your strength. Then when you start developing strength, you start developing more control. And strength plus control equals confidence.” Any clinician can offer this chance to connect and inspire, by finding amputee patients who are doing well and asking them to speak with new amputees about their experience and demonstrate how they walk or run. “Patients usually will jump off their chair with happiness at the opportunity to see it in action,” says Garrison. “Talking about it is wonderful. But to actually see someone performing and doing well on a prosthetic device, you can’t put that into words.” O&P ALMANAC | OCTOBER 2017

OCTOBER 2017 | O&P ALMANAC

PHOTO: Jason Wening, CPO, LPO, MS, FAAOP

Listening is especially important in clinicians work to reduce In counseling his instances when the patient’s physique their patients’ anxiety patients, Jim Young, and/or needs are out of the ordinary, by listening intently and CP, FAAOP, tries a very says Jason Wening, CPO, LPO, MS, answering all of their direct but no less nuanced FAAOP, practice manager and resiquestions. “Make sure they approach. As the owner understand you and you’re and founder of Amputee dency director for Scheck & Siress communicating well with Prosthetic Clinic in in Chicago. A congenital bilateral them,” he says. “Give them Georgia, he tells patients, amputee, Wening is missing both an opportunity to complain “Accept that your limb is fibulas and has severely atrophied calf if they need to, to ask more not going to come back. muscles. “I have an incredibly unusual Jim Young, CP, FAAOP questions, to get advice,” Even the best available limb shape,” he says. “The average says Garrison. Be open prosthetic won’t compare clinician does not see somebody with with them as you help them to develop to your real leg. … If you’re comparing legs like mine.” Coming from a military a realistic outlook on their potential it to the original design, the original family, Wening grew up in O&P shops and abilities. foot, we are going to fall short every and saw several prosthetists with That means asking for feedback, time.” After a motorcycle wreck in the different approaches over the years. and then being willing to make late 1980s, Young underwent almost His best experiences were with proschanges based on the patient’s needs. 30 procedures to try and save his leg. thetists who took the time to see him For years, Young struggled with a Eventually, his leg was amputated as a human being and worked hard to prosthesis that brought him constant above the knee, and he began receiving meet his unique needs. pain, but his prosthetist simply told prosthetic care through the U.S. According to his mother, the least him he’d get used to it. Because of the Department of Veterans Affairs, as he helpful prosthetist Wening ever had discomfort, he stopped was in the Air Force. He recalls having was actually an amputee, using the prosthesis a prosthetist who looked the part— and that stuck with him. always dressed smartly in a three-piece completely, using crutches The clinician was a longto get around. It wasn’t suit—but who didn’t ever address what time bilateral amputee was really going on as Young worked to until he spotted a man at who had weathered the the gym wearing a sleek, accept his new normal. days before silicone liners lightweight prosthesis that Whether they are facing amputaand carbon feet, so his take Young sought out a new on prosthetics that “pain tion or dealing with severe arthritis, prosthetist. Within weeks, was part of the deal.” One all patients need a listening ear and a he was properly fitted with Jason Wening, CPO, of his takeaways from that safe space to share how they’re really a new device and walking experience is that “my life feeling. After all, the ultimate goal LPO, MS, FAAOP without crutches. From story as an amputee is not for an O&P clinician is not just to get that experience, he learned to always the same as anybody else’s life story as a device on a patient, it’s to meet the listen to the patient and trust his or her an amputee,” he says. “It is not the same patient’s needs. After living through experience. as their lived experience.” his experience, Garrison recommends So, no matter what, don’t stop trying to address patients’ needs, he says. “There are a lot of amputees with really challenging limbs, and all they really need is some patience and somebody to listen to them vent for a little bit and not take it personally. As amputees, we all have bad days at some point. ... Part of our job as prosthetists is to help people have the tools to minimize the number of bad days.” What Wening and Young are advocating is the use of “empathetic listening,” which the American Medical Association (AMA) encourages all physicians to practice. “Empathetic listening builds on the concept of empathy and allows one to Jason Wening, CPO, LPO, MS, FAAOP, with his son be fully present for another person’s

experiences,” according to AMA’s Steps Forward online educational program. “When empathetic listening is used in health care, patients and families are often more satisfied and more open to hearing their physician’s advice.” In the current health-care climate, where patients can, at times, feel like just a number in a system, O&P practitioners have an opportunity to help fill the void patients may feel and have a positive effect on their lives and stories.

Setting Realistic Goals

PHOTO: Getty Images/Smileus

Clinicians who have been patients themselves know all patients benefit from setting realistic, measurable goals. What will their new normal look like? Are they looking to be able to carry their child or walk a pet, or are they looking to get back to tennis or long-distance running? By having frank discussions with patients early on, clinicians can help them set and work toward achievable goals. “A lot of people come in expecting to be able to walk and do everything, yet they can’t stand up,” says Young. He encourages patients to start small. Instead of trying to walk a mile on their first day, he has them practice standing up on their own for five minutes. “I’m always super real with my patients,” he says, telling them they have to work on their basic mobility, like the fundamentals of any sport. He often uses metaphors to relate to patients—before you can hit a home run you have to know how to hold the bat and how to swing. While it doesn’t carry the bright lights of other sports, walking is the main event for many lower-limb patients. “The number one indicator of how well an amputee will do is his or her step count,” says Young. He advises his patients to track and log their steps using a pedometer or phone app, and reviews the data with patients regularly. Working in an office, Young averages about 2,000 steps before noon. “If you’re really trying to learn how to walk, if you’re not doing 2,000 steps a day, you’re lying to yourself,” he says. “If you’re being honest, you hold yourself accountable.”

Self-Care for the Care

Provider

A recent study by the Mayo Clinic found that almost half of all physicians in the United States reported feeling burned out, and that burnout and work-life balance for physicians is worsening. Many in health care and related fields experience the same challenges but lack the tools to manage stress and proper self-care. According to Christina Maslach, PhD, a University of California—Berkeley researcher and psychology professor, common signs of burnout include feeling emotionally or mentally drained and/or nauseated; feeling underappreciated, ostracized, and generally “left out” by colleagues and superiors; and feeling you are unable to achieve your best work, or are regularly “phoning it in.” O&P professionals should take time to prioritize their self-care and mental health. In honor of Mental Health Awareness Week, Oct. 1-7, 2017, here are some tips for combatting burnout from Maslach’s “Burnout Inventory Manual”: Practice focused breathing, “which can tap into your parasympathetic nervous system to help you reduce or manage stress.” Find a trusted mentor at work, “with whom you can discuss and strategize other ways to deal with work-related issues” and stressors. Take frequent breaks, “preferably five-minute breaks for every 20 minutes spent on a single task” or time spent sitting at your desk. Utilize ergonomic chairs and desks, and consider incorporating plants and other soothing elements into the workspace.

O&P ALMANAC | OCTOBER 2017

advisor—in part because of the limited “The fact is, if you want to get back into your life, you want to do it and you performance of the available proswant to feel as normal as you can,” says theses. He says many in the industry Garrison. “So that means getting back don’t have the upper-extremity expeto an independent lifestyle, ambulating rience they need to properly care for feeling safe, ambulating feeling secure, this demographic of patients. “I hear and ambulating feeling comfortable complaints from too many people who and without pain and discomfort. And are just frustrated,” he says. “They so those are paramount focuses on the have a bad first experience with their care that the patient’s expecting.” prosthesis and prosthetist. You don’t Of course, as a clinician, want to see someone you also have to be realreject a prosthetic limb just because of one poor istic with yourself about experience, but it can your own capabilities. Just happen.” When advising as important as listening O&P clinicians, he tries to the patients’ needs is to offer “custom advice to knowing when you’re way whatever the individual is out of your league. “When ... what their needs are,” you’re working with he says. “I’ve dealt with— someone and it’s just not Bob Radocy and we build technology clicking, know when to call for help,” says Wening. “Patients get that we’re not going to have all the answers all the time.” It’s not easy to admit when you need help or need to refer a patient elsewhere, but sometimes that’s the best thing for the patient, says Bob Radocy, owner and founder of TRS Prosthetics. After losing his hand in an auto accident in the 1970s, Radocy made his way into the O&P industry as a prosthetic designer and industry

for—people with all types of upper-limb lengths and disabilities. We try to just be honest and transparent about what we have and whether it works for them or not.”

Putting Them at Ease

In addition to building a rapport and foundation of trust with patients, you also want them to physically feel comfortable and welcomed when they come to your practice. Young recalls

Bob Radocy enjoys a kayaking trip using his prosthesis.

OCTOBER 2017 | O&P ALMANAC

his first few trips to the prosthetist: “We drove to the industrial side of town into an old hut-looking building. … Inside, it was just gray with dark paneling—so if you weren’t depressed by the time you got there, you would be before you left.” In designing his own practice, Garrison emphasized that the patient experience starts at the front door. “We try to have a welcoming, homey, friendly environment when you walk in,” he says. “We spend a lot of money on air freshener” to mask the chemical smells many associate with O&P clinics and labs. Garrison’s wife is in charge of the decorating, and she uses soft whites and greens and plenty of flowers throughout the space. “It doesn’t look super clinical,” he says. The waiting room features maroon leather couches and comfortable chairs and rollers that can accommodate patients of all shapes, sizes, and abilities. This way, “the hope starts right at the front door.” That homey environment serves another purpose. It translates into a place where Young’s patients are comfortable coming and hanging out for a while—usually for a full day—instead of coming back and forth for multiple appointments. Being a patient himself, he’s familiar with having countless appointments for something that could just take one day. He says it’s important to remember that many patients, especially children and the elderly, are relying on someone else for transportation to and from the clinic. “And oftentimes, that means a parent or a caregiver is going to have to take a day off work [for a 15-minute appointment], then turn around and do it again next week.” Young notes that many of his patients live in rural Georgia, and it’s not uncommon for them to drive at least one hour each way to see him. So, he prefers to do everything he can in one admittedly long day. He tells patients, “Eat your Wheaties, pack a lunch, bring a book, whatever you need to do. It’s going to be a long day, but it’s going to be one long day, not a bunch of long days.”

HOW DO YOU CALCULATE SUCCESS? EDUCATION HARD WORK

TALENT AND...

THE RIGHT TOOLS SOLVE THE EQUATION WITH AMFIT PROUDLY SERVING FOOT SPECIALISTS SINCE 1977 SALES@AMFIT.COM

800-356-FOOT

VANCOUVER, WASHINGTON USA

By giving patients the time and respect they deserve, clinicians can develop a trust and rapport that translates into a solid, loyal client base.

OCTOBER 2017 | O&P ALMANAC

antennae up for ways to make his patients’ lives easier. “When I’m trying something new, whether it’s a foot [or another product] ... I’m always trying to think, ‘Who would I put this on?’” he says. “Even if I don’t like it on me … maybe it’s a 70-year-old patient with arthritis in her knees or a 20-year-old that’s trying to run a marathon … who does it make sense for based on what I’m feeling?”

Setting an Example

Despite their unique experiences, many amputee clinicians feel they are no better suited to care for patients than their nonamputee counterparts. And the work of an O&P clinician is difficult and draining—mentally, emotionally, and physically. So, in addition to mentoring and providing support, clinicians who are patients themselves must take extra care to prioritize their own self-care and maintain healthy habits. Young pushes his patients—and himself—to stay fit and keep extra weight off, especially if they want to be active and feel good. Maintaining a healthy weight is important for all O&P patients—from those with limb loss, to growing children and teens, to injured athletes looking to get back on the field. Several years ago, Young realized he needed to slim down—especially if he wanted to keep up with his granddaughters—so he worked hard to shed the extra

Lia K. Dangelico is a contributing writer to O&P Almanac. Reach her at liadangelico@gmail.com.

