"The biggest challenge pedorthists are facing today is not where to practice; rather, it is whether or not to focus in one area as opposed to spreading our wings of expertise and utilizing our full scope of practice."
—Kristi Hayes, CPed, President, Pedorthic Footcare Association
"There is a perceived division of retail versus clinical pedorthists, but the truth is there is no division," Hayes continues. "Pedorthics is a healthcare profession concerned with the care of the foot through orthoses, footwear, and other related devices and modifications."
Today's pedorthists are not only keeping up with a rapidly evolving profession, but they are also confronting an uncertain, changing American healthcare landscape; a tight economic climate; and, from the retail perspective, increased competition from big-box stores and online shoe retailers. As other healthcare professionals add the provision of diabetic footwear and orthotics under Medicare's Therapeutic Shoes for Persons with Diabetes (TSD) benefit to their service offerings, they too have become competitors in an already crowded marketplace.
Despite these challenges, many pedorthists are thriving. Pedorthists and their skills are needed more than ever. The diabetes and obesity epidemics continue to rage, and persons over the age of 55 are becoming a steadily higher percentage of the population. On the other side of the spectrum, interest in sports and fitness is growing. Not to be forgotten are children and youths with foot problems due to obesity, sedentary lifestyles, and footwear selection, as well as kids with congenital or medical conditions. All of these populations can benefit from specialized or customized footwear and orthotic solutions.
Although there is no "one-size-fits-all" approach to creating a successful practice and business model, The O&P EDGE interviewed several pedorthic practitioners and business owners about how they are meeting these challenges. Their practices and business operations range from exclusively pedorthic (no retail sales), to central fabrication for healthcare providers (no retail sales), to almost exclusively retail.
However, no matter which business and practice model pedorthists follow, one facet emerged as a top advantage that big-box and Internet retailers can't offer: expert, personalized service to clients and customers.
Family-owned Brown Shoes, Columbus, Ohio, carries an inventory of more than 12,000 pairs of shoes and focuses on the comfort-shoe and hard-to-fit retail markets. Jeff Brown, CPed, president, is a second-generation pedorthist. Brown Shoes' success is based on finding the right niche: comfort shoes. For instance, his company does not aggressively pursue the athletic shoe market although it participates in the New Balance Procare® program, which connects medical professionals to retailers. "There are lots of big-box retail sports stores, and they can pulverize the independent," Brown says.
Brown is a strong believer in maintaining a large inventory, which enables the company to enjoy volume discounts and provide a broad range of styles, sizes, and widths at a competitive price.
With the advent of the Medicare TSD benefits for persons with diabetes, Brown says his company is seeing more competition from O&P facilities and podiatrists. But "although persons with diabetes are growing in numbers, they are still only about 8–12 percent of the population, and the people actively buying diabetic footwear are probably less than 4 percent."
Brown says that therapeutic pedorthic care from a physician's prescription accounts for only about 6 percent of his business. "Not everyone has a problem so severe that they need pedorthic modifications. The market for comfort footwear is bigger than for pedorthic care, but one attracts the other." The comfort market is growing, Brown adds. "Everyone needs a good shoe."
Eneslow Pedorthic Enterprises
Eneslow Pedorthic Enterprises, New York, New York, headed by Robert S. Schwartz, CPed, BOCPD, includes Eneslow; The Foot Comfort Center; the Eneslow Pedorthic Institute (EPI), headed by Schwartz and Medical Director Justin W. Wernick, DPM, CPed; and www.eneslow.com
Eneslow's 50-member staff includes 15 credentialed pedorthists. Besides what it bills as "NYC's largest selection of comfort shoes," Eneslow offers orthopedic and therapeutic footwear, foot orthoses, and related devices, filling prescriptions for more than 200 physicians. EPI offers pedorthic pre-certification courses in cooperation with the New York College of Podiatric Medicine (NYCPM), New York, along with other educational activities. Eneslow also provides free footwear, socks, and insoles to relief workers, disaster victims, and the homeless and offers incentives to customers who bring old shoes and boots for distribution to relief agencies.
