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12/26/2014
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Who Gets Our Money?
From: Jeffrey Kass, DPM
Who, if anyone, gets monies deducted from their income from sequestration? Do politicians get monies deducted from their salary? Are we having money deducted from our income because these bafoons in Congress cannot come to a compromise regarding the deficit? So, in other words, they are not doing their job and we suffer financially? Why is it that I am constantly reading about members of Congress getting raises? Why aren't their salaries frozen like ours are with the Medicare SGR?
Why is it that members of the medical community are allowing sequestration cuts, penalties for this and that...what other profession gets hit with monetary deductions in pay like this? The podiatric community should seriously consider hiring a social activist to help us, as we are too busy getting pre-authorizations to find the time to complain about these issues. New Yorkers don't like hearing or seeing Rev. Al Sharpton too much, but the bottom line is he is a voice that is listened to because he represents a minority people. The medical landscape is changing and we need a "Rev. Al Sharpton" type of activist to help support our causes.
Jeffrey Kass, DPM, Forest Hills, NY
Other messages in this thread:
11/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Jon Purdy, DPM
I had a similar frustrating experience when I sent myself for my first routine colonoscopy. I was told an exam was necessary and received one from their PA. A little palpation here and there and an order for stool examination. To my protest, I was told the doctor will not do the procedure without it. I complied and received my first bill for a CPT 99204. I questioned the validity of that exam level with the office manager to no avail.
On the day of the procedure, the doctor asked if I was ready and said they would be taking me back. I said what about my results? He looked confused. I told him I was told he would not do the procedure without the stool path and he said “that is not true.” So I underwent my procedure irritated about the entire process thus far. In recover the doctor said, “everything looks great, but there was one spot of inflammation I needed to biopsy.” It was a “Where’s Waldo” game to discern anything in the photo, but I know that extra $350 comes in handy.
So they made some good money on me while I was stuck with unnecessary bills, frustration, and inconvenience. This just verified to me of what is out there, and what I do not do to my patients.
Jon Purdy, DPM, New Iberia, LA
11/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: My Surgical Experience as a Patient
From: Joel Lang, DPM
I recently had an outpatient surgical procedure under general anesthesia. While the procedure itself went well and I have largely recovered, I feel there are lessons I can share regarding this experience. I was told to show up early for the procedure to complete about eight pages of medical information forms and releases. So, at a time when I was most anxious about the procedure itself, I had lots of forms to complete.
Between the time I was told in the office that the procedure was necessary and the actual arrival at the surgi-center for the procedure, I accumulated several additional questions for the surgeon and the anesthesiologist. Both were very busy with their schedule at that time and had only limited...
Editor's note: Dr. Lang's extended-length letter can be read here.
10/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Paul Kesselman, DPM
I have to partially disagree with Dr. Tomczak. There is no question that the MD degree may get doors open that another doctorate degree may not. I also know at least 2 MDs who either decided not to pursue residency programs or who quit their surgical residency in midstream to pursue other areas of interest, such as medical IT, etc. This area is growing by the day as physicians with clinical experience and those in medical school see how difficult clinical practice is.
However I know many DPMs who, for one reason or another, pursued work outside the clinical arena in the pharmaceutical industry, orthopedic equipment or orthotics and prosthetics industries, and some even the teaching profession, at one level or another. Other DPMs are working for insurance companies as investigators, others as...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Howard Bonenberger, DPM
Everything is related to the perceived value brought to the table. In their minds, a degree which is universally recognized by the public, VC firms, or other businesses, the MD (DO) can author research on the entire body. The DPM has limited scope which can be covered by orthopedic research, at least in their minds.
Perhaps submit research that is blind as to the authors' names and degrees. It would not be for actual publication but to have it read by someone who is curious. If of high enough quality and the publication inquired, then it would be revealed that the author(s) were DPMs. I may be way off base, I'd appreciate thoughts on this idea.
Howard Bonenberger, DPM (Retired), Nashua, NH
10/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Kathleen Neuhoff, DPM
When I was in veterinary school, I remember my instructors telling us that the difference between a trade and a profession was research, I believe this to be true. We have some amazing researchers in podiatry but they are rare. The value of contributing research should be part of the mindset of us all and as Dr. Secord pointed out, it is not.
