The Impact of the ACA on Pedorthic Practices

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With the Affordable Care Act (ACA) moving toward implementation in January, pedorthic experts have been trying to gauge the impact the new law will have on their profession. In truth, they still aren’t quite sure what it will mean, and that is an uncomfortable spot to be in. But no matter what happens, they say it’s clear that pedorthic practices will need to change the way they do business.

Fear of the Unknown

“It’s not quite fear outright, it’s fear of the unknown,” says Dean Mason, CPed, OST, CO, treasurer of the Pedorthic Footcare Association (PFA). “We really don’t know how this is going to end up and how it will look in its final form.”

Dennis Janisse, CPed, CEO and president of National Pedorthic Services, headquartered in Milwaukee, Wisconsin, agrees with this assessment. “One of the biggest problems is…that I don’t think anyone knows [what to expect],” he says. “There are so many unknowns that we have no idea what it all means.” Mason and Janisse say the way that the federal government and state-run healthcare plans have operated in the past may give some insight into the potential effects.

However, pedorthic practices make up such a small part of the medical community that the potential impact on them hasn’t been discussed much, if at all, by lawmakers.

Mason says the PFA has been constantly monitoring updates in Washington DC and carefully keeping track of anything that could impact pedorthic practices. Even with that monitoring, he’s still uncertain how pedorthic practices will fare when all parts of the ACA come into place. “Until it rolls out and we see what insurance companies are going to do, we can’t really know,” Mason says. In the short term, he thinks that the same insurance companies that covered pedorthic services will continue to do so.

That may change, however, if insurance companies decide to cut costs or decide to follow Medicare’s lead. Right now, a big source of income for many pedorthic practices is Medicare’s Therapeutic Shoes for Persons with Diabetes (TSD) benefit, which took effect in 1993. Pedorthists lobbied for the bill for years before Congress passed it.

In the total scheme of Medicare spending, the diabetic footwear benefit is relatively tiny, Janisse says.

Mason agrees. “The O&P business is a relatively small part of Medicare’s healthcare budget, and we’re one of the smallest pieces of that,” he says. “We’re low-hanging fruit. That means we could be impacted immediately and forcefully or fly under the radar and no one notices us.”

A State-to-State Difference

While the future is still unknown, the experts we interviewed predict that the impact of the ACA on pedorthic practices could vary from state to state. Under the ACA, states can set up their own health plans that will be part of the healthcare exchanges mandated by the bill. For their plans to receive federal accreditation, all the state plans have to provide essential health benefits (EHBs), which are ten statutorily required categories of benefits.

When those benefits were being decided, the National Association for the Advancement of Orthotics and Prosthetics (NAAOP) and the O&P Alliance lobbied the Centers for Medicare & Medicaid Services (CMS) for wording that would specifically include O&P coverage as part of those EHBs. Instead of “durable medical equipment, prosthetics, orthotics, and related supplies,” the law, and thereby the benefits, includes the phrase “rehabilitative and habilitative services and devices,” which can be interpreted in different ways. “It’s a concern that a state could go with the most limited package that does not include prosthetics, orthotics, or pedorthics,” says Steve Fletcher, CPO, LPO, director of clinical resources for the American Board for Certification in Orthotics, Prosthetics & Pedorthics.

Fletcher doesn’t think that states will cut O&P services outright, but pedorthic care, a small part of the overall O&P landscape, could potentially not be included because of the general lack of knowledge about and visibility of this small segment of allied healthcare. For example, it makes regulators look bad if a war veteran returns home without a limb and can’t get a prosthesis, he says. “It’s a little harder to not cover that service than to not include pedorthic services,” Fletcher says. “All O&P providers are at some risk but especially services that are lesser known, like pedorthics.”

The state-to-state difference in plans also means that coverage could vary greatly depending on where the pedorthic practices are located, Janisse says. Medicaid coverage, administered by states, already varies on what’s covered and what’s not, and he assumes that trend would continue with the new state-administered plans. “Right now there are states that cover absolutely nothing of what we do,” he says.

An Uncertain Future

While relying on insurance reimbursements to sustain a pedorthic practice worked for a long time, these practices might need to change their business model, the experts we interviewed say. Even if Medicare continues to cover footwear for people with diabetes, the reimbursements are not keeping pace with the rising cost of the shoes, Fletcher says.

That fact, along with the increased documentation that Medicare requires in order to be reimbursed, means that pedorthists now have to do more work for less money, he says. To offset this, Fletcher suggests that pedorthists who own private practices will need to think of other ways of generating revenue, such as adding a retail aspect to their business.

Janisse says that pedorthists working in larger O&P practices may be spared to some degree. Even if they are making less money on reimbursements, that difference could be offset by the services of the O&P practice as a whole. Individual pedorthic practitioners like him will probably need to make the biggest changes, he says.

He’s in the process of consolidating his five patient care facilities into two locations. The practice will still rely on Medicare for reimbursement but will “cherry pick” only a few insurance companies to work with and have cash-and-carry services for the customers who have no healthcare coverage. The practice will also be focusing more on the retail aspect of the business and introduce some more attractive shoes in hopes that they translate to more sales.

The new business model is meant to cut costs, though he hopes to grow again. “If we feel like we’ve got a good model, then we’d like to expand again when the dust settles,” Janisse says. “We had to make some major changes, and we have to wait and figure out what’s going to happen.”

He’s been in the business for decades and had hoped that his long-held business model could have withstood the test of time. “It’s very difficult, and it’s sort of a scary time,” he says. “I didn’t think, at this point, we’d have to be reinventing the wheel.”

Maria St. Louis-Sanchez can be reached at

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