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RE: High Cost of Drugs (George Jacobson, DPM)

From: Elliot Udell,DPM


Let’s open another can of worms with regard to the cost of drugs. In New York State, doctors are required by law to e-prescribe. My allergist e-prescribed some medication for me. I paid for it at the local pharmacy, only to find out that I could have saved a significant amount of money had I gone to another drug store. The way e-prescribing is set up with insurance companies is that the pharmacy will not give you the final price of the medication until they process the prescription. In order to price compare, I would have had to ask my doctor to send off the prescription to other pharmacies, which he cannot do using his program. This set-up is another example of how our government has set up prescription benefits in a way that does not help the consumer.


Elliot Udell, DPM, Hicksville, NY

Other messages in this thread:



RE: MIPS 2019 Payment Adjustment (Alan Bass, DPM)

From: Ron Freireich, DPM


Correct me if I’m wrong, but I believe we were required to report on ALL eligible patients (Medicare part B, Medicare Advantage, private insurance, Medicaid, etc.). However, our “bonus” payments in 2019 will be calculated only on the allowed amounts from Medicare part B patients, not even Medicare Advantage patients.  Take that to the bank, or not.


Ron Freireich, DPM, Cleveland, OH


Dr. Bass wonders if "Exceptional Performers" of MIPS are going to get bonus money. I think it is a travesty that taxpayer dollars would be given to anyone for recording useless information that takes away time and energy from one's occupation, whatever their occupation may be. An exceptional doctor is one who goes above and beyond caring about the well being of their patients. This cumbersome, pointless data entry should be brought to a stop. 


Jeffrey Kass, DPM, Forest Hills, NY



Re: Costco Selling "Custom" Insoles 

From: Robert Scott Steinberg, DPM


I posted this on Costco's Facebook page. If you feel the same, please post on your Facebook page and on Costco's page:


I was in Costco on Saturday, June 16, 2018, and realized they could save tons of money by getting rid of pharmacists and optometrists! Anyone can read a prescription, count pills, and make people better, right? Digital devices can scan the eye and come pretty close to correcting vision and improving eyesight, right? Of course, they are not going to do that, but they do invite into their stores, people with no licences to advise people that they can make their feet feel better by standing on a mat and have the bottom of the feet mapped. Then produce devices that may cause injury to the foot, ankle, knee, and low back.


So, what if it has a 90-day guarantee?  The damage from devices like these might not show up for months. If you want to try something quick and easy, and inexpensive for foot pain, pick up a pair of rather stiff insoles at a sporting goods store. If they don't work, you're only out $35-$40 bucks, not the $130 Costco charges for their ridiculous insoles. If you have foot or ankle pain, you deserve to be seen by a licensed expert, a doctor of podiatric medicine and surgery.


Robert Scott Steinberg, DPM, Schaumburg, IL



From: Jeffrey Kass, DPM 


Dr. Williams has pointed out there is an alternative to ABFAS. He mentions ABLES. However, unfortunately, ABLES is not according to state law, in some states, going to help you practice above the ankle. For example, here in New York, the law specifically singles out that  one needs to be Board Certified by ABFAS in order to be granted this privilege. One of the largest hospital networks in New York has also recently made ABFAS certification your ticket to OR privileges. 


Jeffrey Kass, DPM, Forest Hills, NY



From: Benjamin J. Wallner


I would like to address a few misconceptions that have appeared in the discussion of the VA MISSION Act over the past few days. Dr. Lombardi’s conclusion that only ABFAS-certified podiatric surgeons will receive an increase in pay as a result of the passage of the VA MISSION Act is fundamentally incorrect. Board certification is just one of many factors in determining market pay at the Veterans Health Administration. The section of the handbook that he has quoted refers to how the VA determines whether a physician or surgeon is board certified—not how the physician or surgeon is paid. 


The bureaucratic machine that is the VA looks at myriad sources to determine pay, including Sullivan and Cotter, MGMA, Bureau of Labor Statistics, among a whole host of other sources. The podiatry section at the VA now faces the formidable task of implementing this legislation and...