Kathleen Neuhoff, DPM, South Bend, IN
10/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Paul Kesselman, DPM
I stand by my partner Alan Bass, DPM, whose opinion is absolutely correct. Each patient encounter should have at a minimum an appropriate history and physical with components of lower extremity systems including but not limited to dermatology and must also include neurovascular and a MSK examination. Any changes in patient history or PE should be well documented and incorporated into the note.
But the change in history is not what will get you paid for a separate E/M nor is documenting a change in the physical examination. It is that last part, the management, what exactly did you do? If all you did was document a change in history, nope. If all you did was document a change in the PE, again, no dice. You must document all 3 issues, ...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
10/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Lawrence Rubin, DPM
A recent post in PM News pertaining to insurance reimbursement compliance said, "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." To prevent confusion of business names, this is not a stated opinion of the 501(c)3 not-for-profit LEAP Alliance.
Lawrence Rubin, DPM, Las Vegas, NV
10/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: David Secord, DPM
Although it pains me to say so, I agree with Dr. Tomczak on the issue of research. In 2013, I practiced in Riyadh, Saudi Arabia, at the King Abdulaziz Medical City, Central Region hospital. At that time, the Chief of the Section, Dr. Abdulaziz al Gannass, was doing Charcot reconstructions (as indicated) as ankle fusions, either with or without talectomy. Instead of using an intermedullary rod, he repurposed the Synthes VA-LCP Condylar Plate (normally used to fixate femoral fractures) to connect the tibia to the calcaneus. The butterfly shape of the condylar plate worked amazingly well at the calcaneus and after removing the distal fibula, laying the plate at the lateral aspect of the tibia to the calcaneus made for a robust structure, as it is a locking screw and plate system with variable angle abilities. The majority of the patients walked on it post-op (although informed that they were to be non-weight-bearing) and none of these patient failed to fuse.
In the case of a talectomy, allograft bone stock was used to...
Editor's note: Dr. Secord's extended-length letter can be read here.
10/22/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Physician or Allied Healthcare Provider?
From: Rod Tomczak, DPM, MD, EdD
We are convinced that we are physicians. Unfortunately, the rest of the world has not universally been persuaded to classify us as such. It’s not so much what the 40,000 or so of us call ourselves, but what does the rest of the world call us? Why is there a reluctance to move us from the allied healthcare provider column into the big boys’ physician column? I always look at economics as a reason for most social problems, then move to self-esteem issues before considering what may be the truth. One horrible truth is that there is nothing we do that other physicians or healthcare providers can’t do.
I was on the admissions committees at both Des Moines University College of Podiatry and the Ohio State University College of Medicine. Yes, there are vast differences. That is not to say that students at the podiatry colleges could not...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
10/14/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: APMA Should Promote Annual Comprehensive Diabetes Prevention Foot Examination for At-risk Patients
From: Lawrence Rubin, DPM
The American Medical Association (AMA) states its policy position on aspects of medical care it believes should be promoted to the public. An example is the information it provides about having regularly scheduled female mammography examinations (see link).
As one of the most senior APMA life members, I suggest APMA develop and promote a policy statement that is posted on the Internet that advocates for an annual comprehensive diabetes amputation prevention foot examination for at-risk patients. When the policy statement is published online, the concerned public could easily promote this information to family, friends, and others through group and individual sharing in LinkedIn and other social media, as well as through APMA-generated national news releases.
Lawrence Rubin, DPM, Las Vegas, NV
10/05/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Robert Kornfeld, DPM
I think it is an absolute travesty that as the years went on, podiatrists have been paid less and less. I agree with Dr. Kass that something must be done. However, it is my opinion that a union will have only limited success because insurance companies will still retain the power of payment. After all, they collect the premium dollars. They don't want to share that money with doctors. You can go on strike, but you will be limited to the power of negotiation and the amount of money that insurance will be willing to let go of.
There is a movement (finally) in medicine back to private practice/direct-pay models. I am friendly with many MDs and DOs who are leading the charge away from...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
10/05/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Irv Luftig, DPM
Although it may be a good thought to unionize physicians, podiatrists, dentists, etc., it's a really bad idea. It was a tactic used by various medical groups a few times up in Canada and each time ended quickly as a miserable failure. There was absolutely zero support from the general public. There was palpable outrage from the public. Simply put, doctors (MDs, DOs, DPMs, DDS’) are perceived as wealthy because "we all make hundreds of thousands of dollars."
