The Prosthetics and Orthotics Podcast
The Prosthetics and Orthotics Podcast is a deep dive into what 3D printing and Additive Manufacturing mean for prosthetics and orthotics. We’re Brent and Joris both passionate about 3D printing and Additive Manufacturing. We’re on a journey together to explore the digitization of prostheses and orthoses together. Join us! Have a question, suggestion or guest for us? Reach out. Or have a listen to the podcast here. The Prosthetic and Orthotic field is experiencing a revolution where manufacturing is being digitized. 3D scanning, CAD software, machine learning, automation software, apps, the internet, new materials and Additive Manufacturing are all impactful in and of themselves. These developments are now, in concert, collectively reshaping orthotics and prosthetics right now. We want to be on the cutting edge of these developments and understand them as they happen. We’ve decided to do a podcast to learn, understand and explore the revolution in prosthetics and orthotics.
The Prosthetics and Orthotics Podcast
Medicare Releases Correct Coding for 3D Printing and More with Joris and Brent
Embark on an emotional journey with Brent as he recounts the heartwarming impact of providing prosthetic care in Guatemala, transforming lives in ways most of us can only imagine. Feel the ripple effects of hope and independence that these vital devices bring to individuals, and understand the critical role of advancements in 3D printing, such as the Bambu printer, in building local medical capacities. This episode is more than just a story; it's an invitation to witness the profound difference compassion and innovation can make in the healthcare sphere.
As we weave through the complexities of the 3D printing industry, we recognize the tenacity of businesses navigating economic turbulence. Join us as we dissect market reactions, talent redistribution, and the strategic shifts that ensure survival and growth in an ever-changing landscape. Joris's expertise is a fascinating exploration of the industry's future, where resilience defines the pathway to success despite dwindling capital and rising challenges.
Lastly, we cast a spotlight on recent Medicare developments and their implications for 3D printed orthotics, setting the stage for a potential revolution in patient care and independent practice. We're talking about a future where mobility meets customization at the doorstep, paving the way for healthcare services that prioritize patient convenience and well-being above all. Discover how these innovations could reshape the prosthetics and orthotics sector, making patient-centered care not just a philosophy, but a practical reality.
Special thanks to Coyote for sponsoring this episode!
Welcome to season seven of the prosthetics and orthotics podcast. This is where we chat with experts in the field, patients who use these devices, physical therapists and the vendors who make it all happen. Our goal to share stories, tips and insights that ultimately help our patients get the best possible outcomes. Tune in and join the conversation. We are thrilled you are here and hope it is the highlight of your day.
Speaker 2:Hi everyone, this is Jonas Peels, and this is another episode of the prosthetics and orthotics podcast, and with me, as always, is Brent Wright. How you doing, brent?
Speaker 1:Hey, doing well yours? Yeah, I know you had AMS. I was in Guatemala, so we've got a lot to catch up on.
Speaker 2:Totally man. So first of all, how was Guatemala man? How was it?
Speaker 1:Guatemala was great. You know, it's one of those things that's very interesting in that I had people that have gone down with me before, and so it's like you just kind of start where you left off, and so it really is almost like a dance. Right, you're doing this, I'm doing this, and at all times it kind of comes together and there's something really cool that happens. And we ended up seeing just a little over 30, 35 patients. Some people were for repairs, but we ended up doing like 25 new devices over the course of six days and we did every single device that you can think of other than a transhumeral or an above the elbow prosthesis. So that includes like a below the elbow prosthesis. We did a hip dysarticulation above the knee prosthesis, below the knee prosthesis, the scimes partial foot, and then we even did some AFO. So it really ran the gamut, and that's what makes it a lot of fun.
Speaker 2:That's good, and you know you've been doing this. How long have we been doing this for?
Speaker 1:So 2006 is when we started, and so that's also. The other crazy part is that some of these patients that we started with when they were three, four years old are now in their 20s.
Speaker 2:So it's it's.
Speaker 1:it's neat to see and it's neat to see how a simple device really has kind of changed their trajectory, and that's why we believe so much in providing the opportunity for kids to have prostheses. I think it, I think it literally can split a family tree and create success down the road.
Speaker 2:Yeah, ok, so we talked about this before, but it means literally, like you know, no job and some job, or really even maybe the high paying job for the circumstances. So really big, big economically, social economically, is a really really big deal Right.
Speaker 1:Yeah, I mean, a lot of these kiddos are going on to, you know, they have a high school and then they kind of have this post secondary, which would be almost like an associates, and then they then they can go on to like a batch, a baccalaureate and then a master's, and so we're seeing some of these guys go into like some business, entrepreneurship stuff, nursing, teaching, you know, things that would not have been in the cards if they wouldn't have gotten a prosthesis.
Speaker 2:OK, cool. And and how's your building up a capacity locally? Because that's what you wanted to do as well. You wanted to, like, empower local people to do a part of this, and how's that working out?
