The previous three issues of this newsletter revolved around how to know whether a patient has already received inserts under the therapeutic shoe program, do they need to receive shoes at the same time or if at all with the inserts and the most recently, how to handle a patient who failed one time of insert and now may require another.
Picking off where we last let off, let’s look at several different clinical circumstances that you may come across, in which patients already have received and clinically failed in pre-fabricated A5512 heat molded inserts and discuss the next steps for successful treatment…
Patient A: Is a morbidly obese diabetic and has sub met 5th bilateral IPKs and a previous healed ulcer. Is this the patient you want to put into a custom milled insert, or would they be better off in a custom fabricated orthotic with accommodations and posting? We may all agree this patient would be better suited to go the orthotic route. Should the patient have a Medicare supplement, it is quite possible that secondary carrier will offer coverage for the orthotics, but not for the additional pairs of inserts (20% of 0 is still 0). But what if they don’t have coverage for orthotics and they only have limited funds to cover out of pocket expenses. Perhaps less than three pairs of A5514 inserts should be ordered, with the number based on the time of the year and with the reasonable expectation that the number of inserts you order will last until the next calendar year. Another example may be to take one of the myriad of off the shelf pre-fabricated functional orthotics which already have posting and top covers and add accommodations and add a corex post with some glue. For those 50+ who were properly trained on orthotic manufacturing in podiatry school this is an example of a lost art, which desperately needs to pass forward to our younger colleagues. For this patient alone we have now provided them with three options, custom milled diabetic inserts (A5514) three or fewer, functional orthotic with accommodations or adding accommodations to a pre-fabricated orthotic. Cost considerations are important as is the exact clinical scenario(s) for this type of patient. Your communication and skill set will undoubtedly affect which may be best for the patient.
Patient B: Is a normal developed diabetic elderly female with an atrophic fat pad and multiple plantarflexed metatarsal heads and associated IPK’s. This patient may be amenable to a custom insert. If it is September when the patient presents to your office one must consider whether this patient honestly go through 3 pairs of inserts in four months? It is highly unlikely. Since this is a cash transaction, you could ask the laboratory to only charge you for one. Again, while extrapolating the costs for one device out for three may be higher, you may be paying much less than for three and you may choose to past that cost savings onto your patient. Your other option is to fabricate this patient a custom orthotic (L3020) type. In both these scenarios, you should let the patient know that the custom inserts do not have the durability of the custom orthotic, with the custom orthotic likely lasting two or more years. Again, one may wish to enter into the equation the patient’s secondary insurance issues and then decide what is both affordable and in the long term interest of the patient.
