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02/15/2014
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Finding the Money
From: Vito J. Rizzo, DPM
I was listening to a news story last night and a thought occurred. This has been a very tough winter for most of our country. Many towns and municipalities have exhausted their budget for snow removal. The story was interesting in that there was a discussion on how officials could get the needed funds to pay drivers and snow removal personal. There was never talk of, well, just paying those workers less. It was clear that the funds would be found.
Why is it then that the solution to shortfalls in healthcare funding results in lower fees for health care professionals but snow plow operators still deserve full pay, with raises every year? And the money will be found somewhere to pay for this. Society will accept that doctors get paid less (and come to think of it, doctors seems accepting of getting paid less). Are municipal workers' rights more of a priority? I know many who earn more than most of my colleagues. Enough?
Other messages in this thread:
10/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Source for Cantharone
From: Paul Betschart, DPM
I was surprised to see on the Dormer Laboratories' website in bold red that Cantharone and Cantharone Plus are not permitted for sale or use in the United States. It is a shame as they make a quality product that is very effective for treating plantar warts. People may be scrambling to find alternatives as their supplies dwindle. Practitioners should contact their preferred compounding pharmacy to see if they can have a compound made with the same ingredients.
I have gotten compounds with the same exact ingredients as Cantharone Plus from Bayview Compunding Pharmacy in Warwick, RI in the past when Cantharone plus was in short supply. It costs a little more per mL than Cantharone but the effectiveness was similar to the original formula.
Disclosure: I have no financial interest in Bayview Compunding Pharmacy
Paul Betschart, DPM, Danbury, CT
10/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
From: Paul Kesselman, DPM
I must admit that those promoting this are either a mentor and friend of the last twenty years (Doran Edwards, MD) or Lawrence Rubin, DPM, a longtime mentor, friend and former teacher of mine at ICPM in the late '70s and '80s. So it pains me to have to offer some criticism of each of their posts. And I will have attempted to speak with or have already spoken with both of them prior to this post being printed.
For one, Dr. Edwards and I have worked together numerous times to improve the therapeutic shoe bill, met with DME MAC medical directors and CMS to improve the accessibility to beneficiaries by removing some of the...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Doran Edwards, MD
I appreciate Dr. Bass's post and his enthusiasm for the Arche LEAP Vitals exam for patients with diabetes. There is one point of clarification that needs to be provided. Dr. Bass wrote, “if a provider has a diabetic patient (chronic illness) who may have exacerbation or progression, and this patient may need a prescription based upon the findings of the LEAP tests, the patient will then meet the requirements for an E/M service.”
The quick and efficient LEAP Vitals tests are all about skin integrity in this high risk population. We understand that “chronic illness” as well as “chronic illness with exacerbation” helps determine, in part, the level associated with the E/M service through medical decision-making (i.e. 99212 versus 99213). By no means does the patient need to exhibit exacerbation or progression of their diabetes to qualify for the LEAP Vitals tests, nor the ability to meet the medical necessity associated with an E/M billing. A prescription is also not required.
Any abnormal findings on the LEAP Vitals Exam, i.e dry and xerotic skin (L85.3) caused by sudomotor dysfunction, is a significant risk to a patient with diabetes. It therefore warrants a care plan, either an initial care plan or a change to a previous care plan that’s not working well. This change in medical condition alone provides the medical necessity for an evaluation and management service through the counseling of the patient on their risks associated with dry skin, and changing their treatment, even if only an over-the-counter skin care recommendation.
Doran Edwards, MD, Former DME MAC and PDAC Medical Director
10/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
From: Lawrence Rubin, DPM
In a recent post, Dr. Freireich said, "If APMA promotes an Annual Comprehensive Diabetes Prevention Foot Examination, I hope they also promote that the exam is not covered by insurance, unless things have changed since this issue was also brought up."
Actually, there has been some progress in gaining covered podiatric Medicare diabetes amputation prevention examination coverage. Although we have not yet succeeded in gaining coverage for a comprehensive diabetic foot examination (CDFE) to screen for many potentially hazardous lower extremity problems, podiatrists can now be well reimbursed when providing...
