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RE: Venture Capitalists Target the Podiatric World

From: Hal Ornstein, DPM  


Corporate America is finally recognizing the value of podiatry. Recently, private equity investors/venture capitalists have taken a very close look at specialty physician groups such as podiatric practices. Many podiatry practices have great growth potential and simply need the guidance and financial backing to significantly increase earnings. Investors are attracted by the prudent, routine medicine practiced in a podiatrist’s office combined with the added benefit of being able to perform profitable elective procedures, such as foot, ankle, and sports medicine surgeries. 


Further, there is the potential for ownership of ambulatory surgery centers. By owning and controlling the operating environment, practices are able to function outside hospitals, leading to better physician economics, improved cost containment, and better access to care for patients. From an investor’s perspective, a business model of an efficient successful practice thriving in one location so that it can be replicated elsewhere is very attractive. In fact, the practices that are most attractive to investors are ones that have developed strategic plans to compete against regional health facilities and acquiring smaller practices. By owning and controlling the operating environment, practices are able to function outside hospitals, leading to better physician economics, improved cost-containment, and better access to care.


Hal Ornstein, DPM, Howell, NJ

Other messages in this thread:



RE: The Importance of Examining Legs 

From: Robert D. Phillips, DPM


I would like to commend the thoughtful letters written by Dr. Forman (4/14/18), Dr. Silver (4/18/18), and Dr. Jacobs (4/16/18). All bring to the fore the important facts that diabetes not only has a negative effect on all the systems in the foot, but that decrease in the utilization of the foot also accelerates the impact of the disease on the other body systems. 


Certainly, the main goal of any podiatrist treating the diabetic patient is to increase the activity level of the patient. Many years ago, I heard Dr. Root talk about no longer thinking of geriatric foot care as trimming calluses and nails and moisturizing the skin. Instead he stated that...


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



From: Bill Beaton, DPM


I would like to comment on Dr. Richard Simmons' post in regard to "non-medically licensed" personnel performing routine foot care and that procedure is billed as if the DPM personally performed the procedure. In Florida, it is against the Florida Podiatry Practice Act for anyone not licensed to perform any procedure that falls under the definition of the Practice of Podiatry.


Florida Statutes 461.003(5) states that "Practice of podiatric medicine" means the diagnosis or medical, surgical, palliative, and mechanical treeatment of ailments of the human foot and leg. The surgical treatment of ailments of the human foot and leg shall be limited to that part below the anterior tibial tubercle.


In my opinion, anyone other than a licensed podiatrist providing palliative foot care or a podiatrist that is supervising a non-medically licensed person is in violation of the Florida Podiatry Statutes and subject to penalties under Statute 461.012(2)(d).


Bill Beaton, DPM, Saint Petersburg, FL



From: Thomas Silver, DPM


I have tons of patients sent to me for "routine care" from large managed care clinics in my area. I often hear from these patients that they were seen by the podiatrists in their clinic and told by them, "I'm a surgeon. I don't trim toenails or calluses!" and that they often don't even look at their feet. They refer them out to the few clinics in my area (population >1 million) that do "routine care". 


In most all cases, I do a full lower extremity exam for these "routine care" patients. Many of the elderly have had knee or hip replacements, so I routinely measure for leg-length discrepancies, excessive pronation, collapsing or collapsed medial column, and I have them stand and walk. As a result, we fit...


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



From: Richard A. Simmons, DPM


Dr. Forman wrote: “I received notification from Medicare that 33% of my visits submitted included an E/M charge. I was told it was above the average.” To me, there are two issues here: 1) do you really want to go toe-to-toe with Medicare defending your E&Ms and 2) I am surprised that 33% is above average. I know that some doctors will challenge Medicare personally and spend a lot of time and effort defending their claims. If your office is equipped to handle this, then go for it. The 33% number seems low and may be something that APMA could look into. 


That said, there may be a lot of practices where “non-medically licensed” personnel are trimming toenails, corns, and calluses, and these offices may simply have a high turnover of procedures without examinations. On a side note, if a PA (physican assistant) or NP (registered nurse practitioner) submits a bill to Medicare, it is paid at a lower fee profile than if submitted by an MD, DO, or DPM; however, when “non-medically licensed” personnel perform routine foot care, that procedure is billed as if the DPM personally performed the procedure. Even though Dr. Forman may be practicing good medicine, it appears that the numbers may simply be against him.