Speaker 1:It's going really well. So we we have we partner with a hospital called Hospital Shalom that is a locally run hospital, but then we also have not only social workers but people on the ground that can take care of things like adjustments or basic new prostheses, like a new below the knee prosthesis or something like that, and then knowing that we're only a phone call away if they get stuck or need help and or what have you. So you know, I really think the next level of this is trying to get somebody that is not only medic have a medical bend to them, so a nurse or a doctor that has, you know, a love for technology of some sort, and get them, you know, potentially scanning and and then 3D printing locally as well. And you know we've talked about the bamboo printer. I actually took one down. We, we did quite a few projects on the bamboo printer while I was down there that weren't somewhere end use. Some were kind of assistive devices to help us do that and that was amazing, and so I actually left it down there.
Speaker 1:And for those that are concerned and all that stuff, I know that bamboo had a recall on that and we're getting the the heat bed replaced, our. It doesn't appear like our issue for the A1 was a problem, but nonetheless we're taking all the precautions and we'll be getting a new heat bed down there to them, but they're also going to use it for some surgical planning because they just got some digital imaging tools down there. So I'm really excited, I'm, I'm. I'm more excited now than ever about, you know, 3d printing and just the talent that's coming around. It is going to be there so we can even gain more and more sustainable you know, momentum Super good, I'm really happy that you had a great time.
Speaker 2:Maybe you're super effective. Sounds really really amazing, yeah, man. Well, I want to hear a little bit about AMS.
Speaker 1:I mean it's I've gotten some feedback on on you know how that went and I mean it sounds like it was a good three, four days and some good meetings and all that stuff. I just you know it was more like an executive or business meeting, at least from the outside Looking in. So I just wanted to hear you know kind of what your thoughts were on the overall arching theme and and kind of attitude, I guess, of 3D printing going forward, as things seem to be tightening on the crazy money side of things.
Speaker 2:Yeah, sure. So, first of all, like the event was organized by 3D PrintDoll Column and 3DR Holdings and just my employer at 3D PrintDoll Column and out of manufacturing research, so I'm gonna be super positive about the event that we organized, right. So it's a small part of that, so I'm not unbiased, right. So it's event in New York. We've been doing it for six years now and it's been a little bit like, kind of the best way to define it if you're into the industry is like we have a mug for all the stuff in the box, right. Then we have Form Next for, like the big announcers, the big jamboree, if you will, for everyone to get together, and then we are really there about like everything that's kind of outside the box, right. So the strategies, development strategies, deployment strategies, investment strategies like you know what's going on in the market, the business, and it was so it's much more. We have a bunch of technical people come there as well, so Wall Streeters as well, and P&E people and VCs and all this, but most of it is business people from the industry and or business people that want to get in the industry, like people who are in CNC and want to think, hey, is 3D PrintDoll for me or people that are, you know, in dental or something like that, and they want to figure out what's going on. So it's much more focused on what we're doing, how you adopt the technology, what is not a good strategy, how the market's up to and all that. And we had a ton of executive, a ton of really like we had most of the really serious business leaders within the industry. So it was super good, really nice to talk to everyone. Overall, the mood was rather sobering, kind of like down and purposefully so, by the way and down to earth, kind of like okay, let's put our shoulders underneath it and get the work done, kind of. That was kind of like the takeaway. Like kind of like let's, you know there's positive stuff going on in deployment and applications and people actually making the technology happen.
Speaker 2:But the investor-storing money add-us thing is a little bit over, for now at least. You know we had there's a lot of SPACs and they have not done well, very well financially, but a lot of VC money thrown at us and now that's going to, because of interest rates and because you know, just of increasing uncertainty worldwide, that's going to be significantly less. So we kind of have to make it ourselves, if you will, and the future is not going to be turbocharged with, like investor money which is going to certain companies that are really good at raising money. There's still going to be some companies that will raise money, either by public markets or by my VC or angel investors, but that's going to be significantly less. It's going to be spread out over more companies and they'll raise less money, we believe overall. So no more like $600 million companies, that kind of thing, although we do know that if you did some kind of AI manufacturing thing, you could still raise a lot of money if you gave it that kind of sauce. But we believe that much more of the effort in the industry is really going to be from us making our own tools better, better materials, better software, better machines and all that working in concert to provide an overall better value proposition. So you know where, something like car parts was first not possible. Now maybe in certain cases it would be for certain low volume cars, that kind of thing.
Speaker 2:So it was a bit sobering, I think, for a lot of people, but I think that was the right message to send, given the state of the industry, given all the data we have, given how it's going and also giving the scene what's working, because there is a ton of stuff that's working.
Speaker 2:There's companies that are growing, doubling in size year on year. There's companies that are doing really, really well, but there's also a bunch of companies that kind of ran out of money at a very inopportune time to run out of money, so that's not good for them. It's not a good day to be them. So there will be a bunch of companies that will fold and there will be a bunch of companies that will be acquired for next to nothing and there will be people that forge ahead. And there's also companies that raise and now have tens of millions in the bank and a really nice time to have millions of dollars in the bank. And there are still some companies that could do a lot of acquisitions and can get companies now on the treat. A company that would value previously at 50 million is now five. So you know there's some bargains to be had as well.
