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RE: MedPAC Recommends Redesign of MIPS

From: Ron Freireich, DPM


In an article titled MedPAC Recommends redesign of MIPS, the following was stated: The Medicare Payment Advisory Commission (MedPAC) made recommendations for changes to MIPS, one of two tracks under the Medicare Access and CHIP Reauthorization Act (MACRA), in its June report to Congress. “MIPS as presently designed is unlikely to help beneficiaries choose clinicians, help clinicians change practice patterns to improve value or help the Medicare program reward clinicians based on value,” the commission wrote. My comments follow.


1)  Are you kidding me!?

2) I would like to know how much time and money went into developing MIPS in its current format and only six months into it, MedPAC is basically stating MIPS is worthless, not to mention the time and money physicians waste incorporating this nonsense into our offices.

3) This SHOULD initiate a swift and strong response from the AMA, APMA, and AOA, and hold someone accountable for this mess. The physician members of Congress should also be contacted to look into this enormous waste of taxpayer’s money. No one asked us about MIPS value in the beginning. We could have told them a long time ago that PQRS, Meaningful Use, and now MIPS are going to be meaningless and unlikely to help anyone.

4) Why is it that everything in the government gets reformed? Oh I know, because it never gets done right the first time. You know what that's called in our profession... a lawsuit.


Ron Freirerich, DPM,  Cleveland, OH

Other messages in this thread:



RE: Template for Credit Card Collections of Deductibles (Jay Seidel, DPM)

From: Farshid Nejad, DPM


"How do you store these slips with a patient's credit card info?" -Seidel


We created a separate dummy account in our Quickbooks and store the numbers in that account.


Farshid Nejad, DPM, Beverly Hills, CA 



From: Jay Seidel, DPM


Dr. Parmelee's form is great; it's clear, concise and gets the job done. However, how do you store these slips with a patient's credit card info? When completing my annual PCI compliance for my CC machine, they made it very clear that storing credit card info properly is very difficult and usually requires a third-party with bank-level security and encryption. 


Jay Seidel, DPM, Baltimore, MD



From: John Parmelee. DPM


Here is what I used while in practice. 



95% of patients had no problem with it. 5% did and they would probably be the ones that you would have had a hard time collecting a deductible balance from.


John Parmelee. DPM, Seattle, WA




Dr. Zale, I have also lost my son to narcotic abuse, so you have my sincere thoughts. There isn’t a day goes by when I wonder, “what if?”…that day never will come. I prescribe narcotics when appropriate, and when they are not, I don’t. It doesn’t always need to be post-operative. If you stub your big toe running into the wall at basketball and fracture the proximal phalanx into 5 fragments... you deserve some. Fall and fracture your fibula…sure.


Ingrown toe nail? Probably not, but then again, there are some who call and need something mild yet more than ibuprofen. I am seeing people writing in sounding as if they would give an OTC ibuprofen for a foot run over by the local school bus and anything more is abusive. We do not, and I do not, treat chronic pain with narcotics; that is not in our purview. But we do treat acute pain, and to deny narcotics when appropriate is wrong and poor practice.


This pendulum swing reminds me of the early '70s when I heard a physician in the cancer wing of the hospital referring to a terminal patient, "we can’t give him narcotics, we don’t want him to die addicted." Let’s not revert to that!


Name Withheld



From: Brian W.  Zale, DPM


I would like to tell you how the opioid crisis has affected me, my wife, son, family, relatives, and friends. Exactly 11 months ago today, my 31 year old son died in the bathroom sitting on the toilet two weeks before his younger brother got married. At 10:00 am, he asked me if he could use that bathroom as we had had some plumbing issues and I said no problem, we had it repaired. At 11:15 am, he was pronounced dead at St. Luke’s hospital here in Sugar Land, Texas. As per the autopsy report, cause of death, opioid toxicity.  


This is a real crisis. Addiction is a terrible thing, a nightmare for everyone involved. It's like being on a electrical fence, you want to get off but you can't. He knew more about the drugs that I prescribe than I did. It has made me a better doctor. I have no problems telling a patient that I won't give them any more Rxs. I have no problem telling these patients I lost my son to addiction. It’s funny how after I tell them that that, they no longer ask for it.  


My son would have been 32 this Wednesday on Valentine’s Day. It's going to be a tough day for my family and myself. God bless you all.


