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Conflict of Interest?

Discussion in 'Canada' started by Bennepod, Sep 30, 2013.

  1. Bennepod

    Bennepod Active Member

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    Due to recent changes in the insurance industry (Canada) regarding orthoses claims, there is a sudden interest on the part of Pedorthists to hire Podiatrists. Essentially the change requires that the "assessment, gait analysis and diagnosis" must be performed by primary care providers and in practical terms this means Pods. Any opinions on potential/apparent/perceived conflicts would be appreciated.

  2. Craig Payne

    Craig Payne Moderator

    I obviously not familiar with what the law is, but I not sure I see what the problem is?

    Podiatrists can employ pedorthists and pedorthists can employ podiatrists.

    Is there something 'shady' about the Pedorthists doing this to get around a legal requirement or is this perfectly legit?
  3. Lab Guy

    Lab Guy Well-Known Member

    In some provinces of Canada, insurance allows for one pair of functional orthotics per year despite they are polypropylene! Amazing. So patients get a new pair every year and the Pedorthotists do very well. Orthotics are a huge business in Canada.

    I wish insurance would only cover orthotics if they are dispensed by a Podiatrist. The Podiatrist should be doing the biomechanical exam, gait analysis and filling out the orthotic Rx form. The Pedorthist can own a lab and fabricate the orthotics.

    Podiatrists go to college for 4 years, Podiatry school for 4 years and three years of residency. They have invested 300K in their education and now have to invest money opening up an office. Anything to do with the foot should go to Podiatrists in my biased opinion. I also think only one pair of functional semi-rigid orthotics should be covered by insurance per life-time (or every 10 years, maybe) to save money.

  4. Rob Kidd

    Rob Kidd Well-Known Member

    I had this conversation years ago while on the staff of Curtin University in West Australia, with another member of staff. They thought that only pods should be able to provide foot orthoses. My view was, and still is, that patients will polarise to where they perceive they get what they pay for. If you provide an appropriate device at a sensible price, they will pay, and more to the point, come back for more.
  5. footpower

    footpower Active Member

    To avoid any conflict of interest should there not be a clear separation between a prescriber and a provider of any service?
  6. Orthican

    Orthican Active Member

    And the proverbial nail is hit square on the head.

    That is exactly the issue here in Canada. Writing prescriptions to yourself to provide yourself income is most definitely a conflict of interest. At least here anyway.

    Also I'd like to comment regarding the coverage Lab Guy mentioned where he was astounded that insurance allows one pair per year.

    I would remind all that only means they are "eligible" for coverage once per year IF required. It does not mean go ahead and do it because you have permission to take the money if you want it. And yes there are those on all sides of the foot orthosis industry that will abuse that. But for those of us who look to be an asset to society rather than a drain we do not abuse it. There must be consideration given to what is best for society as well as the patient. Burning through insurance cash just because you can does not help things in the long run.
  7. Orthican

    Orthican Active Member

    double posted sorry.
  8. Boots n all

    Boots n all Well-Known Member

    So suffer the little children that need a replacement every 2nd year as they grow?
    Or the arthritic client who's foot type and functions so differently in four years time?

    l agree with a lot said here, provider prescribe separation is a good thing in any profession, but as for one orthosis per life-time (or every 10 years, maybe) to save money, l do not agree with that.
  9. Bennepod

    Bennepod Active Member

    Thanks for your comments so far....

    I was hoping for independent validation of some of my concerns, but clearly I have left the subject hopelessly vague. Allow me to be more specific and state a couple of areas of concern.
    1. One result of the insurance policy changes is that orthoses cannot be made (provided) by podiatrists.
    2. Insurers want a separation of prescriber and provider. Hence the orthoses must be made by a recognized pedorthic facility.
    3. Pedorthic practice (ethics) prohibits business relationships with referral sources.
    4. A Podiatrist has a duty to their client (the patient). How does this change when the client (employer) is a Pedorthic facility? Does this compromise independence and impartiality of the Pod? The specific concern here is that the Podiatrist is/may be (factually or apparently) facilitating the business of the pedorthic facility rather than acting in the best interests of the patient.
    5. The following is a section of the Canadian Medical Association guidelines on Medical/Industry relationships: Except for physicians who are employees of industry, in relations with industry the physician should always maintain professional autonomy and independence. All physicians should remain committed to scientific methodology.

