In looking at the application of additional products or services to your practice, it is important to consider both the positive effects on the health of your patients and the financial feasibility of implementing the additional service. Does the new product or service improve the whole-body health of your patients? Does the new product or service provide proper compensation for the clinic's time and effort?
If the answer to both questions is yes, you should consider how best to implement the new service or product into your practice.
Where Orthotics Fit In
Custom-made orthotics are an excellent example of a product that improves the whole-body health of your patients, can easily be implemented in your practice, can provide an additional source of revenue for your practice, and can also compensate or the time and effort the clinic (you) put into evaluating and recommending orthotics.
Determining Need Through Evaluation
The first step in the process is determining how best to evaluate a patient's need for orthotics. We can then review how to demonstrate the need for custom-made orthotics to the patient to increase the likelihood of the patient following your recommendations. Finally, you can assess how adding custom-made orthotics can positively affect the bottom line of your practice.
Getting Started
By far the easiest tool for evaluation of the feet is a digital scanner. As I often tell my patients, this is a way for us to see what the bottoms of our feet look like while weight-bearing, something that we cannot normally see. A digital scan also provides us with an image whereby imbalances can be easily visualized by both doctor and patient.
If digital scanning has not yet become part of your practice, there are additional methods for quickly determining a patient's need for stabilizing the feet with custom-made orthotics. A basic physical evaluation of the patient's feet (including observation of the gait) can be done quickly and effectively to determine if there are signs that orthotics should be included in the patient's care plan.
Start out by observing the patient for foot flare. This can be done even before the patient has entered the examination or treatment room, and provides an effective pre-check.
Observe the patient's feet as they walk and what is going on with their gait. Ideally, the toes should be pointed straight forward while walking. Also note what is happening during the swing phase of the gait cycle. If the patient's toes point laterally and not forward during the swing phase, then further evaluation is necessary. Keep in mind that while indicating the potential need for orthotics, there also is the possibility of a hip and/or knee condition that might be causing lateral flare of the foot.
Classic Wear Patterns
At the beginning of the physical evaluation, ask the patient to remove their shoes. This serves two purposes: We need the shoes off to evaluate the feet and also to evaluate the shoes. Flip the patients' shoes upside down in your hands and check the wear pattern in the heels. A balanced gait should yield a heel wear pattern that is fairly well-centered.
If the wear pattern significantly favors either the medial or lateral side, we will have an indication of imbalance during gait. It's also advisable to check the heel counter of the shoes, as an asymmetrical breakdown of the heel counter's firmness is another sign of imbalance.
Evaluate The Feet
Once the shoes have been checked, we can evaluate the feet themselves. Have the patient stand with their feet approximately 6 inches apart. Kneel down behind the patient and check for any bowing of the Achilles tendons, as this would be a sign of excessive arch drop.
Once you've checked the Achilles, evaluate the arches themselves. Try sliding one of your fingers under the foot at the highest point of the weight-bearing medial arch.
If the finger does not go under as far as the distal phalangeal joint, this is a sign that the arch has collapsed to some degree. Check the medial arches of both feet to determine if there is a difference in finger-under-arch depth, as this will indicate asymmetry between the left and right feet.
Keep in mind that the procedure listed above should take no more than one or two minutes to complete if it is done in a time-efficient sequence.
Keeping the evaluation both simple and effective will minimize the time impact of the evaluation while giving you the most significant information for making a good decision on whether the patient in question is in need of orthotics.
[pb]Communicating to Your Patients and Your Staff
The key to successful patient compliance is effective communication. You must be able to effectively convey to the patient the problem, the treatment plan and why they should follow your recommendations. It may be difficult for patients to make the connection between their symptomatic lower back, hip, and/or knee complaints and an underlying asymptomatic foot imbalance. One of the examples I utilize with my patients is the example of a house built on an unstable foundation.
I tell them, "Over time the house itself will have structural problems related to the foundation problems. Even if you repair the house, the unstable foundation that caused the problem remains. By addressing the foundation you can prevent further problems down the road.
"The same applies with regard to your body. If we address your feet (which are the foundation of your body), we can improve both the speed and the results of your treatment plan."
It is also essential that your staff has an understanding of how orthotics work, as well as their own experiences to draw on.
First, you should take a moment to scan or evaluate all of your staff members and show them how need is determined. If you have a digital scanner, this also serves to demonstrate how the scanning software works, since the process of scanning patients' feet is a straightforward task that can easily be handled by your staff. They can then help support your orthotic recommendations.
To take it a step further, your staff members should also be fitted with orthotics in order to have first-hand experience and personal testimonials they can give to your patients. After all, how can staff members effectively and honestly promote a product they have no personal experience with?
