Laser scanners

Hosting is the easiest part.

The problem is financial. How do we pay for a web repository development like Thingverse or YouMagine focused on foot orthotics?

If there are enough podiatrists around the globe willing to cooperate, it could be possible to launch a crowdfunding campaign.

 

15mm will cover less than 1/3 of the products a person will need to make, unless you're willing to sacrifice on quality of product by putting excess fill into the devices. About 80% of the orders receive here, fit on 1" material, with the rest fitting on 1 1/4 and 1 1/2" material. 1 1/2 and beyond, is likely where 3D printing makes more sense, cost wise. If you're going to manufacture orthotics, you really need equipment that will make ALL of your devices.

As for hardware of choice, whenever I change a spindle or servo, I run a self-calibration routine to put the machine back into alignment, which sets up the boundaries and alignment. As long as the edge finder doesn't get bent by a collision or carelessness, the only real adjustment remaining is for thicknesses. What used to take hours and wasted plastic, now takes minutes with no waste and no guesswork. My newer machines are either Techno machines, or ISEL based products, built in-house. Where you need to be cautious with ISEL based products is in their carriage bearings. If you buy the aluminum ones, you're asking for trouble, at least in my opinion. The all steel construction bearings will last a decade or longer. By your definition, a hub is the same as client/server in my network. A client site outsources machining, and sometimes finishing, to a client/server site.

 

I realistically think that the Autodesk 123-catch business model is the best we can hope for at the moment.
A commercial company like this can offer a cloud based design suite that only occurs a charge once you create the CNC file - you can practice without any charge and only pay for what you need.
The ' money' is in the centralised manufacturing hubs so I think they would need to pay for the above costs.
The interesting things for the labs is that it is a very similar business model to what they have now but they reduce the risk of getting the design wrong - the customers would still have a choice of who they work with and could choose the level to which they want the lab to be involved - machine only or full finishing! A lot of practitioners would not want to take responsibility for their own designs so the labs could also offer a design service as now.

Phil

 

All sounds very complicated to me. Why not just have website with a number of prefabricated foot orthoses designs? Basically the user clicks on the file for the design and size they want, download the file for free and print out the orthoses in their office. Why does it need to be more complicated than that?

 

Any suggestions as to what the cost might be Javier?

 

Simon

What bother having prefab that you can print - why not just buy them and keep them in stock? (Obviously there is a limit to this)
The idea behind digital is that you can make a virtual prefab bespoke by changing its shape, properties etc - either by using a scan of the patients foot or your own creativity.
The office manufacture will be limited for the foreseeable future due to hardware cost. Why limit yourself to one process when you can use a hub that uses the various additive and subtractive tech. Share the cost so we can use the best!

 

I depends on the website capabilities. After doing some research, average prices are around:

Basic repository website 1.500 EUR such as 3D Hacker

Medium repository website 7.000 EUR such as GrabCad

Premium repository website with cloud CAD customizer 50.000 EUR such as 123D

 

Well I guess the advantage of using 3D printing over buying them and keeping them in stock, is that if the files were free the only cost would be in terms of basic materials. The other factors are that most prefabs are made in China, shipped around the globe to distributers (who take their cut) and then are posted out to the clinician or end user- This has environmental and financial impact which 3D printing could avoid. Another factor is that the current prefabs do not have the design features which could be exploited by 3D printing, so it should be possible to make 3D printed prefabs which are different to existing prefabs. Moreover, I think that the vast majority of patients do not need true custom foot orthoses to resolve their problems; rather a prefab with the desired design features will be more than adequate in many cases.

Yes I understand that. It's the model which Joe Jared has been using for some years now. I would prefer to remove the "middle men" altogether though. I do not agree with you regarding hardware availability nor cost. If you want to make a customisable system, make it customisable at the point of the end user, i.e. design the orthoses such that its geometry, stiffness and friction can be physically modified once printed. Or just design lots of different prefabs.

 

As much as 3d printing sounds like manufacturing freedom, it's not. By weight, the spools are 17 times more expensive than raw materials. Real competition needs to exist to bring the price of the printing media down. Somewhere in the mix of machining and 3D printing technology, a 3rd process, recycling, could do just that. As for cutting out the middleman, the irony here is that it is just as easy to cut out the practitioner and ship direct to the patient. After all, don't practitioners mark up the devices by 100% or more, while pretending to be poor when it comes time to pay their bills?

