December 2009

Lower extremity O&P warms to CAD-CAM

By L.W. Barnes

With a start-up cost of many tens of thousands of dollars and a steep learning curve, it’s no surprise that many O&P practitioners have been slow to transition to computer-aided design and computer-aided manufacturing (CAD-CAM).

But today, even clinicians who are wedded to old-school plaster techniques say the technological advances in their field are hard to ignore.

“A lot of practitioners are going this route, otherwise they know they’re going to be left behind,” said Shane Coltrain, CPO, president of Orthotics & Prosthetics East in Greenville, NC, who has been using CAD-CAM since he opened his practice in 2006.  The move to the computer, he said, has cut his fabrication and adjustment time by more than a third.

While the cost associated with computer-assisted fabrication are generally higher than traditional methods, Coltrain and other clinicians say they gain untold savings in time and other efficiencies. Coltrain, for example, whose business is composed mostly of lower extremity cases, said he can modify a transtibial or transfemoral prosthesis in as little as five minutes, versus 30 minutes doing it “the old fashioned way.” Meanwhile, the switch has allowed him to increase the number of patients he sees daily from seven to as many as 12.

“That’s where we make money,” he said.

But the transition to CAD-CAM is not just expensive. It’s a fundamental shift in practice for many practitioners who have been molding plaster by hand for decades and can’t imagine trading their handskills for the grip of a computer mouse. The learning curve, clinicians say, can be daunting for those already running a practice and comfortable with the way they conduct business.

Moving to a new platform not only means upfront costs for software and machinery but a loss in productivity until a new system is mastered. But clinicians say the future is clear: the profession is transitioning, if slowly.

“We’re in the embryonic stages right now in lower extremity CAD work,” said Lawrence Lerman, CO, vice president of Lerman & Son Orthotics & Prosthetics in Beverly Hills, CA.

The industry may be taking “baby steps,” Lerman says, but he also believes that lower-extremity applications do have potential. Eventually, he said, “I think there will be a place for it in my practice.”

Today Lerman uses CAD primarily for spinal and cranial orthoses and is a vocal proponent of the technology (in 2007 he co-authored a study that showed CAD improved the efficacy of scoliosis bracing). But he is still hand-molding for lower extremity orthotics, which he says are not as cost-effective from an insurance reimbursement standpoint.

When the technology is a better fit for lower-extremity use – Lerman points to burn or post-op patients whose skin is particularly sensitive to touch – he would use it. Otherwise, he spends a fraction, he says, by doing the hand molding in-house.

“The proportion of cost to reimbursement works in spine and cranial and prosthetics, but not with lower extremity [for us],” Lerman said. “This may change as companies begin to accept digital scans for their production purposes. The cost savings in shipping and measurement supplies should be a strong incentive to use the technology.”

Jeffrey W. Warila, CPO, president of Eastside Orthotics & Prosthetics in Portland, OR, has been using CAD for about 12 years, but his work approach falls somewhere between the philosophies of those who only use plaster and those who have turned solely to the computer.

Warila still takes molds, but then uses CAD to scan the casts and sends that information to a lab. His methodology, he says, has allowed him to cut the costs of using in-house technicians while still relying on his hands, what he calls his “most valuable tool.” As a result, he says his profit margin – which has about tripled — is higher than that of  colleagues who still rely on old-school methods.

“We have to become more and more efficient today in health care,” Warila said. “With decreases in reimbursements, I don’t know how [other clinicians] can remain profitable doing things the old way.”

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