Editor's note: Mr. Wallner's extended-length letter can be read here.



From: Robert Scott Steinberg, DPM


Dr. Feldman, I find your post arrogant, smug, and condescending. I suggest you think about those who came before you. There is no reason board costs are so high. Let the boards charge more for re-certification, instead of extracting the "last ounce of blood" from the young DPMs. You owe your colleagues an apology.


Robert Scott Steinberg, DPM, Schaumburg, IL 



From: Richard J. Manolian, DPM


Welcome to the opioid epidemic. You quickly will get used to the online Rx history requirement as we have had in Massachusetts for a few years, and it will be enlightening as to what your patients are up to. 


I had some patients that we pull up where they’ve had 50 to 100 Percocet or Vicodin just prescribed only a few days before surgery that we are about to perform. I simply tell them you will not be getting a controlled substance prescription following this procedure based on that, and they understand fully.


Richard J. Manolian, DPM, Cambridge, MA



From: Ivar E. Roth DPM, MPH


I recently interviewed associates with three years of residency training. The spectrum of graduates training was from excellent to below average. One may ask how a graduate of three years of surgical training could be average or below average. The answer is that many programs just do not have the surgical load or variety that is necessary to come out as a fully trained “surgeon”. Many whom I interviewed felt they needed an additional year as a fellow to feel confident. Sadly, three years of training may NOT adequately prepare graduates for practice and or sitting for the boards. From what I saw from the current crop of residents is  that many were under-trained and not ready to become full scope podiatric “surgeons”.


Ivar E. Roth DPM, MPH, Newport Beach, CA



From: Len La Russa, DPM


We, as podiatrists, are all worried about the dwindling number of pre-med applicants applying to podiatry school. Could part of the problem have anything at all to do with the 50% passing rate for ABPS certification? Orthopods don't have that problem. Or is it possibly the chance that there might not be a position available for residency? The low passing rate is much easier to fix than the residency crisis, which is less of a crisis now. Another impediment to getting talent to apply to podiatry school could easily be addressed by increasing the pass rate so that it is no longer such an embarrassment. 


Len La Russa, DPM, Americus, GA



From: Robert Scott Steinberg, DPM.


Lawyers do not bill Medicare for billions of dollars. Lawyers aren't the ones ripping off Medicare. And Florida is the epicenter for Medicare fraud. Don't take it so personally.


Robert Scott Steinberg, DPM. Schaumburg, IL



From: John S. Steinberg, DPM


We apologize for what your friend experienced. However, it is unfair to turn this misinformation into an accusation that Georgetown is somehow discriminatory towards podiatric surgery. I am the co-director of the Center for Wound Healing at MedStar Georgetown University Hospital. Our team is composed of podiatric surgeons, plastic surgeons, vascular surgeons, nurse practitioners, and numerous other specialists.


MedStar Health is a system of over 36,000 employees with 10 hospitals, so I cannot speak for every circumstance, but I can tell you that podiatric surgery is well established here and is not in a discriminatory status. I believe it would be best for you and me to speak directly about what happened rather than have this debate on PM News. Please contact me at 202.444.3059 and I would be happy to reach out to your friend to provide assistance.


John S. Steinberg, DPM, Washington, DC



RE: An Open Letter from Greg Sands of Ortho-Rite to His Customers

From: Greg Sands


Within a few short months, and after a catastrophic fire that completely blindsided me, Ortho-Rite is up and running. It’s good to be back! I am not sure how the fire started. What we do know is that the paper storage is where it started. Paper storage is a ticking time bomb. How it started will remain an unsolved mystery. 


The first thing I want to do is thank my customers for their loyalty and support. I know that the fire has disrupted practices and hurt patients nationwide. I was overwhelmed and shocked, but I focused all my energy to rise above the ashes and rebuild. The building bureaucracies of this new town kept us from operating sooner. To circumvent the red tape, we worked a night shift to get things going. We have cleared the hurdles and we are now producing. Three months of anguish and stress have finally come to an end. I will do anything I can to make whole anybody who was adversely affected.


