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What are patients paying us for? Time and expertise or results?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Pod on sea, Nov 30, 2012.

  1. Pod on sea

    Pod on sea Active Member

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    Regarding treatment with orthoses:
    We all have occasional failures, and patients who respond in an unexpected way (i.e. new pain/niggles).

    A runner has a chronic injury. Orthoses (probably, as they are the thing that has changed) settle the injury, but then a secondary new injury occurs. Runner is not happy.....blames orthoses, refuses to pay for follow-up.

    It may have been the orthoses/the recurrent jumping up and down in front of the Olympics on TV/needing new running shoes that strained their achilles.

    The question I have is this:
    Are we charging for our time, skill and expertise or for getting the right 'results'?
  2. Hi Pod on Sea

    A very apt question and i feel that there are definite differences between the U.K and USA for example.

    Here in the U.K with us on almost exclusive fee paying in private practice, it seems that regardless our patients expects results. But defining the results can be difficult.

    The issue with orthoses is often complex, as they form part of a larger picture in the treatment process and often as a single step in multifaceted treatment, as i am sure we are all aware.

    Both myself and close friends in practice, have found it frustrating on occasion when a long standing and moderately disabling complaint is unleashed upon us by a patient.

    A complete treatment regime of Physiotherapy, stretching, strengthening and footwear is advised along with Orthoses. We also fully explain that steroid injections or surgical input are Likely, but hopefully avoided........Only to be faced with an irate patient 3 weeks later as the orthoses have not worked miracles. Often the first step pain has completely resolved and they are walking limp free at this stage, a comparative huge difference :)

    When questioned as to why they are wearing court shoes, why they have not stretched, why they have forgotten to ICE and why the physiotherapy appointments have not been initiated they can actually look bemused and chalk it of as "have not had time".

    It seems to stem quite often from the fact they have paid "X" amount for a treatment package and associate that with orthoses only....meaning that only the orthoses are required from the patient perspective.

    Now i know the above is not new and is all about setting expectations, hell we even issue written forms that are individual for the patient, to sign and confirm an understanding of expectation!

    It is not a daily issue, but does occur at least twice each year.

    The regularity of thought is always the same, that a result was paid for, even when not offered.

    I personally look at a patient and so customer paying for time and experience/Knowledge. My fees and structure reflect that.

    A case in point occurred today, hence is vivid and me responding here.

    Patient 57, stands at work all day, overweight, lateral instability for 40 years and recent (16mths) ankle injury at work (crush/inversion).

    Does not want surgery and wants to stop steroid injections for o/A pain relief. Also very unstable on ankles and turns an ankle weekly almost when walking dog.

    I advise physiotherapy regularly and refer. Explain that orthoses are unlikely to make any difference to ankle pain level, but will stabilize against inversion.
    Orthoses issued and comfortable, 3 week review no inversion incident and gait is stable laterally. Patient complains about pain and is advised to return for orthopod opinion, but that the orthoses and physiotherapy are preventing continued injury to the ankle, by halting the "sprains" and increasing a qualitative feeling of stability.

    Patient wants a refund of 90% 2 weeks later as still in pain. Despite a signed form explaining that they are to help prevent twisting and rolling of the ankle, but not assist pain levels......

    Again regardless of verbal and written information and irrespective of the full invoice detailing appointments and assessment charges, i really do not think that that small cohort will ever see it differently, i think it is rather a convenient way of trying a health care service, product and methodology free of charge within the benefits of private practice?

    I guess that what i am getting at is another question, can we actually decide if we charge for service or product. Or is the customer perception deep-seated?

    If a set of dentures are uncomfortable, dental patients always say that they have paid an arm and a leg for the dentures and they "are no good" They do not mention that the fitting, expertise and diagnostics form a section of that cost. Or indeed that they have gum disease etc to create the discomfort and have not taken medication or brushed for a week etc!

    Personally if i charged for every consult and all time/service, i would have more time and monies i feel.

    I find that as each year passes i get better at figuring the patient out at first instance, yet there are some that are still perplexing regardless.

    Interested in others opinions on this.

  3. Rob Kidd

    Rob Kidd Well-Known Member

    They are paying for your time because you have the expertise; there is an expectation of an outcome - which may or may not be the result that they had in mind. Rob
  4. Boots n all

    Boots n all Well-Known Member

    l would say they are paying for the outcome.

    They can see/hear your an expert, well qualified and know what your talking about, but this all adds up to what they believe will result in their satisfaction- the right outcome.

    l see a day were insurance companies will only pay on proof of outcome, the right results, especially in the diabetic area of such high risk.

    The outcome is also what drives your business and gets the clients/refers talking to your next potential client
  5. Patients are paying for both our time and our expertise as foot health care specialists. Of course, a good result is highly desirable, but, in my opinion, should never be guaranteed, since we are health care specialists, not automobile repairmen.