Editor's note: Dr. Rubin's extended-length letter can be read here.
10/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Alan Bass, DPM, CPC
As a certified professional coder and someone who has reviewed the Arche LEAP Vitals+ Program, I agree with Dr. Edwards’ assessment. The program provides the user with real-time physiologic findings. Following the guidelines for an E&M visit provided by the AMA, if a provider has a diabetic patient (chronic illness) who may have exacerbation or progression and this patient may need a prescription based on the findings when performing the tests within the program, the patient will meet the requirements for an E&M.
Disclaimer: I have no financial relationship with Arche Healthcare.
Alan Bass, DPM, CPC, Manalapan, NJ
10/14/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Robert Scott Steinberg, DPM
I do not have a problem with "paid for biased speakers for drugs, surgical techniques, and wound care products." I highly doubt any of my colleagues are fooled into using a product or device after a lecture paid for by a corporation. I can read the research for myself and make my own decisions. I want to know the cost to the patient or the hospital. And, of course, is it demonstrably better?
Considering our CME requirements and the fact that some meetings are held in the downtown areas of expensive cities, I'll accept that at least the cost of registering for a conference is reduced thanks to sponsorships. I will maintain an open mind to new things. Seasoned physicians are not easily swayed.
Robert Scott Steinberg, DPM, Schaumburg, IL
09/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: “Why I Chose an NP for My Care” National Commercial
From: Jon Purdy, DPM
If there’s a will there’s a way. The end result is more applications to podiatry school and increased income for practicing podiatrists, both of which result in increased income for the APMA. The APMA, like most large regulatory associations, has expenses that can be reined in. Large expenses for committee meetings can be reduced as well as many of the bloated salaries and lavish meeting expenses for the anointed. Even so, it would be a struggle to fund a national TV campaign. That is why many partner with other symbiotic associations and companies.
Jon Purdy, DPM, New Iberia, LA
09/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From Elliot Udell, DPM
Thank you, Dr. Kesselman for making us aware of this new way in which insurance companies may finally put an end to the practice of medicine.
On one hand, I understand where they are coming from. Drugs like Ozembic are high ticket items and if insurance companies were forced to pay out thousands of dollars for every patient who refuses to try diet and exercise and would rather take injections, they would either go belly up or would have to raise everyone's premiums through the roof.
On the other hand, if I had to pay back for every script I have written for gabapentin or cortisporin otic solution, bankruptcy would definitely be in my future.
Elliot Udell, DPM, Hicksville, NY
09/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
From: Lawrence Rubin, DPM
Along with others in this thread, I am also an APMA Life Member who has no vote and is grateful to Barry Block for giving us an invaluable platform to voice our opinions. Relevant to this thread, back in 2012, I was very active in several APMA activities and worked together with other podiatrists throughout the nation and APMA assigned program personnel in providing the, "Knock Your Socks Off" public information campaign. APMA launched this public service program to educate the public about amputation prevention and other foot healthcare matters, to create awareness of the broad scope of our podiatric practices, and to show the public that we are the preferred providers of footcare.
Although the program was magnificent in structure and content, it depended upon APMA members in all states and communities working closely together in conforming to a program implementation plan. I was assigned the State of Nevada, and was pleased to report that the program did raise community awareness wherever the local volunteer DPMs were willing to participate in the program. Unfortunately, too few podiatrists nationwide were willing to get involved personally or assign their staff members to provide the program elements. For this reason, the program had to be discontinued.
When the Knock Your Socks Off Program was discontinued, I and a small group of Las Vegas APMA members who were providing the APMA Knock Your Socks Off program elements joined together in 2010 in order to help to create the non-profit Lower Extremity Amputation Prevention (LEAP) Alliance. LEAP creates community-based lower extremity amputation prevention programs in collaboration with local healthcare and community services entities.