PHOTO: Getty Images/Sturti

Garrison agrees that time is valuable, and works to ensure his patients’ time in the office is well spent. “The worst thing that I think they could do is rush this patient in and out of their office and treat [him] like a number,” he says. “Some organizations, they just want to see as many patients as they can in a day. Patients need to be given the time that they deserve. … You can’t just treat the amputation. You’re treating the whole person.” By giving patients the time and respect they deserve, clinicians can develop a trust and rapport that translates into a solid, loyal client base. Every patient is looking for an advocate in his or her clinician, but those who are O&P patients themselves have the unique experience of being able to test out new technologies and products and bring that knowledge back to the exam room. For Garrison’s part, he says he doesn’t need to test every new device or item before recommending it to a patient. Instead, the relationship he’s built with them ensures they trust his decisions. “If I tell them, ‘I studied this device and I know it was designed for you and you’re going to benefit from this,’” that seems to be good enough,” he says. But he does show off his abilities in the prosthesis he wears—walking, stopping, turning—more so to show them what’s possible when you have the right device and right fit. Despite his unique needs as an amputee, Wening always has his

weight. These days, he works to keep the weight off by monitoring his step count and getting out to play golf whenever he can. “You’ve got to take time [for yourself ],” he says. That sounds familiar to Wening, who not only wears many hats at work but also has a wife and three young sons to keep up with. “There are plenty of times that I feel like my own self-care is the last thing on the list, but there are some things that I consciously do,” to stay healthy and de-stress, he says. He maintains a healthy diet and carves out time to go running, usually eight miles a week. “At the end of the day, you’re exhausted,” says Garrison. “Mentally and in some cases physically, depending on how actively you’re into doing the fabrication or the technical aspects.” But he makes it a point to exercise at the gym twice a week, where he has worked with a trainer to build and maintain strength in his legs, back, and chest. “I tell patients, ‘Get thin like me. Stay thin. Stay healthy. Exercise.’ And then, I again set an even further example.” He has learned you cannot ignore your strength, especially in your most vulnerable areas. “When you’re doing a casting technique, you’ve got to have strength in your fingers, your wrists, your hands, and your elbows and shoulders to do it right,” he says. At least once a week, when the weather cooperates, he can be found outside taking a three-mile walk. It’s in these moments he can breathe deeply, decompress, and take a break from all of his roles. “I walk for a mile-and-a-half and I sit as long as I want and rest,” he says. He even bought himself a nice pair of headphones so he can listen to music as he walks. He often opts for new age rock music—bands that his children recommend, such as Porcupine Tree. As he walks, he hears the rhythm of his footsteps along with the music that connects him to family—taking his time, in no hurry.

i-limb quantum ®

precision. power. intelligent motion. The first multi-articulating prosthesis that can be controlled with simple gestures.

• Smarter: Use simple gestures to change grips

• Faster: Boost digit speed by up to 30 %

• Stronger: Up to 30 % more power when needed

‘‘

Now available in 4 sizes (extra small, small, medium, large)

‘‘

I love teaching my kids about life and overcoming obstacles. With my i-limb® quantums there is nothing I can’t accomplish. Jason Koger i-limb® quantum user

Visit www.touchbionics.com or ask your Touch Bionics rep about i-limb today. ®

TEL (855) 694-5462 FAX (866) 846-3838 WWW.TOUCHBIONICS.COM

By DEBORAH CONN

Center-Stage Research The recipients of this year’s Thranhardt and Hamontree Awards are doing their part to advance O&P outcomes

NEED TO KNOW • The presentation of Thranhardt and Hamontree Awards in Las Vegas was one of the highlights of the AOPA World Congress and Centennial Celebration last month. • Shenan Hoppe-Ludwig, CPO, received a Thranhardt Award for her study demonstrating improved outcomes for individuals using microprocessor-controlled kneeankle-foot orthoses. Study participants experienced increased mobility, fewer falls, and improved endurance. Andrea Giovanni Cutti, PhD (top), and Ryan Ball

• Andrea Giovanni Cutti, PhD, received Thranhardt recognition for his study of symmetry in transtibial and transfemoral amputees, where he found that typical levels of symmetry changed with the level of amputation and were affected by type of prosthesis. • Ryan Ball was presented with the Hamontree Award for his study identifying two data opportunities for O&P facilities: mining referral source data collected via electronic medical records and purchasing targeted claims data to identify high-volume referral sources.

OCTOBER 2017 | O&P ALMANAC

OMPETITION

for the 2017 Thranhardt Award was especially fierce this year. When the results were announced at the AOPA World Congress and Centennial Celebration in Las Vegas, two researchers were awarded the highest honor. Established by J.E. Hanger in 1995, the Thranhardt Award recognizes individuals committed to advancing orthotic and prosthetic research and education. Shenan HoppeLudwig, CPO, of the Shirley Ryan AbilityLab in Chicago (formerly the Chicago Rehabilitation Institute), and Andrea Giovanni Cutti, PhD, of the National Institute for Insurance Against Workplace Accidents and Occupational Disease in Rome, both received recognition this year. A counterpart to the Thranhardt prize is the Sam E. Hamontree, CP(E), Business Education Award, created to recognize the best business paper submitted for presentation at the annual AOPA event. This year’s winner was Ryan Ball of VGM Group.

Microprocessor-Controlled Orthoses

Hoppe-Ludwig’s study, “The Microprocessor-Controlled Orthosis: What Is the Impact to the User Versus the Stance Control Orthosis and Conventional Locked KAFO?” centered on the functional differences between newer orthotic technology and more traditional devices. “The technology behind the microprocessor-controlled hydraulic knee-ankle-foot orthosis (KAFO), or C-brace, has been in use for decades for prosthetic users—via the C-leg—but is relatively new in orthotic application. Our study was meant to help define its impact on users compared with stance-control and traditional KAFOs,” explains Hoppe-Ludwig.

Thranhardt Award winner Shenan Hoppe-Ludwig, CPO Hoppe-Ludwig and her co-author and study coordinator, Susan DeemsDluhy, tested participants using three types of KAFOs, giving them appropriate training and sufficient time to acclimate themselves to the devices. Subjects, who gave consent and agreed to an IRB-approved protocol, were tested in their own “baseline” devices and then randomized to either stance-controlled

orthoses (SCOs) or microprocessorcontrolled orthoses (MPOs). The subjects were fit with the investigational devices by a certified orthotist. The researchers established baseline performance using a battery of outcomes, including performance-based measures of endurance-distance, speed-distance, balance, functional gait assessment, safety-time, timed ramp assessment, and functional ramp and stairs assessments. They used patient-reported measures including the Modified Falls Efficacy Scale, the OPUS Functional Status and Device Satisfaction metric, and the WHOQOL-Bref scale, and they performed home and community monitoring as well. Following a one-month instructional acclimation period with a physical therapist, subjects began a one-month home phase. Prior to home use, subjects were required to demonstrate safety and independence using the study devices. During the home phase, the subjects used activity monitors and GPS to help define device usage and impact on community activity. After one month of using the device at home, participants returned to repeat outcome measures using the study device. Once completed, the subjects received a second study device and repeated all study activities. The results, says Hoppe-Ludwig, showed that use of an MPO may improve users’ experience by increasing activity and community mobility by reducing falls, increasing walking speeds, improving endurance and balance, and easing difficulty on stairs, ramps, and uneven surfaces. “In general, these results demonstrated greater safety over stance-control orthoses and conventional KAFOs when considering functional use,” she says. O&P ALMANAC | OCTOBER 2017

Thranhardt Award winner Andrea Giovanni Cutti, PhD “Nevertheless, MPOs are similar to all orthoses in that they must be fit to the appropriate candidate to function optimally. Factors other than functional gains—namely, perceptions of safety, ease of use, and trust in the devices—play a role in determining the optimal candidates. We continue to analyze the data obtained in this study, but the results show promise in the technology when applied to the population using KAFOs.” Hoppe-Ludwig, who is grateful for the contributions of the study’s clinical partners (Scheck & Siress, Hanger, and Ottobock Healthcare), believes additional studies are in order to best identify optimal users of the technology. “I also hope there will be long-term studies on how C-brace use affects overall health, with a focus on comorbidities such as contralateral-side overuse syndromes and low-back pain,” she says.

Symmetry Studies

Cutti’s work, as described in “Reference Values for Gait Temporal and Loading Symmetry of Lower-Limb Amputees Can Help in Refocusing Rehabilitation Targets,” began with clear clinical needs. “On one side, we know from the literature that persons with a lower-limb amputation tend to walk asymmetrically, 38

OCTOBER 2017 | O&P ALMANAC

with the literature reporting more time spent and load exerted on the sound side,” he says. Gait asymmetry is of clinical concern because it has been related to a number of major clinical issues, including increased falls, osteoarthritis of the sound limb, and back pain, as well as attracting uncomfortable attention. As a result, one of the almost unquestioned goals of rehabilitation has been to regain symmetry. “But when should we be happy about a patient’s symmetry?” asks Cutti. Some level of asymmetry may be unavoidable, as also highlighted in the literature, so what is a reasonable compromise as a rehabilitation goal? “And should we expect better symmetry from amputees using advanced prosthetic knees such as the C-leg by Ottobock, or energy-storageand-return feet, like the Variflex by Össur? And finally, are we really sure that all amputees overload the sound side, or are there differences between transfemoral and transtibial amputees, possibly indicating different mechanisms related to knee osteoarthritis, and how can we tackle these mechanisms?” Cutti and his colleagues studied 60 traumatic amputees with a good-to-high functional level. They included 23 transtibial amputees, 12 with transfemoral amputations using mechanical knees,

and 25 transfemoral using the C-leg. Ninety-two percent used the Variflex foot. The study also included 10 healthy controls to highlight general trends. “We first verified that it was important to report three indexes of symmetry,” Cutti explains. The first is the ratio of how much time each patient spends on the sound side and on the affected side, or the stance symmetry. Researchers established that it was important to measure the ratio of the peak-force on the two sides when the patient touches the ground with his/ her heel, or first-peak symmetry. In addition, they measured the symmetry of the impulse of the ground-reaction force, which considers the magnitude of the forces that act on the leg when the patient stands on it and the time this force acts, which is the stance time. Researchers found that typical levels of symmetry for stance, impulse, and first peak changed with the level of amputation and that these levels were affected significantly by the C-leg and by the use of energy-storage-and-return feet. “We think our results can be exploited in the clinical routine,” says Cutti. “First, clinicians can compare the level of symmetry of a new patient with the ranges provided and put the patient’s performance and advancements during rehabilitation in perspective. Moreover, health-care and technical professionals might use our findings to compare the effect of different prosthetic components and potentially the effect of different rehabilitation programs. “Second, payors often require justification for advanced prosthetic components. We think that our results support the use of C-leg and energystorage-and-return feet on K3-K4 traumatic patients. “Finally, our results might suggest possible strategies to mitigate knee osteoarthritis of the sound side. Pending further research, transfemoral amputees might take advantage of prosthetic components with improved knee-foot coordination to specifically tackle stance-time asymmetry. Transtibial patients might benefit from improved socket construction that doesn’t limit knee extension, and prosthetic feet with

improved push-off, roll-over shape, and range of motion to reduce the first peak at loading response.” Cutti believes additional research among K2 patients, possibly with nontraumatic amputation, could help set new targets for them as well. He adds, “We also need experimental confirmation that the two mechanisms highlighted above for knee osteoarthritis are really different for transfemoral and transtibial amputees and important for the onset or sustaining the pathology.”

ADDITIONAL THRANHARDT AND HAMONTREE PRESENTERS The Thranhardt Award winners were selected among four presentations given during the World Congress. In addition to lectures by Shenan Hoppe-Ludwig, CPO, and Andrea Giovanni Cutti, PhD, these presentations were selected for the lecture series in Las Vegas:

Introducing the Prosthetic Homologue for Embodiment, Michael Wininger, PhD

Do Foot Orthoses Work? Outcomes From a Multiclinic Study of 6,658 Pedorthic Patient Visits, Michael Ryan, PhD, CPed

Mining Referral Source Data

Ball’s presentation, “Competitive Differentiator: Executing a Data-Driven Growth Strategy in O&P,” is part of an effort to help O&P practices find greater efficiencies and generate new business through the use of data, “a passion of mine,” says Ball. The Hamontree Award winner was He says that data has been used selected from among two business papers against the O&P profession by payor presented at the World Congress. In addisources and auditors over the past few years, so it is time that the industry begins tion to Ryan Ball’s research, the following using data to quantify the value of O&P lecture was given during the conference: and find new business opportunities. Ball identified two main data oppor An Easy Way To Show Health Economical Benefit in Standard O&P tunities for O&P facilities. The first is Practice: A First Experience, Andreas to mine their own information. “Most Hahn, PhD, MSc O&P practices now utilize an electronic medical records (EMR) system, and it is a major investment and expense,” he says. “Savvy O&P practices will mine rank by volume—physicians performing the referral source data available in and should not be treated as such. amputations or referring patients for their EMRs, identifying top referring Larger opportunities should get more custom orthotics and prosthetics,” he says. physicians, trending volumes of referrals resources than smaller ones—it’s that “They can even see which physicians send year over year, last referral received, and simple,” says Ball. “Targeted claims their patients to local competitors.” sales contacts. All of this information data will help O&P practices shrink the With data in hand, practices can then is already at the fingertips of an O&P playing field to the best opportunities in quantify opportunities and create tiered practice, but many don’t think to use it their markets. From there, it is simple to engagement plans to reach for sales purposes.” determine which physicians an owner high-value targets. “Make Using their own EMR should engage and which are better goals, track success,” Ball data will help practices left for dedicated sales and marketing says. strengthen relationships with people. Identifying, engaging, and He notes that the O&P existing referral sources; converting new business growth opporfield largely comprises however, leveraging external tunities are what all providers need to clinicians who have become data sources may help do a better job, and data can help.” business leaders, and most do pinpoint opportunities with Ball sees the use of data by post-acute not relish sales and marketing regard to referral sources providers as a nascent trend, one that is activities. Few practices have who are currently working bound to grow for O&P practices of all Hamontree Award the resources to devote to with competing O&P clinics. types and sizes. winner Ryan Ball marketing, so it is even more According to Ball, facilities can important to identify which physicians purchase targeted claims data to help Deborah Conn is a contributing warrant the time of a business owner. identify high-volume referral sources. writer to O&P Almanac. Reach her at “Referral sources are not created equal “Practices can find data to identify—and deborahconn@verizon.net. O&P ALMANAC | OCTOBER 2017

COMPLIANCE CORNER

How

By DEVON BERNARD

Effective Is Your Plan?

