O&P Growth in Uncharted Territory

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By Maria St. Louis-Sanchez

As news of a global pandemic and nationwide shutdown came last March, much of O&P found itself in uncharted territory.

Jimmy Colson, CO, CEO of POP Prosthetics, headquartered in Las Vegas, says he started to panic.

"I thought we'd all have to close down," he says. "I was devastated. I thought I'd have to let people go."

Almost immediately, he started to see a drop in revenue, especially in orthotics, which made up 60 percent of his business. Like many businesses, POP Prosthetics took out a federal Paycheck Protection Program loan to help cover the loss.

"It was truthfully scary," Colson says. "The unknown factor was considerable. I didn't know if I could pay my people if we didn't have money coming in. I was in tears thinking about how I was going to keep the staff paid."

But as the pandemic wore on, his fears never came to light. In fact, the opposite happened. He has seen revenue at his practices grow by about 15 percent because he invested in marketing and shifted more toward prosthetics. He has had to hire new people and train others to handle the growth.

"As the weeks and the months went by, I realized that business was sustainable, and we were actually able to grow," he says.

"It was something that I could not have anticipated."

Colson is not alone. While many O&P practices have faced hard times during the pandemic, others have been able to grow and expand their businesses in various ways. Some were already prepared for an expansion before the pandemic and others found themselves uniquely positioned in the market when the health crisis hit.


Moving Forward in Uncertain Times

Opening a clinic during a pandemic wasn't the plan when Fourroux Prosthetics, headquartered in Huntsville, Alabama, initially decided to open a new office in St. Louis. When word of the health crisis started coming in at the end of 2019, they decided to open their long-planned clinic as scheduled in February.

"The need for quality prosthetic care is still there," says Eli Walls, who is currently transitioning to clinic lead at the St. Louis practice. "There are a lot of patients who need care, and from my perspective, it isn't about pausing because of the pandemic, it is more about hurrying up to serve those patients."

Thus far, weathering the pandemic has been going as smoothly as possible, say Walls and other Fourroux administrators.

"We haven't shut a door since COVID started, not one single employee has missed a paycheck," says Justin Haynes, CPO, one of two clinic leads in the Huntsville clinic. "We haven't had to cancel appointments and that has allowed us to grow."

That said, there have been challenges. Pre-pandemic, Fourroux Prosthetics' staff would have been able to talk to physicians and referral sources in person to spread the word about their new clinic. Now they have had to change their outreach techniques and find new ways for education.

"Instead of being able to get into their offices in person, we would set up a virtual office meeting," says Fourroux's outreach and communications director. In one marketing situation in their Huntsville-Corporate location, they had a drive-through meeting at a skilled nursing facility, letting staff at the facility pick up boxed lunches as they met one another and learned about the practices' services.

"It's exciting to find workarounds," says the Fourroux team. "When you think there is not a way, we find a way."

At Evergreen Prosthetics and Orthotics, headquartered in Portland, Oregon, a pandemic was never supposed to be part of their growth plan. However, they found themselves dealing with its challenges soon after opening six new offices in four states. The offices were not yet running at capacity when the pandemic hit, and they had to decide whether to stay open.

"We had made a commitment to our patients and employees in those areas and wanted to keep those commitments," says Tim O'Neill, CPO, clinical director and president of Evergreen. Like other practices, Evergreen's marketing during the pandemic was initially a challenge since they were not able to build relationships with referral sources in their traditional ways.

"One of the most important aspects of our marketing is building relationships with referral sources through drop-in and scheduled meetings," O'Neill says. "Restrictions on contact due to the pandemic have made this difficult and led to more phone conversations. The pandemic has also changed the tenor of those conversations—instead of reaching out to share how we can help a patient, we are reaching out to connect with that practitioner to see how they're doing, and if there is any way we can support them personally."

