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Winning on Capitol Hill: a small association scores a major legislative victory.

Small associations can achieve legislative objectives even against seemingly insurmountable odds. It takes careful planning, precision timing, and the right mix of personalities.

Some observers contend that the relative size, financial wealth, depth of human resources, and political power have a lot to do with whether an association can successfully affect the course of legislation in Congress.

Not necessarily. A small, relatively unknown allied health association without a track record on Capitol Hill for either participation in policy development or lobbying was able to prove conventional wisdom wrong by convincing Congress to make a legislative change.

Apprehensive about the complexity of the legislative challenge it faced, the American Orthotic and Prosthetic Association, Alexandria, Virginia, nonetheless felt confident of its position and believed it had a good idea to sell on Capitol Hill. Some of the leadership was also apprehensive about the costs--both financial and programmatic--we would incur, but both the staff and the leadership agreed the project was key to AOPA's strategic position in the health care industry.

AOPA comprises small companies that fabricate, fit, and deliver orthoses (braces) and prostheses (artificial limbs) by prescription. Some patients pay for their care through company health plans, HMOs, or other private means. Many finance their care through medicare, since health difficulties requiring prosthetic and orthotic devices often strike the elderly. We wanted Congress to change the way medicare reimburses AOPA members for products and services.

The issue

The problem began when Congress passed the Omnibus Budget Reconciliation Act of 1987. The act included a provision that took effect Jan. 1, 1989. The provision shifted the reimbursement procedures for orthotics and prosthetics and durable medical equipment to fee schedules from reasonable charge profiles. Congress passed the legislation without consulting the orthotics and prosthetics profession, apparently thinking it was a reasonable and prudent move because both of these fields were reimbursed in a similar manner.

The membership let its staff know loud and clear this was not a mere technicality. Members complained the provision would disrupt their businesses and adversely affect medicare reimbursement for orthotic and prosthetic and patient care services.

Although the change was not supposed to affect fees, AOPA members reported that the notification they received about new fee schedules was resulting in a widespread reduction of fees, confusion over the implementation process, and lengthy payment delays.

AOPA's elected leaders and staff were attending a regularly scheduled board meeting in Phoenix as these and other complaints began pouring in from members in the field, who were being told how the new law would be implemented by the carriers--intermediaries who actually pay medicare claims.

Overcome by the urgency of this issue, the board shelved its agenda and began functioning as a task force to outline an immediate strategy. In those first hours of crisis, the board and staff developed a plan guided by several key principles: consensus, expertise, and speed.

The first step was to identify and appoint volunteers in the field to work with staff and AOPA's chief legislative counsel. They first met in April 1989 to frame alternatives to the current law.

One recommendation was to hire an accounting firm to conduct an impartial study of the new fee schedules' impact on the orthotic and prosthetic community. Enlisting the help of an accounting firm also permitted the association to focus on what it does best: Assess members' needs and present them to the outside world.

The accounting firm compared the 1988 prevailing rates fee schedules to the 1989 fee schedule created under the new legislation. Study findings confirmed AOPA's suspicions about the adverse impact of the new reimbursement methodology.

Building consensus

The next step was a combination of information gathering and consensus building. In June 1989, AOPA invited 75 national leaders of the field to attend a medicare reimbursement conference in the Washington, D.C., area.

A plenary session focusing on the goals of the meeting launched the conference. The real work was done in topical breakout sessions in which members debated the positions and strategies available to the association. Each breakout group reported on its deliberations, and the entire group was polled on its recommendations. The association's senior staff facilitated the process, which led to a set of specific recommendations delivered to the AOPA board by a specially appointed task force.

The task force next presented the recommendations to the entire AOPA membership at the association's October 1989 annual assembly in Reno, Nevada. More than 500 members packed the room to hear the report.

Seeking even greater participation, AOPA sent a medicare survey to nearly 1,100 members asking them to prioritize their solutions to the problem using the recommendations as a basis. We received 163 responses, or 15.1 percent of those sent. The number returned as a percentage of active (patient care) members added up to a 21.5 percent return.

Developing positions

The special task force next met in Alexandria, Virginia, to consider the survey results and establish AOPA's formal positions. Task force members were confident that the membership wanted orthotics and prosthetics to be separated from the reimbursement procedures for durable medical equipment, because more than 98 percent of those responding to the survey stated such a preference.

Consensus on the other two elements of our plan was not so clear-cut, but all task force members stood strongly behind them. The following consensus positions were developed:

1. Congress should create a separate legislative and regulatory category for orthotics and prosthetics.

2. Congress should revise medicare's reimbursement procedures for orthotics and prosthetics.

3. Congress should reduce the number of designated orthotics and prosthetics regional carriers (fiscal intermediaries used to process and pay medicare claims).

A core of five staff members and AOPA's legislative law firm researched these positions to determine legislative feasibility and then drafted model legislation. The AOPA board voted its formal approval in March 1990. It had taken approximately 15 months to develop and agree upon suggested remedies.