Leverage metrics put forth by the Office of the Inspector General to measure the efficacy of your compliance plan

Editor’s Note: Readers of Compliance Corner are now eligible to earn two CE credits. After reading this column, simply scan the QR code or use the link on page 43 to take the Compliance Corner quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.

CREDITS

E! QU IZ M EARN

BUSINESS CE

CREDITS P.43

HE SEVEN KEY ELEMENTS neces-

sary for creating a compliance plan were featured in a Compliance Corner article in the January O&P Almanac. However, simply incorporating these seven elements will not guarantee that your compliance plan will be effective. The plan must be evaluated from time to time to ensure that its core components still meet the goals of your organization and, more importantly, ensure the plan is being adhered to and updated as needed. In early 2017, the Office of Inspector General (OIG) for the U.S. Department of Health and Human Services held a summit with several compliance professionals from the Health Care Compliance Association, representing a wide range of health-care industries, to discuss ways to measure the effectiveness of a compliance plan. This workgroup developed a list of more than 400 metrics (delineating “what

ELEMENT

Written Policies and Procedures

The first step in creating a compliance plan is to develop your company’s standards of conduct, or the broad values that you wish for your organization to follow, and address specific areas that are prone to potential fraud or abuse. This would include such general areas as claims development and the submission process (establishing medical necessity, orders, proof of delivery, selection of codes, etc.), guidelines about kickbacks/ self-referrals, marketing, and retention 40

OCTOBER 2017 | O&P ALMANAC

to measure” and “how to measure”) that can be used to determine the effectiveness and usefulness of your current compliance plan. The use of all 400 metrics is not practical—it is not expected that you would apply all 400 metrics to your compliance plan. The purpose of the extensive list is to provide ideas, or a starting point, from which to evaluate and test your compliance plan. Your facility’s effectiveness measurement process, and the staff members involved in implementing it, should be tailored to your company—just like your compliance plan is tailored to your company. This month’s Compliance Corner provides a brief recap of the seven elements of a compliance plan and explains some of the metrics suggested by the workgroup. Be sure to review the full findings of the workgroup on the OIG website, https://oig.hhs.gov/compliance/101. of records, among other things. The workgroup created 62 metrics for testing whether the standards, policies, and procedures of your compliance plan are adequate, understandable, enforced, accessible, and updated. For example, to test the accessibility of your compliance plan, you could survey employees to see how many know what your policies and procedures are, and if they know where to find a current copy of these rules. If the document is on your website or company server, does the link still work, and are the files still accessible?

COMPLIANCE CORNER

Can you track how often the web page is accessed? Be sure to review the language of your policies and procedures and make sure the verbiage is straightforward and easy to understand. To test the quality of your compliance plan, try auditing the plan by checking when it was last updated and evaluating if it is still relevant. Are you keeping a record of all of the changes made to the policy and documenting when those changes are made? Do staff agree that the policies and procedures assist them in doing their assigned jobs effectively? Ask employees to identify any policies that need to be created that may not be in effect, or policies that should be updated or removed.

ELEMENT

Program Administration

The next step is to designate one employee to be the compliance officer and/or leader of a facility “compliance committee.” This individual must serve as the primary point person for all compliance activities and be responsible for implementing, updating, interpreting, and enforcing the company’s compliance program. There are 68 metrics that can be used to assess whether the compliance officer/committee is effectively administering your compliance plan. These metrics include evaluating the involvement of the board of directors, the resources allocated to the compliance plan, the use of risk assessments, and the overall company’s/organization’s commitment to compliance—including but not limited to employee incentives/promotions.

This would include testing the perception and role of the compliance officer and program. Are the compliance staff considered “solution facilitators” or the “organizational police force”? Also, consider interviewing the compliance officer to determine if he or she is supported in carrying out the duties of the job, and if he or she needs any additional support to fulfill those duties. Is your compliance officer continuing his or her

education/certification or enhancing his or her abilities and knowledge in other ways? Does your company have a “culture of compliance”? Are you engaging in activities to promote and reward compliance? Do you have incentives to encourage employees to adhere to the compliance plan, and is compliance part of your performance reviews? Ask your staff if the compliance officer/committee has an impact on how they do their jobs.

Health Care Compliance and Ethics Week, November 5-11

OPA HAS PARTNERED WITH the Health Care Compliance Association to provide resources for members—including many at no cost—to facilitate participation. This week-long focus on compliance and ethics will give your organization the opportunity to introduce and reinforce the compliance and ethics standards your employees are expected to meet. Participation may contribute to positive perceptions from the broader community about your facility’s commitment to ethical business practices. Taking part in Health Care Compliance and Ethics Week provides an opportunity to thank employees and create a meaningful dialog. It’s not only the right thing to do; it’s just common sense to have an effective written compliance and ethics program for your business. AOPA will make available tools to assist in your participation. Use the press release template AOPA has developed to let your community know of your organization’s commitment. AOPA will be sending out daily compliance tips and the chance to win prizes, and will offer special educational opportunities, during Health Care Compliance and Ethics Week. Posters and giveaways are available to keep your staff engaged. If you don’t have a compliance officer on staff, this is the opportunity to assign that responsibility. Register employees for one or all of the online seminars:

Gift Giving: Show Your Thanks & Remain Compliant, Wednesday, Nov. 8

Compliance and Ethics Association’s hosted webinar, Thursday, Nov. 9

(free for AOPA members)

Teaching Professionalism and Ethics During Residency, Friday, Nov. 10

(free for AOPA members)

Many materials are available on a complimentary basis. This is a cost-effective opportunity to instill a sense of a commitment to a value system documented by your written compliance and ethics program that is a win/win for your company and for your patients. Tools to celebrate the week are available at bit.ly/aopaethics. See the order form on the website to access these resources.

O&P ALMANAC | OCTOBER 2017

COMPLIANCE CORNER

ELEMENT

3&4

Training & Lines of Communication

Two of the seven elements of a compliance plan—implementing training/ education programs for all employees and developing effective lives of communication—were combined into one element by the workgroup for the purpose of creating the metrics to test the plan’s effectiveness. With durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) compliance plans, it’s important to implement education and training programs for both new hires and existing employees, including the compliance officer and management staff. These programs should be routinely revamped to align with current trends. In addition, effective and open lines of communication should be in place, both internally and externally, between the compliance officer/committee and all people associated with the company. Open communication is key to ensuring employees receive clarification about the company’s policies and procedures and are encouraged to report potential incidents of fraud and abuse

OCTOBER 2017 | O&P ALMANAC

ELEMENT

Internal Auditing and Monitoring Systems

The next element of a compliance plan is to monitor ongoing operations to ensure that policies and procedures are being observed and that necessary corrective action can be taken to correct any deficiencies or risk areas. This element has the most metrics assigned to it: 77 metrics to evaluate if a compliance plan has an appropriate auditing/monitoring/reporting system in place to handle issues after they are identified. Consider the following when evaluating your systems: • Do you have a written escalation process, and is it clear when an issue must be escalated and/or reported to the government? • Review your methods in creating your audit plans. What documents or standards do you use when auditing? • Examine your corrective action plans (CAPs). Are people following through with the CAPs, in a timely manner? Does a CAP typically correct the issue at hand? • Finally, consider inviting an outside party to review your methods/ audits; audit the auditors.

ELEMENT

Disciplinary Directives

A compliance plan must include written guidance regarding disciplinary action for anyone, regardless of position in the company, who has failed to follow the company’s standards of conduct and written policies and procedures for compliance. The workgroup identified 34 metrics that may be used to test whether employees understand the consequences for noncompliance, whether discipline is fair and consistent, and whether past noncompliance is considered when employees are promoted. To review the fairness, consistency, and knowledge of your company’s disciplinary policy, the metrics suggest reviewing the policy and answering these questions: Is the policy consistently followed? Is the disciplinary action in proportion to the offense? Is there consistency for similar matters? You also may survey employees to make sure they know and understand the disciplinary actions associated with noncompliance.

ELEMENT

Response and Corrective Action

A compliance plan must include a standardized process that can be used by your compliance officer/committee, or any other management official, for investigating potential violations of codes of conduct or other areas of noncompliance. This process should allow you to act rapidly and correct the action through the proper channels. The workgroup created 71 metrics for measuring and reviewing such things as how investigations should be conducted, the independence and competency of investigators, how issues are escalated, how results are communicated within the organization, and more. Some suggestions include checking for the presence or completion of a compliance log. Does your facility

PHOTOS: Getty Images/ Ridofranz/Milkos

There are 49 metrics to use in testing whether staff and employees have received appropriate training, to confirm whether training is updated based on regulatory changes or identified compliance failures, and to determine whether there are effective and open lines of communication. Regarding lines of communication, for example, the workgroup metrics suggest that you conduct focus group discussions with employees regarding the effectiveness of compliance program

messaging. Do employees know and understand the compliance officer’s or committee’s key message? How accessible is the compliance staff, and what is the perception of the staff? Do employees know how to report concerns, and are their concerns being addressed and taken seriously? One of the metrics for testing the effectiveness of training is to review your training plan and determine if it is the best way to share information with employees. Are the compliance materials being presented in a manner suitable for all employees? How would employees like to have the material presented? Be sure to audit all educational materials used to train new hires over the last two years; is the material still valid, or is it stale? Has everyone been trained— and trained in a consistent manner?

COMPLIANCE CORNER

have a log that lists the actions taken in each investigation, and are there supporting files for each log entry? Is there a pattern of offenses that needs to be reported? You also may determine whether and how investigation results have been documented and reported to senior leadership. The workgroup additionally developed 40 metrics to be used to test how individuals/entities should be evaluated for possible exclusion, conflicts of interest, their understanding of compliance obligations, and other issues; and to evaluate how individuals/entities respond to issues found during these evaluations. While this area of evaluation was not separately identified as an element of a DMEPOS compliance plan, it is part of other health-care compliance plans; since the features of this element are found in the seven elements of a DMEPOS compliance plan, these metrics are worth mentioning. Some of the metrics include the suggestion that employment files should be audited to ensure

documentation supports that newly hired employees were screened before they began working at the company. It also is suggested that annual meetings be held with the individual responsible for conducting the screening; during these meetings, the document retention processes to ensure documentation of the screening function should be reviewed, as should response to findings and whether corrective actions are adequately maintained. In addition to using these 400-plus metrics to evaluate the effectiveness of your company’s compliance plan, you also may reference the Department of Justice’s (DOJ’s) updated guidance for federal prosecutors on how to evaluate compliance programs. Taken together, the OIG metrics and the DOJ guidance document, www.justice.gov/criminal-fraud/page/ file/937501/download, provide a strong framework and starting point for compliance program evaluation. Following the steps suggested in this article will benefit your facility in many

ways. Companies with compliance programs are only eligible to receive cooperation credit under the U.S. Sentencing Guidelines if their compliance programs are considered effective. More importantly, companies with effective plans increase their chances of identifying issues early enough to ensure that problems don’t arise and may be well-positioned to prevent government intervention or investigations. Devon Bernard is AOPA’s assistant director of coding and reimbursement services, education, and programming. Reach him at dbernard@AOPAnet.org. 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:

www.bocusa.org

Make Your First Impressions Count

With Customized Polo shirts, Scrub tops and Lab Coats for your O&P staff

Create an attractive business image, promote your brand, and foster team spirit with AOPA’s new Apparel Program.

•

Choose from the most popular health care industry colors

• Embroider staff names (optional: you choose the color) @ $3.50 per line • PLUS Optional for Polo: AOPA emblem on the sleeve (@ $7.00 ea.)

To order your apparel, go to

• FedX overnight, ground, or Smart Post charged to your credit card. No additional handling charges added!

iconscrubs.com Enter access code: ICON-AOPA Enter your AOPA member id Create your user profile

AOPA is partnering with Encompass Group, a leading provider of health care apparel, to offer members special prices on customized polos, scrub tops, and lab coats.

Whether you are currently using another uniform provider, or just beginning to consider using apparel to build your brand, we hope you will consider using AOPA’s O&P resource.

LAB COAT

• Satisfaction guaranteed.