Growth Through Acquisition

While some practices have grown during the pandemic by opening new clinics, even more O&P businesses have been growing by acquiring other practices, says Riley Phillips, director of recruiting for orthotics and prosthetics with The Newell Group, headquartered in Greenville, South Carolina.

"During the pandemic, I haven't seen as many practices open new clinics as I've seen them acquire other practices," he says.

In most of the cases, the practice doing the acquiring had already planned to grow and wanted to use the opportunity when it arose, Phillips says. He believes the pandemic has played a role, especially for the practices that are being acquired.

"I haven't had any of my clients say anything about wanting their practices to be acquired, but in the back of their mind, with everything going on, and the challenges of reimbursement these days, I think maybe having stability is always in the back of their minds."

Bionic Prosthetics and Orthotics, headquartered in Merrillville, Indiana, has been growing very fast during the pandemic, much of it through acquisition, says Sagar Shetty, BOCPO, director of clinical operations.

Since the start of the pandemic, Bionic has added around nine clinics, five of which were acquired from other practices.

"It's at least 40 percent growth since the start of the pandemic," he says.

The company's growth has been planned for a while, he says, and they wanted to keep moving forward.

"We realized when we started the business early on that the only way for us to survive was to grow and expand," Shetty says. "The pandemic did slow things down, but we kept working toward it and pushing it."

The acquisitions probably would have happened anyway, but the pandemic probably played a role, he acknowledges.

"A lot of these deals were in the works even before the pandemic happened, but for some of these businesses, the pandemic may have contributed and made the decision to be acquired easier," he says.

Thus far, Shetty says they are doing well during these uncertain times. Like other O&P practices, Bionic has less in-person access to referral sources, visits to hospitals and nursing homes are restricted unless absolutely necessary, and patients have put off a lot of elective care—and they are figuring it out as they go.

"We didn't really know what to expect when it happened," Shetty says. "It wasn't like any situation we had been in before. There was no established guideline or strategy. But we took things in stride and kept pursuing our goals with a positive attitude. We continue to pursue our plans to grow and expand as we speak."

Hiring During a Pandemic

Even in a pandemic, hiring has carried on for many O&P practices.

That means practices still need to seek out potential employees, and vet, interview, and hire them. Experts say this process isn't as straightforward as it used to be, but not all the changes are bad. Some changes might even be around post-pandemic.

One of the biggest changes, the experts say, is how interviews are conducted. While some clinics are only doing video interviews, many clinics are likely to conduct initial interviews via video chat and only bring in finalist candidates for an in-person meeting. This has been a change for both the candidates and the clinics, says Kevin Duffy, senior employment specialist for Mary Free Bed Orthotics & Prosthetics + Bionics, headquartered in Grand Rapids, Michigan. Remote interviews can be, well, awkward. When everyone was first getting used to video calls, there were a lot of technical issues, and many times people didn't feel as comfortable on camera as they would in person, Duffy says.

"You can see yourself too in the corner, and it's like you are looking in a mirror while looking at them," he says. Also, since the candidates are mostly calling in from home, that means there might be barking dogs or kids yelling in the background.

"It's kind of funny," he says. "That is life these days. It actually eases the tension a little bit because you are able to laugh about what's going on."

As the months have gone on, it's become easier as everyone has gotten used to the technology. Duffy has been interviewing candidates for resident positions and has talked to people across the country, many of whom have been going to school online. For them, it's now normal to communicate over video.

"Before this pandemic, I didn't really ever use Zoom," he says. "Now I think everyone is aware of it and wasn't surprised when we did interviews over it."

That level of comfort with technology may end up changing the way some companies hire in the future, says Riley Phillips, director of recruiting for orthotics and prosthetics with The Newell Group, headquartered in Greenville, South Carolina.

He's seen more and more companies recruit for administrative or billing positions that will be permanently remote.

"This forced their hand a little bit to hire more remote workers," he says. "But as it works, and they become more comfortable with it, they see it as an option for the future."

