The O&P profession maintains a multifaceted agenda, but the primary concern remains patient care. To provide optimal service, practices must provide intricate, custom prostheses and orthoses.
There is an underlying battle between two fabrication options: in-house and outsourcing. Sources who utilize these options provided O&P News with an inside look at each and assessed the pros and cons.
Details in ‘do-it-yourself’
While central fabrication — a standardized method of outsourcing orthotic and prosthetic fabrication — has gained popularity in recent years, some practices prefer a “do-it-yourself” method for building devices.
Andrew Marsland, CPO, clinical support practitioner at WillowWood, says it could be due to the higher level of control practitioners have when fabricating.
“You have better control, you are able to translate information from the patient to the technical side more efficiently [and] you can be there if a question come[s] up, especially on the orthotic side,” he said. “[Orthoses] tend to be a little more intricate; practitioners want to make sure their interpretation of [the final product] is being interpreted in the right way.”
When practices have direct control of the fabrication process, detailed adjustments can be made onsite and devices may be available more quickly, Andrew L. Steele, MBA, CPO, LPO, of Clark & Associates Prosthetics and Orthotics, told O&P News.
“It depends on the device, [but] there are ways, for instance, with spinal orthoses, [that] we can measure someone today and have it by tomorrow morning.
“However, with other custom orthotic devices, you may have to send a cast out to a central fabrication center. In this case, there is shipping time to and from [the center] that you cannot necessarily make up.”
There are some downsides to fabricating in-house, sources said. One is resource delegation.
In order to successfully operate in-house fabrication, Steele said practices must take on additional real estate, increased labor and time taken away from patients and normal business functions. This could add up to increased expenses, he said.
To avoid some of the overhead expenditures associated with in-house fabrication, many practices have chosen to outsource.
Grímur Jónsson, BSc, IE, operations director of custom solutions at Össur Americas, said while artisanal skills largely defined the profession in early years, many practices are now weighing time and expense to maintain local fabrication operations against their primary purpose of providing patient care.
“Quality craftsmanship and custom prosthetic solutions are still very much required, but today’s professionals also must grapple with increasingly complex documentation and reimbursement requirements, while simultaneously managing their patient care and practice operating costs,” he said. “This is why increasing numbers of practitioners are outsourcing their fabrication needs.”
At WillowWood, Marsland has access to the company’s central fabrication center, and said the learning curve required to build certain devices could be time-consuming when fabricating in-house.
“[Outsourcing brings] a convenience factor,” Marsland said. “If you are doing a device [you] do not have to train local staff to do a huge amount of variation.You can pretty much locate right into one area.”
He added, “With [central fabrication], not only do you get normal types of devices, it also allows you to do the more complicated types of devices that probably do not come up that frequently. In effect, you have [access to] a pool of experience and technologically advanced machinery [and] equipment.”
According to Martin B. McNab, CPO, LPO, president and owner of Optech Orthotics and Prosthetics, that extra support could free up practitioners to focus solely on patient care. McNab’s practice recently began offering basic in-house fabrication, but outsources the bulk of its devices.
“If you do not have a technician to do the technical work, then the clinicians are doing it themselves,” he said. “That has an impact because they cannot see as many patients. But if you outsource that work to a [central fabrication center], you are actually saving money, and allowing more time to focus on patient care.”
He added that outsourcing orthoses is a bit easier than prostheses, as there are not as many variables.
However, much like in-house fabrication, outsourcing has its drawbacks.
“You tend to lose a bit of control,” Marsland said. “Because as soon as [a device] leaves your facility, you are relying on a third party to interpret what you want. Some devices can be complicated, and trying to relay information to someone outside of your building can lead to a misinterpretation somewhere down the line.”
It also can lead to time delays, he said. “One of the biggest issues is turnaround time. Once you start including shipping from where it is coming from or where it is going to — especially if you have someone on the East Coast trying to tap into it from the West Coast — you have an extended timeframe of moving parts around to getting them to the patient.”
Doing the math
It is not clear how many practices fabricate devices in-house vs. how many outsource them, but Jónsson estimates there is a growing number of practices relying on outsourcing to fulfill patient needs.
According to Steele, a 2015 profession survey commissioned by the American Orthotic and Prosthetic Association (AOPA) noted more than 87% of O&P practices utilize central fabrication at some degree.
Marsland, at a facility equipped with both central and in-house fabrication capabilities, uses both.
“My personal way of doing it is if there is a central [fabrication center] that specializes in certain things, there is no point in me trying to reinvent the wheel to do it in-house. The choice is usually to have one or two technical people in your facility to do some of the general [repairs] and then use the central [fabrication center] for the majority of the other work,” he said.
“It can be all-inclusive, or it can be a sort of a mix-and-match type of thing. [It all] depends on the size of your facility and how many offices you have.”
The key is ensuring that the fabrication method works well with the facility, and deciding if it is more beneficial to fabricate a set of devices in-house or through central fabrication, Marsland said.
“It is difficult to say that one is particularly better than the other … there are advantages to both depending on the practice,” he said.
In-house or outsourced, fabrication is a financial decision, according to Greg Mattson, CPTO, CPA, president and chief executive officer of Fabtech Systems LLC, a central fabrication center that specializes in prosthetic and orthotic composite devices.
Because each device is unique, the labor required for fabrication represent a large portion of expenses, Mattson said. “In basic terms, if a company has in-house fabrication, they are on the hook for employee costs all the time — health care, payroll, vacation and so on. They are paying these costs through all business cycles.
