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From: Robert Scott Steinberg, DPM


Dr. Musser asked for advantages and disadvantages. I'll give you one big disadvantage. If you do not do plaster slipper casts, then there is really nothing that separates you from chiropractors, physical therapists, pedorthists, or the shoe store salesman who does a scan. It does not matter which scanner you use. They all make you run-of-the-mill and..... beige. Let the slings and arrows fly, especially from those of you who don't want to get your hands dirty, or those of you who have "trained" your office staff to handle the mundane stuff, or those of you who failed to master the art of casting.


Robert Scott Steinberg, DPM, Schaumburg, IL,

Other messages in this thread:



RE: Microscope for KOH Preps (David Kahan, DPM)

From: Carl Solomon, DPM


I've been doing KOH preps for a while and they're simple. KOH preps don't require a special microscope. No oil immersion, polarization, etc. are needed. You just need low/med power (10X, 40X, occasionally 100X). An adjustable condenser to increase contrast may help but you can do without it.


Carl Solomon, DPM, Dallas, TX



RE: Gary Dorfman, DPM Retires After 50 Years

From: Peter J. Bregman, DPM 


Dr. Gary Dorfman has officially retired from 50 plus years of podiatry. Dr. Dorfman is a former president of the American College of Foot and Ankle Surgeons. He has given much of his time and talent working in various aspects of podiatry and has helped thousands of patients and left his impression on his fellow colleagues.


Dr. Gary Dorfman


His most recent employment was at the Foot, Ankle, and Hand Center of Las Vegas. He finished his last four years of practice doing what he loves and creating bonds with his patients and colleagues that will last forever. Though he is leaving our profession, he will be fondly remembered for his contributions and we wish him well in his retirement.


Peter J. Bregman, DPM, Las Vegas, NV



From: David Gurvis, DPM


I also have a missed appointment fee. I find the “threat” alone reduces missed appointments. Do I apply the fee uniformly? No. Actually, I hardly ever use the fee unless a patient has been egregious in repetitive missing of appointments. What I find then is that if I apply the fee, the patient goes away. The desired result. They fire me and I don’t have to discharge them!


I don’t have the fee on new patients as it is too difficult to make sure that they understand my policy, but if they miss two appointments, I refuse to take them back. As always, there is common sense. Missing an appointment without a call later is frowned upon more than missing with a call later that indicates the patient is sorry and had a lapse in memory or perhaps a real reason.


David Gurvis, DPM, Avon, IN



From: Neil B. Levin, DPM, Mark K Johnson, DPM


We have been extremely pleased with the Konica Sigma CR units. We have three of them in different offices. The base unit fits on a countertop and we use our own X-Cels without any modifications or retro-fitting. It produces great images and and has excellent tools. Lease or loan payments are about $550/mo. for 60 mo. It was our best investment ever!


Neil B. Levin, DPM, Sycamore, IL


We went with the DR system A2D2 from Foz Networks (Zac Childress) , retro-fit to our X-Cel system in 2013.  Lease to own. The A2D2 is very reliable and have good support with minimal issues. Highly recommended.


Mark K Johnson, DPM, West Plains, MO



From: Lynn Homisak


I believe you are asking ‘should you bill a new patient you haven’t even seen yet?’ and ‘should you collect their credit card information prior to their appointment?' Instead of applying a Band-aid on an obvious problem and sending a negative message to patients before you even meet them, why not try to determine the reason WHY new patient cancellations are such an issue for you? 


Yes, new patients must occasionally cancel an appointment. It happens. It is not typical, however, to have a new patient cancellation "problem"; unless of course, new patients are scheduled so far out that...


Editor's note: Lynn Homisak's extended-length letter can be read here



From: Paul Kesselman, DPM 


There is no simple solution to this and there are multiple factors here. On one hand, asking for a credit card deposit on the phone does set a bad tone, but with high deductibles and co-payments and tight schedules, last minute cancellations are also unfair to other patients who otherwise would have been able to obtain care sooner. 