Whether as a lab or practitioner, the idea that there is permanent storage of patient data, both locally and offsite is a good thing. Most pods don't want to get too deep in the design of orthotics as seeing patients and dispensing someone else's work is more profitable. Bringing the final cost of the products down does mean thinking differently in terms of overhead and total business structure.

The people I work with locally will profit off of their own work, and me off of the machining of the shells. For one line of manufacturing, this will certainly keep the final product cost well below the norm while offering an improvement in the quality of life of the people doing the work.

 

Not interested in profit, interested in making people well. Don't believe in capitalism, interested in making foot orthoses available to those that would benefit from them for the cost of the filament.

"Don't believe it when they tell me there ain't no cure
while the rich stay healthy and sick stay poor.
I, I believe in love..."
http://www.youtube.com/watch?v=4dvXG18ZA1I Ironic?

I'm with Adrian Bowyer- "The Guardian said of this, "[RepRap] has been called the invention that will bring down global capitalism, start a second industrial revolution and save the environment..." Yep, I'm with this man. It's amazing how many people have taken the developments from the RepRap project and then tried to make a profit off them... I guess if you are looking through the lense of capitalism, you're always looking to make a pound/ dollar whatever. Like I said, the way we perceive foot orthoses needs a re-think.

Reprap = "Wealth without money"

"Leaning to the left on this one then Spoonz?"- yeah, you could say that.

Come on then, lets stop talking about "hubs" and "profits" etc. Lets start talking about making foot orthoses freely available on t'interweb for anyone that wants them... What's the easiest way to achieve this?

 

I really like this discussion between Joe, Simon, Javier, Phil and others. There is some very good information being discussed here regarding newer technologies in custom foot orthosis manufacture.

Let me add my 2 cents.

We must always keep in mind the patient-consumer, their needs and their expectations. If a patient came to me for a custom foot orthosis and I dispensed to them a pre-fab orthosis, I would feel as if I was being fraudulent to the patient. In addition, if they found out that I was dispensing a prefab orthosis to them rather than a custom orthosis after I made a custom scan/impression of their foot, the patient would have every right to become upset with me since they were told that they were paying for custom orthosis specific for their foot structure and foot/lower extremity pathology, not a pre-fab orthosis.

If I am going to be recommending pre-fab orthoses for my patients, there is no reason for a scan or cast or foam box impression of the foot. I simply have the patient purchase the orthosis from the local running shoe store (or, in other practices, the podiatrist can get a prefab orthosis that they have in their office already) and fit it to the foot in the office to see what specific modifications need to be made to the orthosis to accomplish the goals of foot orthosis therapy for that patient.

3D printing, milling and thermoforming can all be used to produce custom foot orthoses or to produce prefab orthoses for our patients. I believe that it is very important that patients are fully informed of what they are paying for, otherwise, telling the patient they are getting a custom casted orthosis and then giving them a pre-fab orthosis is fraudulent.

If a library system of prefabs is being used, then the reduced wholesale cost and reduced customization of these orthoses should be passed on as reduced cost to the patient and the process should be fully explained to the patient before they make the decision to get these types of orthoses. Just because there are new techologies for making orthoses, the clinician should always first consider the health needs of the patient, and not their own wallet or their own convenience, in making decisions as to the type of foot orthosis needed by their patient.

 

First, I don't believe in what we call capitalism either. When I work with people, I work under a cooperative business model. Everyone I work with is the primary beneficiary of their own work. The SR in the SR4848 design is short for Self-Replicating, for future reference. It's not an original idea to want people to be able to make their own replacement parts. You might be able to make some of the components, but sooner or later, you'll need electronics and , yep, more spools.

I'm more of a John Lennon fan.

 

Maybe you could be the first to provide some freely available foot orthoses designs to add to FODDER, Joe?

More into the Wonderstuff:
http://www.youtube.com/watch?v=Oaa3pxWqDEQ
http://www.muzu.tv/the-wonder-stuff/its-yer-money-im-after-baby-music-video/237366/
http://www.muzu.tv/the-wonder-stuff/circle-square-paranoia-mix-music-video/235166/ etc

 

Based on what they will be used for, I would have to decline. I already made one mistake with my software, allowing users to specify rf/ff width, and lengths. Handing out a prefab doesn't serve the patient. Now, if you emailed an stl of a real patient's foot, and a device were designed for THAT patient only, that would be another story.