“Having worked in both environments, I see the major benefit to outsourcing is that a company is only paying per-device at a flat cost,” he said. “As demand picks up or drops, costs flow in the same direction. It is an easy process to manage and forecast true [expense] to the company.”
Jónsson added practices that outsource could “experience relief from the fixed costs and complexities associated with maintaining fabrication operations at their own location. They avoid the substantial investments required for the necessary real estate footprint, expensive machinery, sophisticated air-handling equipment and labor to perform the custom work,” he said. “Everyone who runs their own operations knows how excessively busy their technical lab can get at times, with relatively slow periods in between. Managing operations with peaks and valleys in demand is straining and usually not cost-efficient.”
While outsourcing can be cost-effective in many ways, Steele, whose practice uses a nearby central fabrication center, said that ultimately, a practice’s expenses will be determined by their operation mix.
“I think a lot of it depends on your mix, on what you are doing as far as production. You have to look at how much orthotics [fabrication] you are doing, how much prosthetics [fabrication] you are doing and what kind of margins you are running at,” he said. “The financial impact can be different based on the type of practice that you have and you have to analyze it based on your mix.
“There may be some scenarios where central fabrication makes sense for everything and there may be some scenarios where it does not. It is a practice-by-practice analysis to make sure you are meeting your financial needs, [as well as] the needs of your clients and referral sources.”
Building a better process
There are common denominators to in-house fabrication and outsourcing that can be used to help the process run more smoothly. While the transfer of vast amounts of specification data to an outside source can leave room for missteps, good communication can make room for success, sources agreed.
Don Pierson, CO, CPed, vice president of operations at Arizona AFO, an Orthotic Holdings Inc. central fabrication company, suggested asking questions if you are unsure about a particular device, adding that more communication upfront can lead to fewer adjustments later. The more detail in the measurements, modifications and material specifications of a cast, the better chance the device will be fabricated correctly.
“Communication is key to getting it right the first time,” he said. “It is on the central [fabrication centers] to call and communicate with their clients to make sure they are on the same page and make the best product for the patient possible.”
Experts suggest keeping a detailed log of fabrication requests and performing a quality control check on each item before and after the fabrication process. If fabricating in-house, practices can double-check a particular device throughout the building process. If outsourcing, they could send a detailed log of device specifications, including a photo or video of what the device should look like.
“Make sure that they have the proper order form, or the most updated order form, and that it is completely filled out with contact information and notes,” Pierson said. “Also, stay up on product knowledge to know what options are offered.”
Building relationships with technicians could ease the fabrication burden, and according to Pierson, it could streamline the communication process. “Technicians are close to my heart,” he said, “that is how I got my start in O&P. I would like to see that program to remain [strong] and grow stronger.”
Fabrication technology has progressed in recent years through the use of computer-aided design (CAD) and computer-aided manufacture (CAM). CAD/CAM has optimized the fabrication process by allowing clear and downloadable visual data, shape manipulation and increased reporting capabilities.
“CAD/CAM basically removes the need to cast a patient, fill a plaster model and modify it,” Mattson said. This has led to reduced production costs and quicker turnaround times when producing a device.
McNab said it has become “kind of a lifesaver for [our practice]. We do not have to worry about taking molds of patients when doing cranial remolding helmets. We are able to scan a child’s head and send it to the central [fabrication center]. So, it is a direct process.”
Another trend that could improve fabrication is the use of 3-D printing. By creating custom objects from a digital model, 3-D printing is changing the traditional fabrication process.
While 3-D devices do not yet compare to current prostheses and orthoses, Steele said these devices could become a viable option in the future.
“I could see us going from a scanned image to a 3-D printed device that could be done within a couple of hours,” he said.
“A 3-D printed socket we [created] at a local university took us about 24 hours — and that was several years ago. I could see it getting down to maybe a half-hour or 45 minutes [and] all of a sudden you have your scan, your socket and it is ready to be fit.”
3-D printing could also reduce the costs of typical fabrication materials, allowing a low-cost alternative for practices, and an option for users to print at home.
Fabrication has come a long way since its inception, and sources say there are more strides to come. Engineers are working in the direction of lighter, stronger and more flexible devices.
Thermosets are merging with thermoplastics, and composites and metals are seeing evolutionary leaps. Green materials are being utilized, and self-adjusting technologies are being researched.
“With some of the advances in the types of finishes of [devices], people want individualistic looks,” Marsland said. “They want to have specific types of fabrication, and the profession will have to deliver.
“Fabrication will offer different materials, molecular materials and variances on traditional resins and lamination methods. I see [devices] becoming more flexible, able to accommodate abnormal shapes and more customized overall.”
According to Steele, devices like smartphones and tablets could expedite fabrication. “As with anything, that is going to get better, faster, stronger and more efficient. At some point, we are going to go from a scan directly to a socket and skip that positive model completely.”
Össur recently introduced its Custom Solutions mobile application, which enables providers to use an iPad and high-quality 3-D scanner to scan limbs and electronically order custom sockets and custom liners in minutes, without requiring casting.
Jónsson said it has saved time and improved efficiency. “Fabrication will become more automated in the coming years, while the practitioner’s focus will narrow even further to where it should be – individualized patient care.”
Sources said advancing technologies can not only revolutionize the way patients are treated, these could provide an opportunity for the profession to evolve.
There is a lot still to discover, Steele said, but in order to keep in stride with the changes, “we need to be ready to adapt.” – by Shawn M. Carter
- American Orthotic and Prosthetic Association. Available at www.aopanet.org. Accessed June 1, 2016.
Disclosure: Jónsson, Marsland, Mattson, McNab, Pierson and Steele report no relevant financial disclosures.