In-house fitting and dispensing can be advantageous for a PT practice.

At a time when competition is high and reimbursement is low, those in the health care field look for ways to grow their client base—and generate a profit at the same time. Keeping ancillary services in-house provides one option to do just that.

Some physical therapy facilities are augmenting their practices through the foot orthotics niche by fitting and dispensing the products as a way to accommodate their patients without having to refer them elsewhere, and to help the practice financially.

“Obviously, our services are under the control of insurance companies, so if you can diversify the services that you offer, the opportunity to get reimbursed for the skills and services that you have is higher,” says Julie O’Connell, PT, ATC, dance medicine manager with Athletico at East Bank Club, Chicago. “Reimbursement is definitely an issue. Our practice is definitely guarded by the insurance companies, so we need to figure out ways to work within that system to be able to continue a business.”

O’Connell, who has been casting for 3 years, says physical therapists can use their expertise to “incorporate themselves into the market share.”

“Being trained and having the skills to do it will definitely help bring a supplemental income to the typical treatment protocols and programs,” she says.

Physico Sports and Rehabilitation Services, Elmhurst, Ill, has provided custom-made and sport-specific prescription orthotics to patients for years. Kyle Watterson, PT, ATC, CSCS, Physico’s director of sports medicine and physical therapy, says foot orthotics account for about 15%–20% of the facility’s business.

“They were doing orthotics before I joined them; I’m going on 3 years now. When I came in, the people doing orthotics didn’t have schooling in it; they were just taking courses on the weekend and trying to figure out how to do it. Now, it’s become much more of a science than just an art,” Watterson says.

“You see a good percentage of the population with a multitude of problems—it might be a marathoner, or someone that’s just having foot problems, and the only time they’ve been in physical therapy is just to get orthotics. So, it’s a good ‘in’ for a lot of people,” Watterson continues.

Physico gets most of its foot orthotics business from referrals sent by an on-site podiatrist.

While most PTs who offer foot orthotics use a laboratory to produce the product, other PTs, such as Stephen Paulseth, PT, MS, SCS, ACT, of Paulseth & Associates Physical Therapy in West Los Angeles, Calif, have taken the entire operation in-house. By providing foot orthotics on-site, a physical therapy facility becomes a convenient one-stop spot for patients, which can also cut down on the time it takes to produce an orthotic and make any adjustments to it.

“The best thing about it is the fact that you’re doing it with the patient that’s being treated at your facility, and if anything needs to be altered or added to the orthotics, or if they’re not tolerating it, you can make those adjustments right then and there. You have a certain control over the patient’s use of them, as opposed to just dispensing them or sending them to someone else to do them for you; and then you don’t know about the quality of it, or whether the patient is tolerating it. It is a nice niche for a practice to be able to offer that service, and the patients like it best of all because they have their referral person right there to deal with it,” says Paulseth, who is also the president of the Foot and Ankle Special Interest Group of the American Physical Therapy Association.

“If you have it right there, you can alter it right away, rather than waiting for weeks for the laboratory to get it back,” Paulseth says. “It can also be refurbished easier in the office than sending it to a laboratory.”

Whether produced at a labotory or in-house, the role of PTs in the foot orthotics niche has definitely evolved over the years.

“When I was in school, we had one casting lab and we heard some lectures about orthotics, but there were just a few physical therapists out there trying it. It seems with the growing population of people using them, that more and more physical therapists are getting into it and realizing the importance of having them,” Paulseth says.

“There’s more of us doing them,” O’Connell says. “I think we’re realizing the role that the foot plays in the function of the lower extremity, and the importance of fabricating an orthotic or using it as an assistive device in increasing the stabilization of not only the ankle but the hip, knee, and lower back. It’s helpful for us when we’re the ones doing the treating to actually be able to contribute to the production or the fabrication of the orthotic because we know what we’re looking for. Sometimes in the communication process between an orthopedist or a podiatrist who’s actually doing the casting and the fitting, we might not be able to get across what we’re looking for with respect to the kinds of modification or things that we’re looking for to increase stability, flexibility, or cushioning across the foot and ankle.”

There have been some in the health care field who do not welcome the competition, though.

“I know that there are some professions that are down on us for doing this and question our ability to do it, including the certified—prosthetists/orthotists, some orthopedists, and definitely the podiatrists—but when you’re applying a clinical tool, like an orthotic, it’s part of the treatment,” Paulseth says. “That kind of device is just a natural thing for a PT to offer, in my mind.”

There are certain considerations that a PT should weigh when deciding whether or not to dispense foot orthotics to augment his or her practice, starting with establishing whether it would serve a need.

“Look closely at your patient population to see if it would be worthwhile,” Watterson advises. “Do you see a lot of diabetic patients? Or a lot of athletes? Review your market.”

Staffing capabilities are another major consideration.

“Evaluate the ability of the staff. You need to have someone fully dedicated to it and who is motivated. If it is a PT that is new to the field, then they can’t be afraid to make mistakes and learn as they go,” Watterson says.

“You need someone to bounce ideas off of, whether it’s an old instructor or a podiatrist, or someone who has the knowledge. So, it would be beneficial to have a team approach for this,” Watterson continues.

“I’ve got a couple people under me that I’m teaching right now, and I tell them: It’s such a frustrating field. As a PT, we are such type-A personalities, we want to put exact numbers on everything and be able to build a scientific thing, but foot orthotics is a mixture of art and science. And it can be frustrating at times; you think you have the perfect prescription, and then what you get back isn’t at all what you had in mind. So, it’s a personality thing. You have to be able to take some defeat along the way to learn how to do this right. It’s a long process; I’m still learning every day,” Watterson says.

O’Connell advises other PTs to familiarize themselves with and utilize the representatives of the different laboratories used to create the orthotics, and to become educated on their products.

“Tap into their knowledge base with respect to the different materials that they use,” O’Connell says. “Having a good relationship with the laboratory that you’re going to be using to actually fabricate the orthotic is a very vital piece of the relationship that you have with your patient and with the actual product that you receive.”

Danielle Cohen is a contributing writer for Physical Therapy Products.