For orthotic and prosthetic clinics in an area with a high population of elderly patients or rural areas where access to health care is limited, mobile O&P services can help clinicians reach these underserved patient populations. And as the baby boomer population ages and the incidence rate of diabetes continues to increase, the demand for home health care is at an all-time high and is expected to keep growing.
“We have an underserved population, so we saw a need to utilize mobile units to be an outreach for our local practices,” Paul Sugg, CPO, CPed, FAAOP, president of EastPoint Prosthetics & Orthotics Inc., told O&P Business News about his decision to incorporate mobile services into his existing clinic.
Sugg’s practice, with offices in Kinston and Raleigh, N.C., offers most fitting and adjustment services with their mobile units to patients across North Carolina.
“The business does improve when you add a mobile practice,” Sugg said. “You are able to reach a population that you hadn’t been able to typically reach before because of travel restrictions or transportation costs. It makes these services available to them in situations where otherwise they would not get served at all.”
For Mike Hogan, CPO/LPO, president of Hogan Prosthetics and Orthotics Inc. in Orlando, Fla., mobile O&P was where he got his start, beginning his career working with a clinician in Northern Virginia who provided mainly mobile services.
“We saw maybe 25% to 30% of patients in his office in Fredericksburg, but the majority was out on the road,” Hogan told O&P Business News. “And what I learned was that there are a lot of folks out there who are not going to receive service if I do not go see them.”
Hogan built and sold three successful mobile practices before opening his current practice in 2011, which serves patients in central Florida. His mobile practice is equipped to offer most orthotic and prosthetic devices, and he uses digital scanning technology to measure and cast patients before sending his measurements to outside central fabrication facilities.
Image: Paul Sugg
“I get all the information that I need during my first visit,” Hogan said. “And then my technicians build the device.”
Another option is a mobile fabrication facility. Rachel Eisenfeld, CPed, owner of Soleful Orthotics and Footwear, created a mobile orthotic business in order to reduce the time that it takes to fabricate and deliver custom orthoses.
“I saw that one of the major patient complaints was the time it took to receive their orthoses,” Eisenfeld said. “So I thought that I could easily eliminate a lot of the time by making the fabrication lab mobile and cut down the 3 to 6 weeks to 3 hours.”
Eisenfeld travels with all of the necessary equipment to cast and fabricate custom orthoses and will either visit the patient at his or her home or set up appointments with patients at local podiatry and physical therapy offices or shoe stores.
“Either the podiatrist or therapist or representative from the shoe store will see the patient first and do a brief evaluation,” Eisenfeld said. “Then I will do a more extensive evaluation, which includes watching them walk and a casting.”
Eisenfeld is then able to cast the orthosis within 2 hours, and the patient can wait and pick up the finished device the same day or receive it another time.
Regardless of the type of mobile practice a clinician decides to adopt, there are several challenges that must be addressed. One of the most important aspects of a mobile practice is determining the type of vehicle to use. A clinician must decide if he or she will be fabricating devices on the road, and if so, what equipment will need to be transported. Travel distance, landscape and climate must also be considered.
Because Eisenfeld casts and fabricates her devices on the road, she needed something larger to accommodate and transport all of her equipment. However, she also had to consider the narrow roads and restricted parking that is typical of Northern Virginia and Washington, DC.
“Finding a suitable vehicle to put the fabrication lab in was a challenge,” Eisenfeld said. “I looked at vans, trailers and even something bigger like an RV, and I found that the box trailer was the best way for me to go based on what my needs were to fabricate and see my patients.”
Eisenfeld houses all of the necessary tools to create orthoses, including a grinder, sander, oven and vacuum press, in the box trailer, which she pulls with an SUV. The trailer has an examination table and is wheelchair accessible, so she can fit patients inside if necessary.
Eisenfeld must also deal with snow and ice during the winter, which can impede business.
“Weather can be a big issue, especially in the winter trying to get a trailer through the snow,” Eisenfeld said. “So you have to weigh safety.”
Similarly, the extreme heat in Florida was a determining factor in how Hogan designed his practice.
