In The News

O and P business news

August 2006
Business to Boot:
Similarities and Differences in American and Italian O&P Facilities

During a recent visit to Italy, I awoke with a smile each morning to the crow of a nearby rooster aptly positioned outside my open bedroom window. Lying in bed and soaking up the sweet respite of a European vacation as the scent of fruit tree blossoms filled the air, I would ponder the constant uncertainties that accompany the unfamiliar surroundings of a foreign country.

O&P facility

I thought it would be interesting to see what an Italian O&P facility looked like.

O&P Facility

After seemingly endless hours of muddling through new and different customs, I embarked upon a quest to find a common thread between myself and my Italian hosts. As the owner of a small chain of O&P facilities, I thought it would be interesting to see what an Italian O&P facility looked like. Being a non-practitioner, in the past I had been enthralled by visiting other facilities in the United States. My quest landed me in Udine, a quaint and picturesque city in northern Italy. After stepping into a foreign facility, I was astounded by both the differences and the similarities of O&P facilities separated by several thousand miles and two dissimilar cultures.

Blending business and culture

There was no watering down of the Italian culture, when it came to business, as the architecture and landscape of Italy was not to be lost on the O&P facility I visited. On a cobblestone street in the center of town, a few miles from the train station, I found the Italian O&P facility. To the left was a pizzeria and trattoria, and to the right was a travel agency.

The exterior of the business looked like many others in Italy — it easily could have housed a drugstore or a gelatteria. Upon entering the premises, however, this facility thousands of miles away from mine, looked familiar. There was a small retail space, the typical reception area, and further back, the fitting rooms. Much to my surprise, as I strolled past the fitting rooms on my way to the fabrication area, I discovered a beautiful open courtyard.

In the elegant fashion of many European countries, this O&P courtyard was brilliantly adorned with hoards of brightly colored flowers. As I spotted several orthoses bagged and set against flowering potted plants soon to be delivered to some hospital or physician's office, I realized that the courtyard was actually part of the office. Smiling at the quaint peculiarities, I strolled through the courtyard and entered the owner's office, ready to get down to business. Taking on the role of foreign correspondent, I asked the owner about running what was, to me, a foreign enterprise in a foreign land.

Finding similarities

As the proprietor explained, the company had been in business for three generations dating to 1929. As the proud owner and I discussed our businesses, we recognized many similarities in our practices. Like my business, there were many aspects of his enterprise that differed from the norm. With 32 employees, they were not the typical O&P business in Italy. Most such facilities had fewer than 10 employees. Also a rare exception for Italian facilities but similar to my business, was the fact that this entity was owned by non-practitioners. Further differentiating them from their competitors, this particular facility had branched out and now offered continuous passive motion, cold therapy, wheelchairs, hospital beds.

O&P facility

Upon entering the facility, I realized I could have been easily touring any one of the facilities I have seen in the United States.

O&P Facility

After winding up the meeting, we stepped outside into the courtyard where I was greeted by the warm, humid Italian weather. Like almost every other business in Italy,even though temperatures reached the mid 80s, there was no air conditioning. As my attention then turned to the familiar sounds of a fabrication facility, I hastened to ask the owner for a tour of the fabrication shop.Upon entering this area, I realized that I could have just as easily been touring any one of the facilities I have seen in the United States. The same old drill presses, routers and ovens were all there.

Interestingly, it was more than just the look of the shop that seemed familiar. In the past, I have noticed a curious occurrence that takes place when management takes a visitor through the fabrication department. First, the technicians respectfully turn down their music so as not to impose upon the guests. Then, they quicken their pace. I noticed the same respect and pride in craftsmanship frequently seen at my offices when we show the fabrication facilities (and presumably even when no tour is underway).

Noting differences

I picked up a leather and metal KAFO that could have been produced by my technicians, but with one glaring exception. Attached to the orthosis was a bright red sneaker. For some reason, most of the younger Italian men seemed to wear red sneakers. I discovered that most of the AFOs and LSOs were made from patterned plastic. The patterns were similar to ours. However, many TLSOs were made of a clear polyethylene, which aids the physician in the assessment of the patient and verifies the contact of the orthosis. That made sense to me.

The most fascinating difference between our two businesses was one that paralleled most other businesses in Italy, adding to the charm of this country. The business hours were not the typical 8 a.m. to 5 p.m. as in Houston, but 8 a.m. to 12 p.m. and 2 p.m. to 4 p.m. There was actually a 2hour break from 12:00 to 2:00 when the business was closed.

When asked the purpose of this midday hiatus, my host answered, "Interruption for the possibility to eat something and rest" I chuckled to myself as I pondered how our physicians and hospitals would accept such an interruption of our daily routine back in Texas — "I am sorry, Dr. Smith, we will have that product on your patient in 2 hours as soon as my practitioner has awakened from his nap" It was also interesting to note that their business was closed on Sundays and Mondays and open on Saturdays. What happens if a patient needs something on Monday? This is Europe ... they wait.

Sharing frustrations over regulations

Now for the strict business end of my tour. When I asked about the governmental regulations, my host heaved a heavy sigh, exactly as I do when asked the same question. It seems a vast majority of his patients use the services of Azienda Sanitaria Locale, Italy's form of socialized medicine, similar to Medicare. Despite the complete absence of managed care in Italy, more similarities of our businesses came to light. For their Azienda Sanitaria Locale patients, six copies of each piece of paperwork are needed.

They have policies similar to HIPAA and obliga¬tory diagnosis codes. There is a standard fee schedule — universal throughout Europe — along with ISO codes similar to L codes in the United States. As many O&P owners in the United States do, my host believed that their cod¬ing system was antiquated, commenting that it had not changed since 1994. Upon hearing this, part of me wanted to say, "Wow, 1994!

Sometimes we do not get that lucky." Turning a light shade of green, I listened to my host talk about their astounding reimbursement rates. Rough estimates of their standard reimbursement rates were as follows: K2 level transtibial prosthesis $2,050; K2 level transfemo¬ral prosthesis $3,000; AFO $375; KAFO $2,000; scoliosis orthosis $350. Precertification is required for every orthosis and the average waiting period is a 5 weeks. An angry patient or a savvy doctor can facilitate the process and obtain approval for an orthotic or prosthetic device in as little as 2 weeks. Obviously, exceptions are made for trauma situations, where certifications usually can be obtained in 1 to 2 days.

Is the European way best?

It was only a short time after my visit that, upon careful consideration, I reevaluated my earlier interpretation of the "antiquated" European system. Who was worse off? Obviously, the European patients suffered as they were forced to wait an unreasonable amount of time for their devices. They did get them free of charge, however.

Guaranteed payment, no audits or probes

Radical thought though it is, the business owner was guaranteed payment. He was not left to wonder whether or not he would be paid for his or her services after providing the device. He or she does not have to face probe audits from the government or requests for clinical documentation for a knee immobilizer. This Italian business owner had no idea of what it was like to have payment denied for an orthosis months after it was applied. To think of it, a 2 hour siesta in the middle of the workday does not sound like such a bad idea.

If you have any questions regarding this article or my visit, call my assistant to schedule an appointment. However, do not call between 12 p.m. and 2 p.m. please. I have decided to try my hand at the "interruption for the possibility of rest."

Joe Sansone is chief executive officer of TMC Orthopedic in Houston.