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01/31/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


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

Other messages in this thread:


05/21/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Brant McCartan DPM, MBA, MS


 


Great MIS recap and points. I am “the younger DPM”, finishing a 3-year residency in 2013. To answer some of your questions, I have noticed about fifty older generation doctors who have never given up MIS - and have been doing so for 30+ years. They are anxious to teach and happy that MIS has a growing acceptance, despite being more so internationally as opposed to locally. I believe the appearance of a resurgence is more due to the industry “getting in the game” (nominally Wright and Trilliant; maybe more companies making screws specifically for MIS style bunion correction).


 


This is interesting because the originators of the MIS bunion-style surgeries rarely use any hardware, if any, in their procedures! But now that industry is involved, it instantly becomes interesting, and a more acceptable, viable option or technique. Show me the percentages of established lecturers or board members in any medical organization who consult for at least one company, likely more. Money talks.


 


Brant McCartan DPM, MBA, MS

05/21/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Steven Finer, DPM


 



When I graduated from PCPM in 1976, I was then fortunate to do a residency and join a local hospital. We were trained to do everything open and follow orthopedic thinking. I bought a small practice from an older practitioner. It was obvious that he was doing in-office MIS after taking a weekend course. The x-ray results were uniformly poor and I found a lot of letters from angry patients and investigations from insurance companies. It was clear to me he had little understanding of basic operative procedures, blood chemistry, and standard operative protocol. I steered clear of all of this and used the hospital only. Now years later, with new techniques, changes in insurance, and the blessing of orthopedists doing essentially the same procedures, MIS has found a place in the podiatry world.  


 


Steven Finer, DPM, Philadelphia, PA


05/19/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Elliot Udell, DPM



 


Having witnessed the origins of MIS and the political squabbles within the profession, I now have a broader perspective on it. Yes, there were two schools back then. There were the "open" surgeons and there were those who took the late Dr.  Ed Probber’s one-week course on how to do MIS (in the back of his Long Island office). The training was often supplemented by learning at other doctors offices and at MIS conventions.


 


There were conflicts and a lot of name calling. Some of the criticisms of MIS were valid and some were purely political. At that time, podiatry was striving to be part of the medical/surgical establishment and MD surgeons did not know from MIS. Today, things are different. MD surgeons are gravitating toward minimal incisional techniques. They do spine surgery, knee operations, gall bladder removals, and hernia repairs using very small incisions. The healing time is reduced. Hence, there should no longer be a need for two schools of thought in 2018. It’s time for foot surgeons to learn open and minimal incisional techniques and choose the best one for each and every patient who needs foot surgery. Let’s leave the politics of it back in the 1970s.


 


Elliot Udell, DPM, Hicksville, NY


05/19/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Burton Jay Katzen, DPM


 


The answers to Dr. Borreggine's questions are long and complicated ones dating back approximately 60 years. Minimally invasive surgery is now the standard of care in many countries throughout the world. However, I can say that resurgence of MIS in the United States can be traced, in no small part, to the exceptional outcomes our surgeons are seeing. This includes less patient downtime and the maximum use of the surgeon’s time and the ability to perform many of our procedures in an office setting or an outpatient ambulatory surgical center.


 


I believe that the future of MIS lies in the ability to teach the procedures in the schools and the residency programs. I am happy to note that the next Academy Of Minimally Invasive Foot and Ankle Surgery LSU lecture cadaver seminar to be held in New Orleans on May 31, June 1, and June 2 will include several residents from programs throughout the United States.


 


Burton Jay Katzen, DPM, Temple Hills, MD

05/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: NJ to Monitor Gabapentin Prescriptions


From: Allen Jacobs, DPM


 


I know a lot of docs who decreased scripts for narcotics and began using gabapentin. Now this: 


 


Dear Prescriber, 


 


Effective May 7, 2018, the New Jersey Division of Consumer Affairs adopted amendments to the New Jersey Prescription Monitoring Program (NJPMP) rules at N.J.A.C. 13:45A to require New Jersey licensed pharmacies and registered out-of-State pharmacies to electronically transmit information to the Division about prescriptions dispensed for gabapentin. The recognition of gabapentin as a “drug of concern” stems from national prescription and overdose data. New Jersey is joining a growing list of states who have already begun to monitor gabapentin use, including those that have scheduled the medication at the state level. 


 


Studies have shown that gabapentin prescribing in the United States has increased...


 


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

05/07/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Kim Antol


 


Sigma Digital X-Ray having sold numerous Alara systems through the years, have all Windows drivers and CrystalView software available to re-install remotely at a minimal charge. As one of the original digital x-ray pioneers having introduced DR digital x-ray into the US in 1997, Sigma has survived the test of time, serving the dental/medical/veterinary community nationwide for over 25 years, with an A+ Better Business rating.


 


Kim Antol, Sigma Digital X-Ray

05/05/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Absurd Repeat Fingerprinting Requirement


From: George Jacobson, DPM


 


I got fingerprinted five years ago as a requirement for Medicaid participation. I don't know if this is just in Florida or a federal requirement. We have a renewal  application and were told I have to get fingerprinted again. Did my fingerprints change? This is an absurd waste of my time. There aren't many places that do this that can directly send the fingerprints electronically. I think I spent around $150 last time. I hate stupid government requirements like this. Do government employees, congressmen, senators, and their staffs have to get fingerprinted every five years? I doubt it. When they start fingerprinting lawyers every five years perhaps it won't bother me as much. 


 


George Jacobson, DPM, Hollywood, FL 

04/21/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Bret Ribotsky, DPM


 


I have used Tsheets for years with a few service employees. It geotags them, and lets you track them while on the job. It runs via their smart phones and works directly with Quickbooks payroll.  


 


Bret Ribotsky, DPM, Boca Raton, FL

04/19/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B


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

04/19/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



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

04/18/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



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


04/18/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



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

04/17/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



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

04/16/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


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)

04/13/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



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

04/12/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



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

04/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



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.


04/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



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.

04/06/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



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

04/06/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



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


04/06/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1c



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


04/05/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


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

04/04/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



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

03/22/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


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

03/20/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



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.
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