Lawrence Rubin, DPM, Las Vegas, NV
09/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: David Secord, DPM
My experience was somewhat the opposite, in that an anchor for one of the local television stations happened into my office for a nail procedure, worried that it would keep her from wearing stylish (I would go with inappropriate, but there you go) dress shoes as part of her work and that everyone she knew assured her that the experience would be akin to a slow trip through hell. She was amazed that she didn’t feel the injection stick (ethyl chloride) and didn’t feel the injection (1% lidocaine with epi, 0.5% Marcaine plain, 8.4% sodium bicarbonate to buffer the injectable back to physiologic pH) and didn’t have any pain after the procedure (no tourniquet needed due to the use of epi in the block). She recommended that the anchor at another station in Corpus Christi see me, as she had the same problem and staved off the procedure for the same reasons. She had the same positive experience.
The two of them began a discussion with me about my practice and I mentioned that...
Editor's note: Dr. Secord's extended-length letter can be read here.
08/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Brian Wm. Zale, DPM
I was sued some 25 years ago by an attorney who I believe just hated podiatrists. PICA was my medical liability company at that time. The patient had bilateral bunionectomies by another podiatrist previous to seeing me. She also had some plastic surgery on her right ankle for a brown recluse spider bite that looked horrible. Needless to say, she was unhappy with the bunionectomies I performed and I was sued along with my assistant surgeon and the resident on the case. She sued me for all the normal things of lack of informed consent, chronic pain, inability to have sex, unable to work, loss of future income, etc.
They had an economics guru expert from University of Houston to figure out her future loss of income. Their expert witness was a "Board certified foot and ankle orthopedic surgeon" from San Antonio who hated podiatrists. My expert was a board certified podiatrist from...
Editor's note: Dr. Zale's extended-length letter can be read here.
08/29/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
From: Ira Cohen, DPM
I join Rod, Larry, and Name Withheld in deciding not to pay the voluntary contribution after 39 years of practice and 4 years of Life Membership. I learned so much from senior DPMs like Sy Lane, Howard Marshall, and a long list of veteran podiatrists.
As California podiatrists, we fought for years to obtain ankle privileges (I believe 2nd in the nation) establishing a path for many states to follow. For APMA to take our contribution and not allow us to vote indicates they have no regard for our decades of experience in medicine and politics.
Ira Cohen, DPM, Boca Raton, FL
08/29/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Steven E Tager, DPM
I too am a life member of APMA. I also did not get solicited for my opinion on the APMA definition of podiatry. I will withhold my contribution this year.
Recalling something about "taxation without representation" comes to mind and who knows more about "history can teach us a lot" than those who lived it?
Steven E Tager, DPM, (Retired), Scottsdale, AZ
08/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
From: Lawrence Rubin, DPM
I am an APMA Life Member. I love APMA and its decisions most of the time, but not always. Not only can we not vote, but in the past, I have found that suggestions for specific positive actions that would benefit podiatry and our contribution to public health have been disregarded without explanation. One would think that new ideas and opportunities would be welcomed and respected and not treated with indifference.
Lawrence Rubin, DPM, Las Vegas, NV
08/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: APMA Member
I am a life member of APMA who was solicited for a $150 voluntary contribution. I did not get solicited for my opinion on the APMA definition of podiatry. I think I'll withhold my contribution this year just like the Life Member in the August 27, 2024 PM News. That's only two of us withholding and it won't make much difference in the APMA budget, but perhaps other Life Members who have not sent their contribution might follow suit and join us. What our action does do is alert the younger members of APMA what the future holds in store for them. Perhaps APMA could count 3 out of 5 Life Members in determining our input.