Speaker 1:Well, and the talent right, the talent available coming from some of these, that are, some of the people that were kind of thinking outside the box, like what you were talking about is, and now they don't have jobs like that, they're going to be finding themselves into some other solutions, and, and some of these people with cash or that have been smart with money, I think there's going to be some interesting times ahead, for sure, right? Yeah, sure, sure.
Speaker 2:And I think that you know certain people have been cutting headcount. I think that's just stupid. It's like it's like a essentially like it was a reaction of a lot of companies oh, we'll cut headcount and we'll cut headcount. And there's companies out there in the wider tech world that had like winning quarters, the biggest quarter they ever had, and then they just cut headcount to kind of make their stock prices seem more attractive. And I think that's a stupid thing. In tech, right, you can always get rid of the worst people you have if you wanted to. But but kind of willy-nilly getting rid of your 20th percent youngest employers or the ones that joined latest, or something like that, is kind of really stupid. And and you know our business it's doubly stupid because there aren't that many people that know what they're doing. There aren't that many people that have a lot of experience. So you know, if you're looking at somebody who has like 10, I know people that are like 10 years experience in materials or software and then they've been let go and it's like, but where are they going to find a replacement? You know they're just going to lose that knowledge. So so I think that that layoff thing is very short-sighted.
Speaker 2:But again, there's a couple of companies that have to do it because they will, they will go out of business. There's, like I know, about a dozen companies that are going to go out of business in Q1. Maybe they'll make it to Q2, kind of this quarter. They should be out of business. They're running on vapor. So you know, for them to lay people off, yeah, ok, you have to. But there's other companies that didn't have that choice, they just wanted to. It was the quickest way for them to to look appealing to investors, yeah, look disciplined, if you will. So then you're just like letting people go for the optics and I think that's kind of stupid in the industry we're in, just because so much what we know cannot really be captured on like a spreadsheet and it's really very dependent on your experience. I don't know. I think that's a rather short side.
Speaker 2:Yeah, you're right, it's an opportunity for people that want to pick up talent. Yeah.
Speaker 1:Wow, Wow. That sounds amazing, though, man, and congrats on a good, good event too. I mean just heard lots of great, great feedback and hate I missed it, but there's always next year, right.
Speaker 2:Yeah, definitely. I mean we'll look at to see if there's some some prosthetics related stuff, then totally we could do something. And otherwise we'll see what we can do. And we always like it. And this is New York, so it's always nice and and, yeah, it's a kind of good, it's a nice, it's a really good event. We're really really happy with this year. So so when we started six years ago or something, I thought it was like really really small. And now it's still small, right, it's like still like like 400, 500 people, but it's not meant to be much bigger, but but still it's much bigger than once was. So that's, you know, we're really happy with that.
Speaker 1:That's really cool.
Speaker 2:So, first off, I was about to say that we have a sponsor right.
Speaker 1:We do have a sponsor, and that is Coyote, and I'm so excited to have them on. You know I'm a big fan of theirs and pretty much all their products, but we wanted to feature another product right, or another product or two of theirs.
Speaker 2:Yeah, sure, sure, I mean I think, I think I okay, just off the top of my head. I don't know if this is your story or thing either. What really surprised me actually was this basalt Coyote composite material right, you know that to me was, was you know a carbon fiber alternative that to me is seen potentially, you know, much more sustainable potentially, but also, just like you know, a much tougher material that is much more suited perhaps for like of the laminations that you'd use in the prosthetic business.
Speaker 1:Yeah, I mean. One of the things that's interesting about the basalt is like who would think like you know, what we should do is create a fabric out of lava rock you know, yeah, I actually think that's a really good one. What type of person thinks of this?
Speaker 1:But you know it's used a lot in tennis equipment. It's used a lot in fire retardant stuff too, but one of the things that I appreciate so much about Coyote is they're kind of they're made for, or they're thinking about, the end user or the amputee or the person that has limb difference. And one of the things that's interesting is that basalt is more flexible once it's laminated with a wet lamination, compared to carbon fiber, and so what they had been doing is they've been having really great success with people in like a polypropylene style socket or copolymer, which is polypropylene with some ethylene in it, and but they were then laminating those sockets and the patients would hate the sockets. Well, it was because it was so stiff with the carbon fiber and they're like man. We need to find something that acts very similar to the thermoplastic, and that's how they landed on basalt. So they actually created this whole, not only the harvesting process, but also the knitting process, to knit this into a braid. That's usable and that's a tough mountain to climb, for sure.
Speaker 2:Yeah, and it's also potentially you know this benefits the patient. It could be more comfortable, it could also reduce your skin irritation and also perhaps there's less when you work with this material, especially in post-machining right and that kind of thing. You actually might be safer for you in terms of the stuff you would, as a worker or employee, whatever breathe in these things. You know, the basalt stuff instead of, like, the e-glass fiber and the resin fibers. Maybe this is actually potentially less harmful for you and your staff right.