Brian W.  Zale, DPM, Sugar Land, TX



From: Elliot Udell, DPM


There are two distinct reasons of why a physician may prescribe opioids. One is for acute post-op pain and by in large the government would not seek to penalize a surgeon for this. The other is prescribing opioids for pain caused by a chronic condition. For the latter, it is best to defer such patients to pain management specialists who seem to have greater leeway than the average doctor in prescribing narcotics for pain management.


A close friend of mine who is an outstanding hematologist and oncologist was called into the ER of a major teaching hospital to attend to a patient having a severe bout of pain secondary to sickle cell anemia. He prescribed an opioid and was reported by another staff member to a government agency, and he was soon brought up on charges of inappropriately prescribing the drug in question. He was able to prove in court that he did the right thing, but lamented to me that the cost of his proving that he was right saved his medical license but cost him over 50 thousand dollars in legal fees.


Elliot Udell, DPM, Hicksville, NY



RE: Limits on Opioid Prescriptions

From: James Breedlove, DPM


A podiatric colleague informed me that after he had done ankle surgery on his patient, he prescribed his usual routine of opioids for this individual. Pain cessation took a little longer than expected, so he sent in a prescription for a refill. He was told by the pharmacist that due to new regulations, a podiatrist cannot refill an original opioid prescription, even for post-op pain, or even write for a new opioid. He was told that for that particular patient, since he had written one opioid prescription for that individual, he would be barred from writing opioids again for that individual. The person would have to be referred to either their primary care doctor or a pain management specialist.  


Yesterday, I went in for my annual medical exam. I mentioned this to my primary care doctor. She said that she is now not allowed to write for opioids at all (she's not in trouble for over-prescribing by the way) and that all her patients, even if they are injured and need immediate medication, she can't write the Rx for them. I went to the site, but going through that site is like trying to solve a Rubik's cube with 55 colors. Comments? Answers?  


James Breedlove, DPM, San Luis Obispo, CA



RE: Formula for Value of a Practice

From: Jon Purdy, DPM


Practices are so individual there is no way to make generalizations about pricing, nor is it possible to closely estimate any particular practice in this forum. One either knows how to place value or doesn’t, in which case professional help is needed. There are tangible and intangible (so called goodwill) factors in pricing. Real estate aside, the tangible is the value of the equipment.


One intangible which is the most difficult to measure and possibly the most important, is practitioner performance. Is the selling doctor a dynamic personality who attracts and maintains patients? Is the seller practicing all aspects of podiatry, and therefore tapping into an entire patient population? Do you possess those same qualities and skills? No matter what the end value of a practice, if you do not possess the personality and skills to run a practice equivalent to, or better than the selling doctor, purchase of a practice may not be in your best interest.


Other considerations in practice valuation are: area demographics, provider saturation, payer mix, referral streams, patient turnover, and assessment of seller practice management skills. Each one of the aforementioned have significant in-depth evaluation measures.


Jon Purdy, DPM, New Iberia, LA



RE: Formula for Value of a Practice

From: David Helfman, DPM


After reading all the articles on valuations of a practice, I would like to try to summarize the topic to ensure we are all comparing apples to apples. The reality is that everyone has given good input but I would like to offer a simple and concise summary of valuation methodologies that will be easy to understand based on real life experience. 


There really are no rules of thumb anymore, and selling a practice is like selling any other service business, so it’s important to understand who is buying your practice and then you can come up with a logical formula and rationale for valuing your practice. I think the easiest way to 

start this process is to put your practice in one of three buyer buckets. 


1. Buyer: Current associate or new podiatrist wanting to buy...


Editor's Note: Dr. Helfman's extended-length letter can be read here



From: Michael Zapf, DPM


My “back of the envelope” way to evaluate a practice is the lesser of 1) the average of the last 3 years net annual income OR 2) 40% of the average of the annual gross over the last three years PLUS $1000 for ever new patient per month averaged over the last 3 years. If a gross is high because of high advertising, then the net will show the truth. If the overhead is tightly controlled or there is inordinate equipment expensed (those lasers and x-ray systems are costly), then the net will show the truth. 