I agree that calling the patient the day before to confirm is far better than collecting a credit card "deposit" on the potential new patient. However, the reality is that tight schedules and last minute (24 hours is last minute) cancellations are unfair to...


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



From:  Brian Kiel, DPM


I have a different perspective on this issue. Even though it can be aggravating to have no- shows, perhaps you are better without them in the first place. Those who do that frequently will be the ones who will not follow instructions for care, especially post-op or with wounds. I prefer not to have those patients in my practice. Also, another aspect is that we do slightly overbook on purpose and when there are no- shows, which happens every day, it leaves me a chance to "catch up.


Brian Kiel, DPM, Memphis, TN



From: Paul Busman, DPM, RN


I wouldn't require a credit card guarantee. Right off the bat, even before you'd established a doctor-patient relationship, you'd have shown distrust for that new patient. You've also suggested that getting their money is more important than taking good care of them. Missed appointments are a fact of life.


A better way would be to call that potential new patient the day before the appointment and remind them of the date and time, and tell them how much you're looking forward for the chance to care for them. 


Paul Busman, DPM, RN, Frederick, MD



From: Ivar Roth, DPM, MPH


Missed first appointments were a continuing source of irritation in my practice. We now take a credit card from all first time patients and bill a nominal amount to make sure the card is real. This amount is deducted from their visit if they come in. We send a confirmation email immediately after they call with a copy of our policy so there is NO miscommunication.  


This has worked well for us. Those who refuse to give us a credit card do not get an appointment. This is a real simple solution. We only charge $75 if they fail to show up or give notice. This policy is really to keep the new patient mindful that our time is valuable when they book an appointment.


Ivar Roth, DPM, MPH, Newport Beach, CA



From: G. Dock Dockery, DPM


I have never seen the dilute 4% dehydrated alcohol version available commercially. It is usually supplied in the 98% version of ethanol and is listed as Dehydrated Alcohol for Injection, USP. I think it is still available online or through Moore Medical Supplies.


G. Dock Dockery, DPM, Seattle, WA



From: Paul A. Galluzzo, DPM


Try Gill Podiatry. They usually sell it in 5ml bottles.  


Paul A. Galluzzo, DPM, Rockford, IL 



RE: Kudos for NYCPM Galway Seminar 

From: Patricia Lee Walters, DPM


I just returned from a fantastic seminar for wounds and podiatry in Galway Ireland. The lectures were great and the Galway Bay Hotel venue was phenomenal. I think every podiatrist should check this group out for next March's seminar. There were excellent lectures and a cadaver workshop was included. The seminar featured world renowned lecturers. Dr. Susan Rice was amazing in the cadaver lab. Thank you NYCPM. 


Patricia Lee Walters, DPM, Tarzana, CA



From: Elliot Udell, DPM


Dr. Secord shines a light on the fact that the exorbitant price of brand name medications charged by pharmaceutical companies to U.S. citizens could not be totally justified by the cost of research. Much of this research, as Dr. Secord points out, is done at institutions funded by taxpayers.


Even if we want to give an inch to big pharm's argument that research expenses are at the heart of why Americans pay so much more than "Canadians" for pharmaceuticals, it by no means explains how drug companies have cornered generics and raised the prices to astronomical levels. All of us are aware of how big pharm was able to exploit a legal loophole and start charging over ten dollars a pill for Colchicine when as a generic it sold for pennies for a tablet.


Econazole cream which is a generic antifungal, used to cost less than two dollars for an 85 gram tube. Somehow, the pharmaceutical firms were able to corner that market and raise the price to over $250 dollars for the same product. The ingredients in the EpiPen for which the company charges over $650 dollars (which we all have in our emergency crash carts) are available for less than $2 dollars. The bottom line is that the American citizens deserve close government scrutiny of what is going on and laws to protect its interests.