It was tough getting restarted after going for so many years. For the rest of my time in this industry, Ortho-Rite will be committed to make it up to all of you who were compromised. I am truly sorry for what happened. I want to maintain and exceed the level of product and service that you were used to. My entire team remains intact and eager to take care of everybody as usual. 


Greg Sands, Owner of Ortho-Rite



From: Simon Young, DPM


I agree with Dr. Jacobs. The one word he used that must be analyzed is “normal”. Insurance companies rate you in relation to your peers. If let’s say, 90% only do C & C, then anyone who does more and deviates from the norm and bills for it falls out of “NORMAL”. The more standard deviations away from normal, the more ABNORMAL your practice is and they don’t question and evaluate why a practitioner is more observant and caring, but instead can consider it fraudulent. 


We as a profession “old” or “new” must change NORMAL. No one will admonish you for raising  a patient's pants legs and looking for abnormalities for referrals, if needed. This will save lives and hopefully garner respect. It’s sad we don’t look at legs routinely, no matter what the state laws. It’s preposterous to think we only did it for whirlpool treatments!


Simon Young, DPM, NY, NY



RE: Kudos to Amerx Healthcare

From: Ted Mihok, DPM


I would like to thank the Amerx Healthcare Corporation for contributing wound care products to our Lions and Rotarian's Joint Service Project in Mexicali, Mexico on April 4 and 5. They have been a partner for over ten years and their generosity is greatly appreciated. The service project has been going on for over 42 years and consists of both medical care and construction in and around Mexicali, MX.  


Ted Mihok, DPM, Alameda, CA



From: Jeffrey Kass, DPM


I am not sure if all the negative comments about Costco orthotics are well guided. I, like most of my colleagues, watch shark tank - and I say kudos to the people who came up with the idea. It's rather ingenious, and from a business point of view, I think they will make money. I think it's ludicrous to point to the inferiority of the product without having seen it or tried it. That is sheer jealousy. Some of my colleagues have been known to have their secretaries cast patients, yet no one is up in arms over that. I'm not sure that I can even agree who the experts are or if there are any when, as Dr. Shavelson points out, there are no studies proving anything. 


The more important question is - should the profession have been able to deem orthotics prescription products to be prescribed only by doctors, and did the profession let us down in that regard? What exactly is the Costco process? When the operator is quizzing the patron on what ails, can this be construed as a medical exam that the operator should not be doing? 


Jeffrey Kass, DPM, Forest Hills, NY



From: Brian Kiel, DPM


I, just like many podiatrists, see patients who have been treated by Costco and urgent care facilities. I, like Dr. Jacobs, will not deal with devices that others have made. I explain that it is a useless device and I cannot and will not take responsibility for them. On the other hand, if someone comes into my office with a boot and a fracture, or an improperly treated condition of the foot, I don't feel that we can or should refuse them. If another facility screwed it up in the first place, then they probably won't get it any better the second. It is our responsibility to do everything we can to help that patient. Of course, proper charting regarding the prior care is critical, but we have an ethical responsibility to care for those patients.


Brian Kiel, DPM, Memphis, TN



From: David S. Wolf, DPM


I respectfully disagree with Dr. Udell's post, "How would you feel if that person leaves your practice and gets a job working for an MD across the street and the doctor starts advertising that he or she now provides foot care by a well-trained PA or NP." These "podiatric insecurities" are still unfortunately part of the paranoia that was ingrained into our training and psyche. When podiatrists whom I have trained moved down the street, it never negatively affected my patient load; it only increased my bottom line. 


Competition is good and healthy as it raises awareness of what a podiatrist's scope of practice is. With the obesity crisis in this country, there will be more work for all of us (think wound care,diabeties, plantar fasciitis, etc.). 


