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Published in the O & P Business News, April 1, 1994
THE ISSUE: PROSTHETIC DEVICE RATING SYSTEM
As a provider of orthotic and prosthetic services and products for twenty-three years I take issue with the idea
that an organization such as The American Orthotic and Prosthetic Association attempts to act as a spokesperson
for our entire industry. As healthcare reform is being contemplated, it's time to put some balance to the underlying
issues concerning orthotics and prosthetics and contribute ideas for positive change.
My first experiences in healthcare came while serving as a surgical technician in an operating room in a Naval
Hospital during the Vietnam War. An orthopedic surgeon I worked with enlightened me when I expressed a desire to
one day become a surgeon like him. He told me, "In the military I am paid a salary, it's the same whether
I do one operation per month or a hundred; in civilian life medicine is like piece work, the more you do, the more
money you make."
The nations largest consumer group recently completed a study of medical care in America; they estimated that at
least twenty-five percent of all medical expenses were for useless medical procedures and equipment. Bloated bureaucracy
adds to increased cost, but the real culprit in healthcare is the incentive to "do everything." While
healthcare reform is being campaigned, criticisms and suggestions come in on every side of the issue. There is
finger pointing, but rarely does anyone take responsibility for waste. Whether it's hospitals, M.D.'s, P.T.'s,
or C.P.'s, the common opinion is every medical procedure or piece of equipment provided is indispensable for "the
benefit of the patient." This of course is nonsense. As a group, prosthetists comport to the view that they
are serving the best interest of the amputee without regard to cost, but profit is an incentive in all industries,
including prosthetics.
When I read "A Question of Funding" by J. Thomas Andrews, C.P., in a past issue of this publication,
I was reminded once again that too much is done in prosthetics, not because it has an increased benefit to the
patient, but simply because it is more profitable to the prosthetist. It is not surprising to witness attitudes
that blame third-party payees for not buying expensive high-tech prosthetic devices since those expressing these
attitudes will profit from these purchases. In prosthetics, technology that is not cost effective needs to be addressed.
We can do a lot to lower costs if we examine our approach to the delivery of prosthetic devices and the system
that has evolved over the years. William Baughn, from the Amputee Information Center in a follow-up article to
"A Question of Funding", states, "The time is fast approaching when those who want to be considered
medical rehabilitation professionals will have to offer more than assumptions and conjecture in order to justify
the horrendous cost of devices of questionable usefulness." I agree.
In private, individuals have different opinions, but in groups, their opinions tend to merge into one. Thus it
becomes the opinion that most benefits the group. This is especially true when it is an economic benefit to the
status quo of the group. The American Orthotic and Prosthetic Association has empowered itself as the spokesperson
for our industry. When it comes to healthcare, finding solutions that work is the only question of importance,
not satisfying the egos of the group. The orthotic and prosthetic industry functions within the rest of the medical
community, as such we have a shared responsibility to find these solutions. We have arrived at the current situation
because there has been an assiduous effort put forth by so-called professional organizations in various healthcare
occupations to walk in lock-step with one another and defend or justify all the services and products they have
to offer. The cartel mentality encourages the promotion of the idea that justifies all the services and products
they sell as being in the "best interest of the patient."
Fabrication of the best possible prosthetic device for an amputee is a function of the prosthetists' artistic ability
in casting and modifying plaster impressions, their technical knowledge of prosthetic components, and the skill
and care with which they put the two together. Couple this with a strong desire to put the patient's needs before
the sale price. We as individual prosthetists and as a group of professionals must strive to provide the simplest,
most functional prosthetic device regardless of its high-tech make-up and/or its cost. It is our responsibility
to ensure that the payee receives the biggest bang for his buck. Equally important is allowing the patient an active
role in the process; often referred to as informed choice. All steps of the restoration process must include the
consent of the recipient after receiving adequate explanation(s) as to a cost/benefit ratio. This process will
pave the way for saving healthcare dollars and work to ensure optimum prosthetic devices for the amputee.
A classic example of the above, is a friend of mine who is a service connected, Vietnam War veteran amputee and
a Certified Prosthetist/Orthotist. He therefore has access to any style artificial limb he wants. However, he chooses
to wears a wooden above-knee quad-socket with a laminated exoskeletal knee-shin combination and a SACH foot, because
this suits his needs. I wonder how many prosthetists would agree with this design of prosthetic device as compared
to the high-tech, high-cost prosthesis.
In conclusion, my suggestion is a challenge to our industry to establish an independent board made up of multi-disciplinary
experts, including prosthetists, design and mechanical engineers, physical therapists and others empowered to systematically
review and rate existing prosthetic devices and their application. The rating system would compare effective functional
return to the amputee and its relative dollar cost for each device. We have to move away from subjective choices
and towards choices based upon objective results.
Someone once said, "Waste is like pornography, it's hard to describe, but you know it when you see it."
I see it, others see it, now let's change it.
Michael Love
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