 

Simon

As much as I applaud your goals, I am far too cynical too think this approach will deliver what we want - just a poor compromised imitation of what we could have.
Profit is not a dirty word as there are plenty of ethical business who use their profits for the betterment of mankind etc.
I would rather pay a small amount and get exactly what I need for my patients rather than compromises on moral grounds.

In reality we all need profit to pay the bills so lets not begrudge any one else doing the same - in moderation of course!

Phil

 

And your expertise in podiatric biomechanics is based upon... Perhaps you could tell those following where you got your DPM? Perhaps we could discuss the research on foot orthoses interventions, Joe? I doubt it though.

But you'd be willing to make bespoke orthoses for free though, Joe? reading you comment above this seems to be implied, so that's just fantastic.

http://www.youtube.com/watch?v=EaCaSb-109k

 

Phil I'm confused because I could have sworn that yesterday you said:

So what changed in 24 hours?

OK, you talk about compromise- how many prefabs are dispensed per annum and are successful in treating the problem? Rhetoric question. When we talk of "compromise" what are we really talking about here- compromise in the profit margin? If patients could download an "interpod" for example, for free... I guess that would change the status quo, but would it really be a compromise since this is what a lot of patients are receiving and paying over the odds for anyway. What if they could get something similar for free?

I'd argue that you are not too cynical Phil; that it's something else stopping this... "profit" certainly isn't a dirty word in a capitalist paradigm. Maybe we should step outside of that paradigm for a minute.

 

Amen. However, I suspect that many don't adhere to your views, Kevin.

 

Simon

The sentiment is still there but I can't see how it can be made reality!
A question for you is would you rather have a poor insole for free or a good one for £2?

As I am sure you are aware, the cost of developing a new product is significant and if no return on CAPEX is possible, commercial companies won't bother at all resulting in a stifling of new ideas.

What I meant by compromise was technical - I have been involved in the design of 10's of thousands of insoles and still haven't repeated every variable to make any one exactly the same. There will always be a variable that has to be compromised on when prescribing insoles and I would rather not have too make to many to get the patient the right solution.

Not really sure what you are thinking with your last comment - do you assume some grand Bond villain plan is a foot - you've been watching too many episodes of the X Files!!!

My only hope is to reduce the strangle hold orthotic companies have on the Uk market - poor customer service, inflated prices, poor staff relations - along with the over inflated prices that some practitioners charge their patients.
I can assure you I have no plans to enter the commercial market again - its not worth the hassle!

Phil

 

Phil, you and I know each other well enough. The truth is this as I see it. At present there are lots of prefabs in the market place. These are efficacious to some of the people, some of the time. 10's of thousands of prefabs are issued per annum. They could probably be more efficacious to more of the people, more of the time if the prefabs had better design intent, and the dispensing practitioner understood the required design intent for the required pathology. There is no reason why a series of prefab designs could not be made available for 3D printing/ milling, free of charge- if we took our capitalist glasses off for five minutes. I have made many thousands of devices for patients that I have assessed, diagnosed, casted, designed and then manufactured, dispensed and followed up upon. Every one I've made has been unique. I've also worked for a commerical lab that pretended to be making custom devices but were really using prefab shells with customised posting, I guess I was producing about 20-40 pairs per day over the course of 6 months... Never met the patients, can't say how they got on. Meanwhile, I've also dispensed many thousands of prefab devices for patients that I have assessed, diagnosed, not casted, dispensed and followed up upon. My conclusion after best part of a quarter of a century of doing all of this? Lets not pretend that the vast majority of prescriptions need to be that accurate because they don't- end of story.

Maybe I'm being simplisitic, but it seems a simple solution to a simple problem to me- make prefab designs free.

As for the "Bond villains", you've worked commercial labs, you know as well as I do how many people running commercial labs have no background in foot health, no interest in anything other than making wonga. I guess the real villain here is the paradigm we were raised to accept as normality. It doesn't have to be that way. It will take a leap of faith to step outside of that paradigm though and we all know how paradigm shifts in podiatry are greeted.

Lets say I could put up a website from which anyone could download a file for a foot orthosis for free, how many designers would be willing to put their designs on there, knowing they would never receive a penny for their efforts? The website would be easy, the downloading would be easy... so what's stopping it? No-one willing to give their work away for free... why is that? I don't get it, maybe it's too simple.