“There are a lot of people out there who have vans with full fabrication facilities,” Hogan said. “But for me, sitting in a van in the summer in Florida is not my idea of fun.”
Hogan drives a mid-size SUV, and since he uses outside facilities to fabricate his devices, he only carries the tools that will be necessary for that particular day.
“I make sure that during the first visit, I get my cast, measurements and use a digital scanner for my prostheses,” Hogan said. “If I give my techs good measurements, I can be relatively sure that the device coming back to me is going to be pretty close, so all that I need to carry with me are tools for minor modifications.”
At EastPoint P&O, Sugg uses Ford transit vans, which are outfitted with the necessary equipment for casting patients, as well as a computer table and laptop with remote access to the main office.
“They are kind of European style and unique looking so they catch people’s eye, but they have a smaller wheel base so it makes it easy to maneuver in and out of residential areas,” Sugg said. “We have a mini compressor and mini routers and tools on a smaller scale. We also have inverters for a power supply so that we don’t have to use the patient’s power supply in their home.”
Mobile vehicles can also serve as an advertising tool, and Sugg’s vans are adorned with the EastPoint logo and phone number.
“We have our toll-free number on the vans, and we get calls from people who are riding down the highway and have gotten our number from the side of the van,” Sugg said.
Travel and scheduling
Scheduling patient appointments is another critical task that needs to be mastered in order to efficiently manage a mobile practice.
“Scheduling is a unique art when you are dealing with a mobile practice because you have a lot more variables than with a fixed facility,” Hogan said. “You have traffic, weather and distance, and you have to figure all of those things in when you are scheduling an appointment.”
In order to accommodate these factors, Hogan has a flexible scheduling policy where he gives patients a window of time instead of a specific appointment time, starting with a 1-hour window in the morning that gets progressively longer throughout the day.
“The window of time expands as the day progresses,” Hogan said. “There is traffic, and you might spend more time with a patient than had been scheduled. We don’t keep people waiting all day like the cable people, but we do have a flexible scheduling policy.”
It is also important to schedule patients in relation to proximity. Since most mobile practitioners are willing to travel a considerable distance, sometimes up to 200 miles to see a patient, distance between appointments must also be accounted for.
“We try to see all of the patients in one geographic area during the morning, and then travel to a different area and see all of those patients in the afternoon,” Sugg said. “But you could have one patient on dialysis and another that won’t be home, so it can be challenging.”
Incorporating mobility into an existing practice or building one from scratch means added expenses. In addition to the start-up costs, which include payment for the vehicle, insurance and purchasing the necessary equipment, vehicle maintenance and gas are additional expenses. It is also important to have a comprehensive insurance policy to cover the drivers who will be operating the vehicles.
“The thing that you want to be sure about is your liability insurance and coverage of these drivers on the highway,” Sugg said. “That is an extra expense that the corporation or individual branch is going to have to take, because you are going to have more drivers on your insurance policy.”
“All of the expenses that are attached to a vehicle — equipment, gas, insurance and all of that for which you don’t get an extra dime — I think is what has held a lot of companies back,” Hogan said. “They think it is too inefficient.”
Hogan acknowledges that a mobile practice is less efficient, and therefore less profitable than a fixed facility. However, he is able to turn a profit by keeping his overhead costs low. The only employees are Hogan and his wife, Barbara, and they outsource a lot of their tasks, such as the bookkeeping and fabrication.
“I don’t charge anything for the mobile service,” Hogan said. “I get paid the same for a below-knee prosthesis as a guy in a fixed facility does, but I make my money because I keep my overhead low.”
These expenses also can be included in the price of the item that is being fabricated, according to Sugg.
“We set up our practice with each of the mobile units kind of like separate offices. Mobile practice may be the best way to say it,” Sugg said. “If the mobile practices are going to get the compensation for the patient, then they bear the burden of the expenses.
“The corporate office has to foot the bill to start, but you want to see that mobile practice turn around and be self-sufficient,” Sugg added.
Another way to increase efficiency and profit is to set up clinics at local offices and visit multiple patients at once.
“You can basically see as many patients as you would in a practice if they are batched,” Sugg said. “If they are 200 miles apart, you may see only four patients a day, and that’s where you have to realize whether your benefit outweighs your cost.”
