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The Business of Medicine

Posted by Mike W on 6/09/05 at 08:48 (176384)

This is one example of my expeience getting a study done on exercises for PF.

A friend of mine is the head Podiatrist Calgary Health Region.

Several years ago I showed him my Foot Trainer Exercises. He liked them and set me up with 5 local Pods who had funding for a formal study. I met with them and they were interested. They selected 5 patients each to try my exercises. When I was setting them up I could call their offices and they would always talk to me. They were supposed to get back to me with their results in about 1 month. They did not contact me so I tried contacting them by phone and they would not take my calls. So I went to one of their offices and he did not not want to talk to me. I asked him did you try the exercises with 5 of your patients he said yes and that they all showed improvement but they were not interested in doing the study.

I called my friend at the Calgary Health Region and he candidly/sadly told me that they turned the Foot Trainer Study down because over 50% of their practice is fitting and making Orthotics. They charge $400.00 for a pair of custom orthotics, so if they were to sell my Foot Trainers for $40.00 they would lose half of their business. This is the Business/Reality of Medicine.

Since this experience I have developed business with different Podiatrists and Physical Therapists who have an open mind and place the health of their patients ahead of the dollar.

Re: The Business of Medicine

Elyse B on 6/09/05 at 09:06 (176386)

hey I paid $600 for orthotics!!! The last podiatrist told me candidly and truthfully that 90% of her business is orthotics so it is my best guess that everyone even for an ingrown toenail gets a prescription for orthotics. FYI, my $600 orthotics are sitting in the closet.

Re: The Business of Medicine

Cyndi on 6/09/05 at 10:03 (176387)

The first POD is saw sent me home with a new appliance almost every visit for 7 months.
He only did things he could make a profit on. I still do not have any orthics and he sent them back twice and I never got them from the last re-fit,( he sayas they were lost) I wonder why he never called me in gmonths to let me know) also I was to get a pair of shoes. After 6 months, I finally afte many requests, got my insurance to re-charge his account.
Now after 1 1/2 years maybe I can see my referral DR again for the orthos and I bought the shoes myself a couple of miles from his practice. He told the insurance co. the shoes were on back order(for 6 months?)

My referral DR did MRI and Bone Scan plus another Nerve Conduction which he made not a dime on except the office visit.
Doctors will bleed you, beware! Cyndi :-)

Re: The Business of Medicine

Terry on 6/09/05 at 13:38 (176398)

Way to go Mike! By the way, I have been using your foot trainers for about a week. Not very long, but I will give it some more time and them post a story about the results.

Re: The Business of Medicine

Richard, C. Ped on 6/09/05 at 15:46 (176405)

I bet they actually sold the foot trainers to the patients and did not want you to find out about it.

It makes my stomach turn when I hear how much some people pay out of their pockets for orthotics. Crooks.

Re: The Business of Medicine

Mike W on 6/09/05 at 17:59 (176409)

I think orthotics can be an important part of dealing with PF but think they should not be so expensive.

Re: The Business of Medicine

Ed Davis, DPM on 6/09/05 at 19:24 (176412)

Elyse:
There are 'bad apples' in every profession. I would not let you personal experiences color you view of a entire profession.
Ed

Re: The Business of Medicine

Elyse B on 6/09/05 at 20:58 (176425)

Ed I know there are 'bad applies' in every profession. How could one not let personal experience color one's view? That is a very simplistic view. I have never said orthotics are not helpful for PF, I just think as I have said over and over again, they are overprescribed and sometimes not necessary at all. Just out of curiosity and with all due respect, Dr. Ed what do you charge your patients for orthotics? It seems that Richard Cped is aghast with the prices one charges for them.

Re: The Business of Medicine

DavidW on 6/10/05 at 07:02 (176432)

I spent $400 on my orthotics, with several adjustments costing $75 each. After a full year+ of wearing them with no relief at all, they are also sitting in the bottom of my closet. I no longer go to see the POD that made them for me. After I refused another adjustment and kindly asked what else we could do to help my pain, he basically said not to come back. The 2nd POD I went to visit also recommended a new pair of orthotics, but I kindly refused, and he accepted that answer. The 3rd POD did not recommend orthotics (Dr. Z). I do believe that the hard orthotics that I was told to wear for so long has made my PF cronic. By the way, that POD also told me to do whatever I wanted on my feet, NO MATTER the pain level, and just take OTC meds for the pain. Being more stupid several years ago, I followed that advice, and today I am much worse off (yet smarter!!).

