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Who Needs Orthotics?
Why four out of five patients over 40 may benefit-
and are willing to pay cash for orthotics.

Chiropractic Economics is pleased to present a quick overview of orthotic therapy in this exclusive interview with Dr. Mark Charrette.

How did you become involved in orthotics?
As a student in 1978, I met Dr. Monte Greenawalt, who was the first chiropractor to instruct me in the use of orthotics. Dr. Greenawalt's influence has laid the foundation for what I teach today.

How have orthotics affected your practice, both pros and cons, in the following areas?
Revenue/billing/collections.
In the 1980's, billing and collecting for examinations, casting and orthotics was much easier and more common than it currently is. Today's practitioner may want to consider offering orthotics on a cash basis.

Personnel/staffing issues.
The laboratory I use requires very little time and material: a simple casting kit and data form are all that is needed. Either the doctor or chiropractic assistant can easily cast a patient.

Additional time requirements.
Examination and explanation takes minimal time (several minutes only). Casting takes a few minutes for a total time frame of less than ten minutes.

Special skills/training.
The training time to learn how to cast a patient is minimal. I recommend the interested doctor attend a seminar on orthotic therapy to properly understand indicators, types of orthotics and rehabilitation.

Overall bottom line.
When orthotics are used properly, it enhances patient results and stimulates referrals. A modest economic gain can be made as well. (Please refer to chart).

Economics of Orthotics

A sample equation of implementing orthotics into the chiropractic practice

 No. orthotics
per month

 Gross revenue
per month

 Gross costs
per month

 Net profit
per month

 Net profit
per annum

 8 pairs

 $1200
($150 x8)

 $660
($120x55%)

 $540

 $6480
($540x12)

What percentage of patients typically need orthotics?
Approximately 80% or four out of five patients above the age of 40 could benefit from orthotic therapy. The indicators will usually show these patients usually have excessive pronation, creating a pronator teres abdomen muscle imbalance that will ultimately create pelvic tilting.

What are some of the indicators you look for in patients?
Two simple indicators to look at are different heel wear and the patient's posture. When I teach, I show how to tape the foot into a position where it can help balance the muscles in the lower extremities. Once the doctors utilize the procedure, the patient can see some benefit.

 

What are the different types of orthotics that are available today?
There are two general groups. The first is rigid/hard and the second is flexible/semi-rigid. There are also two diverse laboratory techniques: weight-bearing casting and non-weight-bearing casting.

What characteristics should a DC look for in an orthotic product?
Because the foot has three arches: the medial longitudinal arch, lateral longitudinal arch and anterior transverse arch, it is important that an orthotic support all three. Since the foot is built for flexible locomotion, I find that semi-rigid and flexible orthotics are excellent for stabilizing the foot/ankle complex. While I'm not implying that rigid orthotics can't be of value, I think a semi-rigid type of orthotic works best most of the time.

What are the services and hallmarks of quality of an orthotic company?
First consider whether the products actually work, then ask the following questions.
­­ Do the orthotics cause stabilization of the foot/ankle?
­­ Do they help achieve normal proprioception?
­­ Are they comfortable to the patient?
­­ Does the company have good customer/doctor service?
­­ Does the company give back to the profession?

How difficult is it to get reimbursed from third parties for orthotics?
My experience is that each year it is increasingly more difficult to get reimbursed via insurance. Probably only 10%-15% of insurance policies currently cover orthotics with the advent of managed care. However, orthotic therapy is valuable to patient outcomes and whether or not it is covered, I believe it is worthwhile to explain the potential value to the patient.

Would you say half or one-third of the patients ages 40 and up would actually use the orthotics?
A lot of it depends on the doctor's actual management skills and how well they communicate with the patients. I'd say the better the doctor communicates and demonstrates to the patient the need for the orthotic, the higher the percentage.

What percentage of your patients use orthotics?
Probably 80% of the patients to whom I explain it. From last April until December I worked part-time with a friend in Iowa training his associates. Their orthotics usage went from about one or two pairs per month to eight or nine pairs.

What is a typical profit margin for orthotics?
Most doctors double their raw costs and that covers the cost of their examination, testing kit, shipping and so forth. For example, if the doctor's cost of the orthotics is $75, the patient's charge would be $150. The actual profit is probably 40% to 45%. It is all based on usage.

What are the payment procedures you use for orthotics?
For the most part, orthotics are not expensive, so the patient will many times pay cash out of pocket for them. My normal procedure is to have a patient pay half up-front. That covers my cost in the unlikely event the patient says they don't want them or something happens. Other doctors just send away for them and have the patient pay when the orthotics come in.

Should patients buy more than one pair, say for athletic and dress shoes?
A lot of times, different shoes need different orthotics. For example, a woman in a pump puts the weight-bearing aspect more on the fore-foot. This type of shoe needs a different support than a work-out shoe would.

What should be considered in a shoe?
Finding the appropriate shoe is simple. You primarily want to make sure the heel isn't already worn; if you see the heel is worn, tell the patient to replace the heels. Make sure the shoe counter is firm and that they have a "ball" fit and it's simple to show how to do that. If they've got the right orthotic and the right shoe, it works.

What do you suggest to DCs who feel uncomfortable fitting orthotics?
There are many seminars available or you can call an orthotic company and ask for help.

What do you suggest for the practitioner considering offering orthotics in his or her practice?
1. Educate yourself.
Learn about the various types of orthotics and the difference between weight-bearing and non-weight bearing procedures.
2. Try orthotics yourself.
Most chiropractors end up needing orthotics, so get yourself tested first. If you're wearing orthotics, your patients are more likely to realize the benefits.
3. No extra space is needed.
I have found that little or no additional office space is required.
4. Staff training.
You can teach your CA basic casting procedures in as little as ten minutes.

I go at it very low key. I let the indicators speak for themselves, instead of saying, "You need this." The old my-way-or-the-highway type of approach usually doesn't work. When I demonstrate the need for orthotics and leave it up to the patient, they may initially refuse, but then say later, "Well, maybe I should get those, perhaps it will help."

Mark N. Charrette, DC, a 1980 summa cum laude graduate of Palmer College of Chiropractic has lectured extensively on orthotic therapy, spinal and extremity adjusting throughout the United States and abroad. In addition to practicing privately for many years, Dr. Charrette received his Bachelor's degree in education (summa cum laude) from Illinois State University.

A Four-Step Orthotic Screening Process

It's not difficult to incorporate orthotic therapy into the chiropractic practice.

1. Adjust the spine first.

2. Check for excessive pronation in the following order: foot, knee, hip, shoulder, elbow and wrist.

3. Perform the casting and molding procedure.

4. Explain the proper shoes to wear with an orthotic.

   
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