    If a patient desires a refund because they didn't get better, I tell them that since I neither promised nor implied any guarantee of a favorable therapeutic result, but did still use all of my years of clinical training, clinical experience and expertise to attempt to give them a favorable therapeutic result, they would not get a refund for the time and clinical service I provided to them.

    The word "guarantee", is never mentioned in my conversations with my patients. Rather, I give them a percentage (eg. there is a 90% chance that these custom foot orthoses will relieve the pain from your plantar fasciitis) that patients with their same condition have experienced therapeutic success with the treatments I am proposing with them. If they don't like the percentages, then I tell them they should not do that treatment. If they don't like any of the treatments or the cost of the treatments that I offer to them, then I suggest they find another podiatrist.

    It is really that simple.:drinks
  6. Rob Kidd

    Rob Kidd Well-Known Member

    Kevin, you are entirely correct in this matter. Rob
  7. Ian Linane

    Ian Linane Well-Known Member

    Interesting thoughts.
    For me the key has been setting up patient expectations from the outset, clearly stating that there is no guarantee, advising my suggested treatment approach makes clinical and/or mechanical sense and getting them to agree they understand there is no guarantee. This applies both to mob work as well as orthotic supply.

    Like Kevin I speak in both percentage improvements but also speak in terms of trade off's. i.e. a possible reduction in pain but more function (being able to do things more and for longer than they have).
  8. Agreed Kevin.

    That's it time to toughen up and allow the patients to take full responsibility for the treatments that they choose, from the full and correct professional advice provided.

    It is so rare that is happens, yesterday was the 1st this year, hence my long post :)

    Yet i remember that one case over the other greatly satisfied patients!

  9. David Smith

    David Smith Well-Known Member


    I would say that we are definentely charging for time but that our time becomes proportionally more valuable relative to our experience, qualifications, expertise and results. We are also charging for devices and the value of those devices are directly related their quality and to the former criteria that relates to their application.

    I believe that complaints are directly related to fulfilment of expectations and expectations are proportional to cost.

    A pleasing and satisfactory outcome from a 50% reduction in pain from the application of a very low cost felt pad or a quick cheap chair side insole, becomes a disgruntled, complaining customer when she has not got the 100% pain relief expected from her £500 orthoses that don't fit comfortably into every pair of shoes.

    I have been quite lucky and blessed that over the years I rarely have had any disputes with dissatisfied customers.

    Here is a recent example of a complaint tho.

    Dear Mrs Smith,Regarding my last appointment for a review of my foot, to see how i was getting on with the inserts for my shoe, to relieve the pain of my heel.When i first came to see Mr Smith i paid the fee to be assessed.After this we discussed what was the best treatment to proceed with,which was to have the inset in the shoes and exercises to do regularly.I understood the cost would be £200,which is what was paid.I understood that this would be the total cost of my treatment,so i was taken by surprised when i was asked for another £30 at the review to see how i was getting on.AS i have another appointment in January for another review,which will incur more costs,i would like to cancel that appointment.thank you,Mrs ----

    Dear Mrs-----
    Thank you for your communication,
    Sorry that you feel that our charges where unfair, we don't want you to feel that way and we always try to apply fair and reasonable fees and charges, so let's see if we can help you out
    You paid £15 for your initial assessment and £170 for the treatment plan advised, which included Quadrastep orthoses modified to match your required prescription, mobilisations and exercises and 8 week review, which includes any modification required to the orthoses if required because they are uncomfortable or do not relieve the foot pain or there are shoe fitting problems. Your foot pain was relieved when using the orthoses and you reported they were comfortable and fit well in your shoes. The 8 weeks gives you time to get used to your new orthoses and time for significant changes in painful symptoms to become apparent, it also allows us to monitor and record how our treatment plans and interventions are working, which enables us to continually improve outcomes for our customers. Any further reviews that are required are paid for at the usual rate.

    Most times there is no charge for the first review at eight weeks and no need for further reviews. Sometimes there are modifications made that require a return for a 2nd or even third review, this is not due to poor treatment or faulty design but just the way things work when treating the human body that is individual and not completely predictable. In your case I took the view that this was extra treatment over and above that explained above and new insoles were designed and provided, ankle mobilisation carried out, combined with advise to meet the particular problem of heel pain when not using the orthoses provided initially. (For example you explained that you do not use the orthoses in and around your home, where you spend a lot of time) A normal charge for this would be around £50 i.e. Miscellaneous Biomechanics £35 time and £15 insoles. I thought it was fair to discount this to £30 as part of the time was already booked for a 1st review.