Re: The Business of Medicine

Dr. Zuckerman on 6/10/05 at 07:56 (176438)

. Orthosis can help along with personal foot trainers, ESWT etc. I personally like the personal foot trainer. It makes alot of sense when used properly.
The bottom line is getting results and I would think that using the personal foot trainer along with correcting biomechanics would give you better results.

Re: The Business of Medicine

Ron on 6/10/05 at 08:06 (176440)

I'd like to know why you think the foot trainers make a lot of sense, or at least why strenghtening the extensors in the front of the foot make a lot of sense.

Re: The Business of Medicine

Elyse B on 6/10/05 at 08:20 (176442)

I am confused as to why custom orthotics costs $400 and above. It takes the doctor, all of 3 seconds to either cast or place your foot in a box. Then 95% of the doctors do not make their own orthotics, they send them out to a lab. Oh wait, the $395 remaining must be for the shipping of the cast!!!

I have a story like the above where the podiatrist charged $600 for the orthotics and wanted to charge $200 for each subsequent appointment to adjust. Nevertheless, I did not return for adjustments. I would have to have mortgaged my home to continue with this podiatrist.

It is interesting, one of my running teammates husband's is an opthalmologist with an office on Park Avenue (and always on the Best Doctors in NY List) and he went to years and years of medical school and he does not even charge as much as that quacky podiatrist. Go figure.

That is why I think pedorthists like Richard are the way to go.

Re: The Business of Medicine

John H on 6/10/05 at 09:00 (176447)

I had a PT cast my foot and order some orthotics from a major company. In his previous job he had spent nearly all his time casting feet for orthotics for a large group of Orthopedic Surgeons.

He told me he would just charge me his cost. He spent about 25 minutes casting my feet. His cost and my cost was $98.00

Re: The Business of Medicine

Richard, C. Ped on 6/10/05 at 15:02 (176467)

I justify my expense for the knowledge that it actually takes to make a pair, and the time involved. Any one can make an 'orthotic', but to do it correctly, that is another thing.

I think pro athletes make to much money. If I were any good, I would not turn down the opportunity to ride the bench for $100,000 per year.

Re: The Business of Medicine

Ed Davis, DPM on 6/11/05 at 16:08 (176550)

Elyse:
Since 70 to 80 percent of the insurance plans cover orthotics in my area, the insurance plans set the fees for the orthotics. A purely cash price would be about $330 for carbon graphite but that includes gait analysis, a biomechanical exam and a complimentary pair of pre-fab orthotics modified to be as close to the real ones (as possible) to be used by the patient until the orthotics have arrived. I can can assure patient's s that he orthotics will be appropriate 98% of the time (nothing is 100%). I adjust the orthotic I dispense in house so I can almost always get them to work. Our fees go a bit higher if we 'finance' the orthotics allowing patients to take several months to pay them off.
Ed

Re: The Business of Medicine

Ed Davis, DPM on 6/11/05 at 16:17 (176551)

Elyse:

It tkaes about 30 minutes for the doctor to perform a bioemchanical exam and gait analysis and 25-30 minutes to take the mold of one's feet since 75% of doctors DO take their own casts. THAT is the RIGHT way and the standard of care. Again, I am sorry that you ran into some bad apples but that simply is not the way those guys were taught to do the work in school! I am a teacher so I know.

If you have read some of the archives, I have begged for an organization that polices quality control in this area.

Ed

Re: The Business of Medicine

Ed Davis, DPM on 6/11/05 at 16:23 (176553)

The lab that podiatrists send their casts to can charge between $85 to $165 for the finished product, not including shipping costs. We need about an hour to take the casts. This is not my imagination -- I teach future podiatrist and it is the right way. I hsve no control over a bunch of renegade practitioners in your area of the country. Lab fees, shipping , insurance and overhead all together make the average orthotic cost about $247 to the practioner.
Ed

Re: The Business of Medicine

Ron on 6/11/05 at 17:56 (176558)

Adding 100% on to the cost of a device isn't unreasonable. Stores do it and they just buy a product. A doctor must get into time and management and satisfaction. Maybe some charge extra to guarantee that the orthotic will work. All this costs money and comes from the patient/customer.