 

My comment above was a response to you devaluing what the labs do for the podiatrists, chiropodists, and other practitioners. You're so hip on 'cutting out the middleman', and yet, the practitioner is the most expensive middleman. It seemed very appropriate to turn the tables on the discussion. From the perspective of a high school dropout with a half dozen disciplines, I see using the defense of 'being educated', as in having a formal degree, as a losing argument. I depend on people with expertise in the field to guide development of my products. Many of them have those expensive pieces of paper.

 

Cost of development is only significant if you hire a bunch of engineers to do the job. If you yourself decide to do something, and if you're willing to teach yourself what's required to do it, it's considerably less expensive. Cost of integrating OreTek into a 3D printer, nothing but my time and an asset swap of 2 OreTek client systems.

 

Cost of providiing foot orthoses designs for free to be downloaded by anyone who chooses to for free? Free, but for your time. Ain't that the truth. Night all. :drinks

Here you go, Joe:
http://www.youtube.com/watch?v=yRhq-yO1KN8

 

If I want a prefab orthosis for my patient, I'll still send them to the local running shoe store where they have about 6 different types of prefab orthoses to choose from and let the patient and shoe sales person decide on which one fits best, all for only $30-40 (US). Then they bring them to me and I modify them, basically at no extra charge to the patient.

Is my way of getting patients into prefab orthoses better than using a 3D mill or custom router to make "prefab" orthoses that the patient can pick up themselves? Yes, I think so. Customers know very little about orthoses and, I believe, need expert help to get optimum results. That is why they come to us for their foot and lower extremity injuries. If the orthoses work well, then cost is of little concern for most patients since they feel it is money well spent to be pain free again.

Podiatrists are just doing what all other specialists do when they provide specialized services such as custom foot orthoses: charging the going rate for a very specialized product and service.

 

So let's say I bought in a prefab for under £10 (17 USD), what would be a reasonable mark up on that would you say, Kevin? Would it alarm if a charge upwards of £80 (136 USD) was made for such devices?

For the record, here in the UK there are probably greater than 100 different prefab orthosis to choose from ranging from a couple of £ to about £30 cost.

BTW, I met someone a couple of weeks ago who had been paying nearly £100 a session to have low-Dye taping applied. Jeez, and these people sleep at night.

Lets' turn it around a little: lets say they come to you, you provide them with a diagnosis and guide them as to a prefab they could download from the net and print on their home printer for the cost of the filament, you still get the consultation fee- they get a prefab prescribed by a podiatrist rather than a shop assistant, they save money in the process and are more likely to get the right foot orthosis for their problem... seems like a win-win to me and cuts out the middle men in the process: shop assistants, distributers etc.- cool.

 

I'd wonder why you didn't buy a prescription device with that money. My rates to my clients for the shells range from $11.77 to $14.88 per pair typical, depending on the thickness of materials used.

 

Your rates are neither here nor there to the person buying the devices since they are unknown to the patient, by the time the practitioner/ shop has got hold of them they will be vastly inflated.

But, I'll take you up on that offer. When I order from you I'll expect the finished custom foot orthoses to arrive in my office having cost me no more than $14.88 per pair including postage, packing and import taxes. Sweet.

 

In effect, we're in agreement that the practitioner is the most costly "middleman", primarily because of expensive pieces of paper. Excellent. Unfortunately for you, theft and embezzlement (Tax and duties) will raise your final price a bit. My clients pay shipping and do their own finishing. However, I do have a local cooperative that will provide finishing for a small fee. Your government will raise that price as well.

 

I thought you'd said they were $14.88 per pair max? You are saying now that they are not $14.88 per pair max. How much are your orthoses to a practitioner in the UK, Joe? Do you know?

We are not in agreement; what I said was this: "by the time the practitioner has got hold of them". Now, if memory serves when you phoned me some years ago "your clients" were in the main commercial labs, and as I recall the nearest one to me back then was a large commercial lab based in Ireland. It is they who raise the fees the most, I'm guessing your £9 orthosis will cost the practitioner getting on toward £100 from the "client"/ lab. Did you know that? Even if the practioner sells to the patient at cost, there has been a massive mark-up by the "middle men" (you can call them "clients", the Orwellian language in which you chose to write your posts notwithstanding, they're commercial labs). Hence, I'd like to remove all middle-men ("clients") from the equation; I'd also like to remove the poxy Orwellian language from the posts here, but that's another story. Which, as I recall, is what I told you on the phone all those years ago. Memory fades though, I've forgotten how it works, Joe. Is it the "clients" that are designing and manufacturing the foot orthoses, and you who is getting £10 per pair for effectively doing nothing? Everyone needs their piece of the pie though, right Joe. Even if they don't know a foot from an anal sphincter.

