Foot orthoses provide early access to patients

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BioMechanics July 2004 Special Section: Foot Orthoses

Foot orthoses provide early access to patients

http://biomech.com/db_area/archives/2004/0407.footorthoses.bio.shtml

By: Andria Segedy

This month's special section looks at foot orthoses. This article

examines technology and the decision to use or not use CAD-CAM. The

following source list has a grid to help identify manufacturers and

distributors by product category. A list with company contact

information follows. Our next special section is scheduled for October

with a focus on prosthetics.

Practitioners from large and small offices are realizing the value of

capturing the patient in need of foot orthoses, even though the product

is low margin and often not reimbursed. Foot orthoses are an opening to

serve patients who are most likely on the road to more serious orthotic

needs because of changing pathologies, clinicians find.

The country's largest provider of orthoses, Bethesda, MD-based Hanger,

has been rolling out its proprietary, state-of-the-art,

computer-assisted design system, Insignia, to its offices (see " Hanger's

Insignia CAD system offers NextFest a taste of O & P, " page 72 ),

promoting its ability to scan the sharp curves of the foot to help make

a better foot orthosis. But professionals at smaller orthotics practices

are finding their own successes in working with patients who need foot

orthoses.

The Insignia system uses a 3D laser image system instead of a

traditional model such as casting or impression boxes, according to

Seattle-based Kaia Halvorson, CPO, LPO, the national director of

orthotics for Hanger Orthopedic Group.

" Insignia allows us to track motion, which some other scanners don't

allow for, " Halvorson said. " As long as the position of the receiver

remains constant, the system can track the motions of the patient and

produce an accurate scan. "

Hanger is leasing the system to its facilities, Halvorson said. The

company plans to have Insignia in all its offices this year. But Hanger

is not limiting its training to orthotics and prosthetics practitioners.

" One of my roles is to train PTs, OTs, nurses, physicians, and allied

heath professionals in how Insignia functions and how and where it can

benefit documentation, " Halvorson said. " This is for their education, so

they can refer patients who may benefit from this technology to Hanger

offices. "

Its ability to record pathologies and progressions is an important

benefit of the system, according to Halvorson.

" (This product) allows us to document any anatomical changes taking

place with the patient, whether in alignment, volumetric changes,

ulcerations, or edema, " she said. " We can document that with subsequent

scans. Instead of taking measurements, which can be subjective, we now

have digital data that can be stored and referenced later. "

One of the advantages is that Insignia can provide objective

documentation to assist the practitioner in securing reimbursement,

Halvorson said.

" A lot of practitioners haven't gone after the foot orthosis market, "

she said. " But orthoses are very important to our patients and we can't

let that market go away. "

Halvorson noted the advantages to the practitioner and to the patient in

earlier referrals.

" A lot of these different pathologies start with the foot but develop

secondary pathologies where they will need the long-term care of

orthotists. Getting the referral a little earlier is the goal, "

Halvorson said.

Pressure transfer

, MPT, CSCS, CPed, looks at the foot as it relates to the

biomechanics of the body in motion. He is a physical therapist at Eagle

Center Physical Therapy in Eagle River, AK, 10 miles outside Anchorage.

One of the tools he uses is the Footmaxx System, which employs a force

plate to measure pressure across the foot as the patient walks on it,

said. The relatively low purchase price of $6000, which compares

favorably to the $10,000 to $20,000 it would have cost him for some

products, allowed him to get into the pressure-sensor field three years

ago.

His patient population includes children and adults, people with foot

neuropathies caused by conditions such as diabetes and arthritis, and

competitive and recreational athletes.

" For runners and more active people, I'm also interested in the pressure

transfer in the foot, " said. " I like to see the dynamic pressure

transfer through the foot, how the foot is reacting to body weight and

ground reaction forces. Then I can relate that to symptoms and objective

measures gathered through evaluation. I'm way into how movement

throughout the chain relates to a person's symptoms. "

With his younger patients, especially those 13 to 18 years old, he is

concerned not only about their rehabilitation from current injuries, but

also about preventing injuries later in their lives.

" Their bodies are growing and you see a lot of biomechanical deficits in

kids that affect their knees, hips, backs, and ankles, especially

deficits in lower extremities, " said.

Research indicates footwear and orthoses change the timing of motion in

the foot. This is important because it may reduce stress to newly

forming joints and tissues and feed the appropriate proprioceptive input

to the body, according to .

" In turn, this makes our rehabilitation program more effective and

prevents injury in the future, especially with athletic kids, " he said.

