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RE: VA Provider Equity Act Introduced in the Senate

From: Jeffrey Robbins, DPM


Senate Bill 1871 “…to clarify the role of podiatrists in the Department of Veterans Affairs” has been introduced in the Senate and has been referred to committee. The is the next step in the long process of bill approval. Once again, this is the result of our combined efforts with the Federal Services Podiatric Medical Association and the American Podiatric Medical Association. 


Jeffrey Robbins, DPM, Cleveland, OH

Other messages in this thread:



From Ron Werter DPM


It was probably a specialty pharmacy which would deal with Novartis to make sure the prior approvals are expedited. Compounding pharmacies are a completely different story. But most likely, even if the patient got the prescription through their own Medicare part D plan, the situation would have been the same.


I assume all of us in practice understand that no matter what the drug rep says about minimal cost to the patient, the true medication cost is between high and outrageous. The rep will tell us, "If your patient can't afford the price of the medicine, we have a special discount so they can get the product for $50." BTW, that doesn't apply to Medicare patients because of the machinations of Congress. I've never understood how the drug company can afford to give away a $1,000 product for $50. Unless...! 


Yes, we should discuss the possible cost of the medications we prescribe, and maybe decide we will not prescribe those medications. But we can also offer alternatives to the prescription topical medications for nails. The OTC nail preparations that we can dispense from our office would cost the patient $40-$50 out-of-pocket for a reasonable size bottle. I can't believe that the efficacy of those preparations could be worse than the 10% quoted for the prescription medication.


Ron Werter, DPM, NY, NY



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



RE: Misinformation About Cartiva

From: Craig Breslauer, DPM


I have been performing Cartiva with positive results since its inception. I have performed over 20 thus far. Compared to most surgeries we do, it is technically easy and quick.The purpose of my post is to garner opinions regarding how to, or not, handle some of the comments I have encountered regarding podiatrists vs. foot orthos doing this procedure. I became aware of a Cartiva Facebook page and have read quite a bit. The majority of the posters have used orthos and many recommended only using a foot ortho. Furthermore, there is a foot ortho who acts as a moderator. I do not know if he is affiliated with Cartiva as a company or sanctioned as a moderator.


If the company supports the propagation of such misinformation, I think our profession needs to address it. I know I see poor outcomes/complications of both fellow podiatrists and foot orthos as I am certain they see some of mine. 


Craig Breslauer, DPM, Stuart, FL



From: Joseph Borreggine, DPM


Dr. Williams, I must sorely disagree with your premise statement with respect to the theme of this article and how the patient was “victimized” by the physician assistant and the pharmacy. This is nothing more than the “drive by media” producing a sensational “fake news” story on how big pharma is destroying healthcare by “overcharging” patients for medication that they may or may not actually need. 


The author of this article makes the reader believe that this patient who seemingly is a well-to-do retiree based on her aforementioned resident geographic locale on “Capitol Hill” was taken advantage of without...


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



From: Elliot Udell, DPM


The story as referenced by Dr. Williams is not about a compounded drug, but is about  Kerydin, which is a brand name drug widely available for the treatment of onychomycosis. It is applied topically and it became available at roughly the same time as Jublia, another topical antifungal. These medications are not only expensive but if used properly, only last a month. What is even worse is that the clinical success data provided by these companies does not rate them as panaceas for the treatment of  fungal nails. They are by no means gold standards. 


In our practice, after fungal testing, we might prescribe these medications, but only if the patient's insurance company combined with company incentives make them affordable. If the patients are going to have to pay over a thousand dollars for a month's supply, we will offer them a choice of several new antifungals which not only can be dispensed from the office but have been shown to be clinically effective. 


Elliot Udell, DPM, Hicksville, NY



From: Elliot Udell, DPM


Let's not get lulled into thinking that the papers showing the health hazards of grinding mycotic nails, quoted by Dr. Markinson, are false because someone we know did not get sick from grinding fungal nails. My grandfather smoked until he was in his 70s and laughed at reports linking smoking with disease. At age 79, he suddenly developed a gangrenous toe secondary to Buerger's disease. The vascular surgeon who amputated the toe told him not to even go near secondary smoke.