Elliot Udell, DPM, Hicksville, NY 



From: Paul Kesselman, DPM


When Medicare Part D first was announced, I was asked to research and write an article on the subject. To my astonishment and much to my chagrin, the pricing of drugs was not set by the government but by private insurance carriers and the industry. This and other issues such as the donut hole, deductibles, etc. have left many seniors in a position of having to choose  food or medicine. 


Many split the doses of medications which may have not been engineered for such a procedure. Some I am told even end up in the ER due to the untoward toxic effects of the resulting...


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



From: John V. Guiliana, DPM, MS


The editor's comments to this are very accurate. "Rules of thumb" are dangerous and the last thing that you want to rely upon since it could mean the difference of a hundred thousand dollars or more if the practice is large enough. Variables in value are created by the extent of buyer risk (known as "capitalization rate"), the calculation of free cash flow, a list of tangible assets, and many additional "factors of production", such as the ability of the buyer to replicate the current revenue stream. A practice of any notable size should most certainly invest in having a professional valuation done.


If I were to reluctantly advise on what RANGE most podiatry practices sell for, it would be quite a big dollar range as it extends from 1-1.25 X NET earnings to 55% of GROSS. Again, for a large practice, that dollar amount could result in a large swing using simple generalities. Seller financing is a common option with a buyout over 3-5 years, and this term naturally would affect the purchase price. 


John V. Guiliana, DPM, MS, Little Egg Harbor, NJ



From: Robert Scott Steinberg, DPM


This is just one more reason to stop accepting Medicare patients. What could a certified orthotist or prosthetist know about casting that we don't know? Why should we stand still for being treated like trash? And, when did Medicare start paying for L3000s, anyway? 


Robert S. Steinberg, DPM, Schaumburg, IL


Editor's comment: The dilemma is that when Medicare enacts a rule, most private insurers follow suit.



From: Bret M. Ribotsky, DPM


I had a very pleasant meeting with the new president of Merz this morning. He was unaware of the situation and assured me that he will assemble a team within the next two weeks and figure out a solution. He said, "Merz very much values its long-standing relationship with podiatric physicians and will do everything it can to continue this relationship.” I’ll remain diligent and persistent with this issue. I’m confident that before the DERMFOOT meeting at the end of the month, the ability to obtain Radiesse will not be an issue for those who are trained to use it.  


Bret M. Ribotsky, DPM, Boca Raton, FL



RE: Best EPAT for Plantar Fasciitis?

From: Dieter Fellner, DPM


I want to reach out to the podiatric community and colleagues to ask for their opinion and advice about shock-wave therapy treatment options, specifically for recalcitrant plantar fasciitis. I discovered there are several different, and confusing, options. After researching this online, I found that many doctors offer and market extracorporal pulse activation treatment (EPAT) shockwave therapy for recalcitrant plantar fasciitis. 


I followed up to read journal articles about the EPAT. There is, overall, a good degree of professional, confidence-inspiring online consensus from various sources to recommend this type of treatment. One such device, seemingly favored by a preponderance of podiatrists is the...


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



From: Ed Cohen, DPM


If this patient came into my office, I would discuss her insurance and ask her if she would like information on where to get better coverage at a more affordable rate. If the patient was interested, I would tell her about our experiences and how we got a 39 year old employee a policy with a $5 co-pay for PCPs, a $10 co-pay for a specialist, a $250 deductible with a maximum out-of-pocket of $500 for $176 a month after the employee tax credit. This person also was a smoker and had cancer several years ago. Another employee, a 45 year old, found a policy for  $218 which also included dental and vision coverage with no deductible and a 30% co-pay on all medical and hospital bills. This policy has a $1,000,000 coverage limit.


We also ask our patients if they are interested in saving money on our prescriptions and if they are, we tell them about the GoodRx website. Every doctor should be familiar with this site because it can save the patient a lot of money. On expensive prescriptions, such as Zyvox, there is a number 855-239-9869 to call where the patient can get the antibiotic for free, based on income. 


