PFA President Dane LaFontsee Addresses the State of Pedorthics
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PFA President Dane LaFontsee Addresses the State of Pedorthics

Editors Note: PFA President Dane LaFontsee, C. Ped., recently received an inquiry concerning the current state of the pedorthic profession, and its impact on PFA. Dane considered the question not only within the context of the present, but as far back as 2003 to dig out some of the root causes that have led us to where we are today. Following is Dane's response, which he is sharing with not only the PFA membership, but the entire pedorthic profession as well.

Dear President LaFontsee:

I don't see a lot of new Pedorthists entering the profession, and it seems like without that, our profession will contract and eventually die.  It also does not seem that other organizations are doing anything to help advance pedorthics.  My question is what can PFA do, and is PFA doing, to help turn the tide on this crisis hitting our profession?

Dear Colleagues:

I want to thank the sender of this tremendously timely and poignant question.

Recently, I considered the factors over the years that have led us to where we are now, and the list is formidable. However, I believe that PFA's responses to these challenges have been, to the best of the organization's abilities, significant.  A short, "sound bite” response just won't do if the membership and the profession are to understand the situation and participate in the solutions that will ultimately benefit them.

That the pedorthic profession is in crisis should be a surprise to no one, if you've kept track of current events:

The economy is taking a hit on everyone.

Pedorthists were hit with several unexpected and expensive Medicare requirements earlier this year; reimbursement levels continue to be low.

Student enrollment in pre-certification schools has declined causing some of the schools to cancel classes and eliminate some pre-cert programs.

With fewer people going through the pre-cert program and into practice, and others leaving pedorthics, the profession isn't growing.

The profession faces an identity crisis with lagging recognition of the value of pedorthic care among referral and potential referral sources.

The profession is segmented among "clinical”, "retail” and "other” pedorthists, with each segment having their own philosophies.

2006 was the watershed year for pedorthics with the merger between the American Board for Certification in Orthotics and Prosthetics (ABC) and the Board for Certification in Pedorthics (BCP).  However, from a certain perspective, I see 2003 as a critical year as well with the passage of the Medicare Modernization Act (MMA) and the loss of the Therapeutic Shoes for Diabetes benefit's (TSD's) stand-alone status to the broader O & P benefit category.  This was also the year that growth in pedorthics peaked, as measured by PFA's membership and Symposium numbers and the number of individuals with pedorthic credentials.

The following is what I believe to be a timeline of the critical factors leading pedorthics to where it is today.

1.  Passage of H.R. 1 – the Medicare Modernization and Improvements Act of 2003 (MMA).  Prior to passage of the MMA in 2003, Medicare's Therapeutic Shoes for Persons with Diabetes benefit (TSD), which PFA helped to create in the late ‘80s and early ‘90s, was a standalone benefit with its own reimbursement schedule.  When MMA re-categorized the benefit under the O & P category, subjecting the TSD to O & P fee schedules, it decreased reimbursement levels significantly across the board.

Over the past six years, PFA has drafted legislation introduced in the U.S. House of Representatives by our Congressional allies to turn the clock back on the impact of the MMA on the TSD.  PFA has attempted to engage its membership in grassroots efforts to garner support for that legislation from respective Members of Congress. Unfortunately member participation has been minimal and corrective legislation had not moved forward.

2.  Merger in 2006 between the Board for Certification in Pedorthics (BCP) and the American Board for Certification in Orthotics and Prosthetics (ABC).  BCP was created by PFA in 1972 as the pedorthic credentialing organization and the two organizations provided the pedorthic profession with a solid identity and strong voice.  Even though the ABC-BCP merger allowed for two dedicated pedorthic seats on the 12 member ABC Board of Directors, it ultimately placed control of the pedorthic scope of practice, future requirements concerning pedorthic credentialing, and the general promotion and identity of the pedorthic credential in the hands of O & P with their solid majority on the ABC board.  Pedorthists credentialed by ABC lost their ability to vote on changes to their professional standards that had existed with BCP.

As you will recall, the summer before the merger occurred, PFA's board communicated to the membership the pros and cons of an ABC-BCP merger, and included a survey to gauge the members' views on a merger.  Based the results of that survey, PFA's board logically detailed its opposition to the merger.Despite its best efforts to represent members, PFA's board received significant backlash for its stance from the membership and the profession.