Speaker 1:Yeah, 100%. I mean, when I was a technician I hated grinding on carbon. You would have to put you know multiple gloves on. I was super sensitive so I would itch for days if I got it on my skin With the basalt. That's not the case, and so, yeah, as far as comfort-wise you know, excluding all the other benefits it's really great for the people that are actually doing the work.
Speaker 2:That's cool, man. I love this as a product. Yeah, and you're right, this is not some simple like build design thing and then we'll make it. This must have taken quite a while to implement this alternative to carbon fiber material, so I think that was really really really very cool. So thank you so much for KOD for sponsoring us. All right, so moving right along. So we talked about AMS, we talked about you know, brent's latest Guatemala adventure Is anything else. Well, we don't have a guest. This is like the most important thing we should mention.
Speaker 1:Yeah, but don't turn it off. You know this is going to be a good one.
Speaker 2:Trust us, trust us. So did anything at all happen in prosthetics land that you were excited about lately, Brent?
Speaker 1:Well, this is crazy and this happened actually while I was in Guatemala. My phone started blowing up because Medicare released a document that says on February 1st. It says 3D printed orthotic devices correct coding.
Speaker 1:So, one of the interesting things is there's been a lot of people that says said hey, does Medicare pay for 3D printing braces? Well, they don't exclusively say they do and they don't exclusively say they don't. And so people it was kind of this reaction like I don't know if I want to do that, because if it's not part of they call it the DMA, pos, quality standards or the quality standards If it's not in there explicitly and Medicare is black and white when it comes to this if it's not in there explicitly, there's definitely some risk that they might not see it your way. As far as using 3D printing, now, they knew that 3D printing was going on and they've known it's been going on for a while and nobody knew that this was going on in the background. And this is what I love so much about this is the people that are working in the background on some of these. A lot of times they want to shut out the noise around the technology and really dig into the potential data, but also then the potential benefits to the patients, and so they did something really interesting in the quality standards. So they talked.
Speaker 1:So they didn't explicitly say 3D printing, but this is the wording they used, and this is talking about custom fabricated items individually made for a specific patient. No other patient would be able to use the item. A custom fabricated item is a device which is fabricated based on clinically derived and rectified castings, tracings, measurements and other images, such as X-rays or of the body part. The fabrication may involve using calculations, templates and components. This processing requires the use of basic materials and this is the key including, but not limited to, plastic, metal, leather or cloth in the form of uncut or unshaped sheets, bars or other basic forms, and involves substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling and finishing prior to fitting on the patient. So those what is that? Four words, including, but not limited to really opened up the door for our field to really start looking at. 3d printing is a viable option of manufacturing according to the quality standards, so I'm really excited about that and I'm excited to see also where that goes.
Speaker 2:Okay, that's cool, but what does that mean? Does that actually mean that it's just a little bit easier, a significant easier, or are you now going to get it refunded all the time? What do you think it'll actually mean on the ground for the practitioner on the site?
Speaker 1:So what it means and this is, I think we have to say, hey, we're not lawyers and we're not, like government, specialists and all this but what this is saying is that 3D printing is not excluded as a viable option to manufacture, in this case, a 3D printed orthotic device.
Speaker 2:Okay, and also I like the fact that they did mention in the preamble to this thing they mentioned out of manufacturing, 3d printing, and they didn't split out the particular technologies. They didn't say this one yes and this one no, so they did keep it kind of very broad with regards to the manufacturing technologies we could introduce or it could be introduced in the future. They kept it quite broad in total as well, right.
Speaker 1:Yeah. So I think it's really forward thinking for this group, who has known to be fairly conservative along the years or over the years, to leave it that wide open, and I think one of the reasons why is they truly see this as a technology that can transform patient outcomes and they don't want to limit the innovation that is in it, so like if they started carving out some of these items then you're saying, hey, there's no innovation there or we're not going to pay for that kind of innovation. So I think leaving it open is wise, but it is one of those things that we as clinicians, certified clinicians and trusted in the care of patients, have to take very seriously. So we're not talking about PLA printed devices in your basement and somebody's going to go walking on it. We've got to be very, very careful on how we use this, because just as quickly as they put this out, they can take it back.
Speaker 2:And I think one other thing is they believe that this is cost effective because otherwise it doesn't only get better Patient outcomes. It's not some magical, mystical robot technology. It's something that actually could deliver these results in a quite a cost effective way, right?
Speaker 1:Well, and I think that is true.
Speaker 1:I think the other thing that they might have taken into account too is you have less and less people that are actually manufacturing these devices, like blue collar workers or the technician side of things.
Speaker 1:The big companies Autobach, osser, hanger they're the ones that have these fabrication facilities, that have multiple technicians and that sort of thing. But what happens to the independence? They either have to send their stuff out because they do not have a technician on site, or there might be other manufacturing capabilities, such as in additive manufacturing. So what that does is also squeeze the timeframe down to where the patient gets their device quicker than if they were to traditionally fabricate it. So I think those are some possible considerations. I was not in the room totally guessing on that, but it makes a lot of sense when you take a look at our field and the technical capabilities are decreasing because we have less and less technicians coming into the field or wanting to be a part of the field, and so this is as our population that needs these kind of products grows, there has to be a way to support it on the manufacturing side.