Ed Cohen, DPM, Gulfport, MS



RE: Setting the Record Straight

From: Bradley Bakotic, DPM, DO


I'd like to set a rumor that has been circulating recently straight. Years ago, due the threat of Obamacare, and changes in reimbursement, Bako partnered with a private equity firm, thereby giving us a nest egg, in case the worst came to fruition. As it turned out, had we not done so, we likely would have been put out of business by the various adverse changes. It was one of the best, and luckiest, business decisions I've ever been fortunate enough to make. Recently, as that fund matured and their stock became available, another firm purchased that stock (recapitalized). I have never given up control of my company, and have retained ownership. 


At Bako, we're going to continue to support the podiatric profession; in fact, during 2017, we'll do so at the highest level ever. This profession is by in large awesome, and we're incredibly fortunate to have had its support through the years. Thank you!


Bradley Bakotic, DPM, DO, Alpharetta, GA



From: David E. Samuel, DPM


Several years ago, better vitamin therapy was introduced by a few companies that started showing better efficacy for diminishing neuropathic pain. You purchase the vitamins and resell them to your patients. You make a little on the vitamins and many times, patients feel better and are happy. 


Good clinical studies on it and biopsy, I'm sure, played a roll in determining what the vitamins ultimately did to warrant a trial with them. We have used these vitamins and some have seemed to give some moderate improvement and some have also not been helpful. It just depends on...


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



From: Bradley Bakotic, DPM, DO


I'm a bit confused by the post related to ENFD by John Hurchik, DPM and some of the subsequent responses, particularly that offered by Elliot Udell, DPM, who seemed to imply that clinical doctors, and their labs, are doing ENFD testing strictly for "massive" financial gain rather than optimal patient care. 


First, let me say that I have been informed that Dr. Hurchik did intend for his note to take the negative tone that it seemed to. Secondly, those that believe that a punch biopsy pays a "massive" amount of money, probably have never done a punch biopsy. The "massive" reimbursement for a punch biopsy is about $85.00. It might buy you...


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



RE: $105 Office Visit Co-Pay

From: Keith L. Gurnick, DPM


Yesterday, a 25 year old female patient returned to my office for a follow-up visit, but with a new insurance plan beginning calendar year 2017. Her health insurance is an Anthem/Blue Cross PPO 60 EPO individual policy with a $105 office visit co-pay, and a $6,300 calendar year deducible. Should this really be called "Health Insurance" or just a major medical policy?


Keith L. Gurnick, DPM, Los Angeles, CA



From: Ed Cohen, DPM


I think if the patient has a good hgba1c, the procedure is safe. The nerve biopsy is slightly more accurate than a Sudoscan. The Sudoscan is a three-minute test where patients step on plates while placing their hands on other plates. I  think the Sudoscan is accurate enough to give you a good diagnosis and has the advantage of not having to treat a biopsy wound. Another great advantage the Sudoscan has is that you can safely run the test on any diabetic patient no matter how high their blood sugar, and the equipment can never cause an infection.


The  patient is usually more receptive to a non-invasive test and the Sudoscan is a good practice builder. The downside is insurance reimbursement, which used to be very good, but has now become a problem in the last few months. In some states, podiatrists are not authorized to use the machine. I have found the Sudoscan a great objective tool to evaluate the effectiveness of my treatments and selling the various nerve food products to the patients can also be a nice revenue generator. Patients also don't mind paying for the test when it is not covered by insurance.


Disclosure: I have no financial relationship to Sudoscan.


Ed Cohen, DPM, Gulfport, MS



From: Connie Lee Bills, DPM


I have been using simple Facebook ads for 2 years. I have a maximum of $5/day based on website clickthroughs. I love it and it reaches existing and new patients and they even have conversations about foot issues as a result. This is an awesome tool. I have not used Google yet, but be sure you have a Google place page (free) no matter what. It will make it easier for patients to search for you.


Connie Lee Bills, DPM, Mt Pleasant, MI