Richard A. Simmons, DPM, Rockledge, FL



From: Lawrence J. Kansky, DPM, JD


As a criminal defense attorney, I have been involved in many felony theft cases such as the one written about by Name Withheld (MA) podiatrist. First, you did not make a mistake in agreeing with the district attorney to dismiss your employee's criminal charges in exchange for full restitution of the stolen $13,000  (In Pennsylvania this is called a "586" which is the PA Criminal Code Rule number that allows for Court dismissal upon satisfaction or agreement of the parties). If your employee became a convicted felon, you would likely have had no chance of getting your stolen money back, because in our judicial system, convicted felons lose just about everything.


In my PA cases, when a criminal defendant breaches the restitution part of their agreement, the victim usually contacts the district attorney, the criminal charges are immediately re-instated, and a warrant is issued for the defendant's arrest. The case then starts all over again, and the defendant cannot claim a due process right violation for lack of a speedy trial. Your state, (MA) is likely very similar to PA, so contact your district attorney as soon as possible.


You are not out of luck just yet, because many times after a defendant is re-arrested, the restitution money magically appears and the victim is quickly paid. Good people sometimes make bad mistakes for a variety of reasons, so I commend you for giving your employee at least a chance for a better life.


Lawrence J. Kansky, DPM, JD, Kingston, PA



RE: Anyone Can be a Victim of Employee Theft

From: Name Withheld (MA)


I just spent a lovely morning in court having to deal with an employee who stole nearly $13,000 from me over a period of four years, beginning in 2008. The original court date was April 9, 2014. At that time, the thief was given the opportunity to pay restitution during a period of probation, or go to jail. I agreed with the district attorney to allow her to pay restitution and not have a criminal record or any jail time. Was this a mistake? This morning, I appeared before the judge asking why, after four years, full restitution has still not been made. According to the original agreement, full restitution should’ve been paid at the end of one year. 


Believe it or not, all of us are at risk for this above scenario. I never thought I would be. It happens more often than you think. Please, please consider that you could be a victim yourself. There are many ways to prevent what happened to me. Please take the steps necessary and don’t let this happen to you. 


Name Withheld (MA)



From: Thomas Graziano, DPM, MD


With all due respect to Dr. Lipkin, the decision to drop out of the insurance networks is not a "knee jerk" reaction as he implied. And as he said, "thinking with your head, and not your heart", is exactly why he and others should drop out. If anyone in solo practice thinks they are going to negotiate better fees with any of these insurance companies, they suffer from delusional personality disorder. It's not going to happen. If you think its all right to devalue your services on one hand to get thrown some crumbs for another service, then continue to practice that way. 


But if you're looking for real solutions, put your big boy pants on and stop putting up with it. I remember some time ago the late Neal Frankel, DPM met with our division in NJ and told us something that stuck with me. He said the CEO of one of the larger insurance companies told him and I quote, "why should we pay podiatrists more when we know they'll work for less."  That statement continues to resonate, and its one of the reasons I'm out-of-network today. I only wish I had done it sooner.


Thomas Graziano, DPM, MD, Clifton, NJ



From: Dennis Shavelson, DPM


I have been using Synergy Global Group for my billing for four years now with excellent rapport and results. Last year, I became a consultant to the group, where I am especially helpful partnering with their clients practicing out-of-network or hybrid (in and out-of-network). The best way I can explain SGG to podiatry is that they are a 10% billing company that charges 4%. In addition, they handle but do not take a % on claims that are not insurance bound. Amit Bose, the CEO of SGG has built a platform that caters to small private practitioners as well as multi-location and grouped practices.  


They have dedicated staff chasing open claims, and their monthly statements and analytics are sophisticated yet understandable. SGG has allowed me to manage my receivables with less energy and frustration and greater profit. I work with their podiatry accounts regarding coding and charting (especially biomechanics and uncovered services), and assist in maximizing OTC sales in practice.   


Disclosure: I am a consultant to Synergy Global Group.


Dennis Shavelson, DPM, NY, NY



From: Dennis Shavelson, DPM


I reviewed the RESA website. They have a homogeneous proprietary plan using software, an algorithm, a technician, and a scanning method developed by a cyclist + engineers to create what they value as a $199 product. Remember the Soles 3-D printed orthotics that DPMs were dispensing that is now out of business having lost $30 million. 