Speaker 2:I think this is a really, really great point you made. We've also talked about this before, but so it's weird. People are getting heavier. People are also. They want more from life. You're not going to do anything when you're 60 or you're retired or something. No, no, you want to travel the world or win a bagel across America or start hiking the Appalachian Trail. I don't know. We're much more bigger dreams. So more mobility, People living much longer. We've got the diabetes and all these other things are also affecting the patient population. You normally would expect that, if there's more requirement for something, that you'd also draw in more practitioners, but yet we're not seeing that.
Speaker 1:Right. I mean, yeah, that's absolutely right. I think that's the whole that additive manufacturing plugs. I think it's very interesting, but I think we have to be responsible in the way that we do it.
Speaker 2:You've talked before that there's less people interested because it's just hard work. It's a lot of hard work. Are there other reasons why there are fewer people joining up? Maybe you're not going to have money right?
Speaker 1:Yes, I get you where you're going there. Education. So we've lost quite a few technical programs over the last probably five years. There's only a handful of them left in the United States and these are the people that are training the technicians. You can learn on the job training, but that cycle is a long time to be proficient in many, many things. That's one reason I think the money just is not there as well for the technical people Now, the technicians that are able to do everything from metal bending to laminations.
Speaker 1:Those guys are getting paid pretty well but that breed is going extinct because the people aren't hanging around in the field for that long. If you're a technician and you get into the field, say younger, and sometimes they'll want to go be a clinician, which is fantastic, but there won't be anybody behind them to do anything. Then the other thing that's been interesting. I was talking to another friend of mine. The people that are doing CAD in O&P, specifically organic shapes fitting to dimension shapes, are getting poached by some of these other companies that need those kind of skills. They will actually look at the orthotic and prosthetic industry and who's doing the digital stuff and they'll get these guys to come work for them. That is also very interesting as well. It's definitely a weird time to be in O&P, but expanding this additive manufacturing, I think, is important.
Speaker 2:Yeah, I think so too. I hope your vision is correct here, because I like this idea of saying you know what we can actually get custom devices, maybe less effort, less money, and that would be more money. Better devices for the patient, but still at the same time, more money and more time for the practitioner. It sounds like a headache. All, just everything that you want.
Speaker 1:Right, yes, but there's some interesting things coming down the pike with our field as well. It's a relatively new certification, which is called the Certified Prosthetic and Orthotic Assistant. So if you think about doctors, a lot of doctors will have PAs Physician Assistance working for them. This is the equivalent of that. So for those that want to be involved in our field and that can do some basic training, some basic education stuff, and then get a lot of on-the-job training, it's a great opportunity to be a part of the field, make a reasonable living, but you're not having to do the whole education for becoming a certified clinician, and I think that's one of the interesting things that I want to see grow is how do you take these certified clinicians and leverage their abilities, especially the experienced ones right, that say have 10, 12 years experience, and we leverage that experience to be able to take care of this population that's booming via extended caregivers like an assistant, and that is still something that I really see happening in the future.
Speaker 2:Okay. And also I think it's like what about this efficiency part of things? You guys have trucks, right, you got like a van with the fabrication equipment in it. You go to people's homes, right. Yeah, that's a convenience factor, right. We're in use of people are in use of getting all their meals. You get shopping delivered to your house. You get like everything delivered to your house now, and just that. You know moving towards a model where you're delivering the services in a truck or a van. That's more convenient. Isn't that kind of maybe in keeping with a lot of other trends? And maybe also, you know, from a business model perspective, you know the whole idea of saying normally I say four guys and now I see six. You know what I mean. That could be really advantageous as well.
Speaker 1:Oh, 100%. And transportation is a big issue for people that are have limb loss, you know they're not able to get themselves around, or somebody that's had a stroke, and they typically will rely on a caregiver or a relative or whatever, and then those relatives then have to take days off, work and all that stuff. So that starts adding up real quick. Or they take public transportation, and here in the US public transportation means a whole different thing. It just means that you will get wherever you're going on somebody else's schedule, even though you might have signed up for, you know, at a different time. And what I mean by that is and this is one of the reasons why we went mobile is we would have a beautiful day scheduled, you know, patient at eight, nine, 10, 11, 12, break for lunch, one, two, three.
Speaker 1:Well, it turns out a lot of those patients were on public transportation, so all of them would show up at one o'clock because they, you know, the transportation would pick everybody up and then, you know, go to the different appointments and then, oh, I need to go to the prosthetic place and then everybody gets dropped off at the same time and then it's like a fire drill right to help all the patients and make sure that they can get on the bus to go home.
