Is There Pedorthic Life beyond the TSD Benefit?

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By Dennis Janisse, CPed

Remember the good old days? Remember when fitting a pair of therapeutic shoes did not come with the specter of Medicare audits, prosecution, and prison time—when it wasn't necessary to hire a full-time employee to chase down physicians' progress notes to ensure you had complete documentation to successfully fight those audits, and patients didn't insist you were trying to make their lives difficult with paperwork requirements that they "never had to have before"? I am referring to life before Medicare's Therapeutic Shoes for Persons with Diabetes (TSD) bill.

With the increasing incidence of diabetes, combined with a large population becoming eligible for Medicare benefits, there has been a proportionate upswing in utilization of the TSD benefit. This upswing has created a significant shift and corresponding growth in the pedorthics world over the last 20 years that is attributed to pedorthic and durable medical equipment companies catering to the TSD market. A similar shift has occurred in the orthopedic footwear industry as many existing manufacturers created or grew their budget shoe lines and several new companies sprung up to serve this market exclusively.

However, as I intimated in the opening to this article, involvement in the TSD market is not without its challenges. In my cross-country travels to OP&P conferences and other professional events, I have witnessed panic among presenters and attendees alike each time Medicare changes documentation requirements, reports of sweeping Medicare audits are circulated, a new Medicare allowable fee schedule is released, or the possibility of eliminating the TSD benefit is even contemplated.

I would like to respond to these concerns with the proposal that a pedorthic business can be built on more than just the TSD benefit. For that matter, there are many less stressful ways to operate. Before we explore what a pedorthic practice might look like beyond the TSD benefit, let's look at what pedorthics as a profession is.

Pedorthics is the design, manufacture, fit, and/or modification of shoes and foot orthoses to alleviate foot problems caused by disease, overuse, or injury. The current definition on the Pedorthic Footcare Association (PFA) website reads as follows: "Pedorthics is the management and treatment of conditions of the foot, ankle, and lower extremities requiring fitting, fabricating, and adjusting of pedorthic devices." The American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC) website says, "An ABC certified pedorthist is an allied health professional specifically educated and trained to manage comprehensive pedorthic patient care. This includes fitting, fabricating, adjusting, or modifying devices that reflect the level of education and training received." The Board of Certification/Accreditation (BOC) describes a BOC pedorthist as someone who is "qualified to provide and/or supervise the assessment, treatment plan development and implementation, follow-up, and practice management of people using prescribed pedorthic devices and therapeutic footwear."

None of those definitions mentions anything about diabetes, Medicare, or the TSD. Why? It's because pedorthics encompasses much more than that. Take a moment to consider the vast number of other foot pathologies about which you have been educated and trained to treat. Plantar fasciitis alone accounts for more than one million physician visits per year in the United States, and an estimated one and a half million people in the United States have rheumatoid arthritis. Osteoarthritis affects almost 27 million people. And the incidence of hallux valgus in people over age 65 has been reported to be as high as 38 percent.1

With this in mind, there are a number of conditions you are equipped to assist patients with outside of the TSD benefit sphere. So, should you decide not to build your practice around being a TSD benefit provider, what are your options? One option is to transition to a cash-and-carry business: I provide you with a product, and you give me money.

For many, a cash-and-carry business model makes sense because it eliminates situations in which a patient comes in without the required physician documentation and becomes frustrated at the pedorthist because he or she cannot dispense the shoes the patient needs without it, or in which the physician doesn't provide proper TSD documentation due to lack of education or lack of cooperation.

Another option is to concentrate on growing your network of third-party payers by contracting with more and varied insurance companies.

Perhaps the two best ways to offset the revenue lost by discontinuing reliance on TSD provider status are to increase your referral sources and to increase or improve the services and products you offer.

To increase referrals, get the word out about who you are and what you do. Market to sports medicine physicians, athletic trainers, and physical therapists. Schedule meetings to talk to endocrinologists, primary care physicians, rheumatologists, podiatrists, and chiropractors and educate them about your services. There are many referral sources outside of the TSD paradigm. Talk to orthotists and prosthetists in your area. You may be surprised how many of them would rather outsource their patients' pedorthic needs.

There are several ways to increase the variety of services and products you provide. Sell retail items like socks, foot lotions, and shoe care products. Offer shoes outside of the diabetic shoe category—shoes that people are willing to pay for. A recent article in Runner's World magazine stated that more than 50 million Americans go running each year with almost 30 million people running at least 50 days out of the year. U.S. running shoe sales account for more than $3 billion annually. Catering to some of that market segment might be another way to boost your bottom line. Another option to increase your selection of footwear is by adding house slippers or supportive flip-flops. These are both examples of footwear that don't go out of style and are easy to stock because they don't require you to carry half sizes or varying widths.

Other service offerings include providing subtalar-control foot orthoses (SCFOs). Many pedorthists and pedorthic-only facilities underutilize SCFOs. Many custom SCFOs, like the Arizona Brace™, the Richie Brace™, and Hindfoot Restraint Brace™, fall within a pedorthist's scope of practice. There are also dozens of prefabricated SCFO options that are easy to inventory and fit, most of which are cash-and-carry items that do not involve the extensive insurance documentation requirement.

The opportunities are endless. Remember, as a pedorthist you possess the knowledge and skills and are uniquely qualified to help treat all manners of foot and ankle conditions, not just those related to diabetes.

Dennis Janisse, CPed, is president and CEO of National Pedorthic Services, headquartered in Milwaukee, Wisconsin. He also is a clinical assistant professor in the Department of Physical Medicine and Rehabilitation at the Medical College of Wisconsin, Milwaukee; adjunct professor at University of Pittsburgh, Pennsylvania; and director of scientific affairs for Orthofeet, Northvale, New Jersey.


  1. Nix, S., M. Smith, and B. Vicenzino. 2010. "Prevalence of hallux valgus in the general population: a systematic review and meta-analysis." Journal of Foot and Ankle Research 3:21.