Rod Tomczak, DPM, MD, EdD, Columbus, OH
08/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Lawrence Rubin, DPM
"Medicare and private insurance cannot always identify an MD's or DO's specialty and their use of billing codes as easily as they can with a DPM after their name." - Reingold
In response to Dr. Reingold's post that suggests Medicare may not know what provider specialist such as DPM, MD, etc., is billing the claim, and that knowing this might alter a payment coverage, this is not the case. A Medicare/Medicaid Provider Number (MPN) on the claim verifies that a provider has been Medicare certified and establishes the type of care the specialist provider can perform. This identifier is a six-digit number. In addition, other than there being a few exceptions, Medicare considers podiatrists as physicians providing what it determines and publishes to be medically necessary for all specialties and is within the scope of our license.
Lawrence Rubin, DPM, Las Vegas, NV
08/26/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Jack Reingold, DPM
I graduated from CCPM in 1979 and retired in 2023, practicing in San Diego, CA the whole time. Luckily, there were hospitals in the area that let me have surgical privileges when I started. Within 15 years, all the hospitals in my area granted podiatrists virtually full surgical privileges (including ankle) and admitting privileges. Managed care arrived and discovered that podiatrists delivered excellent, cost-effective care and began hiring them in great numbers. Kaiser Permanente Medical Group went from none to currently 21!
Hospitalists started calling us and begging us to take patients. Nobody seemed to care about our degrees, caring only if we could take care of their patients (and perhaps off their hands). The hospitals wanted us to take positions on many...
Editor's note: Dr. Reingold's extended-length letter can be read here.
08/15/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Joel Lang, DPM
My heartiest congratulations to Dr. Michael and his "soon-to-be-doctor" daughter for not accepting the status quo. Nothing ever changes until someone decides to change it. Sometimes it only takes a small voice speaking into a receptive ear. If she were my daughter, I could not have been prouder. Jonathan, give her a hug from all of us.
Joel Lang, DPM (Retired) Cheverly, MD
08/14/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Jonathan Michael, DPM
I appreciate all the comments sent regarding my initial post. Here is an update to the situation: My daughter decided to have a meeting with the dean who happened to be fairly new to the school and went to a medical school with a podiatry program. She was very empathetic to the situation and told my daughter that the reason she was told "no" initially by the staff below her is that the rule was set from before she was dean at the school.
She encouraged my daughter to write a letter to the committee laying out reasons why podiatrists are physicians and surgeons. Following the detailed letter by my daughter, we got the news this morning that her wish was approved by the committee and I will (hopefully) coat my daughter at the end of the month at her medical school.
Jonathan Michael, DPM, Bayonne, NJ
08/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B
From: Robert Boudreau, DPM
When I entered private practice in 1984, I wanted to apply at one of our local hospitals for surgery privileges. I called and made an appointment with the chief of staff, a gruff old cardiothoracic surgeon. When I showed up, rather than meet in his office, he chose to hold our meeting in the cafeteria. After going over my credentials and residency training, he said, “I’m sure we can grant you privileges. I often have patients that need a good toenail trimming.” I tossed the application in the hospitals round file cabinet.
Fast forward to the late ‘80s, early ‘90s when PPOs and HMOs hit the scene. The hospital came begging for podiatrists to come to their ORs and do outpatient surgery. I applied for privileges and was granted every privilege I asked for. As my practice grew, I had less time to travel to that facility (a 30 minute drive from my office), and since I held privileges with 2 hospitals within a 5 minute walk from my office, I made the decision to give up the privileges at the distant hospital. I wrote a letter stating my intentions to the grumpy...
Editor's note: Dr. Boudreau's extended-length letter can be read here.
08/06/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Richard Haas, DPM
I have been in practice 44 years and can’t understand why the APMA has not been able to make podiatrists physicians in the eye of the law. I have seen pharmacists giving injections and physical therapists giving wound care freaking our profession out.
Being recognized as a physician should have always been the most important goal of the APMA, not worrying if we are MDP or PMD, etc. Who cares about that if we are not recognized as physicians. Where does our dues money go? DOs and dentists seem to know what to do with their money in regards to political action for their members.