Volunteer team leads the way

A number of volunteer leaders, including the AOPA president and several past presidents of the association, worked together throughout the first phases of the project. The association selected team members for their knowledge of the subject, professional credentials, and dedicated commitment to members' needs. AOPA's executive director, assistant executive director, director of government relations, and reimbursement specialist also worked with the volunteer team. Our legislative law firm provided additional resources.

The mix of people we chose for the team was extremely important. Volunteer input was critical for two reasons:

1. AOPA belongs to the membership, and the association's work affects businesses at all levels of membership.

2. Members have a wealth of knowledge regarding the ways in which medicare reimbursement has evolved since 1965.

Staff responsibility encompassed several areas:

* producing the written materials such as the position paper, fact sheets, and proposed legislative language to support the legislative initiative;

* activating the grass-roots network to contact members of Congress; and

* coordinating the schedule of Capitol Hill visits with legislative counsel and association leadership.

Our legislative law firm's advice on what we could and could not achieve on Capitol Hill was invaluable. For instance, the firm told us any attempt to raise our reimbursement in the face of cost containment would impugn our credibility with members of Congress and their staffs.

The firm's lead partner also used his command of the legislative process and Hill contacts to strategically place our people in the right place at the right time. We knew our subject and we knew the medicare system, but we needed some help in targeting the right audiences and using our resources most effectively.

Selecting a strategy

The word on Capitol Hill, reinforced by the knowledge and experience of legislative counsel, was that freestanding bills were going nowhere. AOPA's legislation would have to be included in the budget reconciliation bill to stand a chance of being enacted.

Budget reconciliation for health issues revolves around the work of the Senate Finance Committee, the House Committee on Ways and Means, and the House Committee on Energy and Commerce. We had to make our presence and our positions known to the members of these key committees--not an easy task, because AOPA had never proposed legislation to Congress in its 73-year history.

AOPA initially focused its efforts on the Health Subcommittee of the House Ways and Means Committee. Our legislative counsel used his familiarity with staff on this committee to pave the way for presenting our position.

Approaching a subcommittee, however, doesn't just happen. AOPA first had to create a presence by meeting with relevant committee and subcommittee chairs to let them know our members had a problem.

During April, staff set up a schedule of visits by leadership to more than 27 members of Congress who served on one of the three committees of jurisdiction. AOPA provided these members and their staffs with a packet of general information and specially printed removable monographs detailing the association's three objectives. Association staff and members of the legislative law firm accompanied AOPA leaders on these visits and reported legislators' positions on the proposals.

One particular event stands out as pivotal in AOPA's campaign. We had brought a number of members into Washington, D.C., to visit with their respective legislators on our initiative. During a luncheon on Capitol Hill, AOPA provided a hands-on demonstration of artificial limbs and braces by a certified practitioner. That short demonstration cultivated an appreciation among key Hill staff members of the knowledge required to fabricate and fit such complex apparatuses.

As the summer wore on, AOPA continued to monitor the position of each relevant committee. Association members were encouraged to contact their senators and representatives who served on any of those three key committees.

We knew that our position made good public policy sense. We weren't asking for additional money from the tight budget of the Health Care Financing Administration (HCFA administers medicare payments); nor were we trying to take money from another group to feather our nest. We simply sought to have orthotics and prosthetics acknowledged as a profession to reduce HCFA's administrative load by advocating regional carriers for orthotics and prosthetics, and to secure a separate fee schedule.

Seeking change that involves a bureaucracy requires considerable patience, but our quest now appeared to have a chance to succeed. Toward the end of the summer, however, the situation took a turn for the worse. Budget reconciliation was turning out to be more complex than envisioned. The legislative process was getting more and more entangled in partisan politics.

There was talk on the Hill of approving a budget that did not meet the required spending targets, which would allow the Gramm-Rudman law to kick in. Such a move would have resulted in sequestration--mandatory across-the-board cuts in government spending. Few politicians were truly interested in that alternative, but both sides of the aisle used it as a bargaining tool.

As days and weeks passed, it became increasingly clear that it would be difficult to obtain agreement on a budget package. Key committee leaders decided that special-interest legislation interwoven into the budget process was complicating matters even further.

Even though we had personally visited practically all committee chairs and subcommittee chairs, we knew that any type of budget deal would exclude all but the most meritorious amendments. All special-interest proposals were ranked and divided into the short list and long list. Since no other legislative vehicle existed in this Congress (freestanding bills would not be considered in Congress, given the tumultuous atmosphere), not being on the short list virtually guaranteed nonenactment.

Our last meeting with our "champion" on a key House subcommittee would be our final opportunity to make a case for speedy enactment of AOPA's proposal. He listened to our arguments and saw merit in them. We came out of the meeting with a promise to include language for a separate orthotic and prosthetic section in the law and a mandate for a General Accounting Office (GAO) study of the fee schedules. It was determined that HCFA would have to initiate regional carriers, but we were assured that Congress would not object.