Just because some people have not yet gotten sick from breathing infected nail dust does not mean that either they or others won't.


Elliot Udell, DPM, Hicksville, NY



From: David Williams, DPM


This story made me sick to my stomach. If you are not having a talk about the cost of care with your patients, you are doing them a tremendous disservice and ultimately hurting your own practice.


David Williams, DPM,  El Paso, TX



RE: PM News’ "Top Podiatric Research Institutions"

From: David G Armstrong, DPM, PhD, MD


I have read with considerable interest the very thoughtful commentary largely bemoaning the perceived lack of emphasis on research in our podiatric medical institutions, worldwide. Perhaps we within this specialty could take a hint from other institutes of higher learning and make a list - because everyone loves a list. I suggest a PM News "Top Podiatric Research Institutions" ranking much as U.S. News or others rate other institutes of higher education.


The metric might be based on self-reported annual: a) federal/not for profit research funds, b) industry-sponsored research funds, c) publications per faculty member, per calendar year, d) h-index or i10 index (a measure of per-publication impact) for faculty members. All of these could be collated by the editorial staff and reported. 


Not a week goes by that one of us reading this note gets a call from a prospective student asking "what's the top school in the specialty?" While this is always subjective, the fact of the matter is that we can't manage what we can't measure. This might be a nice start and I think it could give some friendly competition that could do nothing but improve education, research, philanthropy, and ultimately clinical care. 


I am sure that each of the deans of our specialty's institutions would be happy to report these findings. Bragging rights are often powerful motivators for countering institutional inertia. Schools that don't report would be glaringly evident. I am equally sure that we would love to see these rankings posted and increase over time. 


David G Armstrong, DPM, PhD, MD, Los Angeles, CA



From: Michael L. Rahn, DPM


I had to chuckle when I read Dr. Luongo's posting about meeting a resident from the late 1990s and he referred to the recent meeting as "so many years later.


Drs. Enrique Spiegler and Michael Rahn


Last year, I met a newly arrived "resident" at a retirement facility where I provide care. He introduced himself and told me that he had taught at NYCPM. I was so delighted to get re-acquainted with vascular surgeon, Dr. Enrique Spiegler, who taught us at NYCPM. The last time I had seen him was in 1969. 


Michael L. Rahn, DPM, McLean, VA



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: NJ Former Resident Meets Attending After Many Years 

From: David P. Luongo, DPM


Every year, kids play their last games of Little League baseball at a week-long tournament in Cooperstown, NY. On my team’s fourth game, to my amazement, while meeting at home with the umpires, the opposing coach was very familiar looking. He then introduced himself as Dr. Steve Lemberger, one of my residents at St Clare’s/St Vincent's Hospital from the late '90s.  


What a coincidence, so many years later, here we are, meeting on the Cooperstown ball field representing our kids' 12U baseball teams the Maywood Hawks vs. the Freehold Fusion. We both had an incredible week, an experience for our boys they will never forget. It truly is a small world!


David P. Luongo, DPM, NY, NY



RE: Funded Podiatric Medical Research: An Overlooked Potential Source of  Revenue for Education and Training

From: Leonard A. Levy, DPM, MPH


In the March 9, 2018 issue of PM News, I reported on the obvious benefits of podiatric medical research to the profession, other professions, and the lay public. One very important thing not mentioned is the very important benefit of funded research to medical school revenue. It should be noted that the Association of American Medical Colleges reports annually the sources of revenue for allopathic medical schools. In both private and public schools granting the MD degree, tuition provided only about 4 percent per year of the total revenue.


In 2016, for example, federal and private grants provided 22 percent of medical school revenue (source: Association of American Medical Colleges, 2016). While the grants I was able to acquire certainly directly supported research, they also provided a considerable amount for salaries and fringe benefits of faculty and support staff as well as equipment, travel, and consumable supplies. The time is long overdue to make funded research a priority in podiatric medical education.


