Different ways to cast orthotics

[shezadeh]

I have shadowed a few podiatrists. Each one seems to use a different method of casting (plaster, foam impression, digital/pressure sensitive pad). Apparently even 3D scanning is something in the works (I have not seen this at a clinic yet).

Which do you prefer and why?

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[Feli]

Fiberglass is pretty much the only logical way to go in my estimation, and you can bill some insurances for supplies to offset its slightly higher cost vs plaster (but that difference is not too significant anyways when you count how plaster tends to ruin floors, clothes, probably loses you patients due to crusty feet, etc). Plaster is a mess and just takes too much time (even "fast" plaster) and MAs generally won't like it if you train them to cast. The digi or pressure scan ones won't truly capture the forefoot/rearfoot relationship... which is the whole point of functional casting of orthotics in the first place. There are many reasons the digitals haven't really caught on, and they've been around awhile.

Foam impression is just for accommodative stuff.... kinda apples to oranges.

...Everyone has their own methods, though. Many can work in the the right hands, so it's a matter of getting exp and comfort with any method of casting and then communicating what you want to the lab on the Rx slip you mail with it.

 

[Scrantonicity]

I use foam boxes and also digital scanning (from time to time). It just takes less time, and the orthotics I get back are all fine. Fiberglass and plaster are definitely more accurate, but messier and more time consuming. To each their own. Orthotics are all voodoo magic anyways...patients that come to me with orthotics made elsewhere always look very similar no matter how they are casted. Either patients love them or they hate them. Just like pre-fabricated inserts...

 

[shezadeh]

Thoughts on fabricating your own orthotics vs. referring a patient to an orthotics/prosthetics clinic? There appears to be overlap in the area of orthotics.

 

[Shiyuan]

I send out... I dont have a workshop to modify orthotics like most orthotists do. Better bang for patient’s buck sending out IMO. (Only flaw is you lose potential $$$)

 

[heybrother]

Hospital employed podiatrists are probably going to send out every single time. They are paid on RVUs so the incentive of a "high reimbursing office product" isn't real to them.

The price of customs is highly variable in offices - historically the majority of people I spoke to charged $350, but I'm hearing much higher numbers from others lately. You may be getting glassy eyed here but its likely because you don't know what other things pay. A new patient visit with bilateral x-rays and bilateral injections on decent insurance can be $300 and requires no sales component. A new patient bilateral matrixectomy can hit $500.

The manufacture of the orthotic ie. the creation of the product is associated with a cost for the office that is variable and ranges from probably $85 to $200. That cost to the office "has to be" reflected in the price to the patient theoretically, see below.

Some people will attempt to charge orthotics to insurance through medical necessity. I've met people who literally had their office manager check every patient's insurance prior to seeing them to see if they qualify for custom orthotics. That's obviously garbage. That said, this theoretically exposes them to the fee schedule of the insurer in question. I've reviewed some of our data and seen BCBS pay $250 for a patient's custom orthotics. That may not be good reimbursement if you paid an upper end price to have the orthotic manufactured.

We are experiencing more competition in this field - there are custom companies advertising on facebook sending people foam boxes. PT, chiropractors, Good Feet store etc are all pushing this and interestingly at times charging prices multiple times what we charge. Most of these people have no idea what is actually going on with the patient.

I personally think pedorthists do a good job, but if you think you won't hear about it if they botch it - haha. I sent some lady off for bracing semi-recently, she didn't like the AFO, and she tells me about in detail. Also, its entirely possible they will charge the patient $350 for some sort of garbage accomodative orthotic that will only last a year when they could have had a functional orthotic that will last a life time.

Last of all. This is really not worth fretting or worring about, Its entirely possible to have a great practice and never make custom orthotics. This is one of those things that is talked about way too much. A good custom orthotic for the right person should simply be a nice additional service you provide as an expert of the foot and ankle.

 

[CutsWithFury]

I refer to Hanger clinic for all my AFOs and orthotics. I have zero time to mess around with orthotics or modifying. I don't have a lab where I can grind down orthotics and my hospital is too cheap to buy any modifying pads etc. It is just a headache. I refer these patients out and the company takes care of all the BS. It is a win win for me.

 

[Shiyuan]

I refer to Hanger clinic for all my AFOs and orthotics. I have zero time to mess around with orthotics or modifying. I don't have a lab where I can grind down orthotics and my hospital is too cheap to buy any modifying pads etc. It is just a headache. I refer these patients out and the company takes care of all the BS. It is a win win for me.

100%

 

[dtrack22]

All of our ortho clinic’s DME is outsourced. So a company supplies, stocks the office with, bills, and collects for all DME items. They have a prosthetist/orthotics who does all of the custom orthotics and AFOs. He even comes to the office every few weeks to fit/mold patients in our office which is nice for the patients since their office is based out of a larger metro 30-40 min away. When patients don’t like them it isn’t my problem, when Medicare pulls “same or similar” crap on a boot and don’t pay it isn’t our problem. I’m happy to never mess with DME/orthotics/AFOs ever again.

 

[Feli]

All of our ortho clinic’s DME is outsourced. So a company supplies, stocks the office with, bills, and collects for all DME items. They have a prosthetist/orthotics who does all of the custom orthotics and AFOs. He even comes to the office every few weeks to fit/mold patients in our office which is nice for the patients since their office is based out of a larger metro 30-40 min away. When patients don’t like them it isn’t my problem, when Medicare pulls “same or similar” crap on a boot and don’t pay it isn’t our problem. I’m happy to never mess with DME/orthotics/AFOs ever again.

Does he rent from your group for office space on that date he visits, or is he a part-time employee of the group?

You don't have to "mess with" DME to profit from it

 

[dtrack22]

Does he rent from your group for office space on that date he visits, or is he a part-time employee of the group?

You don't have to "mess with" DME to profit from it

He is an employee of the clinic (think Hanger) that is supplying and stocking the DME for us. The patients can drive up to them to have casting/fitting done, he just happens to come out to us as needed as a convenience for the patients. Remember this is rural-ish and so any additional services the patients can get done in town is a benefit to them. I would bet money he is salaried by the clinic that employs him so really he’s doing it as a courtesy or more likely as a condition of that clinics contract with our office. If they didn’t have reps to come down and help fit OTC braces (not so much foot and ankle but some of the knee braces and back/shoulder stuff) or an orthotist to come down and cast here, we could just as easily farm out the DME to Donjoy or a different local company/clinic.