Now, if you were streaming a foot orthotic file to me, for $15 and I was printing it in my office for the price of the filament, the patient could have it for... hmmm. Which I'm hoping is what Phil Well's is saying although he was quoting £2 (which is gonna put you out of business unless you drop your prices, Joe). Hope you can see my point though, all. The middle men, the "clients" as Joe likes to call them and the people getting money for nothing all need removing from the custom foot orthoses process, and prefabs should be free to all. I really do need to go to bed now though.

This is why I'm not interested in "hubs", Phil.

 

Nobel prize Economy Professor Milton Friedman, popularize the axiom "There ain't no such thing as a free lunch"

Somewhere on the production chain, someone pays a price in exchange for a good or service.

Ironically , innovation driven capitalism has created the tools (Internet, your computer, the wires through bits travel through one point to another, people getting paid to maintain this infrastructure, etc) to allow yourself to expose your point of view.

Financial speculation is a consequence of capitalism, but the end of themalthusian trap and poverty fighting is also a result from capitalism.

99% of readers are against financial speculation, but not against wealth free market economy creates.

For those who lived under planned economy;like my own parents suffered the Spanish fascist version (communists are not the only ones who advocate for this economy) during 20 years, I can assure you a capitalist redistribution system is the minor devil.

I can see 3 main advantages about low-cost desktop manufacturing machines (CNC and 3D printers):

1.- It allows freedom of choice to practitioners regarding orthotics manufacturing. You can do it yourself or outsource some steps or the whole process.

2.- It will expel dishonest operators from the market.

3.- It will unleash INNOVATION

Let's return to Professor Friedman. It does not exist a good or service "free". At some point there is an opportunity cost tangible (money) or intangible (time).

There are some experiments out there, just visit 3D files repository websites. But there are website maintaining aggregate costs, who someone pays, and designers upload their designs expecting a return on investment through a job or designing contracts.

I do not see why it can not be done for foot orthotics market. Always there is a cost and a ROI expectation; tangible or intangible.

 

So instead of standing up and demanding lower theft and embezzlement, you expect me to pay the father ( your governement), their dues, and free shipping? _My_ prices don't raise one penny when I deal with internationals. While acting as a backup for the lab you mentioned while their machine was down, Shipping, taxes and duties, more than doubled the unit cost. What we found was that the US Postal service offered the best price for a minor delay compared to Fedex.

Yes. Typically, they charge from 50 to 80 pounds sterling. They also pay considerably more to have raw materials shipped to work with and unlike the states, they pay their people reasonable salaries. Speaking of which, how I am able to provide a finished product for less than $50/pair is actually simple. The structure of the businesses does not include a CEO/manager salary, and everyone involved works from their homes.

First, I've created a very low overhead, which allows me to help the people I work with grow into full client/server sites. 2ndly, they aren't £9 orthotics. They are orthotics made specifically for the patients. How I've structured my own business makes it possible to keep things inexpensive and highly competitive with other companies.

You're calling me Orwellian? Practitioners rarely, if ever, sell orthotics at cost. Also, the term clients goes both ways. Your emphasis of the lab as "middleman" is a considerably smaller piece of the pie than the practitioner. As long as you focus on the lab, you can count on a redirect to point out the most glaringly expensive middleman.

In your country, the lab consists of mostly Chiropodists. I've personally been in this industry for nearly 2 decades, and 14 years for myself. It's quite easy to spot cases of fecal saturation.

My point, which again you seem to keep trying to spin, is that labs exist for a good reason, just as practitioners do. Pound for pound, the practitioner is the most expensive "middleman", which also points out who is making the most for the least amount of work. I don't stream foot orthotic designs. I provide systems that can be used to provide the proper device to a patient, which would never qualify as a prefab, unless, for some idiotic reason, the user of the system chose to copy a different patient's foot. Even when my software supports 3d printing, I seriously doubt many will want to use it. Doctors are paid well to see patients, and generally outsource the finished product to labs, maximizing their availability to the patients. Just as there is a symbiosis between myself as a manufacturer and the cooperative of finishers, a similar one exists between doctors and labs.