POLO TS SHIR

B SCRU TOPS

O&P ALMANAC | OCTOBER 2017

& NOW

THEN

O&P Education Education requirements for orthotists and prosthetists have evolved as the profession gains recognition within the health-care arena

Then & Now is a monthly department for 2017. As part of AOPA’s centennial celebration, O&P Almanac will feature a different AOPA product or service and discuss how it has evolved over the years. This month, we focus on AOPA’s involvement in the progression of O&P education.

HEN AOPA WAS FOUNDED 100

years ago, most O&P facilities were mom-and-pop shops, and education came in the form of on-the-job training passed from one generation to the next. But as the profession has evolved and devices have become more complicated, formal education has become increasingly important. Throughout the years, AOPA has provided education, training, and information that have been vital to O&P professionals. In addition to annual and local meetings, seminars, webinars, and publications, AOPA also has worked to advance and promote the O&P schools. Today’s orthotists and prosthetists are required to earn master’s degrees in O&P—but that has not always been the case.

THEN

In the first few decades of the association, AOPA played a significant role in advocating for the profession as well as ensuring O&P professionals were properly qualified. In 1947, the organization—then called the Orthopedic Appliance and Limb Manufacturers Association (OALMA)—worked in cooperation with the U.S. Department of Veterans Affairs (VA) in “the first large-scale effort toward the training of prosthetists,” according to an early document titled, “History of 44

OCTOBER 2017 | O&P ALMANAC

Prosthetic-Orthotic Education.” By January 1949, “20 short courses for the fitting of suction-socket above-knee prostheses had been presented in various parts of the United States.” In 1948, OALMA members recommended the formation of an organization with the responsibility to establish minimum requirements for the operation of a limb or brace facility to ensure that patients would receive adequate service. After informal discussions with the Department of Justice, the American Board for Certification of the Orthotic and Prosthetic Appliance Industry was formed on Sept. 9, 1948, which later became the American Board for Certification in Orthotics and Prosthetics Inc. (ABC). Thus, the terms “certified orthotist” and “certified prosthetist” were adopted for those who met certification requirements. The first certifying exam was held in New York City in 1951, with 51 individuals earning certification. At the recommendation of an ABC advisory committee, OALMA’s Education Committee, led by McCarthy Hanger Jr., developed on-the-job training schedules and course materials for related training to meet the adopted standards for apprenticeship training. “The apprenticeship program of OALMA seemed

well accepted in 1954,” reports the “History” document. “Many individuals were registered under the program. Over the years, however, it fell into disuse, due mainly to the lack of availability of formal instruction to augment the on-the-job training. In addition, the terms ‘apprentice’ and ‘trainee’ have not been well accepted in the United States, where the emphasis seems to be on formal training at institutions of higher education.” Around this time, universities began to establish schools for O&P professionals, as an alternative to attending selected training programs at locations across the country. The University of California–Los Angeles (UCLA) began to offer its Prosthetic Education Program in 1952. In January 1953, the first of 12 six-week upper-extremity prosthetics courses for prosthetists was conducted at UCLA. Other colleges, including New York University (in 1956) and Northwestern University (in 1959) followed suit, offering courses in above-knee prosthetics, orthotics, and other O&P topics. In 1958, an 18-month program in upper-extremity orthotics was established at Rancho Los Amigos Hospital in Downey, California, then expanded to a 24-month program to include lower-extremity orthotics. In 1959, OALMA, under the leadership of President Karl Buschenfeldt, CO, appointed a six-person Committee on Education. The committee was charged with devising a profile of what should be expected of prosthetists and orthotists in the future, and developing a plan to reach that goal. The committee worked under the chairmanship of E.W. Snygg from September 1959 until September 1961, when the responsibilities were shifted to OALMA’s Committee on Educational Standards. “A tangible benefit of OALMA’s Committee on Education was the development of a correspondence educational program directed at individuals who were just entering the field of prosthetics and orthotics,” reports the “History” document. This program “was put together

O&P Master’s Programs The 2017 listing of Orthotic and Prosthetic Practitioner Programs accredited by the National Commission on Orthotic and Prosthetic Education and the Commission on Accreditation of Allied Health Education Programs includes the following 13 master’s programs: • • • • • • • • • • • • •

Alabama State, College of Health Sciences Baylor College of Medicine (Texas) California State University Concordia University (Minnesota) Eastern Michigan University Florida International University Georgia Institute of Technology Loma Linda University School of Allied Health Professions (California) Northwestern University (Illinois) University of Hartford (Connecticut) University of Pittsburgh (Pennsylvania) University of Texas Southwestern Medical Center University of Washington

by selecting numerous courses from different curricula offered through the International Correspondence Schools.” Unfortunately, few students enrolled in the program because it was deemed too time-intensive for professionals who were already busy. AOPA partnered with ABC in 1970, calling for the development of an organization focused on continuing education for O&P professionals. As a result, the American Academy of Orthotists and Prosthetists was founded in November 1970. During this same time frame, AOPA helped develop a guideline for O&P education coursework essentials, universal orthotic-prosthetic terminology, and new occupational titles and job descriptions.

In 1993, the O&P profession was formally recognized as an allied health profession by the American Medical Association. During the late 1900s and early 2000s, the mom-and-pop model eroded, and an era of mergers and consolidation led to larger O&P facilities—although many smaller facilities continue to prosper. Clinicians upped their institutional education at O&P schools offering bachelor’s degrees. The year 2013 saw the O&P educational requirements elevated to an even higher level when the National Commission on Orthotics and Prosthetics Education (NCOPE) stated that, going forward, a master’s degree in O&P would be the minimum educational standard to become a certified practitioner. Charles H. Dankmeyer Jr., O&P ALMANAC | OCTOBER 2017

CPO, believes that the educational advancements of O&P professionals can be credited in part to the efforts of AOPA. “Between 1968 and 2017, there has been extraordinary change in the requirements to become certified,” says Dankmeyer, who served as AOPA president in 2014-2015. “None of those changes would have happened without AOPA’s efforts, legislatively and with the O&P schools.” Dankmeyer notes that AOPA has helped obtain funding for educational institutions throughout the years, and has worked to gain acceptance and reimbursement for advanced componentry for O&P patients. “A lot of work is done behind the scenes at AOPA,” he says.

Medicine Medical Faculty Council at Northwestern University. Seven institutions offer accredited O&P technician programs, says Robinson, and pedorthic education also is evolving, with higher expectations associated with their didactic training. “Academic institutions are also interested in offering assistant-level education programs as NCOPE and CAAHEP create educational standards,” he says. Robinson notes that additional educators will soon be needed at the O&P schools. “While the faces that routinely attend the educator meetings are relatively consistent, there will likely be an ongoing need to develop clinicians into becoming effective

AOPA World Congress Student Luncheon, Sept. 8, 2017

NOW

Today’s O&P students can attend one of 13 practitioner-level education programs at institutions that have been accredited by NCOPE and the Commission on Accreditation of Allied Health Education Programs (CAAHEP). In addition, there are several educational options for O&P care extenders, says Chris Robinson, MS, MBA, CPO, LPO, ATC, FAAOP(D), assistant professor of physical medicine and rehabilitation and president of the Feinberg School of 46

OCTOBER 2017 | O&P ALMANAC

educators and researchers, given the number of experienced faculty that will be eligible to retire, or pursue other avenues, and the likely expansion of educational programs to meet the needs for qualified O&P professionals based upon the Workforce Demand Study commissioned by NCOPE,” he says. Robinson also explains that colleges and universities are affected by trends across the higher education industry, which may have an impact on O&P education going forward. “The combination of declining state fiscal support

and lower enrollments across postsecondary institutions across the board could adversely affect the viability of a program, although I am optimistic that O&P profession awareness initiatives have aided in maintaining a pool of qualified candidates for the programs,” he says. “There is a strong emphasis throughout academia on offering high-quality education and maintaining a high level of placement after the completion of school. I sincerely believe all of the O&P educators are committed to programmatic improvement, which encourages a continued dialogue with the graduates in addition to seasoned O&P professionals. “Ongoing open communication with relevant stakeholders will help drive the O&P educational programs to deliver content that is relevant to the current state of the profession while helping address the needs of future employers and the patients we serve,” adds Robinson. “Placement of practitioners hinges on fostering a strong network of residency opportunities.” Robinson also expects the content and format of O&P education to evolve in the next five to 10 years. He predicts that educational programs will become somewhat more differentiated based upon the areas of expertise at the universities that house the O&P schools. “For example, programs housed within top-tier research institutions will have the opportunity to better leverage their clinical research expertise beyond the training of competent clinicians,” he says. Today’s master’s level students hold lofty career aspirations, Robinson notes, “often beyond simply working in the clinic, which is compounded by the increased focus on collaboration in the clinic team and quality practices inherent to today’s health-care delivery model. It will become imperative that the O&P schools identify resources within the home academic institutions to effectively engage the students at a level that meets their expectations while offering context and insights beyond the day-to-day operations of the O&P clinic.”

AOPA Celebrates

Health-Care Compliance & Ethics Week November 5-11, 2017

Why Should you Participate? • Demonstrate your company’s commitment to ethical business practices. • Create awareness of the Code of Conduct, relevant laws, and regulations. • Provide your staff with recognition for training completion, compliance, and ethics successes. • Reinforcement—of the culture of compliance for which your organization strives.

AOPA has developed tools and resources to assist you. Learn more about our products, special webinars, compliance tip of the day, how to win prizes and more at bit.ly/aopaethics.

www.AOPAnet.org

BRIDGE TO THE FUTURE: THE INTERVIEWS

Prosthetic Skin Artificial skin will allow future patients to sense pressure, temperature, and texture By CHRISTINE UMBRELL

Bridge to the Future: The Interviews is a monthly column for 2017. As part of AOPA’s Centennial Celebration, O&P Almanac will look to the next 100 years—by interviewing noted experts in the O&P field to learn their vision for the future of O&P. This month, we speak with Levent Beker, PhD, a postdoctoral researcher in the Bao Research Group, about developments in prosthetic skin.

HILE MANY O&P professionals

OCTOBER 2017 | O&P ALMANAC

Artificial skin has come a long way since its inception, and research has evolved from centering on burn victims. Until the late 1900s, replacement skin for burn victims was limited to grafts via patients’ own skin or cadaver skin. These skin grafts were often risky and could lead to tissue rejection or bacterial infection. In the 1980s, two researchA stretchable electronic skin consisting of ers—John F. Burke, MD, sensors and electronic components from Harvard University, conformally adhered to skin and Ioannis Yannas, PhD, from the Massachusetts to realize materials that can not only Institute of Technology—developed a conform to be placed on body organs, material known as the first “synthetic skin,” composed of cow tissue and shark but also can communicate with the nervous system of the body, according cartilage. This material became the to Beker. “Currently, artificial skin first commercially available synthetic research is very active, and researchers human skin and was used in treating are working toward integrating this burn victims. technology to patients with various Artificial skin technology has skin-related problems as well as to advanced in many ways since then. develop robotic systems that can mimic For example, “spray-on skin and human touch.” temporary-skin methods involving Bao and the research team are culturing of healthy cells” have been working on a material that can wrap used to focus on burns where cultured prosthetics with electronic skin that cells are applied on damaged skin, can sense pressure, heal when cut, says Beker. In addition, “permanent and process sensory data. The goal skin graft is a method where healthy is to develop “soft yet grippy” elecskin is extracted from the body and applied onto damaged sections on mesh tronic skin—which integrates sensing scaffoldings.” skin (touch, chemical, biological, Taking these types of studies to a and temperature-sensing “skin”) and new level, the team has developed an is built on flexible and stretchable artificial electronic skin concept that substrates that are biocompatible utilizes stretchable semiconductor, and biodegradable, to be powered by conductor, and insulating materials stretchable solar cells and batteries.

PHOTO: Amir Foudeh, Jie Xu, Sihong Wang and Zhenan Bao (Stanford University)

are laser-focused on the technological advances of prosthetic devices, a team at Stanford University is conducting some groundbreaking research in the realm of prosthetic skin. Under the supervision of Zhenan Bao, PhD, the K.K. Lee Professor of Chemical Engineering at Stanford, the Bao Research Group is working on prosthetic skin technology that could have a significant impact on amputees in the years to come. “Once artificial skin technology becomes more prevalent, it would help [the] seamless integration of prosthetic limbs to the human body,” says Levent Beker, PhD, a postdoctoral researcher in the group. Such technology would “decrease the recovery time” for patients and assist them in performing activities of daily living and continuing their day-to-day lives, he says.

Remarkable Progress

This material would allow amputees and burn victims to pick up small objects and, ultimately, allow prosthetics to be wired to the nervous system to deliver a sense of touch.