Now he's looking into more advanced systems with pressure sensors that

can be put into patients' shoes, said. He wants to put patients

on a treadmill and measure dynamic foot pressure before and after

changes in footwear or orthoses. Weeks later he can then remeasure the

foot to determine how well the orthoses are working and to provide

documentation that could help justify the orthoses' success to a

third-party payer, said.

" The more concrete, objective data we can give to a third-party payer,

the stronger our argument for reimbursement, " said.

Reimbursement woes

Private insurance reimbursement is higher than other payers',

said, and Eagle Center is a preferred provider for several companies.

Medicare reimbursement, however, has been low and the process can be

tedious.

" It's been problematic, " said of Medicare. " We often have to

submit invoices three or four times. "

His experience with Medicare reimbursement for patients with diabetes

has been similar.

" We found the reimbursement so low we actually pulled back from the

Therapeutic Shoe Bill, " he said. " And we have to submit the bills

multiples times. It's not cost-effective. "

In Salem, MA, Wall, PT, CPO, owner of Wall Prosthetics & Orthotics,

said he'd rather not provide foot orthoses because of their low margins.

But they are part of his line because his referral sources send those

patients-as well as patients who need other orthotic products, from foot

orthoses up to cervical orthoses.

On his staff has a certified orthotist/board-eligible

prosthetist, a physical therapy assistant, a technician, and a

three-person administrative staff, two of whom are versed in

reimbursement.

" (Having a knowledgeable staff) enables us to keep ahead of the curve of

accounts receivable, " Wall said.

Wall worked as a pediatric physical therapist for six and a half years

before becoming a certified prosthetist/orthotist. His client population

is primarily pediatric, and many referrals come from early intervention

therapists for children with developmental delays. Pediatricians also

send patients to Wall before they send them to an orthopedic surgeon or

a pediatric physiatrist, he said. Everything is made to a patient model

except for the navicular cookies (generic arch supports for kids and

adults, used for treatment of mild pes planus), he said.

He's looked at using a system that provides a contact measurement of the

foot's surface (Amfit System) but chose to stick with what works for

him. Cost is also prohibitive for Wall.

" I opened the practice four years ago and I'm still paying off those

bills, so I don't have the money to buy a CAD-CAM system, " he said.

Massachusetts Medicaid covers orthoses but reimbursement is not good, he

said. Most insurance companies in the state do not cover foot orthoses.

" Most of what we deal with is private pay, " he said.

He also adjusts his rates for families based on a child's age. He has

five different rates, based on age and intervention.

" We're just trying to keep ahead of the bill collectors based on the

reimbursement rates, " he said. " We try to make it so we can realize some

profit on a device and provide service without breaking the bank for the

families. I do a lot of follow-up care. I want to see patients back on a

regular basis to be sure the device is working. I don't charge for the

follow-up and it gives them more bang for their buck. "

Communication key

Good communication with patients during an initial free consultation

generally keeps them from walking out without the needed orthosis,

according to Staci Dorr, PT, CO, branch manager for New England Brace in

Manchester, NH.

Patient diagnoses vary and include plantar fasciitis and nonspecific

foot pain with activity, Dorr said. Her office also sees people with

rheumatoid arthritis and a large diabetic population.

" We encourage people to have an evaluation and we show them an example

of the materials we would recommend, " Dorr said. " We inform them of the

process of how we mold the product and what their costs will be. We're

only going to bill for the device we make or fit for them. "

Harvard Pilgrim Health Care of New England, which serves Vermont and New

Hampshire, has started to cover foot orthoses because patients have made

a case for them, Dorr said. New England Brace has had individual cases

reimbursed by Blue Cross Blue Shield, as well. The need for foot

orthoses is not new information to insurers, Dorr said, and they know it

is not just a cosmetic gimmick.

" I can appreciate them not covering the off-the-shelf product, but it is

different when the patient is being evaluated by a clinician and the

orthosis is being made for them, " she said.

A good portion of their business is in custom orthoses.

" We do make a fair amount of custom inserts for older patients with

rheumatoid arthritis, " Dorr said. " We also manage vascular issues that

are not related to diabetes. Patients in need of foot orthoses are not a

population we market to; they find us because people have foot issues. "

New England Brace does not use CAD-CAM, Dorr said, preferring to use a

more traditional system and make orthoses from plaster casts.

" There's something to say for the person working on the cast being the

person who saw the patient, " she said.

Part of reason her firm hasn't entered the high-tech market is because

of patient feedback, Dorr said. She has patients who had been to

orthotists who used pressure-plate systems and the patients were unhappy

with the results.

" People like a person to touch them and evaluate them, " Dorr said. " To

use a machine to assess something that you can determine with your hands

and eyes seems redundant. We're getting good results with what we've

been doing. "

Andria Segedy is a contributing editor to BioMechanics