Speaker 1:And so for us it was. It was actually a little bit more on the selfish side. It was hey, we should be able to try to control our own schedule, and so if we're running late it does matter, but people are waiting in the comfort of their own home, it's not like they're waiting in our waiting room. And so now we have control of our schedule where we can have specific goals of meeting of. You know, hey, we're going to, we've got a patient literally at eight and nine, 30 and 12. And, yes, there's some driving time in there, but it is efficient and it's a great use of our clinicians time.
Speaker 2:I think this is a really brilliant thing you guys do. I think it's more of a stuff like that, especially the limb loss and the stroke people oh goodness, I know people have had a stroke and for them to go places it's a very, very kind of difficult thing. So I think that kind of thing is really great. Convenience wise is a keeping patients that would often find difficult to use your services and also just owning a schedule. I didn't even thought of that that's. You know, that's a super great reason for doing it, and the reason I like it is just like that, more patient contact in a more convenient way. You know that that that, especially if it's difficult for you to get around, that to me would make a huge difference if I have two equally quality, able, kind of like prosthetic people I can go to and one delivers it to my house. Yeah, okay, I'm going to go with the guys that come to my house, you know.
Speaker 1:Yeah Well, and I think one of the distinctions. So there are a lot of companies that will say, oh yeah, we'll come to your house and they'll just show up in a you know, their Honda, fit or truck or whatever you know, and they don't have the tools to actually make something happen. So make something happen on site. And so we've been very intentional on that side of things, where we've got grinders, we've got glue, we've got drill presses, all the things to make an adjustment on site. So the patients aren't without their device. And I think that's an important distinction to make. But unfortunately that a lot of times falls on the patient to ask that question. You know, and you wouldn't think like, oh yeah, I come to your house and the follow up question should be well, if you come to the house, will the job get done, or do you have to take whatever you do and take it back to your shop and then bring it back to me?
Speaker 2:Yeah, it's just a funny thing. That's a good one. It's also really interesting. We always talked about before about the parallels between the dental industry and prosthetics, but there's a similar thing there's lots of small partitions, lots of patient contact, if you will, lots of custom devices, and the custom devices are smaller and dental. That's why there's millions and millions of parts, tens of millions of parts, that are being printed each year in dental Actually much more. If we took a county of visual line and we're talking about like maybe 800 million devices or more, maybe close to a billion devices in total. So that's a lot In total. These devices are so big, the market around it has become big.
Speaker 2:So we looked at dental for trends for prosthetics as well. One of the things I've noticed that in the dental what's really important is to reduce the two things that are driving some innovation. One of them is to reduce the procedure time, to just say, hey, normally this would take one day or whatever. And then the second thing is to reduce the amount of patient visits. Say, we can implant this brace or this thing or whatever in one visit, and it used to be that it would take two. Is that something you think that we could do more in this industry as well.
Speaker 1:Yeah, absolutely, and there's different types of prostheses that we do that. There are more complex and you can run into more issues. So those types of prostheses, those are not going to be delivered at home. And so when we talk about some of these other prostheses it is simple, potentially adjustable so they can adjust their volume, and kind of just straightforward on how to put the prosthesis, on how to take it off and leaving, like the higher activity sorts of prostheses vacuum, suction, that sort of thing to people that are going to come into the office.
Speaker 1:And here's why To have vacuum or suction you have to have a sealed system and unfortunately that's also the weakest link of a whole prosthesis. There's a gel sleeve that goes over top and creates that area of sub-atmospheric pressure or vacuum underneath. But what happens when you kneel onto that sleeve and you poke a hole in it? Well, it starts leaking. And then it starts leaking. It doesn't fit as well.
Speaker 1:And then you make a phone call and say, hey, my prosthesis isn't fitting as well. And then somebody has to go out to go see the patient and say, oh, you know what? You've got a hole in your sleeve. Right there we need to either turn your sleeve, replace your sleeve, flip it upside down, whatever it is, to move that hole out of the way of leaking, whereas we could have prevented it altogether by not choosing that system for our patients. So I would see that that's been a growing process for us. But over the last I guess 13, 14 years we've somewhat cracked the code on what makes the most sense and absolutely we try to make sure whatever we provide we call it an oops factor. There's an oops factor that's built into the prosthesis where if the patient doesn't put it on the right way or there's some other things that go on, we may not have to take a phone call because we've not only educated them but we've created the prosthesis in such a way to expect some of those things.
Speaker 2:That sounds like a very valuable approach, really great for both sides to say Also the inconvenience of trying to get another appointment and all that stuff. That would be really really terrible, I think as well. And with the guards, this thing, the Medicaid approval thing do you think it's going to super radically change the industry or is it just like a nice little boost for out and over? There's a nice little boost for 3D printing in orthotics and prosthetics.
Speaker 1:Well, I think already it's given a little bit of a boost. I think the jury is a little bit out there and it really depends now on who these companies align with whether or not they're going to have success. If it's like, our industry is very interesting our profession there's always a discussion whether we're an industry or a profession. That's for another story. But for our profession, when people have a bad experience, they'll a lot of times just write off the whole thing and be like you know what? I'm just going to keep on traditionally manufacturing, and you and I both know that's really not the approach to take.