Benefits for Patients

Artificial skin technology will provide patients the ability to sense pressure, temperature, and texture even after they lose some portion of their skin, according to Beker. “Currently, with the stretchable material technology, several types of sensors can be embedded inside the artificial skin, and researchers are trying to connect these sensors’ output to the nervous system to provide information to the brain.” Achieving that goal will require the development of sensors that have outputs similar to the mechanoreceptors inside the skin. “Usually, conventional sensors output parameters such as capacitance or resistance proportional to pressure or temperature,” explains Beker. “However, mechanoreceptors send information through frequency and amplitude. Therefore, sensors that have similar

output characteristics need to be developed.” The researchers also will need to overcome challenges associated with stimulation of the nervous system. “In order to stimulate the correct nerve via correct stimulation frequency and voltage, necessary materials and electrode technology” will need to be developed, Beker says. Researchers at the Bao Group are working to overcome these challenges so that amputee patients will be able to function more intuitively. “The advantage of the artificial skin technology is that sensors and actuators can easily be implemented inside the system,” explains Beker. “This would help the artificial skin to be able to communicate with devices both outside and inside the human skin.” Current developments in brain-machine interfaces help patients to control prosthetic devices, and “combining the artificial skin concept with this technology would allow a seamless integration between the human body and prosthetics, and help transmission of the required signals to the prosthesis.”

Beker also notes that, as optogenetics technology progresses, new communication paths may allow artificial skin to communicate with the cells inside to develop more sophisticated systems. Over the next 10 to 20 years, patients that need artificial limbs may be able to take advantage of artificial skin technology in two ways, says Beker. “First, the conformal electronic skin can be mounted on the artificial limb and provide touch feeling to the patient. Second, communication between the prosthesis and the nervous system can be made via the artificial skin.” Much work remains to be done to develop prosthetic skin that will benefit amputees and allow for more intuitive prostheses, but significant progress is being made by Bao and her team. Forward-thinking prosthetists should be on the lookout as researchers build a foundation for a new generation of prosthesis users. Christine Umbrell is a contributing writer and editorial/production associate for O&P Almanac. Reach her at cumbrell@contentcommunicators.com.

Realize the facts. O&P care improves quality of life and is cost effective! Learn more at MobilitySaves.org. Reasons to visit MobilitySaves.org

O&P CARE IS A SAVER, NOT AN EXPENSE TO INSURERS!

Visit MobilitySaves.org. Follow us on social media!

Learn about the study proving how orthotic and prosthetic care saves money

Find supporting data to get your device paid for

See how amputees rallied when their prosthetic care was threatened

“Search Mobility Saves” on Facebook, Twitter, and LinkedIn

O&P ALMANAC | OCTOBER 2017

THE GLOBAL PROFESSIONAL Carlos Quelhas' facility, Padrao Ortopedico, features a painted mural, representing the surrounding city, on one of its entryway walls.

Carlos Quelhas Porto, Portugal O&P professional shares experiences as a clinician and business owner O&P ALMANAC: How did you get

your start in the O&P profession?

CARLOS QUELHAS: I went to a univer-

In celebration of the Second O&P World Congress, held in conjunction with AOPAâ&#x20AC;&#x2122;s 100th anniversary celebration September 6-9, in Las Vegas, the O&P Almanac is featuring a question-and-answer section with international O&P experts. Each month, we spotlight an O&P professional from a different part of the world to find out how O&P is practiced across the globe. Carlos Quelhas

Porto, Portugal

OCTOBER 2017 | O&P ALMANAC

Two of Quelhas' team members at work at Padrao Ortopedico from scratch, a prosthetic workshop for military personnel, which I did and ran for nine years, until 1983. At that time, there were no formal schools in Portugal, and all we could learn came from short-term courses, individually organized by some companies, such as Ottobock. In addition, we could go abroad and take short courses. And one time, we invited New York University to come here and give us a course, for three weeks, in lowerlimb prosthetics, above-knee, and also biomechanics, where I think I learned more than ever. So, I had a background in chemistry, good for plastics behavior understanding; I had a background in engineering, which helped in understanding biomechanics; and I had a

PHOTOS: Carlos Quelhas

sity but, with only two years missing to complete a chemistry engineering degree, I decided to abandon the university and go into the Marines; there, I went to Africa, where my country had several wars at the time, in Angola, Mozambique, and Guinea. After almost two years in Africa, I stepped on a landmine and lost my left leg, below the kneeâ&#x20AC;&#x201D;that was the end of my military career. I came back to Portugal and spent the following year at a rehab center and a hospital. At the rehab center, I started being curious about what they were doing and how they did it. I started asking questions, then I asked for books, and, at last, I started to work with them. I was lucky enough that my prosthetist was one of the two men who had been sent by the Portuguese government to New York University in the United States to get a degree in prosthetics, so he was the right person to answer my questions. After a year working as an apprentice, I was sent to Brazil for my first proper course, sponsored by the World Rehabilitation Fund. When I came back, I found a professional environment where the majority of the technicians had not received formal education. It was thus easy for me to find my first job in 1974. After a year, I was invited by the military handicapped association to build for them,

The team at Padrao Ortopedico great passion for all of this. The result was that, for more than 10 years, I taught orthotics and biomechanics in several physiotherapy and occupational therapy courses. And for four years, I taught classes at one of the two official prosthetic schools that are now running in Portugal. In 1983, I decided to go and work for myself. I opened a workshop called Padrao Ortopedico, large for the time, with about 250 square meters. Then, in 2000, I began to be contacted by foreign companies to be their distributor in Portugal. The first one was Blatchford. I accepted and eventually created a second company, also called Padrao Ortopedico, but dedicated to the import and distribution of prosthetic and orthotic components. I also created a third distribution company, called GOBIONIC, which is now owned by three of my oldest employees.

The workshop area at Padrao Ortopedico In 2014, we moved the workshop to a larger, 600-square-meter space, which is more modern and conveniently located in town. Two years ago, we started a joint venture with some people in Holland to work for them, and so we created a new company, the fourth, dedicated to central fabrication, called Excelart. O&P ALMANAC: Describe a typical

work day for you.

QUELHAS: My day starts at 7:30 in the morning and goes until at least 7:00 in the evening from Monday to Friday. Traditionally in Portugal, lunch hour, from 1:00 to 2:00 p.m., is spent at home, where I usually have my meals. Since my distribution company, my workshop, and my home are no more than 5 or 6 kilometers apart, I go back and forth all day long, from distribution to workshop and back. Sometimes we are asked to evaluate a patient in a hospital, and either myself or one of the CPOs working with me will go there to give our opinion. We also have several visitors a year, either from manufacturers or foreign patients, and, on those occasions, our lunch is with them, not at home. O&P ALMANAC: Describe the loca-

tion where you provide services. PHOTOS: Carlos Quelhas

Joel, the facility's mechanical engineer

QUELHAS: We are now located in a brand-new workshop, built from scratch. There is plenty of space and light, plus a large green area outside. We have 20 parking lot spaces for our patients and workers, to ensure

patients never struggle for a space when visiting our facility. O&P ALMANAC: What types of

patients do you typically see, and what types of devices do you fit for these patients?

QUELHAS: Typically, we can divide our patients into three major classes. First, there are the private patients. These are just a few, wealthy people who are looking for a better service. They always come with a doctorâ&#x20AC;&#x2122;s prescription, as in Portugal we are not allowed to make a device for anyone unless prescribed by a doctorâ&#x20AC;&#x201D;and not just any doctor; it has to be a rehab doctor, an orthopedic surgeon, or a vascular specialist. They usually come with prescriptions for microprocessorcontrolled knees, carbon-fiber feet, or bionic hands, so these jobs are usually the most expensive. Second are the military handicapped, such as myself. These individuals [are covered by the government] for everything they like. But since the vast majority of them are now in their 60s or 70s, they do not want dramatic changes in their devices. These patients want more or less the same thing they have been using since they first underwent amputations: belowknee sockets with pelite, articulated feet, quadrilateral or CAT-CAM sockets, friction knees, monocentric and regular. A few of these individuals want more updated components, such as polycentric, hydraulic knees. Third is the general population, which will receive, one way or another, O&P ALMANAC | OCTOBER 2017

Quelhas and his team have been collecting historical O&P pieces, which they display at a museum within their facility. some reimbursement from the government. They are fitted according to prescriptions from the hospital’s doctors, which means that they have a basic prosthesis or orthosis. In addition, thanks to a special partnership we have with an individual in France, we do a lot of work making silicone prostheses, mainly for partial amputations: very cosmetic, nonfunctional, and very expensive. O&P ALMANAC: How are the devices

you provide paid for?

OCTOBER 2017 | O&P ALMANAC

O&P ALMANAC: Describe your

educational background and any certifications you have. How do you keep your skills sharp?

QUELHAS: My formal education was in chemistry, and all the [O&P] skills acquired were throughout the years, in several places; there were no schools at the time. To keep my skills in place, I try to [work on] those more challenging cases, those that require an innovative solution. I love those challenges, such as children with congenital problems that an ordinary prosthesis does not solve—these cases keep me alive and useful.

O&P ALMANAC: What’s the biggest

challenge you face as a practitioner, and how do you deal with it?

QUELHAS: The biggest challenge is that

we cannot do our work as we should; our profession is considered as inferior, and the fact that we must quote for every work we do, without seeing the patient, is the proof that, sometimes, we are not making a prosthesis but just building up components that someone said should be applied. To have qualified people [providing prostheses and orthoses] is expensive, and that is not taken into consideration. In my group, I have three CPOs, one biomedical engineer, and one mechanical engineer, and, to take advantage of their skills, I would need to have freedom to work and that is not the case. We do not have the space to develop and try new solutions. On the other side, we are forced to use silicone liners for almost every patient, which is very expensive and, in my opinion, completely wrong as they only serve, in most cases, to mask a socket’s problems. With the money spent in liners, we could do much better work in the socket or knee. O&P ALMANAC: Describe any chari-

table work you or your organization does. QUELHAS: We have done, from time to time, some devices for people who cannot be included in any of the installed systems. Our charity, if you want to call it that, is to develop, at our expense, new solutions for people and apply them, not receiving for that any money.

PHOTOS: Carlos Quelhas

QUELHAS: Private patients pay for everything. Afterwards, they include the costs in their [tax] declarations. All others have some kind of reimbursement, in a rather complicated system that works more or less like this: • The military patients will not pay anything; the government pays 100 percent of the cost. • Patients sent by insurance companies do not pay for anything; insurance takes care of everything. However, if patients want more expensive items, they must go to court against the company; they usually win. • Public servants will have a partial reimbursement system that will pay more or less for 80 percent of the cost of the device, and this is not bad, considering that the reimbursement charts are updated at least every two years. • Members of the general population, only covered by the National Security System, also have the right to be reimbursed; the problem is

that for them, the reimbursement table was made in 1979, I believe, and as far as I know, never updated; this means that in many cases, the reimbursement, nowadays, is not enough to pay for their trips to the workshop. • There is a very small niche of people, working, who are able to prove, with a doctor’s report, that they could be more efficient if they had a better prosthesis; for those, once again, the reimbursement is 100 percent. The major complication of the system is that most of the paying institutions ask, before making the order, for three different quotations from three different workshops. The institutions then select a workshop not by the quality, but by the price. Thus, in many cases, we are not able to fit what we think we should but what is possible, within the previously given budget.

MEMBER SPOTLIGHT

American Prosthetic Components

Supply Source Wisconsin company offers modular prosthetic components and related O&P equipment

MERICAN PROSTHETIC COMPONENTS LLC (APC)

OCTOBER 2017 | O&P ALMANAC

COMPANY: American Prosthetic Components OWNERS: Privately held PRESIDENT: Jeff Braun LOCATION: Green Bay, Wisconsin HISTORY: 23 years

Jeff Braun

that each prosthetic device they fabricate provides the ideal fit.” The company also offers suspension devices that include their own shuttle locks, pins, and tooling. Carbon fiber and fiberglass are available in different diameters. APC also supplies preforms that are pre-tied carbon layups. The company’s customers are prosthetists, hospitals, and clinics, ranging from facilities with only one office to those with 30 or more. APC sells directly as well as through distributors. The company also has a presence worldwide through distribution in other countries, including Canada, Australia, Germany, Italy, and China. “Our two primary focuses are quality and delivery,” says Braun. While prosthetic components do not require quality testing in the United States, according to Braun, Europe mandates compliance with the International Standards Organization (ISO), and all of APC’s products are designed to meet ISO 10328. APC uses an outside third party to do its ISO 10328 compliance testing. “Our products feature tight tolerances to ensure a good fit between components,” says Brad Curtis, the company’s co-founder. “The standard

industry fasteners have a zinc coating and are designed to resist 96 hours of salt spray testing. We have our fasteners specially coated, and that increases the water resistance in our titanium adult and pediatric line to more than 1,500 hours of salt spray testing. The benefit to practitioners is they don’t have to fight with rusty screws, which can be a major issue with modular components.” “These water-resistant fasteners, used in conjunction with our drain hole clamps and pylons, allow prosthetists to use our components with confidence in a water leg or a shower leg device,” adds Braun. APC offers a five-year warranty on modular components. The company offers free etching on pylons to its direct customers, including practitioners, hospitals, and clinics. Some choose company logos. Military branch logos, such as those of the U.S. Army and Marines, also are available. Ensuring fast delivery is a priority for APC. With the exception of custom-etched pylons, most components ordered before 2:00 p.m. ship the same day, says Curtis. APC invests in research and development, which is done in-house, often relying on feedback from clinicians who are looking for a particular product or who have suggestions for improving existing ones. Looking ahead, Braun plans for continued growth. “We stand out thanks to our ISO testing, excellent quality, and fast delivery,” he says. “Our customer service is second to none—a human being will always answer the phone. What we do is critical for people to make their lives whole, and we are committed to doing our best for everyone involved.” Deborah Conn is a contributing writer to O&P Almanac. Reach her at deborahconn@verizon.net.