Schwartz is a former president of the Pedorthic Footwear Association, now known as the Pedorthic Footcare Association (PFA), and served on the PFA board for many years. He has been a faculty member of several university pedorthic education programs and has published numerous articles about pedorthics and footwear. He currently is an adjunct instructor in the Department of Orthopedic Sciences at NYCPM. However, even a large, successful company such as Schwartz's is feeling the effects of increased competition and a tight economy. Schwartz especially notes the impact of large Internet shoe retailers, which he describes as unfair competition because they can sell footwear without having to add sales tax. "That's an immediate discount to the consumer of almost 10 percent," he says. Plus, many online retailers offer free shipping and returns, which otherwise would offset their sales tax advantage. "So buying in-store costs the customer more and business costs are higher in a retail environment," he says. Other costs associated with doing business continue to rise, particularly taxes and employee health insurance, Schwartz points out, adding that banks are currently less willing to lend money even to strong businesses to help manage cash flow during tight periods; they are also charging higher interest rates.
However, Eneslow says he is weathering the storm. Expert customer care is one factor that has helped his business succeed. All of Eneslow's customer service and sales staff are trained in pedorthics at some level, he notes. "That is what makes us unique—we can take care of everybody," he says. "We can take care of people who come in with a medical need; we can take care of people with a comfort need. Most customers don't want to take care of their feet with a doctor's prescription first; they want to take care of their feet by having someone who understands what they need and can fit them with it. We know the right questions and we ask them. We know the right products and services and we provide them."
Hersco Ortho Labs
Hersco Ortho Labs, Long Island City, New York, is a central fabrication facility that provides custom foot orthotics, AFOs, custom-molded shoes, and Richie Braces® to healthcare professionals. Co-owners Séamus Kennedy, BEng, CPed, and his brother Cathal opted for this business model because, as Kennedy explains, "One of the major advantages of being a pedorthics-related central fabrication facility, as opposed to a retail pedorthics operation working directly with patients, is that we do not have to deal with insurance [companies] or Medicare/Medicaid. We don't have to file claims and wait for months to get paid."
Kennedy sees pressure on costs as the clearest trend in the industry. "At each level, from the direct consumer or patient to the ordering practitioner up to the insurance payer, there is a real push to lower costs…. The concern is that quality will be sacrificed in favor of price." He stresses, "Regardless of cost pressures, we need to always maintain the highest standards. That is what will sustain us in the long term."
Kennedy uses his company's experience to illustrate his point. Hersco originally accepted some retail customers because the margins were so much better. "However, we quickly realized that we needed to either specialize in direct patient care or central fabrication. It is very difficult to do both well. Running a good lab requires 100 percent of your energy and focus."
For pedorthics as a whole, Kennedy sees great opportunities in the sports and niche retail markets. There are so many interesting foot health areas and trends from barefoot running and minimalist shoes to diabetic issues and summer wear," he says.
Though he acknowledges the difficulty of competing with large retailers, especially on price, Kennedy says the advantages of specialization can make the difference for a pedorthic business. "We can offer knowledge, personal service, consultation, and expertise," he says, adding that it's important for pedorthist business owners to publicize those benefits to referral sources and the public.
Dane LaFontsee, CPed, owner of Orthletek, Milwaukee, Wisconsin, operates his practice solely as a healthcare professional, with no retail component. A former PFA president, he is an enthusiastic proponent for the continued development of pedorthics as a healthcare profession. He also is a retired ballet dancer and has a special interest in sports pedorthics, providing services for the Milwaukee Brewers, the Milwaukee Ballet, the Milwaukee Wave, and the Marquette University, Milwaukee, basketball, soccer, and track and field teams, as well as recreational athletes. He has lectured and published on pedorthic subjects and is an assistant clinical professor of physical medicine and rehabilitation at the Medical College of Wisconsin, Milwaukee.
