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From: Bob Hatcher, DPM


A comment in Dr. Koon's 9/18/2017 post brings to mind an aphorism I've been hearing for many years which is promoted as the solution for the problems of today's medical practices. That is to "work smarter, not harder". It certainly sounds wise but what does it actually mean? It doesn't seem to offer much in a pragmatic way to our young, or even some of our seasoned yet struggling doctors. Platitudes are a dime a dozen.


There is likely a kernel of truth here but shouldn't we flesh it out to make it actually useful to those who really need help? What do you doctors who have successfully worked smarter rather than harder think?


Bob Hatcher, DPM, Raleigh, NC

Other messages in this thread:



From: James E. Spitsen, ARM, CIC


I would like to address the “malpractice issues” brought up by Dr. Forman regarding requests to trim fingernails. Most malpractice insurance policies cover the procedures that are specified in the Podiatrist Practice Act of any particular state. This of course would be subject to the terms and conditions of the insurance policy including any exclusions for certain procedures that a policy may contain.


If a podiatrist is performing a procedure that is outside the scope of practice for their license, it is likely they have no coverage for that under their malpractice insurance policy and could be subject to disciplinary problems as well. Disciplinary defense coverage may also be declined if the issue arises out of a procedure outside the scope of practice for a podiatrist.


I suggest to all podiatrists that they should be familiar with the practice act in the states where they practice. They should consult their board and/or attorney if they are considering any procedures that may be outside the scope of their license. I am not an attorney. I am an insurance professional who has worked in the professional liability marketplace for podiatrists for over 18 years and in the general medical malpractice marketplace for over 30 years.


James E. Spitsen, ARM, CIC. Lincoln, NE



RE: Kudos to David Arkin, DPM

From: George Jacobson, DPM


With the posting of so many of our colleagues recently passing away, I'd like to congratulate Dr. David Arkin, CCPM Class of 1983, on his retirement. Live long and prosper. When you retire, do it while you have good health, so you can enjoy all that you worked so hard for. Enjoy retirement Dave; you deserve it. 


George Jacobson, DPM, Hollywood, FL



RE: Dragon Voice Dictation

From: Ira Meyers, DPM


Every once in a while, someone has a question regarding voice dictation. I have been using Dragon Dictate for 10 years. Up until recently, I found the program to be fair. I recently upgraded to Medical Version 4 and I am pleasantly shocked how well it works. If you have been holding off waiting for an almost perfect dictation program, now is the time. 


Ira Meyers, DPM, Huntingdon Valley, PA



From: Ed Davis, DPM 


Dr. Stempler requested assistance with finding affordable health insurance. The market for individual health insurance policies as well as small groups is not favorable. The best solution I have found is to join a PEO. PEOs or professional employer organizations were once known as employee leasing companies. These organizations allow small employers to aggregate resources so that they can offer the type of employee benefits that larger employers may offer.


There is a cost for PEO services but it is offset by lower health insurance costs as well as other benefits. Not all PEOs are the same, so contact several to compare. Our office uses Justworks which is a New York-based PEO.  


Ed Davis, DPM, San Antonio, TX



From: Joel Lang, DPM


When I was in practice, I was searching for health insurance at affordable premiums. I looked at organizations that offered group plans. At one time, I was a member of the Washington Writers Guild. I had no particular interest in the organization, but they offered affordable group insurance and I qualified for membership due to a number of nationally published articles I had written. Their annual dues were a pittance compared to the large insurance premium I would have had to pay. Search for local organizations and join up - even if you have to volunteer.


Joel Lang, DPM (retired), Cheverly MD



From: Jengyu Lai, DPM, Elliot Udell, DPM


Starmark/Trustmark could cover as few as five lives when the entity becomes self-funded.


Jengyu Lai, DPM, Rochester, MN


I am a graduate of Landmark Worldwide. They teach that if you have a complaint, it is ineffective to gossip about it. Instead, the issue should be raised with someone who can do something about it. 


This applies here. Many of us have, and will have, problems attaining affordable health insurance, but we are not the ones who can do anything about it. The ones who can do something about it are our congressmen who could introduce legislation to make the Affordable Health Care Act affordable for everyone. Now, before Election Day is the best time to contact them. 


Elliot Udell, DPM, Hicksville, NY



From: Warren Joseph, DPM


I feel your pain! We were getting our insurance through my wife’s teaching job at a University. After she left the position, we have been on COBRA, which ran out September 30!  We have been looking for decent coverage for months. We found a reasonable “Short Term” catastrophic plan, which will only cover us for 3 months which started today. In the “Marketplace”, the best we could do was a BC/BS PPO Bronze plan at $1,900/mo and a $15,000 out-of-pocket deductible! Of course, there is only one provider, Independence Blue Shield. We hear that come Nov. 1 when Open Enrollment begins, 2 more insurers will enter the fray so maybe, just maybe, there will be some competition. 


