In daily American orthotics and prosthetics practice there exists a remarkable determination of individuals to embrace novel concepts in the face of daunting obstacles. Our system of reimbursement values the status quo, and because it is known, it is defined and its cost has been calculated. This systematically determines much of the technique and technology that orthotists and prosthetists can be expected to draw upon to serve their patients.
Our profession is controlled in this manner. Clearly, at least one goal—if not the primary goal—is cost-containment. That, as one goal, is reasonable. Budgets are limited and financial conditions tough in historic terms. However, best serving the needs of patients with limited resources really needs to take into account more than just cost. Cost is not value. Value is only determined by really understanding what is gained for the cost incurred. We desperately require more economic research in our field to determine the true cost-effectiveness of our options without shortchanging the effectiveness part of those measures. As an example, I was involved in a rehabilitation project that had a profound positive impact on the spouses and families of the amputees involved. The additional value was clear, but I wonder if that real value would ever be considered in light of the cost of the technology used?
Without considering effectiveness, our system actually discourages innovation. Yet, individuals continue to innovate. Orthotists and prosthetists go on trying new approaches and evaluating new technologies. I think this speaks a great deal about how so many in our profession value the patient above the process. We want to provide the best and greatest function for our patients, and will take on personal risk, and even loss sometimes, to achieve that. With a lack of evidence, we'll even turn to our own experimentation. It is a very positive response to a very constraining situation. I don't know if we will ever create a better system, but we can thank the innovators for not giving up.
David A. Boone, CP, MPH, PhD
Journal of Prosthetics and Orthotics