Location (spare bedroom or medical center), equipment (even three lasers and digital everything), appearance of the front office, and everything else, is accounted for in the income and the new patients, already. New patients are the lifeblood of a practice, so a steady supply of new patients should be rewarded. But if all those new patients came because of heavy advertising, then this will be accounted for in the net value.


Michael Zapf, DPM, Agoura Hills, CA



From: Mark Block, DPM


Generally, there are three different approaches that are used in the valuation of companies: the asset approach, income approach, and market approach. You can learn more about each of these approaches in APMA’s “Quick Reference Guide for the Purchase or Sale of a Podiatry Practice.” I also recommend participating in APMA’s webinar on “What to Know When Purchasing or Selling a Podiatry Practice.” 


This webinar is scheduled for Thursday, February 8, at 8 p.m. EST, and Sean Saari, CPA/ABV, CVA, MBA, a valuation expert, will be the presenter. There will be time at the end to ask questions. If you are an APMA member, you can access the quick guide and sign up for the webinar at  


Mark Block, DPM, Boca Raton, FL



From: Robert T Morris III, DPM


In light of the recent debate on practice valuations, I thought I might add my thoughts to the mix. I debated for a long while purchasing an established practice vs. opening outright before electing to open up on my own. Call me naive, but in today's world I do not see the value in what many of those selling established practices are offering. I get it, you worked your whole life to develop your nest egg into something worth selling upon retirement, but is the price you seek really worth it? 


Let's start with facilities. Does your older office desperately in need of modern furnishing really command top dollar? We've all seen the surveys on PM News. Many older doctors are still...


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



From: Bret M. Ribotsky, DPM


I have been consulting and advising for the past 18 months in the buying and acquisition market for medical dermatology practices. While I have not specifically worked with the DPM market, the foundations and principals from the hedge funds and private equity people are similar. It’s all a function of EBITA (Earnings before interest, taxes, and amortization. EBITA refers to a company's earnings before the deduction of interest, taxes, and amortization expenses). 


In simple terms, it’s the PROFIT left over after you have removed your ownership from the practice and paid someone (or you) to do the work you have done. For example, if you're a single practitioner and your practice gross is...


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



From: John V. Guiliana, DPM, MS


I wholeheartedly agree with Dr. Kashan and Dr. Ressler. It saddens me when I hear physicians state that "their practice has no value and they will someday just close the doors". Surprisingly, I hear this quite a bit.


A practice is a living and breathing entity. It needs to be continuously nourished and maintained. Marketing, continuous quality control, investment in technologies, optimizing processes, etc. all create inherent value throughout the years. In the end, the fair market value can be computed through various techniques which often revolve around net earnings and an applicable capitalization rate. Leave that to the experts. But there are buyers out there, so please take good care of your practice and it will certainly provide you with post-retirement income. 


John V. Guiliana, DPM, MS, Little Egg Harbor, NJ



From: Jack Ressler, DPM


I am very interested to find out the amount of time that passed between when the podiatrist passed away and when the practice was put on the market. I'm sure the deceased podiatrist had an excellent relationship with his patients that probably could not be duplicated by the revolving door of podiatrists who pitched in to help in this unfortunate situation. It led to a perfect storm for that other podiatrist. Although grief and shock by the family of the sudden death of their loved one probably prevented the practice from being put up for sale earlier, that delay cost them a very marketable practice. 


The other podiatrist who opened was very fortunate/underhanded to be able to take advantage of a unique and sad scenario that rarely occurs. I do not believe Dr. Name Withheld’s conclusion about a practice not having inherent value. A thriving modern up-to-date practice should have a good marketable value, especially if the seller takes the time and markets it properly. I worked very hard in my practice for many years and was able to sell it. I took the time to market it properly and got a nice return for my hard work.


Jack Ressler, DPM, Delray Beach, FL



From: Brian Kashan, DPM


I just read the posting by Name Withheld, about how he would choose to open an office next to an older practice instead of purchasing an existing practice. Although the circumstances he describes, with the sudden passing of a doctor is different than the more common scenario of a retirement, there are several similarities. If the practice has been a successful practice and is valued correctly, it should be an attractive opportunity for someone to acquire. 


There are several factors that I feel are being overlooked in the mindset of Name Withheld. Firstly, it is much easier to get a bank loan when...


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



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



From: Robert Fridrich, DPM


In late 1970s, I gave those flu shots due to an epidemic in Cleveland.