Re: The Business of Medicine

Ed Davis, DPM on 6/11/05 at 20:45 (176562)

Ron:

Doctors do not consider orhtotic therapy a commodity to be bought and sold. A process is involved. That process involves an exam and if the exam leads to the conclusion that an orthotic would be eneficial, then it may be utilized. The doctor performs a biomechanical exam and gait analysis taking a large number of measurements. The plaster used to take the impression is applied in a number of different ways depending on the neeeds of the patient. The doctor then has a negative cast of the foot with the foot held in a partially corrected position as well as a number of measurments. The lab recieves the partially corrected negative cast and makes a positive cast out of that thus producing a partially corrected postivie cast. The posivitve cast is then modified per the doctors instructions, the modifications based on the measurments, biomechanical exam and gait analysis. the end result is a corrected postive cast.

The lab then takes the correctd postive casts and molds the orhtotic 'shell' over that which can be made of plastic, fiberglass, carbon graphite or a combination of the above.

Finally the orthotic shell has corrections added to that such as posts (wedges), metatarsal elevations -- about 42 such corrections exist.

The doctor then fits the orthotic to the patient observing the degree of correction achieved. Some patients tolerate a lot of correction early on; other need mild correction with the doctor bringing the patient back to grdaully augment the corrections.

The orhtotic is not made necessarily to cure a symptom but to change the biomechanics of the foot which lead to a symptom or set of symptoms. I can always guarnatee that I can change the biomechanics of the foot for the better. I cannot guarantee that changing the biomechanics of the foot will lead to a cure just. Same with ESWT -- it can change the tissue quality involved which usually helps plantar fascia but it cannot guarantee a symptomatic cure. I use the treatment triad sconcept to let patientns understand that there are 3 necessary components that must be delat hwith to cure plantar fascia. The doctor must determine which of the components, if not all need attention and treat them SPECIFICALLY with the mdoality designed to mitigate each component.

I know of no absolute way that I can prove, unless I subject a patient to an elaborate gait analysis study, that the orthotic has met its goal. Its goeal is to change the mechanics of the foot, nothing more, nothing less.
so guaranteeing a cure of symptoms sounds like a nice concept but is truly unrealistic if one understands the purpose of each treatment.

I could almost guarantee that I could examine Elyse, determine which components ofthe treatment triad need attention and how much and thus cure her. But she must first understand what each modality is doing specifically and what it is not doing.

I am speaking from the point of view of a teacher and the 'ideal.' People in the field know all of this but elect to take all kinds of short cuts and some are out for a fast buck. I have spent little time in Elyse's neighborhhod but if she had a lot of poor practitioners who are not provideing proper treatment, she will get a very distorted view of what constitutes poper treatment and what does not.
Ed

Re: The Business of Medicine

Dr. Z on 6/12/05 at 09:24 (176577)

Ed,
Very good explanation that I am glad you took the time to explain. There is both an ART and SCIENCE to bimechanics and orthosis. I do believe that if patients understood the goal of orthotic treatment the end result would be better.

Re: The Business of Medicine

Elyse B on 6/12/05 at 14:51 (176602)

thanks for your comments. Not sure where you live but orthotics are NEVER, EVER covered in NYC no matter what insurance you have. So it is always out of pocket, that is why I think $600 is highway robbery.

Re: The Business of Medicine

Elyse B on 6/12/05 at 14:54 (176603)

Bad apples, I guess 6 qualifies as bad apples. I have never had a 25 minute biomechanical exam. Casting takes 10 minutes whether it be cardboard or the plaster stuff. Never has it been more than that. I would love to hear from other posters on this Board who have had their podiatrists spend that much time on their feet.

Re: The Business of Medicine

Elyse B on 6/12/05 at 14:55 (176604)

well you sound like a miracle worker. I gave up on orthotics and will; never, ever see a podiatrist again, with all due respect.