These clinics are also mutually beneficial to the therapist or podiatrist because it gives them a competitive edge.
“It’s a convenience for the podiatrist or health care provider that I am working with and allows them to be a little different,” Eisenfeld said. “It gives them a competitive edge over their competitors by offering something that isn’t offered anywhere else.”
Dealing with Medicare and other insurance providers also can be an issue for mobile practices. If mobile services are offered in addition to those already provided by a fixed facility, then the services can be billed through the main office. However, if a mobile practice is not attached to a fixed facility, then it cannot receive a Medicare number.
“If you don’t have an office, you can’t get your Medicare number or [facility] accreditation,” Hogan said. “Having a commercial, fixed facility is an absolute requirement now.”
Medicaid, the Department of Veterans Affairs and other managed care contracts require facility accreditation for reimbursement, so Hogan maintains an office in Orlando to comply with regulation, but rarely sees patients there.
“It satisfies the government, but it’s a lot of overhead that I would personally rather not have to pay,” Hogan said. “But you have to in order to play the game.”
To avoid paying for an office that she will not use, Eisenfeld does not accept insurance from her patients.
“I don’t directly accept insurance, but I do give the patients everything that they need to file it themselves [and get reimbursed],” Eisenfeld said.
Despite the challenges of creating and sustaining a mobile practice, providing the services can offer a multitude of benefits for clinicians and patients.
According to Hogan, visiting patients in their homes allows him to better understand his patients and how and where the device will be used. He can also educate patients and their families about the device they are receiving.
“I can learn more about my patients in their homes than I ever could in a clinical situation,” Hogan said. “Practitioners will never understand the challenges that patients face unless they go out and see where these people live.
“I get a much better perspective of the patient’s capabilities within their own home because they are walking in familiar territory and are not worn out [from traveling to the office],” Hogan added.
Patients will also have all of their shoes readily available at their home, so modifications can be made at delivery, which is especially important for orthotic devices.
“Having the patient’s shoes and orthoses readily available in their home that they can grab what they need is a great benefit,” Eisenfeld said. “That way all of their shoes are in one place and we can analyze and figure out what is going to work.”
And mobile practices also present opportunities to develop relationships with new referral sources with home health professionals, therapists and podiatrists and educate them about the device that the patient will be using.
“A benefit is the relationships we build with the therapists we go out and see, especially if we see patients in their therapy clinics,” Sugg said. “If you are going to a hospital or nursing home to see the patient, then you are building relationships that are long lasting.”
Hogan agreed. “My PTs and I work together. I provide the device properly fitted and aligned and hand it over to them so they can train the person on how to use that device in the environment in which they are going to use it,” he said.
Mobile services also allow clinicians to explore new and innovative business and marketing ideas. For example, Eisenfeld often schedules appointments with customers at local shoe stores.
“I work closely with shoe stores because it is a nice complement to what they do,” Eisenfeld said. “They can provide custom orthoses and shoes to their patients at the same time.”
Image: Mike Hogan
She also takes her business to various running or athletic events to consult with potential patients.
“It is nice to have the mobile office because people can actually see what you are doing and get a feel for it,” Eisenfeld said.
Ultimately, offering patients the option for mobile services creates enhanced service that cannot be paralleled by the service in a fixed facility.
“The one thing that has made me competitive is service,” Hogan said. “[A fixed facility] cannot provide the kind of service that I do, because the patient has to go to them.”
And although a mobile practice may mean longer hours and more stress, patients are appreciative and grateful for the option.
“People like the idea of me coming to their house and seeing them vs. them going somewhere,” Eisenfeld said. “The ability to go somewhere that they are familiar with and not have to go find an unfamiliar place makes it easier on them.”
“The demand for home health is going to continue to grow,” Hogan said. “It is a multi-billion dollar industry right now, and if you’re not thinking home health, you are not going to be a player in a very large market.” — by Megan Gilbride
Disclosure: Hogan is the president of Hogan P&O, Sugg is the president of EastPoint P&O and Eisenfeld is the owner of Soleful Orthotics and Footwear.