 

At todays rates $14.88 is £8.71, so you're right, they are not £9.00 foot orthoses.

Meanwhile your middle men or "clients" as you like to call them are charging the practitioner...

What percetage mark up is that? You right though, all of those people working in the labs and the CEO need to be paid , right? Except if the data file was provided directly to the practitioner who then printed it at their leisure, none of those salaries or overheads would be necessary. You'd still get your $14.88 from the clinician, but the clinician would get the foot orthoses for £8.71 + materials, Hmmm.

Now, I'm no mathematical genius, but I do know that £80 is currently $136.62, not $50 as you stated above. So you are not providing a $50 custom foot orthosis are you, Joe? Rather you are providing a $136 foot orthosis- that's a big difference, particularly since you stated that they cost $14.88. What percentage mark up is that, before the patient has even seen the foot orthoses?

Really? You've been manufacturing foot orthoses for two decades? Frankly, I don't believe you. Your history is still viewable via a google search for "Joe Jared". :drinks

Love a bit of Voodoo Economics, me... http://www.youtube.com/watch?v=KQCShKW-nfA

 

And meanwhile, the other more costly middleman, the practitioner, is doubling down.

I wouldn't pay £2 for a prefab. Even the notion of using a prefab, to me is a question of ethics.

I am providing foot orthotics to my clients at the price that I said I was. You, oh, and speaking of Orwellian, are attributing behavior of others as my behavior. That stinks of fecal saturation. And, lastly, I stated clearly I have been in the industry for nearly 2 decades, with Q3 of 2015 being the 2 decade mark. In April of 2000, I went on it alone, teaching myself what I needed to to reduce cost of hardware. Today, counting inflation, the cost of that hardware is about 9.5% of what it used to cost. As for google, :deadhorse:. Keep wacking away at it. You might feel better.

In the past year, I opted to support clients directly, which has proven to be an inspiration for several improvements in manufacturing, including making my machines idiot proof in terms of alignment. All in all, going from designer to designing manufacturer has been a win win for everyone involved. In fact, and combined with a cooperative business model, it will likely put even Walmart's prefab business model to shame, keep manufacturing domestic, exclusively using patient data, and help others to prosper, all while reducing the final cost of devices to about 60% of competing labs. I know where my moral compass points. do you?

 

1) Agreed.

2) Unfortunately, no it wont. In every network, there will always be people who take shortcuts. A realtime audit, however, could make a serious difference, But it would have to be similar in function to how restaurants get visits from the health department to make a real difference.

3) At best, it provides the opportunity for those so inspired to do something special. I look forward to people I work with suggesting something new or describing what they do after the devices are finished, if only to automate that process, saving a human step. Some people wouldn't be inspired even if there was a direct brain interface.

 

I've worked with many people who have both expertise and those degrees you refer to, and that you're using that as a weapon is of little meaning, at least to me. There are actually 2 labs I currently give devices to as a kick start in their newly founded businesses. In 5 cases, I've advanced client systems, one in recent weeks. 3 of them are completely paid for now. As far as why those two individuals receive special treatment, to me, it's an investment in personal ownership that in the long run will pay for itself.

Real education is inspired by decisions. Many decisions over the past 8 years have added disciplines, and because of those added disciplines, eliminated dependency on engineering and machining, lowering the final cost of hardware dramatically. Actually listening to what labs and practitioners need has resulted in many new designs and variables, now amounting to now more than 400 variables involved in making a prescription device. Separating the work of manufacturing and finishing represents a major life/work paradigm shift, which, for this impoverished community is sorely needed. The simpler and more repetitious work will stay in the community, and the finishers will make significantly more money per pair than I will off of manufacturing.

 

It is statements like your first two above which lead me to ask you how long you'd held a DPM for, Joe.

Can you tell us what the clinical evidence says about the efficacy of prefabricated foot orthoses, Joe?

You are questioning the ethics of practitioners around the globe who efficaciously provide prefab foot orthoses to their patients, yet you've never treated a single patient in your life. It doesn't matter how many "clients" you have or the advice you are giving them, you don't know what you are talking about when it comes to patient care and the ethics of using prefabricated devices. End of story.