Re: The Business of Medicine

Ralph on 6/12/05 at 17:22 (176616)

Elyse,
My Pod came into the room with a tech, looked at my feet and the paper that I had filled out in his office waiting room. He ordered xrays and walked out.

I had 4 xrays taken and returned to the same room. The Pod returned to my room in about 15 minutes and said he would put a small injection into my foot and tape it after he had his 'girl' make some molds of my feet for a pair of orthotics. He never told me how much they would cost me nor did we discuss what they would look like or be made of. I found out on this visit that apparently only the 'girls' at the front desk talk about the cost of things and only those things that insurance doesn't cover. You never seem to hear what the doctor charged for his service at least I didn't know what my costs were that day accept for the orthotics.

The Pod told the 'girl' (his term) for his tech to put my heel in neutral when she put the plaster wraps on my feet and walked out of the room. I laid on my stomach for this procedure and another one of his 'girls' came in to the room. The two of them chewed the fat about what they did the night before while one of them put the wet plaster wrap on my feet. I have no idea if my heel was in neutral or not, but I know what bar she went to. She said don't move and they both walked out of the room.

I don't remember how long I layed there, but only one 'girl' returned to remove the cast. Next the Pod returned to give me the shot and taped my foot tightly and large enough so I could not put my shoe back on. He told me keep the tape on as long as possible, he'd see me in two weeks and go check out.

Only at the check out counter did I find out the orthotics would cost me $350, they were not covered by my insurance and they needed to be paid for that day and if I didn't want them I'd still have to pay for the casting.

My second visit wasn't much better. The 'girl' brought in the orthotics and said walk around the office in them until the doctor came in. He looked at my feet and asked me how the orthotics felt. I said they hurt and he said I needed to get used to them. End of second visit.

Third visit was just as spectacular. I complained that the orthotics were hurting my feet and now the second foot had the same pain as the first. Doctor examined the orthtoics and called his 'girl' into the room. He told her to grind the bottom of them and when she returned she said to try these for a few weeks.

Fourth visit doctor scratched his head and couldn't understand why the orthotics were causeing me pain. He had his 'girl' grind them again and said have another go at them.

There was no fifth visit. If you want them they are in my closet.

Re: The Business of Medicine

Elyse B on 6/12/05 at 17:28 (176617)

Ralph why don't we collect the orthotics from those on this site, we would have some collection. I see that your visits to a podiatrist were very similar to mine. I guess I can top that with the $250 per visit doctor (the infamous doctor of the $600 orthotics). Went to him, got to the examining room. He came in, felt my feet, said 'oooohhh' I can help you. Left the room. 5 minutes in total. His 'aide' who is not a doctor, came in and made me step in the box for orthotics. Did not tell me how much they cost etc. etc. Never watched me walk. I went back one more time and he charged me $200 to look to the orthotics. Never went back because it is highway robbery to charge for adjustments that he does not do at all and has to send to a lab. My internal medicine doctor charges less.

Re: The Business of Medicine

Ralph on 6/12/05 at 18:05 (176621)

I forgot to mention. I agree with you about the cost of this piece of plactic called an orthotic. I think it is outrageous and patients are being taken to the cleaners on them. There is no way they cost this much to manufacture. I know for a fact that those foam boxes that are used by some pods cost pennys because they purchase them in volumn.

If you look at websites that offer people a money back guarantee if you are not completely satisfied with their $300 -$500 pair of custom orthotics and think about it they can well afford to do this because they still make money on you and spend about $1.50, if that, to see if you end up purchasing their expensive orthotics in the process.

They charge you up front a non refundable service type fee for processing, a foam box and 'the work they do' to make your custom orthotics say something like $39.00. You say heck why not give this a try because my $300 fee for the orthotics will be completely refunded if I don't like the orthotics so instead of loosing $300 I'm only spending $40 bucks to try them.

They send you out a foam box that costs them about 2 cents per box ( check the cost on the internet), but you pay for the postage in both directions.