So, I can’t help you with any suggestions; but I can commiserate. I too would love to hear from anyone who may have some thoughts on obtaining coverage.


Warren Joseph, DPM, Hatboro, PA



From: Alicia Ericksen, DPM


I'm responding to Dr. Mark Stempler's concern with obtaining affordable health insurance for his family. My family was in the exact same predicament, with similar premium and deductible; absolutely unaffordable. We took a leap and became members of a bill sharing network. A few of my colleagues and patients have done this. There are several out there, and we found the right fit for us.  It has honestly been the best decision, and I cannot foresee making exorbitant payments to a health insurance company ever again.   


Alicia Ericksen, DPM, Seneca, NE



From: Richard Adams, DPM


I have been using a scribe in my clinic for about three years. The benefits of a scribe are many. The benefits of a virtual scribe include one less body in an already cramped exam room, no necessity to purchase equipment, and no additional employee on your payroll. 


The downside of a virtual scribe involves occasional, but rare, IT concerns. In my opinion, if you choose the correct virtual provider, you will be very pleased. 


Richard Adams, DPM, Granbury, TX



From: Richard D Wolff, DPM


I have not used a virtual scribe, so I cannot offer an opinion about that. Pretty sure Dragon Naturally Speaking, which I have used, is not the same. For years, I have used a scribe and have found it helpful in many ways. Patients have commented about how their other doctors are buried in their computer during the encounter, whereas my patient has my undivided attention the entire time. I ramble off my physical exam quietly to my scribe, who checks it off on "Quicksoap". I speak to the patient about their condition and treatment plan as the scribe writes it down.


My scribe will also note if the patient expresses pain with a facial expression, as they don't always tell me as instructed. As I begin my treatment, my scribe is dismissed, and she goes to start the note in the computer at another location. This situation has worked well for me. My scribe has learned to pick up on the subjective part of the note and she relays the follow-up plan to the scheduler.


There are additional benefits. Patients have also developed a rapport with my scribe and will ask about her if she is not present on a given day. She has also developed the habit of reviewing the patient's chart. She will let me know if there are any insurance coverage issues and she will let me know if the patient is due for new diabetic shoes, should they desire it. I have found this system to be invaluable.


Richard D Wolff, DPM, Oregon, OH



RE: Podiatry Outpatient Infection Guides from the Joint Commission and the CDC

From: Kevin McDonald, DPM


Podiatrists should do as much as possible to prevent the spread of infections in their offices.


The Centers for Disease Control and the Joint Commission have recently completed guidelines and a manual to prevent the spread of infection in outpatient podiatry settings. This Manual and Pocket Guide represent the most current and evidence-based knowledge and procedures in infection control for podiatry offices. Every practicing podiatrist should consider this information vital and applicable.


The Guide to Infection Prevention in Outpatient Podiatry Settings and companion pocket guide are available on the CDC and Joint Commission websites: CDC webpage Joint Commission webpage.


Kevin McDonald, DPM, Concord, NC



From: Joel Lerner, DPM


I am responding to Dr. Portela's question about hard to get medications. MD Buying Group has been able to supply their members with hard to find meds such as Lidocaine, Xylocaine, Marcaine, and others. It is limited to 3 vials per doctor, but is available. 


Joel Lerner, DPM, Palm Beach Gardens, FL



From: R. Alex Dellinger, DPM, Allen Jacobs, DPM


I use a company called EBM Medical. They only use products that are proven effective. One advantage is you don't have to stock the products in your office. You send a "script" (order), the product gets shipped to the patient, and you get a deposit into your account for the difference in the wholesale price and what your charge is. These are cash price only items. Their main product is a Metanx substitute that is fantastic. They have many products, from topical antifungals to topical creams, wart compounds, etc. You can customize your product list how you see fit.   


R. Alex Dellinger, DPM, Little Rock, AR


I utilize products from EBM. They actually have all of the products you asked about. They provide an excellent model for dispensing  quality products without the need to maintain in-office inventory. 


Allen Jacobs, DPM, St. Louis, MO



From: Allen Jacobs, DPM


Dr. Udell’s question is an important one. Patients with diabetes, PAD, chronic edema, history of recurrent cellulitis, or who are immune-compromised, require active treatment for onychomycosis. The high cost of topical antifungal medications reinforces the need for proper speciation to assure the possibility of response to the prescribed agent. Utilization of topical antifungals should be restricted to early, distal disease. 


Personally, I utilize topical amphotericin B compounded with urea, terbinafine, and thymol  (available through EBM), combined with nail reduction for topical management. Oral terbinafine, when appropriate, remains the most effective therapy for management in the adult and geriatric patient. It is the most cost-effective therapy available. The potential adverse sequella of oral terbinafine has been exaggerated by those selling alternative topical agents, or simply not understood by those unfamiliar with the literature on this subject.