    We do not usually charge for any 2nd or 3rd review where the problem is resolved and no extra work is required even though the appointment time is booked out. So, if things go to plan, it is unlikely that you would be charged for your next review. However in this case, and because you are not satisfied with the fee structure, if there is any extra work that is reasonably connected with respect to the initial problem then we will not charge you for that either. If you do not think that the insoles provided have added any extra value or reduced symptoms then we will also refund £15 upon their return.

    We try to be reasonable with our quotes, so that customers will always pay a fair price for the treatment received and understand what those charges will be. With the infinite variations that present with each individual customer sometimes there can be a disparity between what the customer expects and what we intend to provide. On the odd occasion when this happens we welcome feedback such as yours so that we can sort out the problem and try to avoid the same happening to other customers in the future. We hope that the solution above is agreeable to you and we will see you again for a review. Regards Dave Smith

    Dear David Smith,
    Thank you for your e.mail and explanation.I appreciate all what you have explained to me.I will keep the innersoles,because they do help about the house in slippers.As you know i'm going to speak to the GP clinic about a possible injection which i will be very cautious of undertaking.I think i will probably be ok now as i think the problem may well be solved now as walking in shoes is now ok and the innersoles for indoors seem to be working.I will leave it at the moment about another review,but if nearer the time i think i need to come i will contact you.regards -------

    Note that her complaint was more about her expectations rather than the actual treatment or outcome or absolute cost.

    NB I have cautioned her about the possible risk of corticosteroid injection in the Achilles tendon :eek:

    Regards Dave Smith
  10. One more point to consider: the successful podiatrist will always be one that is confident in their skills, can communicate that confidence to the patient, can predict a good percentage of treatment success to the patient, and then can deliver to their patients that treatment success on a regular basis.

    My sense is that many podiatrists, especially those with only a minimum of training and experience, are so lacking in confidence of their own skills that most patients will quickly sense their lack of confidence. Patients who do not sense confidence in their own podiatrist will never have the same confidence level in their treatment success when compared to when that same patient is being treated by a podiatrist who does have great confidence in their treatment success.

    For the practicing podiatrist, the continued pursuit of post-graduate training is not for the sole purpose of simply increasing the podiatrist's training and skills. Rather, an equally important purpose for the continued pursuit of post-graduate training is so that the podiatrist's patients will sense the increased level of confidence in the podiatrist's planned treatments. In this way, patients become more willing and helpful participants in their own treatment success, treatment successes will become more numerous and the podiatrist will become a more respected and valuable member of their medical community.

    These are important concepts that all podiatrists should keep in mind throughout their practice careers.
  11. Pod on sea

    Pod on sea Active Member

    Thank you for all of your responses, it's an interesting and important debate to have. This morning a letter arrived from the Society of Chiropodists and Podiatrists to say that the cost of indemnity insurance will rise next year- presumably as a result of more claims being made? The more clarity we have with patients regarding their expectations, the more we will be protecting ourselves.
    I have always attempted to manage the expectations of my patients, and they sign a form that says that orthoses may not address all of their symptoms and success cannot be guaranteed. But I think that they see/read/hear/remember what they want to. Perhaps this is because they are in pain and/or desperate for a solution.
    I suspect most of us are giving our time unpaid occasionally sorting out 'niggles' with orthoses. It comes with the territory and helps build goodwill. There's a balance to be found, but I do think we need to be as clear as possible about what we are offering.
  12. Pod on sea

    Pod on sea Active Member

    Thanks for your helpful post, Kevin.
    Can I ask what you base your percentages of success on- experience/research outcomes?

    How do you deal with unexpected unfavourable results e.g. The tib post tendinopathy (or the thing that brought them to you) settles, then the achilles (not been an issue before) starts being problematic?
  13. The cost increase in profesional indemnity insurance with the Society is because of a higher risk weighting for podiatric surgery, which is covered under the same insurance package as that for general podiatric practice.
  14. Not according to their letter, I quote: "and in particular the cost of providing insurance cover for all members (excluding Podiatric surgery which is now insured separately)."
  15. Then I stand corrected. Passing on in good faith from someone supposedly "in the know". I guess it may simply reflect the rising costs of PII and insurance generally. Speaking with my dentist this morning, he tells me that his protection insurance has risen 80% this year and one of the reasons is the number of claims from patients against retired practitioners. It works like this. Dentist A sells his practice caseload to Dentist B. Patient presents for examination and Dentist B suggests she needs a new crown. Patient states is is not problematic. Dentist suggests it has been wrongly fitted and will cause problems in the future - easiest option is to submit a claim against former dentist and insurance will pay for new crown. Seemingly this has become common practice in some areas and has led to an substantial increase in insurance claims over the last 24 months.

    There is certainly an increase in those seeking medical malpractice claims - a patient/solicitor who specialises in medical insurance claims tells me that his workload has increased ten-fold over the past five years and I have certainly seen a rise in the number of cases I have been asked to provide opinions for litigation claims.

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