You step in the box and return it to them. They have your check or charge number for the service fee of say the $39.00, make the orthotic and send it to you and again you've paid their postage. When you receive the orthotics the $300 fee for them is put on your charge prior to them sending out the orthotics.

You try the orthotics, but they hurt you. You call the doc or company and they tell you to return them for an adjustment. You agree and pay the postage and send them back.

This step can be repeated until you find that the trial time period which is usually stated in the ad or agreement that you sign for trying the orthotics is running out and if you do not return the orthotics within that period of time you will be charged the full amount of $300 for the orthotics so you send them back asking for your refund.

The doc credits your account for $300 but has made $39.00 minus 2 cents for the foam box and probably had one of his 'girl' make all and any of the adjustments during this entire trial process. He is in his office seeing patients. This is just his 'mail' operation.

Maybe you and I should get some foam boxes and put up a website. At $40.00 per foam box that we sent out to people willing to jump on our money back guarantee just to try OUR brand of orthotics we'd be making money too. After all we'ed be offering a complete money back guarantee if they don't like them and only a $39.00 service fee, postage, and manufacturing fee for trying them.

Let me know when you want to purchase those foam boxes:*

Re: The Business of Medicine

Elyse B on 6/12/05 at 19:40 (176624)

Ralph I am ready to go into the foam box business immediately. Can I quit my day job?

You described a perfect scenario but that 'ain't' going to happen because podiatrists make the bulk of their income from orthotics. I am convinced that podiatrists convince patients that they 'need' orthotics. When people are in pain, they will believe anything like you and I did.

I have said this before, I am on a running team of about 35 women and I would say that 90% of them do not wear orthotics. I do believe in orthotics to help biomechanical issues such as supination and overpronation. I am not convinced that orthotics help PF which I believe to be caused by muscle weakness.

One other thing I need to add. Since none of the 6 podiatrists did a gait analysis or minimally watched me walk, I went to a running store and had my gait analyzed by video tape. GUESS WHAT.... I have a completely neutral gait, I do not overpronate and I do not supinate. Hmm, wonder why I was prescribed orthotics by 6 podiatrists?

By the way the only podiatrist that I know who refunds money on orthotics is Dr. Kiper for this Silicon Dynamic SDO custom orthotics. I know because I tried them and gosh darn it he returned my money. I find it completely interesting that the podiatrists on this board think the SDO's are a 'gimmick' and do not hold much standing by them.

As I said before, if I ever decided to wear orthotics again, I would go to a pedorthist like Richard Cped. I trust them more than as Dr. Ed says 'a few rotten apples.'

Re: The Business of Medicine

Dee on 6/12/05 at 21:29 (176632)

Too bad his 'girls' can't find a better employer. It's a good thing he didn't have one of his 'girls' do surgery on you.
Your post was hilarious, but sadly true.
I have a over a dozen pairs of custom orthotics sitting in a bag. The best was from a pedorthist and the worst were from pods who rely on off site labs. My most recent pair is from a pod and the adjustments just weren't working for me. I asked I could just go down to 'the Lab' (aka manufacturer), and he refused. I believe most labs are run by pods who are entrepreneurial and have found a way to make a better living.

Re: The Business of Medicine

Ed Davis. DPM on 6/12/05 at 21:41 (176633)

Elyse:
i can see how the podiatrists you saw make the majority of their income from orthotics but that certainly is not where the majority of my income comes from, nor that of my local colleagues.
Ed

Re: The Business of Medicine

Elyse B on 6/13/05 at 02:23 (176642)

sorry I find that hard to believe.

Re: The Business of Medicine

Ralph on 6/13/05 at 09:43 (176650)

Dee,
You're right about that. I sure wouldn't want one of his gum chewing 'girls' doing any more for me than they did. I didn't like their gum snapping professionalism.

I never thought about who actually owns or invests in Orthotic labs but you bring up a good point.

Doesn't it make you wonder just how many pairs of orthotics are sold each year and the total amount of sales in the U.S. I certainly do. I also wonder how many of those are sitting in closets today.

Re: The Business of Medicine

Moderator on 6/13/05 at 10:18 (176657)

No more responses to this post here. Create the topic on the Social board for this discussion.