By the way, if a clinician were to put the same percentage mark-up on your orthoses as the "client"/ lab does, using your costings the clinician would be selling the device for around £730.00 per pair (remembering that according to you, the initial price is £8.71 and the lab charges the practioner £80). I don't know many clinicians in the UK who charge such elevated prices for custom foot orthoses- maybe there are one or two in that London. If someone was trying to charge those kind of prices in the vast majority of places in the UK, the patients would laugh at them and rightly so because as you said, they cost less than £9 to produce.

 

Placebos treat illnesses too. Remember the phase 4 commercials? I believe both you and Dr. Kirby were exposed to a situation where you were told one thing, and the opposite occurred. That same client, after reading this thread asked me if I thought it was wrong to prescribe a prefab. I responded, "Not if their honest about it being a prefab". Some very large labs use libraries of positives, quickly matching a 'library' positive to a device and thermoform using that, billing it out as a prescription device. I think if we're going to make a device for a patient, we should use the patient's foot (or data) to make it.

Because of MY overhead, I can get by making the shells for $6.67 over material costs. I keep those costs as low as possible for my clients to help create a scenario that allows them to save money and eventually grow into a client/server site, instead of borrowing from a bank. Shipping alone is generally at or above that amount for international shipments and is mitigated by shipping multiple orders at once. I work from home, and always have, with 0 employees. As a result., comparing my 'cost' to other's sale price is not a viable comparison. These same overseas labs pay considerably more for raw materials, labor, workspace, and yea, taxes. That reminds me. How does VAT add value to the product?

Manufacturing the shell is only a small part of the process of making a device. Using just the shell as your argument against a completed product 'markup' is unrealistic. for one product line, my plan is to make work available to a cooperative and to make sure the workers make $15.00 per pair for their labor, which will bring the final price to the clients at something around $40~$50 per pair. As the finishing is nearly identical from pair to pair, I think it'll work, but there will still be some training required, and they will have to understand that finish quality is make or break for the cooperative. The DPM work, requiring special attention, is shipped on to one of 3 labs, and they have their own billing, which is significantly higher. Just as the practitioner seeing the patient charges for their time and expertise, so do the labs. I think if I had to deal with a situation like this as a manufacturer, I'd show the doctor the door and remind them that it swings both ways, end of story.

 

Simon,

Thought i'd mention that there are already free downloadable and semi customisable templates available if people want to make their own off the shelf devices. Last time i checked they were pretty average and you could change length and width maybe?

I actually think it is a good idea Simon but the main issue at the moment is the cost of materials. As Joe pointed out other manufacturing techniques are still much cheaper. So that's why i just stock off the shelf devices in our clinics as an alternative because they are cheaper then me printing them. (Although I'm not as nice as Kevin telling them they can come back and get modifications at no charge )

If i get time one day i might create a range of uploadable templates. It's just the time and if you wanted to give people something decent you would need a catalogue of 50 types and sizes.

You also get into the realm of people thinking they can then self prescribe when in reality what people are paying for is experience, knowledge and results. The internet can offer this some times but there are always variations of every condition that we as podiatrists know but others do not.

I think alot of the problem with orthotics are the simple things that they are often uncomfortable and don't fit in their shoes and if we can't get that right as clinicians then they may have been just as well off with an off the shelf. This is when i have a problem with excessive fees charged and patients just leaving them in their cupboard. Whilst i believe we are entitled to charge for our service and experience it should only be if it's reliable, repeatable and evidence based. I'm sure this will lead to development of condition specific orthotics.

All of the technology and ideas mentioned will happen i'm sure i think people that want off the shelfs will print them and if they don't work they will come and see their podiatrist!

Simon you have mentioned you want to have the control of the design process and you think that will fix everything but in reality you are one of few podiatrists that wants or is willing to take the time for this process. I can spend an hour designing one pair of orthotics and when you spend that much time it is not a viable process. So anyone crunching their numbers on costs will then not bother only the truly keen / academics will.

Javier 3d desktops will unleash innovation you are right but i think what it will fuel is better research and outcomes into orthotics. It is easy to print multiple orthotics with different properties to see what works without laboratory error. Most studies to date have been based on plaster casted orthotics with too many variables So hopefully this will improve outcomes to patients and also our scope of practice.

 

At this stage for us it is taking 8-9hours just to print one size 36 last, thats not a pair, just one foot, a lot of work a head for us.

 

Justin:

Sorry I won't have time to visit the lab when I'm flying through Brisbane in a few weeks to lecture at the Townsville Conference. Sounds, however, like some interesting developments are occurring and hope you keep us informed of the latest developments.