3.  Continued real reduction in Medicare Reimbursement.  For years, Medicare has continued to reduce in real terms the reimbursement for the A codes under the Therapeutic Shoes for Diabetics benefit (TSD) – along with the amounts for most other benefit programs as well.  Far too many pedorthists have looked at Medicare and the TSD as the "golden goose,” and have been hit by the continued decline in reimbursement to the extent that they either terminate their Medicare supplier agreement or leave the profession altogether, creating significant patient access issues.

While PFA believes that pedorthicly servicing the at-risk diabetic population is critical, there are many other applications of pedorthic modalities within a pedorthic practice.  Exploring those opportunities, and providing the additional services within the pedorthic scope of practice to other populations, is a key to a more successful pedorthic practice.  Through various Symposium sessions and continuing education programs, PFA has provided its members with the inspiration and knowledge to expand their practice, and will continue to do so in the future.

PFA also continues its aggressive government affairs/lobbying efforts to further advance awareness of pedorthics, work towards more equitable reimbursement rates, and best define qualified supplier for Medicare's TSD.

4.  Creation of the ABC Certified Fitter of Therapeutic Shoes/BOC Footwear Specialist.  Over a year ago, ABC, the Board of Certification/Accreditation, International, and the pedorthic pre-certification educators created this lower level credential.  The reason for the new credential was to provide increased patient access to simpler pedorthic modalities, as the fitters could only provide off the shelf shoes and orthotics within their scope of practice.  Unfortunately, it doesn't seem to be working out quite the way it should with some fitters practicing outside of their scope, doing the work of credentialed pedorthists, and applying for Medicare billing privileges by indicating on the CMS-855S form that they are pedorthists.  Applying as pedorthists is "legal” because Centers for Medicare and Medicaid Services (CMS) never definitively determined who really is and is not a qualified supplier under the TSD.  PFA has advocated CMS that the only truly "qualified supplier” of the TSD are credentialed pedorthists because they are uniquely educated and trained to evaluate, fit, fabricate and dispense prescription shoes and inserts.  Period.

On April 23, 2009 BOC discontinued their footwear specialist program, instead encouraging their existing Certified Footwear Specialists to "step up” and become BOC Pedorthists.  ABC last week reaffirmed their commitment to the ABC Certified Therapeutic Shoe Fitter credential.

One of the unintended consequences of the new credential has been tangible concern by CMS with other credentialed individuals lacking the level of education attained by credentialed pedorthists, which has resulted in CMS reinstatement of the facility accreditation and surety bond requirements on pedorthists while new DMEPOS quality supplier standards regulations are promulgated.  Another consequence is the impact that the new credential is having on pedorthic pre-certification education, with schools that provide pre-cert education reporting significant annual decreases in enrollments, causing some of the schools to eliminate or consider eliminating their pedorthic pre-certification program.

PFA has worked to mitigate these consequences by aggressively lobbying CMS and its allies in Congress to allow pedorthists the exemption in exchange for providing the National Supplier Clearinghouse (NSC) proof of professional qualifications via pedorthic credential or pedorthic license.  CMS has considered PFA's solution to this problem and refused implementation.

In an effort to increase pre-certification enrollments, PFA took the lead in managing a "pedorthic summit” consisting of ABC, BOC, PFA, the pre-certification providers, and other interested parties.  The goal was to identify an initial target audience and generate interest in a career in pedorthics.  This effort stagnated after the initial meeting in November, with the parties half-heartedly working on the text for a promotional brochure and indicating that PFA would need to drive and underwrite the entire effort.  Currently, a complete rewrite of a promotional brochure is underway by a volunteer from COPE.

5.  ABC implements experience requirement prior to pedorthic exam.  Effective March 2, 2009, ABC pedorthic exam candidates are required to possess a minimum of 1,000 hours of patient care experience (750 hours in a clinical setting and 250 hours in a retail setting).  This experience must be obtained in a pedorthic patient care facility prior to becoming eligible to sit for the ABC exam.