PHOTOS: American Prosthetic Components

has been providing components to the prosthetic industry since 1994. In 2011, the company was purchased by Beverly Capital. APC has invested heavily in new technology and other efforts to expand the business, and it’s working—the company has grown more than 40 percent in the last two years alone, says Jeff Braun, APC president and chief executive officer. Located in Green Bay, Wisconsin, APC added about 14,000 square feet to its facility last year, increasing its space to more than 25,000 square feet. The building houses all manufacturing, distribution, engineering, and administrative functions. APC has 24 full-time employees in Green Bay. APC manufactures modular prosthetic components for lower-limb amputees, which are designed in standard adult, heavy-duty, and pediatric versions. The standard titanium line has a wide variety of options, and the majority of its components are rated to 365 lbs. The stainless adult component line has a rating of 300 lbs., the titanium heavy-duty line is rated to 500 lbs., and the titanium pediatric line is rated to 132 lbs. The company offers different types of alignment adaptors that include offset pyramids, offset plates, flexion plates, slide adaptors, and adjustable dual adaptors. It also offers different clamping adaptors to achieve optimal alignment. “I look at our offerings as an erector set of components,” says Braun. “We provide prosthetists the tools to make adjustments so

By DEBORAH CONN

Who is an innovator? Who is held to the highest O&P standards? Who is committed to life-long learning? I AM. I am a big part of great possibilities.

I AM ABC. Visit abcop.org today to find out what ABC can do for you. 703.836-7114

MEMBER SPOTLIGHT

Precision Orthotics & Prosthetics

By DEBORAH CONN

Social Engagement Vegas facility demonstrates a commitment to its patients and the surrounding community

IMMY COLSON, CO, WILL

OCTOBER 2017 | O&P ALMANAC

Jimmy Colson, CO (left), and Jeff Eschenburg, CP

FACILITY: Precision Orthotics & Prosthetics LOCATIONS: Las Vegas and Henderson, Nevada OWNER: Jimmy Colson, CO HISTORY: 13 years

Jimmy Colson, CO

strength in continuity of care, as most employees have been with the facility for at least five years. The company’s lead prosthetist, Jeff Eschenburg, CP, is an above-knee amputee himself as the result of a farming accident when he was 12. Eschenburg, who spent four years working with surgeons in Michigan to improve amputation techniques, has a special rapport with patients as the result of his own experience, says Colson. “Our patients deserve someone who knows what they have been through,” he says. Some of the facility’s patients are highly engaged in athletic endeavors. One patient, an above-knee amputee, has been ranked number one in the world in para-skeleton. Colson says he gets chills watching him compete. “It is unbelievable how fast he

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

PHOTOS: Precision Orthotics & Prosthetics

be the first to tell you that he has come a long way. “I was raised by heroin addicts and was homeless on and off until I was 20 years old,” he says. But his first job in the field, working as a tech at Nevada Limb and Brace for $7 an hour, sparked a love for the O&P industry. Colson obtained his GED, became certified by the Board of Certification/Accreditation as a fitter and then as an orthotist, and eventually became certified as an orthotist by the American Board for Certification in Orthotics, Prosthetics, and Pedorthics. Colson worked for Hanger after it acquired Nevada Limb and Brace, until he decided to open his own facility, Precision Orthotics & Prosthetics, in October 2004. The fledgling company had exactly one employee—Colson, who mortgaged his house and worked a second job as a nightclub promoter to get things started. Today the business employs 18, including a prosthetist, an orthotist, a pedorthist, and three prosthetist-orthotists. Colson’s wife, Sara Colson, is a certified mastectomy fitter. The main facility is in Las Vegas, with a fulltime smaller office in Henderson, about 15 miles away. Three technicians fabricate nearly all devices in Precision’s lab, although the facility uses a digital scanner to outsource cranial helmets. Precision O&P’s business is about 40 percent prosthetics, says Colson, who notes, “We can be working on 30 prostheses at once.” He cites the facility’s

goes—he is fearless!” Another patient, a bilateral amputee, is a Purple Heart recipient who travels with the Veterans Golf Tour. Most of Precision’s marketing efforts center on word of mouth, a company website, and social media pages, as well as advertising on television. “We also appeal to the Hispanic population because we have bilingual practitioners on staff,” including Yahve Gonzalez, BOCO, lead orthotist and pediatric specialist, says Colson. Colson emphasizes Precision O&P’s commitment to its community. The company and its staff have sponsored families, fit homeless people with shoes, and worked with local cancer organizations. “A couple of years ago, we received congressional recognition for our community service work,” he says. “Because I grew up poor, I have a special place in my heart for these families.” Looking ahead, Colson would like to expand into different states. He is considering offers to open facilities in Utah, Arizona, and Hawaii. No matter how large the company grows, Colson’s focus will remain on the individuals he serves. “We get to know each and every patient. They definitely feel like they are part of something special, a part of the [Precision] family,” he says. “This business means the world to me, and I want to make it a good experience for everyone who walks through our doors.”

NEW! Co-OP

Co-OP

An AOPA Member Benefit As an online reimbursement, coding, and policy resource, this site includes a collection of detailed information with links to supporting documentation for the topics most important to AOPA Members. Like a Wikipedia of all things O&P, the Co-OP incorporates a crowdsourcing component, which is vetted by AOPA staff, to garner the vast knowledge and experience of our membership body.

Resources include: • State-specific insurance policy updates, • L code search capability, • Data and evidence resources, and so much more!

Learn more and sign up at

www.AOPAnet.org/co-op. www.AOPAnet.org

AOPA NEWS

AOPAversity Webinars OCTOBER 11

NOVEMBER 8

Gift Giving: Show Your Thanks & Remain Compliant Demonstrate your appreciation to patients and referral sources while adhering to the guidelines surrounding gift giving. AOPA experts will explore the following topics: • When are gifts to referral sources acceptable? • When are gifts to patients acceptable? • What do you need to know about the federal antikickback regulations? • What are some tips for creating a compliant gift-giving policy?

AFO/KAFO Policy Make sure you know all of the rules and requirements outlined in the Ankle-Foot Orthosis/Knee-Ankle-Foot Orthosis (AFO/KAFO) Policy. Hear from experts who will share their knowledge and answer the following questions: • What documentation must exist in order to use the KX modifier on a claim? • What are the coverage rules for AFOs with ambulatory versus nonambulatory patients? • How should repairs to AFOs and KAFOs be billed? • When is it acceptable to use a custom-fabricated AFO/KAFO? • What are the major components of a Medicare medical policy?

AOPA members pay $99 (nonmembers pay $199), and any number of employees may participate on a given line. Attendees earn 1.5 continuing education credits by returning the provided quiz within 30 days and scoring at least 80 percent. Register at bit.ly/2017webinars. Contact Ryan Gleeson at rgleeson@AOPAnet.org or 571/431-0876 with questions. Sign up for the half-year series and get three sessions FREE! This includes two bonus webinars added for Health-Care Compliance & Ethics Week Nov. 5-11. All webinars that you missed will be sent as a recording. Register at bit.ly/2017billing.

OCTOBER 2017 | O&P ALMANAC

Products & Services For Orthotic, Prosthetic & Pedorthic Professionals

AOPA Coding Experts Are Coming to Phoenix, AZ

EARN 14 CEs

PHOENIX

NOV. 6-7 | 2017

AOPA MASTERING MEDICARE:

Top 10 reasons to attend:

ESSENTIAL CODING & BILLING TECHNIQUES SEMINAR

Get your claims paid.

Increase your company’s bottom line.

Stay up-to-date on billing Medicare.

Code complex devices

Earn 14 CE credits.

Learn about audit updates.

Overturn denials.

Submit your specific questions ahead of time.

Advance your career.

Join AOPA November 6-7 in Phoenix to advance your O&P practitioners’ and billing staff ’s coding knowledge. Join AOPA for this two-day event, where you will earn 14 CEs and get up-to-date on all the hot topics. AOPA experts provide the most up-to-date information to help O&P practitioners and office billing staff learn how to code complex devices, including repairs and adjustments, through interactive discussions with AOPA experts, your colleagues, and much more. Meant for both practitioners and office staff, this advanced two-day event will feature breakout sessions for these two groups, to ensure concentration on material appropriate to each group. Don’t miss the opportunity to experience two jam-packed days of valuable O&P coding and billing information. Learn more and see the rest of the year’s schedule at bit.ly/2017billing.

10. AOPA coding and billing experts have more than 70 years of combined experience.

Sheraton Grand Phoenix 340 North 3rd St, Phoenix, AZ Book by October 13 for the $179/night rate. bit.ly/2017billing Find the best practices to help you manage your business.

Participate in the 2017 Coding & Billing Seminar! Register online at bit.ly/2017billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. .

www.AOPAnet.org

O&P PAC UPDATE

2017

with a

PURPOSE

HE O&P PAC UPDATE

provides information on the activities 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*: • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 60

Jeffrey Alaimo, CP Lisa Arbogast Vinit Asar Gerald Bernar Jr., CP, LP Devon Bernard David Boone, PhD, CP, MPH Frank Bostock, CO Jim Campbell, PhD, CO, FAAOP Tina Carlson, CMP William Carver, BOCP Doyle Collier, CP Robert Compton, CPed Kenneth Cornell, CO Don DeBolt Edward De La Torre Joseph DeLorenzo, CP Thomas DiBello, CO, LO, FAAOP Mitchell Dobson, CPO, FAAOP Traci Dralle Ted Drygas, CPO A.J. Filippis, CPO K. Michael Fillauer, CPO Thomas Fise, JD Esperanza Friedman, CO Arlene Gillis, CP, FAAOP Elizabeth Ginzel, CPO, LPO Ryan Gleeson Eddy Gosschalk, CPO Elizabeth Hammer, BOCO, CFO Michael Hamontree OCTOBER 2017 | O&P ALMANAC

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Steven Herrera, CPO Denise Hoffman Michele Hogan Ralph Hooper, CPO Jack Jones Jr., BOCO, CO John Kenney, CPO, FAAOP Curt Kowalczyk, CO Alfred Kritter, CPO, FAAOP Robert Leimkuehler, CPO Betty Leppin Eileen Levis Sam Liang Anita Liberman-Lampear, MA Elizabeth Mansfield Brad Mattear, LO, CPA Yelena Mazur Dave McGill Martin McNab, CPO Joseph McTernan Andrew Meyers, CPO Wendy Miller, BOCO, CDME Catherine Mize, CPO Aaron Moles, CPO Kelly O’Neill, CEM Michael Oros, CPO, FAAOP Curt Patton, CP Don Pierson, CO, CPed Walter Racette, CPO(E) Ricardo Ramos, CP, CPed, LP Jack Richmond, CPOA Dewain Ritchie John Roberts, CPO Duane Romo, CPO Bradley Ruhl Ivan Sabel Scott Sabolich, CP Scott Schneider Dale Sheen, CO David Sisson, CP Mark Smith, CP Chris Snell, BOCO Ronald Snell, CP

• • • • • • • • • •

William Snell, CPO Jack Steele, CO Bernie Veldman, CO Frank Vero, CPO James Weber, MBA Jay Wendt, MBA Jeff Wensman, CPO Ashlie White Eddie White, CP Shane Wurdeman, PhD, CP, FAAOP, MSPO • James Young Jr., CP, LP, FAAOP • Pam Young The purpose of the O&P PAC is to advocate for legislative or political interests at the federal level, which 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 individuals who support the orthotic and prosthetic community. To participate in, support, and receive additional information about the O&P PAC, federal law mandates that eligible individuals must first sign an authorization form, which may be completed online: https://aopa.wufoo. com/forms/op-pac-authorization.

*Due to publishing deadlines this list was created on Sept. 15, 2017, and includes only donations/contributions made or received between July 24 and Sept. 15, 2017. Any donations/contributions made or received on/or after Sept. 15, 2017, will be published in the next issue of the O&P Almanac.

NEW MEMBERS

HE 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. At the end of each new facility listing is the name of the certified or state-licensed practitioner who qualifies that patient-care facility for membership according to AOPA’s bylaws. Affiliate members do not require a certified or state-licensed practitioner to be eligible for membership. At the end of each new supplier member listing is the supplier level associated with that company. Supplier levels are based on annual gross sales volume.