Allen Jacobs, DPM, St. Louis, MO



RE: Kudos to Dr. Charles Morelli

From: Brad Bakotic, DPM, DO


The Rhett Foundation would like to give a boisterous shout-out to Dr. Charles Morelli and all of the physicians on his international mission team.


Dr. Charles Morelli (L) on medical mission


We are both humbled and proud to have sponsored this group through their recent mission, as they selflessly worked and sacrificed to provide podiatric medical care for the people of Nicaragua. This is what it’s all about! 


Brad Bakotic, DPM, DO, Alpharetta, GA



RE: Separate E&M Codes for Podiatrists

From: W. David Herbert, DPM, JD,


I understand that there have been studies which have established that timely and proper podiatric intervention can reduce the need for foot and or leg amputations. This E&M issue apparently started by CMS might be an opportunity for podiatry to actually position itself in a more advantageous position. 


There could be E&M codes that only podiatrists could use. Any new enrollee in Medicare would have to be evaluated by a podiatrist within a year of enrollment. If this new enrollee is already diagnosed as a diabetic, maybe requiring this examination sooner maybe appropriate. We must remember this is all about politics! I have been in and around politics enough to know that this could happen if approached properly. The podiatric profession has been able to use the political approach very effectively throughout the years. This is only offered as a possible starting point.


W. David Herbert, DPM, JD, Billings, MT



From: Daniel Chaskin, DPM


Kudos to Jeffrey Kass for providing a link to file a complaint. Since most licensed podiatrists are not employed by the VA, I believe that economic parity in Medicare is more important than economic parity in the VA. 


Lawrence Rubin hit the nail on the head when he mentioned about CMS discriminating against podiatrists. I believe such economic discrimination departs from federal antitrust law and affects interstate commerce because podiatrists are defined as physicians under federal law. Even in NY state, podiatrists are specialists licensed to perform physical examinations in conjunction with podiatric treatment. This is no different than other specialists performing physical exams in conjunction with their specialties. 


The U.S. Dept. of Justice has a website where podiatrists can email to ask the antitrust division to investigate and to advise CMS if they are in full compliance with federal antitrust law. If enough podiatrists send emails or if the APMA sends out a letter to this agency, this might ensure the economic parity that podiatrists always had for many years. I am not an attorney and the above are my personal opinions. 


Daniel Chaskin, DPM, Ridgewood, NY



RE: Pillars of Our Profession

From: Richard M. Hofacker, DPM


A few weeks ago at the KSUCPM awards banquet, Dr. Richard Ransom took this "classic" picture of a couple of our distinguished colleagues. You might say, they are the "Arnold Palmers" of podiatry. 


Seated are Dr. and Mrs. Alan Spencer.  Standing is Dr. Ray Suppan, Sr.


Just about everyone in this profession has been taught, consulted, or helped in some way by Drs. Spencer and Suppan. Podiatry owes a great deal to these fine pillars of our profession.


Richard M. Hofacker, DPM, Akron, OH  



RE: CMS' Discrimination Against Podiatrists

From: Jeffrey Kass, DPM


The Sept. 10th deadline is around the corner. CMS has proposed some devastating reimbursement policies that could cripple some practices. The single code for E&Ms has already been discussed. More devastating is the visit and procedure ruleCMS is proposing to reduce the lower allowed amount by 50% of either the E&M visit or procedure when billed the same day with a -25 modifier.


If anyone values their financial future, you must take action! I have provided the link to write a complaint in your own words (Some feel sending repeated templates has less effect.). This is not the time to make assumptions that because you belong to an association, the problem will be taken care of for you. This is the time to take two minutes out of your day to potentially save thousands of dollars from being taken out of your pockets for the hard work you perform. Please spare the moment.


Thank you to everyone who participates and tries to make a difference.


Jeffrey Kass, DPM, Forest Hills, NY



RE: CMS' Discrimination Against Podiatrists

From: Lawrence M. Rubin, DPM


The decision of the CMS policy-making gurus to try to save some federal dollars by cutting payment for E & M medical care provided by podiatrists is, to say the least, ill-founded and discriminatory. I believe in healthcare cost-containment measures, but only if they conform to existing rules and regulations. This proposed rule does not do this. For it to conform, Medicare would have to first change its definition of the word "physicians." 


APMA is expertly representing us in its efforts to maintain parity with the other professionals designated by Medicare as physicians – MDs, DOs, optometrists, and chiropractors. With this in mind, I believe what CMS is attempting to do with podiatry should be a “Heads Up!” to optometrists and chiropractors. If CMS gets its way with podiatry, I bet optometrists and chiropractors will be next on its attack list. I hope APMA is keeping this in mind and discussing this issue with the optometric and chiropractic national professional organizations. Together, we could be stronger. We could be a united force in trying to convince Medicare to maintain present Medicare parity regulations.  