Having NP/PAs you have trained who work in a PCP's office will only enhance your practice as they will know what services that they and their new boss do not want or know how to do. "The more the merrier".


David S. Wolf, DPM, Houston, TX



From: Tina R. Sechrist


Our office has been working on this issue as a mass adjustment project with Palmetto GBA since early March.  The following has been posted on the claims issue log of Palmetto:


Issue Identified 3/26/2018: It has been determined that a routine foot care service edit, based on the Routine Foot Care Local Coverage Determination (LCD), L37643, has been edited incorrectly and only allowing one CPT/HPCPS code identified in the LCD per patient, per claim. This issue affects claims for dates of service on or after February 26, 2018.


The editing will be updated to reflect the LCD’s intent, which is to allow any medically necessary routine foot care services for a given patient once within a 60-day period. Providers must bill all routine foot care services for a 60-day period together on one claim for one date of service. The CMS Mutually Exclusive Edits to prevent improper payment when incorrect code combinations are reported will continue to apply to each date of service billed.


Provider Action: 3/30/2018: There is no provider action. This CPIL will be updated once the editing has been updated and Palmetto GBA will perform adjustments on affected claims. 


Tina R. Sechrist, East Cobb Foot & Ankle Care, Marietta, GA



From: Paul Kesselman, DPM, Simon Young, DPM


Thanks to Dr. Borreggine for pointing out it was a PA at the derm practice who wrote the Rx. He is absolutely correct that all prescribers should have some sense of the patient’s cost of their prescription regimens.


Paul Kesselman, DPM, Woodside, NY


I am incensed at the term “fake news”. It is a term to indicate intent on lying vs. ignorance. Furthermore, it’s a term used by leaders who are authoritarians and themselves are promoting false ideology and facts. Yes, Kerydin and Jublia are not compound pharmacy drugs, but they surely charge the same. The PA might have been misinformed or didn’t care. It's true that the patient did have documented onychomycosis, but was her health in grave risk? These abuses nevertheless should be exposed. 


We should ask the Reps what are the costs of these medications. Anything products advertised or promoted by a Rep. are really, really expensive. It’s unconscionable to pay $1,500 for 10 ml Kerydin or 8 ml Jublia. Treatment can cost over $10,000 for let’s say 10 nails with a low cure rate, provided it’s involving the matrix. Anterior superficial, you can bump up  the cure rate to 26%. 


Boutique pharmacies charge outrageous prices but we write the prescriptions and they laugh all the way to the bank, and insurances and patients blame and complain to the prescribers. If you have commercial insurance (NOT MEDICARE, MEDICAID, TRICARE), you can pay out- of-pocket for $100 in my office area. What’s wrong with that picture? This is an outrage which doesn’t only involve podiatric practitioners but all medicine and should be outlawed and regulated. This has little to do with R&D. R&D is a farce at this point.  


Simon Young, DPM, NY, NY



From: Sara Tradup


We have our old x-ray films recycled and they will pay you for the silver content and provide you with a certificate of destruction. We use B/W Recycling – they will even cover the shipping costs to send x-rays to them as long as you have at least 50 lbs of films. We have used them three times so far over the years, with great service every time


Sara Tradup on behalf of Peyman Elison, DPM, Surprise, AZ



RE: Lack of Podiatric Authors in Our Journals 

From: Bryan C. Markinson, DPM


Many have lamented and seek answers on the lack of high quality peer-reviewed published podiatric research. Some blame the colleges, others blame APMA. I take a different view. Why does there have to be blame on any level? The importance of original academic research in medicine is self- evident. However, it is still a minority in all fields who churn out the research. 


Be that as it may, since 1977, when I started podiatry school, there was NEVER a milieu for research in any of our colleges. Original research is much more complicated than one might think, and very costly. Since working in a very research-oriented academic institution, I can tell you that “research” is done on weekends and nights, with armies of...


Editor's note: Dr. Markinson's extended-length letter can be read here.