Educational Displays Can Make a Big Difference
An educational display in your clinic provides your patients with additional information on what they will be investing in. Brochures can provide more information on orthotics, saving you and your staff considerable time explaining the nuts and bolts of orthotic support. Patients will be able to see and feel the orthotics to better understand how important proper arch support is to their overall treatment plan.
A display with several different types of orthotic samples, along with brochures and other literature, can be placed in a visible spot in your reception area. While your patients are waiting for the start of their appointment, they can read through the literature and learn more about orthotics, turning their time in the reception area into an educational experience.
Additional samples can be kept in the examination room for use while explaining the need for orthotics to the patient. Letting the patient hold and examine a sample orthotic while you explain the need for proper arch support creates a connection for the patient between what you are describing and what they have in their hands. This can definitely help the patient understand and value your recommendations.
What to Say
An important step is necessary after your patient has been evaluated and has seen the information and samples. The next step is to explain your recommendations. If you are utilizing a digital scanner, there are some simple methods to follow when reviewing a foot scan with a patient.
First, you can compare the patient's foot scan with an "ideal" scan. This visually demonstrates the need for orthotics. Ask the patient, "Does your scan look the same as the balanced scan?" Ideally, the areas of solid contact with the scanner surface should be limited to the heels, forefeet, and several of the toes. In the case of collapsed arches, areas of the midfoot will also be in contact with the scanner surface.
The extent of arch collapse can also be shown by how much of the midfoot (from the lateral to medial standpoint) is in contact with the scanner surface.This provides a straightforward visual tool for the patient to see that their arches are collapsing and require support.
Additionally, you can use the scan to compare one foot to the other. Ask the patient, "Do your feet look the same or different?" Differences between the left and right foot scans (especially in terms of the difference in arch collapse between the two feet) again serve to highlight foot concerns that can be addressed with orthotic support.
Finally, you can explain what these differences mean. Bring everything together by explaining how the differences that the patient has noted in their scan can impact (and likely are already impacting) their spinal and lower extremity health.
If you can make the connection between what they see and how it relates to their complaints, the patient will be much more likely to follow your orthotic recommendations. In essence, you will have given them the knowledge to value what you recommend.
[pb]The Bottom Line for Clinical Practice
Chiropractic publication surveys have shown that the average chiropractor sees about 25 new patients per month. A clinical study by Dr. John Hyland showed that at least 75 percent of patients are candidates for orthotics.1 Based on these figures, the average doctor of chiropractic could be fitting approximately 18 patients per month for custom-made orthotics:
It is important to keep in mind that this equation only takes into account your new patients. Of course, you should also take into account both your current and past patients (when they revisit) by evaluating their need for orthotic support.
It is also important to note that some patients will need more than one pair, depending on the different types of shoes that they wear (high heels would require a different pair than athletic shoes). So, as you can see, orthotics can end up being a major part of your practice.
How to Figure Out What You Should Charge
In terms of how much you should charge for orthotics, there are several perspectives to keep in mind.
First and foremost is this: You are taking clinical time to evaluate and recommend orthotics for your patients, as well as taking time to fit the orthotics once they arrive, and you should be appropriately compensated for that time.
Second, just as is the case for all your services, the rate you charge for orthotics on your fee slip should be consistent for all patients. Establish the same rate or "mark-up" for the orthotics and maintain it.
In terms of mark-up, there are several methods for setting your fee for orthotics. I personally recommend a set dollar amount for your mark-up. This will help maintain consistency of fees, as well as keep the cost of orthotics reasonable for your patients.
Additionally, some insurance policies might allow for partial or total coverage of orthotics if need can be demonstrated. Proper coding of patient complaints and documentation of orthotic need in your report of findings can greatly aid in the process of receiving appropriate insurance reimbursement for orthotics and related services.
The amount of added revenue can vary from practice to practice based on the size of your practice and the number of new patients you see each month. Revenue can vary from several thousand dollars to as much as $20,000 per year.
A Bit of History
Orthotics in some form have been around hundreds of years, with some historians dating their origins to innkeepers who made and sold felt insoles to weary travelers complaining of foot pain.
Then came arch supports, which shoemakers constructed from leather.
But the real leap in technology came in the 1960s when a new generation of thermoplastics became available. These products could mold to a form when hot and retain the molded shape after cooling. This was the beginning of true orthotics.
Adding Orthotics: The Overall Practice Benefits
Evaluation and recommendation of orthotics in your practice has at least three main benefits that make it a no-brainer addition to the services you currently provide:
Reference
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Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