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL



RE: Let’s Make Podiatric Medical Research a Priority

From: Leonard A. Levy, DPM, MPH


With interest, I have participated in and have been watching the discussion on research in podiatric medicine hosted by PM News over the past week. For the past 18 years, I was Associate Dean for Research and Innovation at the Dr. Kiran C. Patel College of Osteopathic Medicine of Nova Southeastern University and am now Professor Emeritus. However, I continue to provide instruction in the development of research protocols including grant proposals at the institution. As a result, students and faculty have been given basic guidance, instruction, and provided with motivation to develop skills and a motivation for research activities. 


While I personally had written many successful proposals leading to at least $26 million in grants, I also was able to identify and implement programs funded by smaller grants/endowments that resulted in competitions for students and faculty, leading to an appetite to seek funding and write research papers. We desperately need to engage in similar projects in podiatric medicine. Unfortunately, our college and residency faculty as well as students seem to be intimidated by this process. It is time for a major expansion of the process that cultivates a strong research environment in the profession, sharing our contributions with the professional and lay public. I am strongly convinced that we can do this.


Leonard A. Levy, DPM, MPH, Ft Lauderdale, FL



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: Bill Beaton, DPM


In conversations with my billing company E-Professional Technologies, we have researched this situation and, yes, this is a national issue and we are equally outraged. We can still obtain information on Medicare deductibles for regular beneficiaries. However, there is a fairly new program for Medicare/Medicaid beneficiaries called Qualified Medicare Beneficiary (QMB). 


For QMB patients, providers are not permitted to charge the patient anything. So the government, in their infinite wisdom, has decided we are not entitled to know how much we are paying on behalf of each patient! If we can't collect the money, then essentially we are paying the bill on their behalf. Is it $1 or is it the entire $183 deductible? We are not allowed to know. If you see 100 patients at a nursing home in one week, that could mean $18,300!


I called First Coast Service Options (which is the Medicare MAC for Florida) and asked them how we could determine the amount that we would be responsible for, and I was told we are not allowed to know. I have written my congressman about this. It is literally outrageous that a doctor is responsible for paying a patient's deductible and they are not allowed to know how much is at stake. I am now playing a game of holding all QMB claims until I see that all other patients have met their deductible and I'm going to assume they have too, but that's not very accurate.


Bill Beaton, DPM, Saint Petersburg, FL



RE: The Importance of Challenging Medicare

From: Amy Schunemeyer, DPM


So, I noticed that my Medicare allowable was less than the Novitas website posted allowables for my claims coming back for 2018. There is a Novitas mistake that they were following the WRONG fee schedule up to 2/23/18, and they are working on resubmitting corrected claims. This is one problem fixed. 


And, I notice that the increased payment adjustment is in the form of a positive ($xx.xx) adjustment on our EMRs. This is quite a software accounting nightmare. How are others handling this? These are a few of my questions because I am NOT receiving increased payment from the many, many....


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



From: Connie Lee Bills, DPM


Yes! We have the same problem in Michigan. I am not a Medicaid provider, so I face “eating” the deductible and being paid $0 for services. I am contemplating not seeing any Medicare patient that is categorized “QMB”. These are the only ones you can’t see the deductible for.


Connie Lee Bills, DPM, Mt. Pleasant, MI



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



RE: Lack of Podiatric Authors in Our Journals (Brian Carpenter, DPM)

From: Don Peacock, DPM, MS


I agree with Dr. Carpenter and all the other posters on this topic. As a profession, we need to support research and especially teach the process to our students. A class on "How to Write a Research Paper" at the colleges would be a good start. I myself am guilty of not publishing results including data I have sitting around. For a private practice podiatrist like myself, we are so busy with the details of running our practices that research is placed on the back of the list.


For those in our field in the academic arena, they are publishing as expected. Most podiatrists I know do not even know how to write a research paper or even a level 4 case study series. I learned the process in graduate school, not in podiatry school. To get research done, we must first teach the process to our students and figure out how to support podiatrists in academic as well as private practices in their endeavors.


Don Peacock, DPM, MS, Whiteville, NC



RE: Inability to Verify Satisfaction of Deductibles

From: Ira Cohen, DPM


For years, we have been able to verify benefits and deductible satisfied on all of our Medicare patients via NaviNet, Office Ally, or directly through Medicare Portal (in our case Noridan Southern California). We would hold claims until their Medicare deductible was satisfied on the Medicare-Medical portal to avoid lower reimbursement from Medi-Cal.