To obtain a separate section of the law for orthotics and prosthetics, we were asked to give up a cost-of-living update for 1991 that would have amounted to $10 million. However, we were assured that it would be restored for the four years following 1991.

After this pivotal meeting, AOPA sought to consolidate its position by urging members to support the House Ways and Means Committee's version of budget reconciliation. We sent action letters to members asking them to contact their senators on the Senate Finance Committee; they ended up sending more than 400 letters. Personal visits to a number of senators also laid the groundwork for them to be receptive to the profession's cause. After these efforts, all we could do was wait for the conference to reconcile the differing versions of the bill.

Finally, we heard some encouraging reports from the conference--AOPA-sponsored provisions had survived. The bill was a must measure for the administration, so we didn't fear a veto. All our planning and strategizing had paid off.

The results

A separate statutory reference, Section 4153, now permits Congress to consider orthotics and prosthetics in their own rights for purposes of medicare budget proposals. It also encourages HCFA to recognize the difference between orthotics and prosthetics and durable medical equipment in current and future regulations.

The new law provides for a one-year moratorium for orthotics and prosthetics on the transition to regional pricing. This was intended to permit HCFA to complete a review of fee schedules and correct flawed data before such schedules become final and permit the GAO study on fee schedules to be completed.

The new law also provides for a study of the orthotic and prosthetic reimbursement procedures by GAO. This study could become the vehicle for a separate fee schedule for orthotics and prosthetics.

Informing the membership

Next, AOPA leadership reported the legislative victory to the general membership. The association sent members a special-edition newsletter that prominently featured pictures of the volunteer leaders who had given so much of their time to the effort. This initial newsletter also outlined the specific statutory language changes and an explanation of how that would affect our members on a day-to-day basis.

Of course, AOPA did not expect to convey all the complexities of the change in the law by issuing one newsletter. We realized the importance of explaining the situation to members face-to-face and responding to their questions.

AOPA held a series of six seminars across the country. The curriculum included a review of the statute, how the change would affect our members, what new regulations were likely to be issued, and how our members could deal with them. A staff reimbursement specialist led the seminars with assistance from legislative counsel.

AOPA is still involved with some of these issues and continues to monitor the annual budget battle waged in Congress, but the fundamental changes it achieved in 1990 should serve our members well for the foreseeable future.

Influencing the Process

While every issue is different, there are some common ways to begin to influence a national legislative or regulatory debate. ASAE Government Affairs offers these 10 suggestions.

1. Identify the problem. Listen to your members. Tracking mainstream media and trade press reports is another effective means of identifying a potential legislative issue early.

2. Define the issue. Determine its relevance and how it affects your membership. Should your association get involved in the legislative process, or should it educate the membership? A government relations committee of members and staff is a good forum for making these decisions.

3. Research the issue. If the decision is to take an active role in the debate, the next step is tracking down the activity to date. In a legislative debate, if a bill has already been introduced, get the bill number from the office of the representative or senator who introduced it. Then check the bill's status by calling the House or Senate documents office.

4. Form a task force of members and staff to plot the association's course of action. The task force examines the issue and develops a response--a written position paper that the board or its executive committee can approve.

5. Seek out coalitions with which your association may work. A coalition of groups with a unified view has a much better chance of success on Capitol Hill than a single association.

6. Mobilize your grass-roots. Match up members with their representatives and senators. Bring your members to Capitol Hill to talk to their legislators. On an active issue, a constituent carries much more weight with a legislator than an association staff member ever will. Use staff for lobbying maintenance and members for hot issues.

And urge your members to call their legislators and follow up with letters advocating the association position. Make it easy for members to act. For example, give members a brief position paper, a list of members of Congress, and the body of a letter to personalize. They might, for instance, explain in the letter the impact a bill would have on their particular association's membership.

In all districts, don't forget the media. Craft letters to editors and send members to impress your position on newspaper editorial boards.

7. Identify legislators who are sympathetic to your cause and make them your "champions." They can lobby on your behalf. For example, they can get hearings started so your members may testify.

8. Line up cosponsors for legislation you favor. If you want a bill to pass, ask your members to urge their legislators to cosponsor the bill through phone calls and letters. Get your congressional champion to ask colleagues to cosponsor the bill or, if you don't support the legislation, to remove their names from a bill.

9. Continue to monitor the issue. Even if the bill dies in one session of Congress, it will probably come up again in the next. You need to be ready to act at a moment's notice.

10. Keep the issue and all you do to represent the association's interest in front of the membership. If members see progress, they'll stay interested and support the effort.

Be honest, be prepared and willing to compromise, and don't give up. An issue may come up in session after session before any final action occurs. So keep repeating the process. It may take years, but it's worth it.

Ian R. Horen, CAE, is executive director, and Charles K. Unger, CAE, is assistant executive director of the American Orthotic and Prosthetic Association, Alexandria, Virginia.
COPYRIGHT 1992 American Society of Association Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1992, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Title Annotation:American Orthotic and Prosthetic Association
Author:Unger, Charles K.
Publication:Association Management
Date:Oct 1, 1992
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