LaFontsee believes in a holistic approach to healthcare and shares a facility, Invivo Wellness and Fitness, also in Milwaukee, with other independent but complementary practices, including physical therapy, chiropractic, nutrition, fitness, and health psychology. LaFontsee partners with three retail stores where he conducts in-services with their fitters in fitting appropriate footwear with orthotics. "I feel very comfortable sending patients to them for footwear," he says. "This way we're not in competition; we help one another succeed. Thus, I don't need to do retail." These retailers may refer customers to LaFontsee for more difficult foot issues. If over-the-counter orthotics and footwear won't help, LaFontsee may suggest they see a physician for a custom device prescription.
LaFontsee feels strongly that the pedorthics field should emphasize being a healthcare profession as differentiated from retail. "Mixing retail and pedorthics has been a big problem in reimbursement from Medicare and insurance companies," he says. "Often, they cannot—or will not—decipher the difference between an over-the-counter device and shoe and a prescription shoe and orthotic. It just clouds the issue."
Shane's Foot Comfort Center
Kristi Hayes, CPed, has followed her father Shane Hayes, CPed, founder of Shane's Foot Comfort Center, Seattle, Washington, into the pedorthics profession and into national leadership. Shane Hayes, a past PFA president, is an industry leader who has served the profession in many capacities and is the only certified pedorthist to be published in the Journal of the American Medical Association (JAMA). Kristi Hayes is the current PFA president.
Kristi Hayes advocates for the increasing recognition of the profession through better education, focus on the entire scope of pedorthic practice, and appropriate and professional marketing of pedorthics as a healthcare profession.
If the TSD ever ceased, some pedorthic practices would be in serious trouble, she says, echoing the concerns of others in the profession. Therefore, she recommends that pedorthists use all the tools in their toolbox, not concentrating solely in one area, such as diabetic footwear and inserts under the TSD, but also widening and marketing their practice to attract referrals and clients for the expert care of foot problems that are caused by other conditions.
On both the healthcare and retail side, Hayes provides some practical suggestions for coping with tough times, such as maintaining inventory in a shared space with other pedorthists in different, non-competing metro service areas, and downsizing expensive office space. Other cost-saving measures could include sharing facility space with healthcare providers in pedorthics or other disciplines, or working as a mobile pedorthist with hospitals and physicians and performing orthotic fabrication and shoe modifications in an inexpensive location such as a home office or other acceptable and appropriately designed area.
Terry's Shoes Foot Care Center
Terry's Shoes Foot Care Center, Willoughby, Ohio, is split almost equally between pedorthics and retail, says owner Terry Trentini, CPed. His retail business focuses on comfort footwear and wide widths. Trentini has an upbeat, optimistic attitude, noting that when he started his business in 1989, times were tougher than they are now. "We really haven't been affected by the economic climate, perhaps because we have a good reputation and a strong business and referral base."
Although many other pedorthists look at podiatrists as competitors, podiatrists and endocrinologists are Trentini's biggest referral sources. "We approach podiatrists with the idea that we can help with their more difficult cases from the shoe and orthotic fitting standpoint, thus freeing them up for other types of patient care."
Trentini even points out the bright side if TSD coverage were to end. Although his prescription pedorthic practice is about 80 percent diabetes-related, Trentini says, "If the TSD did end, I think this would create a huge opportunity for pedorthists, since then probably everyone else providing Medicare diabetic footcare would leave. However, many persons with diabetes realize that without proper footwear and inserts, they could develop serious complications, so they would just go ahead and pay for it out of pocket."
Different Paths Lead to Success
Although their business models differ, each of the pedorthic businesses interviewed for this article share a number of characteristics: a high standard of excellence in customer/client care; a passion for the pedorthic profession; and good business and practice-management skills. Each has found a niche in the pedorthic healthcare and retail worlds. Finding the balance that works for your business is the key to sustained success.
Miki Fairley is a freelance writer based in southwest Colorado. She can be reached at