Alliance Orthotics and Prosthetics LLC 800 E. California Street, Ste. 1 Gainesville, TX 76240 940/668-1118 Member Type: Patient-Care Facility Alan Sheppard Capstone Orthopedic 19845 Lake Chabot Road, Ste. 302 Castro Valley, CA 94546 510/537-1210 Member Type: Patient-Care Facility Glen Ellis Cotton Orthotic and Prosthetic Associates LLC 6311 W. 110th Street Overland Park, KS 66211 913/338-2672 Member Type: Patient-Care Facility Daniel Cotton

Ergoresearch Ltd. 2101 Le Carrefour, Ste. 200 Laval, QC H7S2J7 Canada 450/973-6700 Member Type: International Sylvain Boucher Family Foot Health Specialists PC 718 Lomas Blvd. NW Albuquerque, NM 87102 505/843-6464 Member Type: Patient-Care Facility Foot Care Store 3281 Fairlane Ruins Road, Ste. 7 Wellington, FL 33414 561/791-1213 Member Type: Patient-Care Facility Bruce Newman, CPed

Inmotion Prosthetics & Orthotics LLC 5309 Wurzbach Road, Ste. 200-8 San Antonio, TX 78238 210/465-9113 Member Type: Patient-Care Facility Elkin Echeverri Limbionics of Raleigh Inc. 3824 Barrett Drive, Ste. 102 Raleigh, NC 27609 919/441-0023 Member Type: Patient-Care Facility Marco Calcagno Macy O&P LLC 305 Flanders Road, Ste. 6 East Lyme, CT 06333 860/333-5558 Member Type: Patient-Care Facility Maughan Prosthetic & Orthotic Inc. 9220 Ridgetop Blvd. NW, Ste. 110 Silverdale, WA 98383 360/698-2229 Member Type: Patient-Care Facility Justin Maughan, CPO, LPO Mid State Artificial Limb Co. Inc. P.O. Box 31092 Jackson, MS 39286 601/981-2229 Member Type: Patient-Care Facility Troy Luster Nevada Orthotics & Prosthetics 3435 W. Cheyenne Avenue, Ste. 102 North Las Vegas, NV 89032 702/233-5500 Member Type: Patient-Care Facility Petra Thiessen, CFm

Prosthetic & Orthotic Group Orange County 26300 La Alameda, Ste. 120 Mission Viejo, CA 92691 949/272-2237 Member Type: Affiliate Parent Company: Prosthetic & Orthotic Group Inc. Reliable Prosthetics and Orthotics 1505-C S. Glenburnie Road New Bern, NC 28562 252/638-8989 Member Type: Patient-Care Facility Todd Ank, BOCPO Reseda Prosthetics Inc. 18441 Bryant Street Northridge, CA 91325 818/993-5441 Member Type: Patient-Care Facility Jeff Vranesh Ropp Orthopedic Clinic 2075 East West Maple, Ste. B 207 Commerce, MI 48390 248/669-9222 Member Type: Patient-Care Facility TOPMED 755 Grande Allée Ouest Québec, QC G1S1C1 Canada 418/780-1301 Member Type: Institution Claude Morin Youngstown Orthopaedic Associates 6470 Tippecanoe Road Canfield, OH 44406 330/758-0577 Member Type: Patient-Care Facility Lori Sapp

O&P ALMANAC | OCTOBER 2017

MARKETPLACE

Feature your product or service in Marketplace. Contact Bob Heiman at 856/673-4000 or email bob.rhmedia@comcast.net. Visit bit.ly/almanac17 for advertising options.

Another Interface Innovation From Allard USA Available Now!

CoverKIT™ 2.0

Provides a smooth surface that extends from the top of the anterior shell all the way down the strut to the foot plate, allowing pant legs to slide easily over the brace and at the same time keeps the brace in position without the need for straps. • CoverKIT™ 2.0 has the same SoftKIT™ padding that protects the skin. • Kit includes two narrow neoprene pads to create a pressure-free channel to help relieve any potential discomfort from boney prominences. • Available in sizes XS–XL. For more information, contact customer service at 888/678-6548 or info@allardusa.com to order yours today!

ALPS Flex Sleeve ALPS New Flex Sleeve (SFX) is a new seamless knitted construction. It features ALPS HD Gel which has a relatively firm nature and provides maximum comfort while providing a great degree of control. The SFX has a 30° pre-flexion which allows for ease of bending and reduces bunching behind the knee. For more information, contact ALPS at 800/5745426 or visit www.easyliner.com.

Custom Stealth Foot Orthotics Custom carbon-fiber foot orthotics—and boy, are they pretty. And strong. And lightweight. Trusted to protect the feet of our service members, this beauty goes more than skin deep. Fabrication available from foam boxes or Amfit digital files in two rigidities (firm or flex). Corrections and adjustments are molded into the carbon fiber to eliminate movement of pads and edges during wear. EVA heel counter maintains stability in the shoe or boot. Contact our customer service team to learn more today, orders@amfit.com or 800/356-FOOT(3668), x250.

OCTOBER 2017 | O&P ALMANAC

Foam Box Lab Services for Diabetic, EVA, and Rigid Orthotics FootPrinter allows you to send your own boxes or use ours. Standard EVA orders manufactured in three to four business days; diabetic A5513, carbon fiber, and polypro in three to five days. PDAC-approved A5513 diabetic pricing includes shipping costs for bi-lam and tri-lam styles. EVA available in soft, medium, dual, firm, and cork blend. Carbon-fiber fabrication offered in flex or firm to best suit your patient. Milled polypropylene available in three widths and thicknesses for excellent fit and wear. Get started right away by emailing orders@amfit.com for an account form, or call 800/356-FOOT.

Custom Sockets When You Need Them Custom sockets and systems are made from your measurements and adhere to the patented design principles established in our standard sizes. Shown here from left to right, Flexion Contracture, Ischial Weight Bearing Transtibial, Symes, and Knee Disarticulation custom sockets. At FLO-TECH® custom sockets and systems are shipped on the same day as ordered, if order is received prior to noon Eastern Standard Time. We also have components for all systems. More info at www.1800flo-tech.com.

LEAP Balance Brace Hersco’s Lower-Extremity Ankle Protection (LEAP) brace is designed to aid stability and proprioception for patients at risk for trips and falls. The LEAP is a short, semirigid ankle-foot orthosis that is functionally balanced to support the foot and ankle complex. It is fully lined with a lightweight and cushioning Velcloth interface, and is easily secured and removed with two Velcro straps and a padded tongue. For more information, call 800/301-8275 or visit www.hersco.com.

MARKETPLACE Ottobock Dynamic Vacuum System (DVS) The Dynamic Vacuum System (DVS) bridges the gap between valve and Harmony socket technology. Integrating innovative design with simplicity, the DVS reduces the movement between the limb and socket associated with limb volume fluctuations. The DVS generates vacuum during walking and maintains this elevated vacuum in both swing and stance phase. This sets it apart from passive systems, such as valve, where a vacuum is only generated in the swing phase. Increased suspension forces and intimate fit enhances the user’s perception of the ground beneath them. Dynamically, it adjusts to the user’s activity level. Call your local sales representative at 800/328-4058 or go to professionals.ottobockus.com.

design. dexterity. intelligent motion.

Catalyst•Propel OA Now Available in Custom

Designed to reduce the pain of knee osteoarthritis, and increase stability by reducing pressure, the Catalyst•Propel OA’s defining feature is its dual Q-hinges, which provide the ability to change the overall valgus/varus angle of the brace for optimal correction leverage. In addition, the Catalyst•Propel OA’s patented Active Thigh Cuff (ATC) reduces migration and enables a more custom fit in a mechanically adaptable system that moves with the thigh musculature through the full range of motion. Catalyst•Propel OA is now available in a custom brace, orderable through the easy-to-use eCast app. For more information, call 800/652-1135 or visit www.vqorthocare.com.

2017 AOPA Coding Products • Smarter: Uses simple gestures to change grips. • Faster: Boost digit speed by up to 30 percent. • Smaller: New form-fitting anatomical design reduces profile in every dimension. For more information, contact Touch Bionics Inc. at (855)MY iLimb or visit www.touchbionics.com.

AOPA Compliance Guide CD—Updated This Compliance Handbook helps patientcare facilities follow the fraud and abuse prevention guidelines recommended by the Office of the Inspector General. This product will assist you in developing a compliance plan for your facility, including guidelines for developing a standard of conduct, billing policies and procedures, and much more. With the help of the AOPA Compliance Handbook CD, you will be able to create an effective audit/quality assurance program to monitor compliance and conduct introductory training sessions for employees. • AOPA Compliance Guide CD—Updated: $159 AOPA members, $318 nonmembers

Get your facility up to speed, fast, on all of the O&P Health-Care Common Procedure Coding System (HCPCS) code changes with an array of 2017 AOPA coding products. Ensure each member of your staff has a 2017 Quick Coder, a durable, easy-to-store desk reference of all of the O&P HCPCS codes and descriptors. • Coding Suite (includes CodingPro single user, Illustrated Guide, and Quick Coder): $350 AOPA members, $895 nonmembers • CodingPro CD-ROM (single-user version): $185 AOPA members, $425 nonmembers • CodingPro CD-ROM (network version): $435 AOPA members, $695 nonmembers • Illustrated Guide: $185 AOPA members, $425 nonmembers • Quick Coder: $30 AOPA members, $80 nonmembers Order at www.AOPAnet.org or call AOPA at 571/431-0876.

Order at www.AOPAnet.org or call AOPA at 571/431-0876.

O&P ALMANAC | OCTOBER 2017

AOPA NEWS

CAREERS Pacific

Opportunities for O&P Professionals

CPO, CO, CP, CPed, and Lab Technician

Job location key:

Chino and Temecula, California

- Northeast

We are a growing well-established, privately owned, multioffice, ABC-accredited O&P corporation providing services in Southern California looking to add to our team. We are currently looking for experienced CPO, CO, CP, CPed, and lab technicians who will support the company’s vision, mission, and values and provide premier prosthetic and orthotic patient care. Employment opportunities for practitioners currently in Chino and Temecula. Candidates must be energetic and motivated individuals who possess strong clinical, technical, and interpersonal interaction skills. They also must be patient oriented and innovative, and desire a long-term career with a growing company. A rewarding place to take the next step in establishing a great career and make a difference. We offer competitive salaries and benefits. Salaries are commensurate with experience. Local ABC-accredited practitioners preferred. Send résumé to:

- Mid-Atlantic - Southeast - North Central - Inter-Mountain - Pacific

Hire employees and promote services by placing your classified ad in the O&P Almanac. When placing a blind ad, the advertiser may request that responses be sent to an ad number, to be assigned by AOPA. Responses to O&P box numbers are forwarded free of charge. Include your company logo with your listing free of charge. Deadline: Advertisements and payments need to be received one month prior to publication date in order to be printed in the magazine. 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. Submit ads by email to landerson@AOPAnet. org or fax to 571/431-0899, along with VISA or MasterCard number, cardholder name, and expiration date. Mail typed advertisements and checks in U.S. currency (made out to AOPA) to P.O. Box 34711, Alexandria, VA 22334-0711. Note: AOPA reserves the right to edit Job listings for space and style considerations.

Human Resources Fax: 951/734-1538 Email: careers@inlandlimbandbrace.com

O&P Almanac Careers Rates Color Ad Special 1/4 Page ad 1/2 Page ad

Member $482 $634

Nonmember $678 $830

Listing Word Count 50 or less 51-75 76-120 121+

Member Nonmember $140 $280 $190 $380 $260 $520 $2.25 per word $5 per word

ONLINE: O&P Job Board Rates Visit the only online job board in the industry at jobs.AOPAnet.org. Job Board

Member Nonmember $85 $150

For more opportunities, visit: http://jobs.aopanet.org.

A large number of O&P Almanac readers view the digital issue— If you’re missing out, apply for an eSubscription by subscribing at bit.ly/AlmanacEsubscribe, or visit issuu.com/americanoandp to view your trusted source of everything O&P.

OCTOBER 2017 | O&P ALMANAC

Mid-Atlantic

Orthotist, Orthotist/Prosthetist, Certified Fitter, ABC/BOC Orthotist Ohio

COOPC, established in 1991, is a well-established multifacility company in central Ohio with two openings currently available: 1) licensed orthotist or licensed orthotist/prosthetist, and 2) certified fitter or ABC/BOC orthotist. COOPC offers a great benefits package and salary that's commensurate with skills and experience.

