When you order and pay for a custom prescription foot orthotic from an orthotic laboratory, how sure are you that the device received is truly “custom”? When your patient pays you for a perceived custom foot orthotic, is the patient really getting what he or she paid for?
This will be the first in a series posted on my blog, which will explore a potential crisis facing the podiatric profession and the custom prescription foot orthotics industry.
Prescription foot orthoses are the cornerstone of non-operative treatments utilized by podiatric physicians. The vast majority of foot orthotics dispensed by podiatric physicians are custom functional orthoses, which follow principles of fabrication taught by Merton Root, DPM, in the 1960s. This technique of neutral suspension casting — creation of a positive cast model, balancing of the positive model to correct frontal plane forefoot to rearfoot deformities and molding of the custom device to the corrected cast — has been taught to students of podiatric medicine for over 50 years.
When a podiatric physician sends a cast to a laboratory for fabrication of a custom foot orthosis, the assumption is that the device he or she orders will follow these long established principles of fabrication. In reality, the fabrication techniques of foot orthoses has changed radically over the past 20 years. Instead of hand corrected plaster positive casts, most “custom” foot orthoses are made from computer images and the actual correction of deformity may not ever occur.
The custom foot orthotic industry is headed into a state of crisis based upon a number of critical issues: ethics and accountability, verification of outcomes, coding and reimbursement, increased operational costs and reduced profitability. Furthermore, fewer and fewer podiatric orthotic labs are actually manufacturing devices according to the principles assumed by podiatric physician customers. The days of hand crafted, Root-style, balanced foot orthotics have long since passed. The age of digital technology has allowed some labs to cut corners and save time in producing custom corrected foot orthoses. In fact, many podiatric physicians are being duped into purchasing so-called “custom” foot orthotics, which are actually prefabricated devices.
A closer look at trends in the current podiatric foot orthotics industry should give grave concern to the prescribing physician who is still committed to providing quality outcomes for his or her patients.
The first critical issue is the practice of some labs to provide a prefabricated orthotic when the physician has actually submitted a cast and prescription for a custom device. I know of at least two large labs operating in the United States who carry out this practice on a daily basis.
When I use the term “prefabricated,” I am referring to a practice in which a device is manufactured on a prefabricated cast, not on a model of the actual patient. This so-called “library” system of orthotic manufacture is acceptable if the lab acknowledges the method and prices this prefabricated device accordingly. Some ethical labs actually sell library devices along with custom devices but at different prices. Unfortunately, other labs do not disclose their dishonest fabrication techniques and continue to sell library devices when the doctor has prescribed a custom orthotic.
An obvious solution for the prescribing doctor to keep his or her lab honest is to request a return of the positive cast with the orthotic devices on each and every prescription.
Unfortunately, we will discover a new dilemma and most practitioners are unaware of this. Most large foot orthotic laboratories do not manufacture their devices on traditional plaster casts. Automation has taken over with CAD-CAM technology as positive casts are now “milled” from wooden blocks.
Next month, I will further explore the pros and cons of automated custom foot orthotic manufacturing.