From: Kathleen Neuhoff, DPM


I am a veterinarian as well as a podiatrist. As a requirement for achieving board certification, it was necessary to submit two papers suitable for inclusion in a peer reviewed journal in addition to the usual case presentations and two days of testing. One of the reasons this was done many years ago was because the feeling in veterinary medicine is that one of the main differentiating factors between a profession and a trade is the production and publishing of research. If such a requirement became a part of the board certification requirements for podiatry, I am sure we would see a rapid expansion of research!


Kathleen Neuhoff, DPM, South Bend, IN



From: Name Withheld


Kudos to Ms. McCormick for bringing this issue to light regarding continued use of chemicals to "disinfect" podiatry instruments. From what I recall, most of those chemicals only sterilize an instrument after 6-8 hours or more of being immersed. Since most podiatry offices are turning over a patient every 15-30 minutes, there is serious potential for spread of onychomycosis, MRSA, Hep C, etc. from patient to patient if these chemicals are utilized. 


There will be others that disagree, but there is no excuse to not have an autoclave and sterilize every instrument between patient use! Autoclaves are not that expensive and we have advanced beyond chiropody. Those that are still using chemicals are no better than some of the pedicure salons that...


Editor's note: Name Withheld's extended-length letter can be read here.



From: Janet McCormick, MS


The EPA-approved label on Benz-All says weekly. It does not say, however, if Benz-All is rendered ineffective by bioburden, meaning it might or probably needs to be changed earlier. The EPA requires that hospital disinfectants kill certain benchmark microbes and Benz-All does that. Many disinfectants, however, are tested for further levels of kill, and these are added to the label as "label dressing" since no disinfectant at this level kills everything. In other words, it's designed to improve sales. Keep in mind that there are many organisms it does not kill, but that is true of every disinfectant, no matter the brand. Only sterilization kills them all = use of an autoclave.


There are those that say disinfection is the okay-level of care for podiatry instruments unless you are performing invasive treatments. But any treatment can cause any level of invasion by instruments (in any type of care - podiatry or otherwise), even by accident, so any procedure must be performed under aseptic conditions Doesn't that call for sterilization of instruments in podiatry? Even in the offices? I am always shocked when I go into a podiatry office and there is no autoclave! But it happens way too often! In a survey of podiatry offices in my area, 4 out of 6 offices did not have an autoclave. 


Janet McCormick, MS, Frostproof, FL



From: Richard J. Manolian, DPM


I for one would not want to be the doctor who gets inspected and has to then prove how much of this product I bought to match the patient load and requirements of changing it on a 2 to 4 week basis depending on whom you listen to.


In addition, I would then have to show proper paperwork as to the change in schedule and process of how instruments were utilized in the setting. Gas or steam sterilization seems to me a more definite way to avoid this quagmire with any board of any state.


Richard J. Manolian, DPM, Cambridge, MA



From: Name Withheld 


A few years ago, a well-respected practitioner passed away in an untimely manner. He had a long standing practice that was busy from day until night, a modern office in a building affiliated with a top hospital and well-trained staff. His practice continued in the interim with help from volunteers, but when his family tried to sell it, they could not get a reasonable offer for the practice; not even an unreasonable one.


Instead, someone who purported to be “a friend” opened up a new office in the same building and poached the patients with a blitz of advertising. Setting up the new office and the professional marketing campaign cost maybe 20% of what he would have paid the family. Within a couple of months, he enjoyed the same busy practice, in a modern office, affiliated with a top hospital and with a well-trained staff. And he had paid pennies on the dollar.


I came to believe at that moment, after decades in this business, that a practice has no inherent value. It is no longer the “retirement account” waiting for us. If I had it to do over, I wouldn’t consider buying a practice. I would open one near an older practice and with marketing’s help become the newest, best-trained, most modern option available. Face it. Patients love the next new thing. Only our older patients look for long-term relationships, and they aren’t going to help sustain a practice. Patients these days look on Yelp for ratings to make their healthcare choices!


Name Withheld
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