This also broadens the potential candidate pool, he says. If an employer is open to a remote position, they might find someone with skills and expertise who isn't available in their local market. He says a client of his in Michigan recently hired someone in Iowa who specializes in O&P billing.

"Now that we have the infrastructure to do this, you are seeing more and more companies open up their searches nationwide to find the best candidate versus the best people who can work locally," Phillips says.

For clinician positions, Phillips says he's seen the same number of applicants for the most part. The pandemic, for different reasons, has balanced out the quantity of people applying, he says.

"You could have a certain practitioner who might have thought of looking for a new opportunity but decided to stay put because of the pandemic," he says. "But you also have a practitioner who, because of the pandemic's impact on their practice, is looking for a new role unexpectedly."

For administrative jobs, the experts are mixed about the impact that the pandemic has had on applications. Phillips says he has seen an uptick in applications for administrative professional applications, which he attributes to more people looking for work.

At Bionic Prosthetics and Orthotics, headquartered in Merrillville, Indiana, director of operations Joe Antorietto says Bionic's clinics, which are in five states, have had a much harder time finding and keeping administrative professionals.

Those positions are typically held by women applicants, many of whom have children, he says. They tend to bear the brunt of the childcare duties and have had trouble balancing home and work during the pandemic. Antorietto says he has seen that impact at Bionic.

"Some of our employees gave it a shot to make it work with home and work responsibilities, and it just didn't work for them," he says. "Now we're seeing fewer applicants apply for these jobs in the first place. Many potential applicants feel like they just need to be at home right now."

The Right Business Model for the Time

When Eric Neufeld, CPO, FAAOP, opened Agile Orthopedics in Denver, he saw a need for mobile O&P services. Many O&P patients come from vulnerable populations and their mobility is limited. With a mobile clinic business model, he figured he could meet his patients where they needed him, whether it was at their homes, a skilled nursing facility, or even their physician's office.

As it turned out, that business model was a perfect fit for a pandemic. Patients in skilled nursing facilities have often been unable to leave but still sometimes need emergency care. Patients at home who are vulnerable to COVID tend to feel much more comfortable meeting with a clinician on their front porch than they would be going to an office and coming into contact with many more people.

Since the pandemic started, Agile has added three new mobile clinics and now spans much of Colorado. A lot of that growth comes from patients seeking Agile out because of the mobile model, Neufeld says.

"We've really grown as patients increasingly become aware that we exist," he says. "We're a choice for them when they think about what they might want differently in the style of care they receive."

There are still challenges, he says. It can be difficult to enter a skilled nursing facility, and clinicians tend to only go there when the need is urgent. At many nursing facilities, clinicians have to take a COVID test before entering, so once they're in, they try to see as many patients there as they can.

Clinicians are also working on their own for the most part, which means they must perform the roles of office administrator, technician, and prosthetist/orthotist all in one visit.

"We have to have practitioners who are very independent, innovative, and creative," he says. "I've been lucky enough to find several of those practitioners who align with this practice model."

While there was an initial drop-off in business at the beginning of the pandemic, it has been steady growth since then, he says. A mobile model, he found, works both before and during a pandemic.


A New Way of Doing Business

At the beginning of the pandemic, Colson first shifted his business away from orthotics and toward prosthetics out of necessity. In many cases, orthotics were elective, but he thought that prosthetics would always be necessary even during a health crisis.

As it turned out, this forced business decision was the best one he could have made, he says.

"It takes as much time to fill out the forms for compression hose as it does for an AK," he says. "The pandemic gave me more time to focus on higher dollar items, and lo and behold, it was more profitable."

POP Prosthetics has hired new people, including a technician to help with the additional prosthetics patients.

"If there's another closure, who knows what might happen, but right now business is insane," he says. "I'm not saying that orthotics and prosthetics are pandemic-proof by any means, but growth during a pandemic is possible."


Maria St. Louis-Sanchez can be contacted at msantaray@yahoo.com.