I welcome the competition from Costco that will help educate the foot and postural suffering public towards the need for customized orthotic props. My insult comes from Costco stating that the DPM product is worth $300 when mine are...


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



From: Allen Jacobs, DPM


I wanted to share some thoughts with regard to the issue of what to do when individuals present to an office with orthotics made at Costco, the Good Feet Store, or similar non-podiatric facilities. 


Simply stated, you have completed undergraduate and post-graduate training, including training in biomechanics and kinesiology. Your decision as to the nature and type of orthotics to be utilized, and the specific corrections to be utilized in those orthotics, are unique and individualized based upon an examination of that patient and a determination of multi-variant factors resulting in...


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



From: Doug Richie, DPM


Nine years ago, I posted a blog documenting my experience with a patient who had purchased "custom" foot orthotics from Costco.


To my surprise, this blog posting became the most popular blog entry ever posted on the Podiatry Today website, primarily due to the readership of the general public. Today, over 116,000 people have read the post. The comments on this blog are also interesting, but my own message is still valid today. Commercial entities who provide low cost, ineffective foot orthoses will only increase awareness and motivate the general public to seek quality foot care interventions provided by qualified podiatric physicians.   


Doug Richie, DPM, Seal Beach, CA



From:  Steven E. Tager, DPMShashank Srivastava, DPM


I too saw the ad. This sort of thing is malignant in this country. All who think they can capitalize on the benefits of orthotics try to do so. It suggests to me that we as a profession lack the necessary influence over this type of misrepresentation. This is possibly because there are insufficient concrete guidelines for orthotics prescriptions?


Steven E Tager, DPM, Scottsdale, AZ


I also saw this in my Costco mailer. My feeling is that this is largely an automated process that is not under the oversight of a physician. This has been an increased trend in the DC, Maryland area with various shoe stores that offer a similar service. This was quite frankly very predictable. One of the downsides to easy digital scanning is that it opens the floodgates to this type of automation and scaling that eventually devalues the product. My feeling is that with 3D printing, this will probably be more prevalent in years to come.


Shashank Srivastava, DPM, Rockville, MD



From: Harry A. Harbison, DPM, Elliot Udell, DPM


I always find it interesting that podiatrists seem to think "custom orthotics" are a prescription-requiring item. Please be aware that in-shoe orthotics (i.e.- ala Root style) do not require a prescription in any state or province in the USA. There are no requirements that a "medical professional" be involved in the fabrication of these items. To have these items paid for under a third-party payor may require some sort of "prescription" for medical necessity documentation.


Harry A. Harbison, DPM, Long Beach, CA


We use a scanner in our office to send images to a lab. It's not rocket science and I had no delusions that non-podiatrists would use the same technology. Chiropractors, orthotists, and PTs are making custom orthotics and some use the same labs that we use. Now it's Costco.


The question we should be asking is how to manage the patient who gets a custom set of orthotics from Costco and then asks us to make adjustments to help manage his or her foot problems. I already encountered this problem in my office and wonder how others will approach this problem.


Elliot Udell, DPM, Hicksville, NY



RE: Costco Selling Custom Orthotics

From: David Feingold, DPM, Paul Busman, DPM, RN


I was browsing the publication, published by Costco, and to my surprise there was an advertisement for custom insoles. The company is listed as RESA. They have a scanner that you step on and then a 3D printer fabricates an insole. They state that a medical grade orthotic cost $300.00 or more and theirs is $139.99 for adults and $99.99 for children under 16.  I am curious how my colleagues react to this and question if this is a custom orthotic and needs to be prescribed by a medical practitioner.


David Feingold, DPM, Kearny, NJ


I found in my Costco members' newsletter that they're apparently getting into 3-D printed orthotics (yes, they use the term orthotic, as well as insole). Your foot is scanned by an "operator", who then asks questions about your activity, shoe type, etc., and the insoles are printed while you shop. There is no mention at all of any type of podiatric or medical personnel involved in the process.


Paul Busman, DPM, RN, Frederick, MD



From: Elliot Udell, DPM


It may seem all well and good for you to lighten your case load by training a PA or NP to perform most of your day to day "bread and butter" podiatric procedures. How would you feel if that person you trained leaves your practice and gets a job working for an MD "across the street" and that doctor starts advertising that he or she now provides foot care by a well-trained PA or NP?


Elliot Udell, DPM, Hicksville, 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: 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: 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



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: 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

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