Speaker 1:With additive manufacturing, you're going to have some amazing results but there's going to be some times where you might be left with your head scratching. But you're going to want to make sure that you align with the right people that are doing the things that you want to do and not trying to take what's you know trying to change the way you care for patients. So you know what I mean by that is, if there's a specific brace that you make and there's a function that you want, don't let them try to sway you into. Hey, this is kind of like it, but not really so really see if somebody will sit down, listen to you and see and have an honest conversation of hey, is this something that can be created in an additive manufacturing?
Speaker 1:And we know that additive manufacturing can't create everything. There are some definitely limitations Cost is a lot of them. So there are some products that it's never going to make sense to use additive manufacturing for. But then, on the flip side, some of these more complex products, it will absolutely make sense, and not only financial sense, but also timing-wise, how quickly you get a product. So my encouragement to people as they see this coming down the pike is finding somebody that you can align with and kind of just hold on to them and work together with them to create a product line specifically for you.
Speaker 2:That's a good idea. I think it's wise advice, good, good, well-heated advice, and with the guidance that the profession and an industry I would always consider yourself, and it's much more important to consider yourself as a profession. I'll give you an example. My granddad was a butcher and he was a butcher in the center of town and if he thought himself as an industry the meat industry he would see himself. But he saw himself as a craftsman, which of course made him make better products. It made him more proud of what he did and it was our family business as well and it was something he would pass on.
Speaker 2:But at one point the center of the town where he was in in the Netherlands changed and it became all those local stores, a local shoemaker. The local, all these kind of disappeared and he was kind of alone trying to apply his butcher trade. But there were a lot less people buying directly from him. And the second thing was that the supermarket came up and a lot of people were just buying their meat from the supermarket. It was cheaper, right. And the third thing that happened is that a lot of people would want more convenient food, which would also go from the supermarket. So there's some butchers that then adapted and all of a sudden started eating, offering pizza and pasta, all sorts of stuff. And then the fourth thing of course that happened is the veganism the rise of vegetarian veganism, the reduction of the meat eating generally by people. All these things happened and because he saw himself as a craftsman, it was at the one point very difficult, but he did see it in the right way Because of course we all know how it would survive.
Speaker 2:As a butcher, like, there's two things you can do. You can either really become the craftsman and become the number one, really luxury, high-end butcher of that area I'll go to Sarah's steak because she has the best steak, or whatever right. The second thing is to really do things and see yourself as a craftsman of food and then say you know what we're going to make? All these ready-made meals for people and that's how we're going to expand, right? Any other kind of industrial way of looking at it or looking at the meat industry as a whole and feeling defensive about that business isn't going to get you to a strategic alternative that will actually make it work. You can't get cheaper at one point. You just don't have the scale right. The supermarket has. You can't really industrialize your own production offer really cheap because, well, there's always going to be somebody themselves directly to the supermarket. It's cheaper.
Speaker 2:So looking at yourself in industry is looking at everyone, but looking yourself as a craftsman is looking at your own business and sometimes the business decisions are very, very local and very, very hyper local and it's just about you as a craftsman differentiating yourself. I think, for example, the delivering thing that you do, the visiting people home thing, that is something that is within the very well, the possibilities of everyone that has an orthodox and prosthetic practice, right, that's not a huge investment, that is a doable thing for nearly everyone, at least if you want to do a bear bonds, right, and that's the thing that would also work for the butcher and the owners who say, hey, you know what? Instead, we're going to deliver right, and we're going to seek out those customers that can't come to us anymore I don't want to or we're just going to deliver across the town and make our area bigger at a higher price. So, for those of one quality, and so I think always, my personal advice would always be to see yourself as the craftsman, because then, and the profession, the passion, right, because then you're actually, as a small business, going to actually kind of figure out what you could do within your limits rather than just complaining about everyone's becoming vegan. Yeah, ok, good luck. What are you going to do about this? Right, you're one guy with a little shop. You're not going to change everyone's mind, right, it's like a global trend.
Speaker 2:So I think definitely it would be. You know, you could see yourself as an industry, but I think, looking at yourself from the perspective of being a practitioner and being a craftsperson, I think it would be much more valuable in letting you understand what's important for your business, that relationship, that actual innovation, the actual handy work that you could do and no one else could. That follow up with a much more personal way, the high bob, knowing what kind of this person's golf game and knowing how you can improve that person's golf game specifically for the specific invention for them. So I think that kind of personalized thing is, I think, the things that would tend to matter. And looking yourself in an industry that's under threat from India or consolidation or something like that, it doesn't do any good, right, it's not going to let you survive, you know. That's what I think about that.
Speaker 1:Well, I definitely like that kind of analogy too, with your dad being the butcher and such. I think what's interesting, though, it's also what we're seeing happening in Medicare. So I would agree 100%. We are a profession and not necessarily an industry. However, Medicare looks at us currently as an industry that needs our expertise, I feel, and here's what I mean by that.
