Licensure: The act or practice of granting licenses, as to practice a profession.

Certification: A document certifying that one has met specified requirements, as for teaching.

There has been an ongoing debate on the merits of mandatory state regulation versus voluntary national accreditation. The intent of this article is to make the consumer aware of the differences between the two and how they could affect your prosthetic care. It will also provide an update on which states have passed legislation affecting prosthetists, orthotists and pedorthists (foot prosthetists) and where they are in the implementation process.

In 1996, inMotion published an article on the history of educational and accreditation standards for the prosthetics profession. In 1993, the American Medical Association (AMA) finally recognized the practice of orthotics and prosthetics (O&P) in the United States as an allied health profession. Educational standards established by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) were implemented the following year.

The difference between licensure and certification is the force of law. The state agency that regulates any health profession can prevent an individual from providing health care in that state. Certification or any other voluntary accreditation cannot provide the same safeguards to the public. In states without licensure, anyone can provide prostheses, regardless of their education, competency, or business ethics.

The practice of O&P serves to improve and enhance the lives of individuals with disabilities, by enabling them to resume productive lives following serious illness, injury or trauma. Americans deserve the best care available, and will benefit from the assurance of initial and ongoing professional competence of orthotists and prosthetists practicing in the United States.

States that have passed legislation believe that the increasing population of elderly and physically challenged individuals who need O&P services requires that the O&P profession be regulated to ensure the provision of high quality services and devices. The present unregulated system for dispensing O&P care does not adequately meet the needs or serve the interests of the public. In keeping with state requirements imposed on similar health disciplines, licensure of the O&P profession will help ensure the health and safety of consumers, as well as maximize their functional abilities and productivity levels.

The rationale behind certification of individuals and accreditation of organizations providing prosthetic care is self-regulation. Professional accreditation boards will police themselves by endorsing educational standards, establishing minimal competencies, and enforcing standards of ethical conduct and business practice. But the maximum penalty for individuals/companies that violate those policies is the removal of their certification or accreditation. The only redress that a consumer would have against a prosthetist or the prosthetic facility would be civil litigation.

Through licensure, states will also establish the same types of policies to regulate the prosthetic profession. But their policies are mandated and violation of those policies could lead to fines, loss of license, the right to practice in that state and, in the most severe cases, imprisonment. They will restrict the provision of prostheses by individuals that do not meet the state's requirements. Instead of the consumer seeking redress for him or herself, the state is obligated to do it for them.

Since 1995, six states have passed regulations licensing prosthetists and orthotists. (Several also regulate pedorthists.) New Jersey, Mississippi, Florida, Texas, Washington, and Illinois have implemented their laws or are in the process of creating the regulatory rules for the enforcement of their laws. Five other states either have legislation pending or have organized professional/consumer groups that are creating legislation.

Although each of these states has different language in their legislation, there are also some common features:

All have some type of regulatory board made up of professionals and consumers that is under a regulatory or health agency of the state. All require the CAAHEP education standards (or their equivalent) or will at some future date.

All have some type of time limited "grandfathering" for individuals currently providing care.

All have standards of professional conduct and malpractice.

Finally, most have some type of reciprocity with other states or national accreditation bodies that have equivalent education, testing and competency standards.

Three of the states that require licensing (New Jersey, Mississippi and Illinois) mandate that applicants must pass the American Board for Certification in Prosthetics and Orthotics (ABC) practitioner certification examination (or its equivalent) before the individual can receive their state license. The other states, Texas, Washington and Florida, have contracted with the ABC to provide the written and/or written simulation examination for their applicants.

"Grandfathering" is in the legislation language of the six states to allow individuals to continue to provide care so long as they meet some minimum requirements. State legislatures are very hesitant to regulate someone out of business. The individual statutes governing this area are usually based on either experience or a national credential. Experience varies from three years (Texas) to seven years (Illinois). All of the states utilize ABC's prosthetic and orthotic practitioner certifications (CP, CPO or CO). Some recognize the credentials granted by other accreditation boards for orthotics and pedorthics. Although "grandfathering" is not ideal, future licensees within the state will have to meet the established educational standards and all licensees will have to abide by the other standards or care established by the boards.

As a consumer, what does all this mean to you?

First, if you live in a state that requires a license to practice as a prosthetist, make sure that your prosthetist is licensed. If you have problems, bring it to the attention of the regulatory agency or board that oversees prosthetic care.

In states that do not have licensure, seek out individuals who have national accreditation that is based on the highest standards in the areas of competency and education. If you have problems, bring it to the attention of the accreditation board that has accredited the individual. If you think licensing of prosthetists is a good idea, work with statewide, professional groups and consumer advocacy groups to pass prosthetic, orthotic and pedorthic) legislation.

Unfortunately, no license or certification is a guarantee of total satisfaction with your prosthetic care. Both are only benchmarks of established educational standards and minimal competency. A successful outcome in prosthetics, like most of medicine, is greatly influenced by the technology available, and the health condition and attitude of the amputee and not just the ability of the health care professional.

About the Author . . .
Terry Supan, CPO, is an associate professor and director, orthotic prosthetic services, at the Southern Illinois University School of Medicine in Sprinfield, Illinois.