Robert Fridrich, DPM Retired, Green Valley, AZ



RE: PC vs. LLC vs. PLLC (Marianna Blokh, DPM)

From: Joseph Borreggine, DPM


I suggest you review these articles that I found through a simple Internet search: Article 1, article 2. And after reading them, then I would decide. But before you do so, know that President Trump’s new tax (law) makes an LLC more attractive than a PC by helping to reduce your pass through income in an LLC by 20%. The corporate tax rate has also dropped from 35 to 21%. 


This article helps explain the new tax rules for 2018 for pass through income: But, when all is said and done, a good CPA and tax attorney must be consulted to secure the best advice.


Joseph Borreggine, DPM, Charleston, IL



RE: Allowing Podiatrists to Administer Flu Vaccinations

From: Elliot Udell, DPM


This year's flu epidemic is considered the worst in ten years. In NY State, Governor Cuomo has issued a directive to allow pharmacists to give vaccinations to kids as well as adults. If a pharmacist can give a flu shot, even though they do not give injections regularly, why shouldn't podiatrists be allowed to give flu shots? Are there any other professionals who give as many injections as podiatrists do?


Not only are we trained to give injections but because we deal with the elderly population, we would reach people who might not go their pharmacy or primary care doctor and get an injection when necessary. I call on the respective state societies to push their local legislatures to allow podiatrists to administer flu vaccinations.


Elliot Udel. DPM, Hicksville, NY



RE: Calling Patients is Powerful Marketing Tool

From: Hal Ornstein, DPM


A powerful marketing tool is to call each of your new patients the end of each day. Ask what questions they have and thank them for coming into the office. If you are concerned about them having your cellular number, get a low cost rechargeable phone from a department store. If the patient is a talker, politely say you have other patients you need to call. You will be amazed about the kudos you will receive from this simple task.


Hal Ornstein, DPM, Howell, NJ



RE: Inexpensive Podiatry Chair Restoration

From: Michael Lawrence, DPM


Over three years ago, I got a great deal on an SUV.  The only problem was the two front seats were broken down due to some extremely large previous owners. So they had to be replaced and the ones I got were used in great shape from the same year, make, and model. They should have matched colorwise but for some reason did not. I researched my options and came up with a product made by Colorbond car seat paint for leather and vinyl, and with just a little effort, refinished those seats myself, matching perfectly. The vehicle is driven daily and the seats still look great, three years later. Two seats for less than 80 bucks.


When I was in practice and my chairs were getting worn and outdated, how nice it would have been to know of such an option. I spent a lot to have them re-upholstered, losing them to service for days on end. With this product, you could literally prep and apply in an evening and they'd be ready for use the next day!   


Michael Lawrence, DPM, Chattanooga, TN



From: Pete Harvey, DPM


Our staff uses a free virtual a time clock called Redcort Software. I then enter the hours in That software calculates the amount of the check and payroll tax. My staff prefers a paper check (which are the only paper checks I write) but the amount can be deposited into their account electronically after set-up. The data is then sent to my CPA. She then sends all notices to the employee including year-end tax withheld, etc.


She also manages all quarterly reports. Taxes due are paid electronically through managepayroll. Her fee is $40 per quarter. You must have a CPA who is familiar with managepayroll. I asked the company and they sent a list of ten CPAs in my area who use their service.


Pete Harvey, DPM, Wichita Falls, TX



From: Paul Baumgarten, DPM


I highly recommend It is free and you keep track of all employees. They clock in on any computer and clock out. It also has a GPS feature so that if someone tries to cheat you, i.e. clocking in at home or something, you can tell. 


Paul Baumgarten, DPM, East Glenville, NY



RE: Noridian Medicare's Portal for Checking Patient Eligibility or Deductible

From: David L. Kahan, DPM


Just a head’s up to those that utilize the Noridian Medicare portal for checking patient eligibility or deductible status. The site will NO LONGER show you the deductible status of those patients who are considered “special needs”, i.e. Medicare and Medicaid (SNP). In the past, you may have held claims until deductibles had been met so you did not have to eat the deductibles. Now you will have to just guess or ask the patients when they come in whether they have been to the doctor and estimate the deductible remaining. 


David L. Kahan, DPM, Sacramento, CA