Speaker 1:Doctors, physicians, surgeons, they all get paid by the time and the procedure that they do.
Speaker 1:Well, we only get paid by the device that we provide, and that includes all the follow-ups, all that stuff.
Speaker 1:We get a one lump sum payment, which can be good and sometimes can be really bad. But here's the interesting part of that and don't take this as pushing back on the profession, but I would much rather so. Right now, our table of fees have increased. So what was let's just call it $1,000 last year is now $1,080. So we got an 8% increase this year, whereas physicians are taking a hit of 20%, 30%, 40% on their deliverables, and they're obviously a profession at their craft. So, in the same way, I'm like hey, if the people that are paying us consider us an industry and our prices just keep on going up where the professionals professions are going down. I would much rather be the person that's providing an item at high skill, where our reimbursements continue to go up and things like additive manufacturing get opened up to us to provide for our patient and not really care about how are we labeled in the eyes of the payers? They see our value. They might not just call us as a profession. Does that make sense?
Speaker 2:Yeah, I totally understand. It does formulate and also, especially it's like the other industries are looking at is insurance and it's like this giant multi-billion dollar thing. So definitely that framing or how they see you totally makes a huge difference.
Speaker 1:Yeah well, and I'm like man, if they want to pay for my time and I see what they're doing to other people's time they're paying less. I don't mind being called Brent the leg guy or Brent the brace guy. My reimbursement continues to go up, and we have a larger population that we're going to be fitting and needing our skills and that sort of thing, so it's a double-edged sword, but for me the labels don't matter. I would be livid, though, as a surgeon or something else, or a doctor that has my reimbursement cut for my time, and my time starts becoming less and less valuable. That's really. I guess the crux of the matter is that our time we're able to leverage a little bit more because we're providing a whole service and we're getting paid for a whole service right, and not our 15 minute increments. So there are times where we're gonna win, there's times that we're gonna lose, but we are in control of that, whereas surgeons, if they're paying for their time only and they keep on getting cut, they've got no place to turn.
Speaker 2:Yeah, actually there's another in the Netherlands. We have a system that by and large, is a socialized insurance system, so actually the premiums are ridiculously low. You're back 200 bucks a month and the costs are really low. And if you get something terrible like cancer, something that's also essentially free, you have a deductible of something, but not something that is disastrous as that. So the system, I think, works a lot more better than your system.
Speaker 2:But there's one thing that is really similar and it has a really unintended side effect, and what they did is for a lot of things. They came up with a standardized procedure and actually looked in depth, like if someone breaks their arm, how long does it take to do it, what are the materials costs and what is kind of the. Usually it's 15 minutes, sometimes it's 23 minutes. That's a good, sensible approach, right, but what happens now is that what you really incentivize to do is be like the broken arm factory or the gallbladder surgery factory Just do the same procedure over and over and over again. Now, meanwhile, if Mary has something really cutting edge and super exciting and really difficult surgery, then maybe you shouldn't do it because that's not exactly very cost effective.
Speaker 1:Right.
Speaker 2:So all the cutting edge stuff that's really gonna get the skill of the doctor to a higher level and is gonna be really kind of life saving and it's gonna be like kind of like going like, okay, this person doesn't have a chance, that we're gonna give her a chance, not gonna stop. It really doesn't make sense to do that.
Speaker 1:Right.
Speaker 2:So there's no real like perfect way to do it, I think. But I think, either way I like what you're saying is that you're sure, if you could do a particular process at a particular time with a particular cost, that you have more control, and I like that very much from a business perspective. And I like that also because then I think we have been talking about this, this has come up a bunch of times about us, both of us this is the whole idea that for some people, maybe they should be just talking to patients all day, maybe it's better, and then they shouldn't be fabricating as much, or they should only be fabricating those one or two things that are like super special, or maybe, like I would do, all of the APOs. I mean you should do a different part. You know what I mean.
Speaker 1:That's right.
Speaker 2:And maybe we should just more look. People should look much more at this specialization or just saying you know what I love the patient contact side of things. Why do we even make anything? Why don't I just like go to some CFAB thing through everything you know?
Speaker 1:Yeah, no 100%. I think the specialization being efficient being you know the experience to where you know you're able to do something that is much quicker. That would take you know somebody else that isn't as experienced in this particular thing less time. It makes total sense and I do think that that's where the market is going for sure.
Speaker 2:All right, see, I told you guys it would be interesting, so we would like to thank you for listening. Thanks very much to Keody for sponsoring this episode. They're a great company. We love them. Go check them out. And thanks very much for being here again, brent today.
Speaker 1:Oh, this was great. Yes, thank you, and I mean it definitely stretched some of the ways that I was thinking and expressed. I'm gonna have to go back and listen to some of this stuff to make sure I said it right, but hey, it's what I was feeling in the moment, so we'll probably just let it roll.
Speaker 2:Okay, cool, all right. Hey, thanks everyone for listening to another episode of the prosthetics and orthotics podcast. Have a wonderful day. Music.