Recently ,we discovered that on the Medicare-Medi-Cal portal only, we can no longer see if their deductible is satisfied. We called Noridian and they told us, "You don't need to know that information because the patient is not responsible for deductibles anyway - Medi-Cal is. This is outrageous and unfair. My guess is that they have worked out a deal with the state(s) to reimburse us less. Is anyone else experiencing this? If this is a national issue?


Ira Cohen, DPM, Downey CA



From: Alison Silhanek, DPM


Regarding the paucity of research in podiatric medicine and surgery. PLEASE. Let us call it like it is. It is all about money. It is all about funding (or lack thereof). Unlike other allopathic medical sciences, there is no funding for research in podiatry. As someone who pursued research with an otherwise well-funded residency program for 10 years, I can confidently say that there is minimal funding for research in our profession. Neither the APMA nor ACFAS provides adequate funds. We are our own worst enemy. After 10 years of vigorous effort with minimal support or reward, I gave up. Why would I expect more from anyone else?


Alison Silhanek, DPM, Smithtown, NY



From: Name Withheld


I read all of the posts about this subject and shake my head. Requiring residents to do research will not increase articles. When I finished my residency, it was a goal to contribute back to the profession by writing papers, lecturing, and teaching. Truth be told, today’s graduates' goal is to become consultants and lecture for industry for significant income.


I am not saying these people are bad; they are just human. Blaming ACFAS is not the solution. Requiring lecturers and committee members to publish will eliminate those who volunteer and may be great committee members and surgeons.


Name Withheld  



From: Simon Young, DPM


With 3-year residencies programs, a publishable, even collaborative, paper should be a requirement for graduation.  So much research can be done over their tenure as residents and they should recruit their podiatric director, administration, and other specialties in neurology, orthopaedics, ER, medicine, endocrinology, dermatology, podiatry, rheumatology, infectious diseases, biomechanics, physical therapy, etc. What a plethora of topics available to be researched and put us on the map. We need to show the other professions that foot pathology is more than nails and callosities.


When I was a residency director, it was difficult to impossible to get my residents to publish or offer research ideas. I did have the cooperation of administration and some specialties but not all. The ER was willing so I was able to get one research paper published.


NYCPM has a relationship with Ireland Podiatry School and they present more research than our graduating 3-year residents. What are they doing right?


Simon Young, DPM, NY, NY



From: Brian Carpenter, DPM


I think this is a very important question/observation by Dr. Borreggine. Dr. Saxena mentions George Liu, DPM recently ran for the ACFAS board (and won) on the platform that DPMs need to do more research and start maintaining registries which I 100% agree with. 


One thing that Dr. Saxena did not mention is that we have a very large and powerful society, The American College of Foot and Ankle Surgeons, which states that part of its mission/vision “is to advance and improve standards of education.” The college has over 300 volunteer leaders serving on committees and serving on educational faculties. One of their strategic initiatives is to “advance scientific and clinical research to maintain leading edge competency among our members“ and “deliver superior continuing medical education to enhance competency at every level of professional training.” 


Just as with the residency programs, the College is rewarding those with little to no academic experience or background and placing them into leadership and educational roles. Good examples of this are at the Annual Scientific Meeting in Memphis next month. They have 12 speakers who have never published in the Journal of Foot and Ankle Surgery (JFAS), the College's own journal. There are currently 4 members on the Board of Directors and 52 committee members who also have not published in the JFAS. For us to truly gain parity in medicine, we have to be doing the work of the other medical professions, and research and publishing are at the top of the list that we are lacking in.


Brian Carpenter, DPM, Fort Worth, TX



From: Stephen Doms, DPM


I, too, have asked this question. When I completed my surgical residency in 1981, it was a requirement that residents, individually or as a team, write an article suitable for publication to the Journal of the American Podiatry Association (JAPA). We three residents wrote and published our article in JAPA for the February 1982 issue. Is this no longer a requirement of podiatric residencies?  If not, I think it should be.


Stephen Doms, DPM, Hopkins, MN
Gilden 314