Lawrence M. Rubin, DPM, Las Vegas, NV



RE: Doctors' Pay Cuts Never Mentioned

From: Jeffrey Kass, DPM


On Thursday, President Trump announced that he wanted to cancel pay raises for civilian federal employees who were due for a 2.1% increase. He wanted to do this to save money as the federal budget deficit continues to skyrocket. Why should any federal workers get raises at all, while doctors continue to get docked 2 percent while we are still in sequestration (Not to mention the 2 percent to lose if the new E&M proposed guidelines go through)? 


Any time news like this hits mainstream media, the medical community has an opportunity to tell America how they have been taking a 2 percent hit for years, yet never is anything mentioned.


Jeffrey Kass, DPM, Forest Hills, NY



RE: Pedicure Drill for Podiatry

From: Robert D Teitelbaum, DPM


For several years, I have been using an incredibly inexpensive ($3.00 or less) pedicurist drill in each of my treatment rooms and in my ALF/NH bag. I found them just by searching for "Pedicure Drills" on my laptop and getting multiple ebay sites with these drills that use 2 AA batteries. First, you discard all the multiple heads that are supplied. Then, you can use dental (that's right--dental) burrs from Henry Schein's Dental division - which is older and much larger than the podiatry section. I had my dentist order S.S. White stainless steel burrs that come in a ten pack and are 1.5 mm in diameter. They are not expensive. These burrs fit right into this drill by a friction lock--as do the accessories that come with it.  


Why this little drill is better than a 120 volt rheostat-driven one is exactly because it is not that powerful. When you have nail borders that cannot be curetted easily or painlessly, it is precisely the instrument to use. You can de-bulk a hypertrophied border to the point that you can then do an angled cut to give your patients relief. These burrs are very sharp and effective, so the constant, moderate speed helps to keep you in control. Along with this find, I discovered many smaller 120 volt drills that each of our suppliers offer, but at major price reductions. This confirms the old idea that "if it used by a 'doctor', we can double the price."


Robert D Teitelbaum, DPM, Naples, FL



RE: Drug Pricing Insanity  

From: Robert D. Teitelbaum DPM


I was interested in prescribing Ertaczo cream for my patients, as it seems to be effective for dermatophytic and candidial organisms. When I searched for it on Google, I was taken aback by the amazing prices. For a 60 gram tube, the average price was $830. Even in real estate, they deal in "comparables" for recently sold homes. How many of you out there prescribe antifungal cream in this range? I was told some years ago by a pharmacy tech here at my CVS store in Naples that, "Medicine is a racket." How true, how true.  By the way, my practice does not support that point of view. And this example can only enhance one's suspicion, of "Big pharma."


Robert D Teitelbaum DPM, Naples FL



From: Vito Rizzo, DPM


As a healthcare professional and now having the distinct advantage of serving in the U.S Congress, Brad Wenstrup should be leading the charge in reforming healthcare and advocating to put medical professionals back in charge. He should take no contributions from insurance companies that have a record of putting profits before patients and should be focused on eliminating the channeling of healthcare dollars into any other purpose than patient care. He should never stand behind or support policies that undermine the protection of the sick and less fortunate. Being a representative can be easy if certain principled actions are followed.


Vito Rizzo, DPM, Bay Shore, NY



From: Lawrence M. Rubin, DPM


Name Withheld believes that CPT code 99214 should not be billed by podiatrists. I disagree. Medicare and generally other insurance payers consider podiatrists to be foot and ankle physicians licensed to practice the "medicine" referred to in our Doctor of Podiatric Medicine degree. E/M code appropriateness is based primarily upon the "nature of the presenting problem" and the depth of the history, examination, decision-making, and in some instances, time expended. This applies to all physicians who provide E/M services. Podiatrists are not excluded. 


For example, we are frequently faced with having to make complex diagnostic and care management decisions, especially in older, high-risk patients who present with debilitating manifestations of several chronic diseases and their co-morbidities. E/M care for this class of patients could meet the standards necessary to bill higher level codes. I suggest that those who believe that podiatrists should never use codes for providing higher level E/M services review the E/M coding requirements carefully. 


Better yet, the APMA and some independent podiatric consultants offer marvelous correct coding seminars and workshops. Their costs are very reasonable, and what you will learn will probably immediately pay for the cost of attending. Just one caution. Higher level codes should not be billed indiscriminately. And when there is an established treatment plan that does not require providing future higher levels of history, examination, decision-making, or time spent in counseling -- they should not be billed. 


Lawrence M. Rubin, DPM, Las Vegas, NV
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