Contact: Sherri Smith Phone: 614/231-4256 Fax: 614/231-0127 Web: www.COOPC.org Email: 231HALO@coopc.org

CAREERS

Inter-Mountain: For Sale

Northeast

Small Community O&P Business for Sale

Clinical Educator Rockaway, New Jersey

Allard USA, the world leader in Carbon Fiber AFOs, is seeking a clinical educator. • We are looking for a dynamic CPO/CO to provide technical support and educational programs to our customers and staff. • Candidates must be able to write and develop educational programs, and review and edit technical literature and collateral support materials. • Ability to communicate to both small and large groups of medical professionals is required. • Allard USA will provide a competitive salary and an excellent benefits package to the right candidate. If you are ready to join a winning team, email your résumé or CV to Maria.Overton@AllardUSA.com, or mail to: Allard USA 300 Forge Way, Ste. 3 Rockaway, NJ 07866 Attn: Human Resources Department

The Source for Orthotic & Prosthetic Coding

Mid Texas CPO working about 16 hours per week desires sale of seven-year-old P&O practice in small mid-Texas city. Approximately 100,000 people live in primary market area (city and surrounding communities). 188-bed regional medical hospital with 53+ physicians and 600 employees in community as well as a standalone day surgery center managed by a large community hospital in another city. 1,700-square-foot facility with one year left on a three-year lease, renting for $700/month. Experienced office administrator experienced with OPIE medical office management software currently works 33 hours a week and is willing to work for several years more. Could be a good satellite office or start-up practice for young practitioner. Gross billings are $180,000 to $220,000 per year with net cash income of $150,000 to $175,000. Multiple up-side potential possibilities for increasing sales, including myoelectric upper-limb and microprocessor lower-limb services as well as high-tech orthotic services. Very reasonable price and terms. For more information, email info@aopanet.org and reference “October ad—Texas practice.”

Morning, noon, or night— LCodeSearch.com allows you access to expert coding advice—24 hours a day, 7 days a week.

HE O&P CODING EXPERTISE the profession has come to rely on is available online 24/7! LCodeSearch.com allows users to search for information that matches L Codes with products in the orthotic and prosthetic industry. Users rely on it to search for L Codes and manufacturers, and to select appropriate codes for specific products. This exclusive service is available only for AOPA members.

Log on to LCodeSearch.com and start today. Need to renew your membership? Contact Betty Leppin at 571/431-0876 or bleppin@AOPAnet.org.

NEW

Manufacturers: for 2017! AOPA is now offering Enhanced Listings on LCodeSearch.com. Don’t miss out on this great opportunity for buyers to see your product information! Contact Betty Leppin for more information at 571/431-0876.

www.AOPAnet.org

O&P ALMANAC | OCTOBER 2017

CALENDAR

2017

November 6-11

October 11

AFO/KAFO Policy. Register online at bit.ly/2017webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org. Webinar Conference

ABC: Written and Written Simulation Certification Exams. ABC certification exams will be administered for orthotists, prosthetists, pedorthists, orthotic fitters, mastectomy fitters, therapeutic shoe fitters, orthotic and prosthetic assistants, and technicians in 300 locations nationwide. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

October 26-27

International African-American Prosthetic Orthotic Coalition Annual Meeting. Atlanta Marriott Suites Midtown, 35 14th Street NE, Atlanta, GA 30309. For more info, visit www.iaapoc.org or contact Tony Thaxton Jr. at thaxton.jr@comcast.net or 404/875-0066.

ABC: Application Deadline for Certification Exams. Applications must be received by November 1 for individuals seeking to take the January Written and Written Simulation certification exams. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

Health-Care Compliance & Ethics Week 2017. AOPA will be celebrating Health-Care Compliance & Ethics Week and will be providing resources to help members celebrate.

November 6-7

2017 Mastering Medicare: Essential Coding & Billing Seminar Coding & Billing Techniques Seminars. Phoenix. Sheraton Grand Phoenix, 340 N. 3rd Street, Phoenix. Book by October 13 for the $179 rate by calling 800/325-3535 or by calling the hotel directly at 602/262-2500. Register online at bit.ly/2017billing. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

Teaching Professionalism and Ethics During Residency. For more information, email Ryan Gleeson at rgleeson@ AOPAnet.org.

November 20

Inaugural Gavin Scoliosis Program Certification Course. SERC at the North American Spine Society Headquarters, 7075 Veterans Blvd., Burr Ridge, IL 60527. Convenient housing next door at the Spring Hill Suite, Marriott. ABC credits available. • Learn how to get in brace corrections appropriate to curve types. • Learn how to maintain balance. • Learn proper follow-up and how that affects outcomes. Contact GSP@gavinorthoticsconsulting.com.

Apply Anytime!

Apply anytime for COF, CMF, CDME; test when ready; receive results instantly. Current BOCO, BOCP, and BOCPD candidates have three years from application date to pass their exam(s). To learn more about our nationally recognized, in-demand credentials, or to apply now, visit www.bocusa.org.

Let us

your next event!

Free Online Training

Cascade Dafo Institute. Now offering a series of seven free ABC-approved online courses, designed for pediatric practitioners. Earn up to 10.25 CEUs. Visit cascadedafo.com or call 800/848-7332.

CE For information on continuing education credits, contact the sponsor. Questions? Email landerson@AOPAnet.org.

Calendar Rates

“Three Amigos” of a Compliance Program— Compliance Officer, Legal, and Human Resources— Can Work Together To Support and Advance an Effective Compliance Program. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

November 10

November 5-11

Gift Giving: Show Your Thanks and Webinar Conference Remain Compliant. Register online at bit.ly/2017webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

November 9

November 1

www.bocusa.org

November 8

CREDITS

Phone numbers, email addresses, and websites are counted as single words. Refer to www.AOPAnet.org for content deadlines. Send announcement and payment to: O&P Almanac, Calendar, P.O. Box 34711, Alexandria, VA 22334-0711, fax 571/431-0899, or email landerson@AOPAnet.org along with VISA or MasterCard number, the name on the card, 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.

OCTOBER 2017 | O&P ALMANAC

Words/Rate

Member

Nonmember

25 or less

$40

$50

26-50

$50 $60

51+

$2.25/word $5.00/word

Color Ad Special 1/4 page Ad

$482

$678

1/2 page Ad

$634

$830

CALENDAR December 1

ABC: Practitioner Residency Completion Deadline for January Written & Written Simulation Certification Exams. All practitioner candidates have an additional 30 days after the application deadline to complete their residency. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

December 7-9

Shirley Ryan AbilityLab: Elaine Owenâ&#x20AC;&#x201D;Pediatric Gait Analysis: Segmental Kinematic Approach to Orthotic Management. Chicago. 25.5 ABC credits. For more information, contact Melissa Kolski at 312/238-7731 or visit www.sralab.org/education.

December 13

New Codes and Other Updates for 2018. Webinar Conference Register online at bit.ly/2017webinars. For more information, email Ryan Gleeson at rgleeson@AOPAnet.org.

2018

January 19-20

ABC: Orthotic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

January 26-27

ABC: Prosthetic Clinical Patient Management (CPM) Exam. ABC Testing Center, Tampa. Contact 703/836-7114, email certification@abcop.org, or visit www.abcop.org/certification.

February 23-24

PrimeFare Central Regional Scientific Symposium 2018. Renaissance Hotel, Tulsa, OK. Contact Cathie Pruitt, 901/359-3936, email primecarepruitt@gmail.com; or Jane Edwards, 888/388-5243, email jledwards88@att.net; or visit www.primecareop.com.

April 26-28

New York State Chapter Annual Meeting (NYSAAOP). Rivers Casino & Resort, Schenectady, NY 12308. For more information, visit www.NYSAAOP.org

September 26-29

January 5-7

AOPA Leadership Conference. The Breakers, Palm Beach, FL. Top executives at each AOPA member company are invited to this exclusive event. Contact landerson@AOPAnet.org for more information.

January 8-13

AOPA National Assembly. Vancouver Convention Center. For general inquiries, contact Ryan Gleeson at 571/431-0876 or rgleeson@AOPAnet.org, or visit www.AOPAnet.org.

2019 September 25-28

AOPA National Assembly. San Diego Convention Center. For general inquiries, contact Ryan Gleeson at 571/431-0876 or rgleeson@AOPAnet.org, or visit www.AOPAnet.org.

ADVERTISERS INDEX

Company

Page Phone

Website

ABCOP Allard USA ALPS South LLC Amfit

55 9 15 33

703/836-7114 www.abcop.org 888/678-6548 www.allardusa.com 800/574-5426 www.easyliner.com 800/356-3668 www.amfit.com

Amputee Coalition

800/267-5669

Cailor Fleming Insurance Ferrier Coupler Inc. Flo-Tech O&P Systems Inc. Hersco Ottobock Touch Bionics VQ Orthocare

5 27 17 1 C4 35 7

800/796-8495 www.cailorfleming.com 810/688-4292 www.ferrier.coupler.com 800/356-8324 www.1800flo-tech.com 800/301-8275 www.hersco.com 800/328-4058 www.professionals.ottobockus.com 855/694-5462 www.touchbionics.com 800/652-1135 www.vqorthocare.com/ecast

www.amputee-coalition.org

O&P ALMANAC | OCTOBER 2017

ASK AOPA CALENDAR

All About A5513 Recent publications provide guidance on proper use of the custom diabetic insert code

AOPA receives hundreds of queries from readers and members who have questions about some aspect of the O&P industry. Each month, we’ll share several of these questions and answers from AOPA’s expert staff with readers. If you would like to submit a question to AOPA for possible inclusion in the department, email Editor Josephine Rossi at jrossi@contentcommunicators.com.

On Aug. 10, 2017, the Pricing, Data Analysis, and Coding (PDAC) contractor announced that, based on the previously published coding clarification, it would initiate a Coding Redetermination Project for diabetic inserts described by A5513. As part of this project, all previous A5513 PDAC coding verifications will be end-dated effective May 31, 2018. Manufacturers and central fabrication facilities that wish to have their products PDAC-verified for A5513 will need to submit a new application to the PDAC. This applies to both new products and existing products that were previously verified by the PDAC.

What is the current status regarding the use of A5513 to bill Medicare for custom diabetic inserts?

Q/ A/

On July 13, 2017, the durable medical equipment Medicare administrative contractors published a joint publication addressing the proper use of Health-Care Common Procedure Coding System code A5513, which is used to describe molded-to-patientmodel diabetic shoe inserts. The joint publication indicates that in order to meet the requirements of the code descriptor, diabetic inserts billed using A5513 must be molded over an actual model of the patient’s foot. The use of generic, electronic, or “virtual” models, where custom fabrication occurs without creation of a physical model of the patient’s foot, does not meet the code descriptor, and diabetic inserts fabricated this way cannot be billed as A5513. According to the joint publication, inserts fabricated using generic, electronic, or virtual models must be coded as A9270, noncovered service. 68

OCTOBER 2017 | O&P ALMANAC

What about custom-molded diabetic inserts that are fabricated within my own facility?

While inserts manufactured within the walls of an O&P practice for delivery to Medicare patients of that practice do not require a PDAC coding verification, providers must, upon request by the PDAC, provide sample inserts and a description of the process used to fabricate the inserts. Any inserts billed as A5513 that are manufactured within the walls of an O&P practice must meet the revised definition for A5513 and must include the creation of a physical model of the patient’s foot as part of the fabrication process.

What happens if a manufacturer has not received coding verification for A5513 on or prior to June 1, 2018?

Products that have previously been verified by PDAC as appropriate for A5513 can continue to be billed using A5513 until May 31, 2018. Products that have not been reverified by PDAC as meeting the requirements of the code descriptor for A5513 by June 1, 2018, must be billed using A9270, noncovered service.

Will new products have to be PDAC-verified for A5513 prior to June 1, 2018?

The PDAC has indicated that applications should be submitted well in advance of the May 31, 2018, end date to allow adequate time for the PDAC to complete its review. Products that are currently PDAC-verified for A5513 may continue to be billed using A5513 until the May 31, 2018, end date. Medicare claims for diabetic inserts described by A5513 with a date of service on or after June 1, 2018, will require a new PDAC coding verification using the requirements outlined in the July 13, 2017, coding clarification.

Yes. Products that are new to the market or that have not previously been PDAC-verified as appropriate for A5513 will have to be PDAC-verified before they may be billed for using A5513.

Editor's Note: On Sept. 29, 2017, AOPA and the American Podiatric Medical Association (APMA) sent a joint letter to CMS Administrator Seema Verma expressing their concern about the recent DME MAC coding clarification for HCPCS code A5513. The AOPA/APMA joint letter may be read at bit.ly/A5513letter.

amp Sean’s story is an example of a successful fight for access to prosthetic care. If you and your patients are experiencing Insurance challenges, visit AmplifyYourself.org to tell insurance executives and legislators that no is not an answer. The Amplify initiative is turning up the volume to make sure everyone has access to the care that they need.

Sean told his insurance company that “No” was not an answer. Read his story at AmplifyYourself.org and share yours today.

HarmonyÂŽ P4

Creating strong connections with limb volume management

Dual vacuum chambers help reach vacuum quicker

Connects directly to the socket eliminating external tubing

Our smallest mechanical pump with torsion and vertical shock