PFA certainly agrees with a future increase in the pedorthic education standards leading to certification; however, PFA is at odds over the drastically increased number of hours of patient care experience that are required immediately.  PFA supported a phased approach to the increased work experience requirements, which is supported by the difficulties experienced by individuals seeking licensure in the State of Florida struggling to meet a much more limited 40 hour work experience requirement.  Many practices are reluctant to provide training to perceived future competitors, and most candidates cannot afford the cost, especially now, of being away from home and business to obtain the 40 hours.  Compound this by 25 times, and you have a scenario with fewer and fewer people looking at pedorthics as a viable profession.

6.  Merger of NCOPE and CAPE.  In January of this year, the Commission on Accreditation of Pedorthic Education (CAPE) merged with the National Commission on Orthotic and Prosthetic Education (NCOPE).  CAPE was organized six years ago by PFA and BCP initially as a committee but eventually as a standalone organization funded by PFA and BCP.  CAPE established accreditation standards for schools providing pedorthic education, and was the next to the last stand-alone pedorthic organization.

PFA opposed the merger between the two accrediting organizations as it places the future of pedorthic education standards under the absolute control of O & P, mirroring the issues related to the merger of ABC and BCP.

So, how is PFA responding to these challenges to the profession?

1.  Continuing Education – PFA continues to be a primary provider of continuing education for the pedorthic profession.  PFA produces the ever-growing annual Symposium and Exhibition.  In response to member's requests for distance learning opportunities that were more affordable and didn't require travel and lodging, PFA this year eliminated its "in-person” continuing education seminars and invested heavily in infrastructure to deliver webinars and on-demand/online continuing education programs.  The first two webinars that were held in April were unbelievable successes with high participation.  (Personal thanks go to Erick Janisse, for his program "Pedorthic Management of the Diabetic Foot” and Brett Richey for "Pedorthic Coding and Billing:Introduction to Insurance (Part 1 of a series).”)

2.  Pedorthic Coding Manual – After a two-year effort, PFA has completed the first comprehensive HCPCS coding manual for the pedorthic community, cross-referencing the pedorthic scope of practice with all applicable HCPCS codes that a pedorthist can utilize and bill to, expanding and better interpreting descriptors, and much more.  By the time you read this letter, the manual will be available for purchase by the pedorthic community and PFA continuing education programs based on the coding manual will be in development.

3.  Advocacy - PFA continues to lobby CMS to recognize credentialed pedorthists as the qualified supplier under the TSD and, concurrent with that recognition, re-exempt pedorthists from the onerous facility accreditation standards and surety bond requirements until new regulations are developed for all DMEPOS suppliers and providers and fairly applied.

PFA also is working to advance pedorthic licensure legislation at the state level that is fair to pedorthic practitioners and orthotists and prosthetists, and continues building support for legislation that will enhance reimbursement rates for the TSD.

PFA has been and continues to be the advocate for the pedorthic community.However, we cannot do it alone.  Your voice needs to be heard by Members of Congress, the credentialing organizations, CMS, and all the members of the footcare community.  To date member voices have been muted, limiting the ability for PFA to effectively advance the pedorthic message.  PFA has been successful at making the connections to the decision-makers, but members hold the key to influencing policymakers so that they cast their opinions and votes for the pedorthic profession.

I ask every member to answer future grassroots calls from PFA by participating on committees and responding to calls to action.  To make a difference all pedorthic professionals must work together when called upon.

4.  Rebranding – One of the pedorthic profession's greatest challenges is its dated image and lack of recognition among the patient population and referral sources, although PFA has made significant inroads in this area.  PFA and pedorthics today lacks recognition, but PFA's rebranding efforts are intended to breathe new life into a quickly a vanishing profession.

PFA's volunteer leaders say it over and over – we want your input, ideas, and participation.  We need to increase the numbers of members working to improve the current damaging environment.  We need your solutions, we need your voices, and we need you to work to improve and save your profession.  The pedorthic profession and PFA are at a cross roads right now.  One direction leads to a successful future, the other leads to the demise of a proud and respected allied healthcare profession and its professional association.  As a united group with the support of its knowledgeable and diligent association, we can save the pedorthics profession.

Dane LaFontsee, C. Ped.


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