    I would like to comment on Craigs assertion that Pods can hire Peds and vice versa. Podiatrists are primary care providers who diagnose and treat. ONE of the treatment options available to them is the provision of orthoses. The Pedorthists role is the fabrication of said devices. So a Podiatrist may hire or sub contract to a Ped this technical function. In this case the clients interests are served and seen to be served without conflict as there is no apparent pressure exerted on any party to choose orthoses over any other treatment. However where a Ped hires a Pod, the financial interest of the principal is served in the generation of orthoses, hence an apparent/real conflict.

    Any thoughts??
  10. APodC

    APodC Active Member

  11. Boots n all

    Boots n all Well-Known Member


    Would you also say that a Podiatrist in private practice should not see a client to prescribe and provide an orthosis themselves?

    You as a Podiatrist would see a client that needs an orthosis and refer them on?
  12. APodC

    APodC Active Member

    That was a rapid dive into the murky depths of the issue.

    Should the prescriber and the supplier be allowed to be the same person? Should the pharmacist be allowed to recommend products? Should the real estate agent recommend a property?

    My personal view is that the moral hazard involved in overtly selling a product is in fact less challenging than arrangements where third parties can apply covert influence to drive perverse behaviour. There are however moral hazards for practitioners to navigate. Professionals need to constantly test their assumptions and recommendation to avoid breaching their duty to the patient.

    Asking the following questions help:
    Would I recommend this product if I wasn't selling it?
    Am I being sufficiently transparent about earning a margin?
    Am I acting in the patients interest in my recommendation and supply?
    Does the price reflect reasonable value to the patient when taking into account things like convenience, quality etc.

    However, moral hazard is ever present and is one of the most difficult challenges faced by professionals of all persuasions. What I can be sure of is that there will be people with strong views at each end of the spectrum on this one.
  13. Boots n all

    Boots n all Well-Known Member

    Damian, how is that " a rapid dive into the murky depths of the issue"

    It is the basis of the entire thread.

    Can an individual, be that and individual practitioner or an individual company employing many practitioners, be both the prescriber and supplier?
  14. APodC

    APodC Active Member

    In Australia, the rules say that a podiatrist can be the supplier, much like in dentists or pharmacists (with Over The Counter drugs). This brings responsibilities to bear on Australian podiatrists and I must say I think they manage those moral responsibilities very well.

    In Canada, the structure and rules appear to be different and I believe there are some moral hazards that clinicians need to be aware of and manage differently in thier context. I'm not sure what the answer is but I think there would be an interesting public debate if drug companies started buying medical practices.

    If you're looking for a black or white answer, this is an area that is mostly grey and the issues and opinions vary widely.
  15. Boots n all

    Boots n all Well-Known Member

    l totally agree with you, a very grey area indeed and not confined to just our profession in allied health.

    l remember my Mother having this same debate with an optometrist 40 years ago.
    "Your son needs glasses, let me sell you a pair."
  16. Lab Guy

    Lab Guy Well-Known Member

    In Canada, orthotics should be a covered service for the first pair but patients should pay out of pocket for a second pair for their other shoes, a third pair for their dress shoes, et. Paying out money every year for orthotics does not make sense as it leads to dollars being wasted. Instead, there should be a medical necessity letter sent to the insurance company stating why the patient needs a second pair of orthotics within 2 or 4 years (child or arthritic patient).

    Here in the USA, it is uncommon for insurance companies to pay for orthotics and when they do, it is usually a low amount that your barely paying your over head. We also usually require to submit a letter of medical necessity for approval.

    Funny how people find money to pay for cigarettes, drinking, 60 inch tvs, et. People will pay for what they want not what they need. If they need orthotics, they should be educated that they should want them as well as they will feel so much better. At the end of the day, the cost of custom orthotics are not going to break the bank.

  17. Orthican

    Orthican Active Member

    Actually they are covered here in Canada Steven. It jut depends on the circumstances.
    Coverage for them here is obtained through many sources. Private insurance is the obvious one. Health spending accounts are another used by many employers as well.
    In addition we have AISH (Assured Income for the Severely Handicapped. (AISH requires prior approval) Also for those with diabetes and are considered high risk for wounds we have a therapeutic foot and wound program that pays for one pair of shoes and custom insoles each year as needed. Here in Alberta there is yet another avenue of coverage for them called "Alberta Works" and they will cover depending on need as well. What percentage of your service is covered is relative to that amount you charge for the service. The main way the podiatrist here gets around the issue is to not use the coverage options but just charge cash for the foot orthosis.
    Last edited: Oct 7, 2013

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