-Thank you

Re: The Business of Medicine

Liboralis on 6/13/05 at 15:39 (176693)

If 90% of her business is orthotics then she must not be very good

Re: The Business of Medicine

Liboralis on 6/13/05 at 15:45 (176694)

First it does not take 3 seconds to cast a foot, especially in plaster. $600 is a ripoff but there are many costs involved like OVERHEAD. Do you go to a nice restaurant and complin that they are getting rich and that they should let you bring your own meat in and they should prepare it and serve it and charge you what it costs you to make it yourself?

Re: The Business of Medicine

Liboralis on 6/13/05 at 15:58 (176696)

Elyse, just curious what you do for a living

Re: The Business of Medicine

John H on 6/14/05 at 10:12 (176758)

We often hear the words Over Pronation and Suppination. I wonder what the standard is. Many people pronate to a great degree and have no problems what so ever. How many people have the so called perfect foot strike? Very few I doubt. I would guess that we often try to correct the way we have been walking for a lifetime only to make things worse. It makes some sense if you injure your foot which causes you to change your gait or foot strike to make a correction. If you have been so called 'over pronating' for a life time you may be treating the wrong problem with orthotics. If you are a basketball player, distance runner, mountain climber you 'may' need some foot support and stability before a problem develops.

Re: The Business of Medicine

John H on 6/14/05 at 10:16 (176759)

Ralph I purchased a pair of custom orthotics which were cast in the PT's offices. They are a well known brand. He said he would only charge me his actual cost from the manufacturer. He showed me the invoice. They were $98.00 including shipping. They would have easily have cost me $300 - $400 from some professionals.

Re: The Business of Medicine

John H on 6/14/05 at 10:45 (176761)

Sounds like you live in NYC Elyse. I think a typical visit to a Podiatrist in Little Rock with Medicare reimbusement the Doctor will receive less than $40 unless he gives you shots or performs x-rays which they seem to do even if you had them only a month previous. If one gets ESWL for a kidney stone the billing cost may easily exceed $7000. Medicare will probably reduce that to around $2000. Some Doctors refuse Medicare patients or limit them for this reason. Recently Medicare was going to reduce the amount paid to Doctors even more which would drive more Doctors out of the Medicare field but Congress changed their minds and gave them a slight raise for most procedures. When you buy a new GM car approximately $1100 of the cost of the car goes to cover employee medical cost. The distinct possibility exist that GM could face bankruptcy in the coming years. I would think (do not know) that perhaps 20% of your Doctors billing charges go to insurance overhead. Most Doctors these days finish 10 or so years of training several hundred thousand dollars in debt. One can only guess what a Doctor practicing in Manhattan pays in overhead. Currently it is more difficult to get into Vet School than in Med School. There are fewer openings. Many people who would formerly have chose med school find that a vet rarely gets sued, has good working hours, does not have problems getting paid, no insurance problems and can make just as much money. It cost me more to take my cat to the Vet than it cost me to go to my family Doctor. One of my Doctors is leaving his practice for a year to donate a year of his time on the medical ship HOPE. I went to see my family Doctor who I had not seen in several months. She loves horses and has a farm with a number of them. She had been thrown off her horse straight over the head and landed flat on her head and broke her neck. Hit just like Christopher Reeves. Fortunately she only weighs about 100 lbs. He spinal cord was not injured but swollen. The day I saw her she had just removed the cast and had some slight numbness but said it would go away. She said she would be back on her horses as soon as she can as that is what she likes most in life. A cow scared her horse. I think most Doctors are pretty good people and like anyone who has spent years of training in a very specialized area hope to maximize their profits. Sort of the American way of medicine and business. Government and insurance do limit what they can make although we may not know it. Doctors have one of the highest suicide rates of any profession. Why? Most of us complain about our Doctors including me but I sure would not change our system for any other. I can see my family Doctor within an hour 6 days a week without an appointment. I can see most specialist without a referral within 7-10 days. I can see a Podiatrist within 3 days. By the way my feet still hurt!

Re: The Business of Medicine

Ed Davis, DPM on 6/14/05 at 14:59 (176770)

Elyse:
No miracle worker. Just your average podiatrist.
Ed