Richard Haas, DPM, Temecula, CA
08/02/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Rod Tomczak, DPM, MD, EdD
Jonathan, it’s a shame you can’t help your daughter put on her white coat for the first time in public, and, yes, I think it is a form of discrimination. For years, MDs looked down on DOs and still do, but it is much more subtle. They could always use the fact that DOs took the COMLEX licensing exams instead of USMLE and supposedly the COMLEX was easier to pass than USMLE. Now DOs can take USMLE so MDs don’t have the “we take a tougher licensing exam” platform to look down from. And, there are not enough MD graduates to fill all the residency slots in MD hospitals, so MD hospitals have generously condescended to accept DOs into their residency programs.
Don’t let the MDs kid you, there are huge economic incentives to suddenly treat DOs as academically equal to MDs, about a 100,000 reasons per resident per year. This becomes very important when rural hospitals are trying to keep the doors open and it doesn’t hurt big teaching...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
07/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A
From: Greg Caringi, DPM
I have read this thread with interest. My OCPM classmate and Kern Hospital co-resident, Dr. Eric Lauf, took on this problem and published his research in 1982, "Manual dexterity: its importance in podiatry" (J Am Podiatry Assoc. 1982 Jun;72(6):291-8.). Since Eric passed much too soon (at the age of 47), I will recall this to the best of my ability. Eric had a friend at the Case Western Reserve Dental School. Even then, dental school admissions took spatial relationships and manual dexterity testing seriously. After observing their metrics, Eric tried to apply them to the students at OCPM.
Unlike dentistry, there was a poor correlation in podiatry. His research became of practical use when Eric introduced the use of the Purdue Pegboard Test (a psychomotor test of manual dexterity and bimanual coordination) as part of the screening process in selecting residents at Kern Hospital. I later began using the Purdue Pegboard at Suburban General Hospital when we selected our surgical residents. It became an important part of our selection process. On a personal note, this reminds me how great a loss it was to our profession when we lost Dr. Eric Lauf in 2001.
Greg Caringi, DPM - North Wales, PA
07/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
From: Steven Kravitz, DPM
I fail to understand why there is so much attention to podiatrists or at least some podiatrists trying to expand scope of practice beyond that of our specialty area - the foot and ankle. The concept of the serving as gatekeeper brings many questions, and I agree with Dr. Rodney Tomczak. The DPM degree has served me well and the podiatrists I know. My colleagues (many in wound care) have benefitted from their education and ability to practice medicine within the scope of DPM degree they earned. That degree points to the general public and more importantly to other medical providers that we are indeed specialists in the foot and ankle pathology. We have developed very good reputations generally; we as a group provide excellent service to patients. At the end of the day, it is the patient that matters.
Becoming gatekeepers necessitates overseeing treatment of medical conditions out of our scope of...
Editor's note: Dr. Kravitz's extended-length letter can be read here
07/01/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 2
RE: Observations on the Changing Face of Medicine
From: Elliot Udell, DPM
I have a patient who is a soon-to-be retired psychiatrist. Whenever he would come into the office, we would have discussions on many topics not related to psychiatry or podiatry. He was very well aware of all facets of general medicine. If I asked this physician a medical question, he knew the answer. He later told me that he works one day a week in the ER doing emergency medicine and this helps him keep up with the entire medical field. In another case, my former GI specialist who just retired was able to comment with interest and expertise on any medical issue aside from the GI system.
I am now faced with seeing a whole new battery of young specialists in different fields and if I ask them a question outside their specialty, their answer tends to be, "It's not my field, go to an appropriate specialist." I am seeing more and more of this happening and some of these doctors are board certified in internal medicine and if the question does not directly relate to their subspecialty, the wall in the room can give me a better answer.
As a podiatrist, this may be good. We are specialized and only responsible for the foot, and so many other young specialists seem to have developed amnesia to all aspects of medicine other than their own narrow specialties. Perhaps the degree given to these physicians should not be an MD or DO but for example, "doctor of orthopedics or doctor of oncology, etc. Being a doctor of medicine is becoming less and less relevant in today’s practice.
Elliot Udell, DPM, Hicksville, NY
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