The public doesn't care about overhead, salaries, etc. Most people make $50,000 or less, maybe a bit more. You will be viewed as greedy, wealthy, uncaring, and if you withhold services in a strike, then watch out for the swift reaction from politicians and the public. Politicians will make mince meat out of you and the public will hate you. It won't be pretty and you will potentially be losing your patients' trust for years.
Irv Luftig, DPM (retired), Toronto, Ontario, Canada
09/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Robert Kornfeld, DPM
I thoroughly enjoyed reading Dr. Tomczak's post about how exciting it is to have a new APMA administration that finally understands what is happening and is going to do something about it. Well, I am a 1980 graduate of NYCPM. If you do the math, I graduated 44 years ago. And during all 4 1/2 decades that I have been a podiatrist, APMA has been "working" on making things better for us. Sometimes, they work "hard" at making things better. Yet, in all these years, not only has it not gotten better, it has gotten so much worse.
I won't go into details about my personal issue with my own NYSPMA which I quit many years ago, but what I will say is if anyone out there wants to make things better, you need to stop counting on APMA and do it yourself. When I realized that nothing was changing for the better, I decided to do it myself. And to be honest, my efforts to improve my professional experience all paid off without dues to an organization that is always working hard for us but never seems to accomplish what they promise.
I'm sure I'll catch some backlash for this, but my career is nearly over and I don't care what they have to say about me and my opinions. Of course, what I have already heard is if I'm not a dues-paying member, then I'm part of the problem. Nah. My career was amazing in spite of, not thanks to, APMA.
Robert Kornfeld, DPM, NY, NY
09/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Jon Purdy, DPM
Regarding the post from Dr. Tomczak, I did find that very amusing. I don’t intend to do a back and forth on this, but suffice it to say, I never put someone’s name in print without their permission. I’m sure that person would have been fine with it had I asked.
All associations post-covid have struggled, which necessitated change. As treasurer of the American Academy of Podiatric Practice Management, there has been change required of our own organization. We welcome constructive criticism, as it helps us improve and grow. It’s no different for the APMA. Time will tell, but I like the vibe they are currently putting out, and its leaders seem to be in tune with positive change.
Jon Purdy, DPM, New Iberia, LA
09/26/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Rod Tomczak, DPM, MD, EdD
I wonder if Jon’s letter was written tongue in cheek. If accurate, Jon’s report about a recent encounter with a secret agent from APMA who assured Jon there are changes a comin’ at APMA headquarters gives cause for celebration. That’s tongue in cheek. If what Jon was told is indeed true, and why should we doubt anything out of the mouth of an unnamed secret APMA leader, then I am grateful that the spirit of Deep Throat is alive and well in Washington, DC. One difference between the original Deep Throat and the APMA Deep Throat is that the current mole is wearing old Rohadur orthotics posted to the casts to throw off younger potential trackers.
But there is a disparity between these new APMA promises and those made in the waning moments of the Nixon administration. Deep Throat’s assertions proved to be true. Both the current APMA Deep Throat and the Watergate Deep Throat were accurate when they presently advised Purdy and in...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
09/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Kathleen Neuhoff, DPM
I have always found it interesting that when gabapentin was only available as Neurontin, insurance companies would not pay for it because it was off-label use. Then Lyrica came on with it on-label used for diabetic neuropathy, but at a high cost. So, the insurance companies would decline Lyrica until the patient had tried and failed gabapentin, which was still off-label.
We all know that cost is never considered an adequate reason for choosing a drug, so when my patients would decline Lyrica, I had them sign a consent form advising them that we were using gabapentin in an off-label manner, and that they had declined my recommendation for Lyrica.
I do the same thing when I am using something off-label for surgeries. For example, I use cryoablation for most of my neuromas with very good success, but I have the patient sign a form telling them that the instrument I’m using was not designed for neuromas. Many of my colleagues thought I was a bit paranoid, but maybe I was not!
Kathleen Neuhoff, DPM, South Bend, IN
09/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Justin Sussner, DPM
But how often do all of us get a fax or email or phone call that "ABCD" antifungal cream needs pre-approval, all for what may be a $20 generic. Isn't it the insurance companies' fault for not requiring the big ticket items to be pre-authorized first? This doesn't make sense to me. Maybe they just don't trust DPMs, and let the MDs do whatever they want.
Justin Sussner, DPM, Suffern, NY
09/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Ron Werter, DPM
What I don’t understand (and maybe the lawyers among us could explain) is how does the insurance company have the legal right to charge the doctor for writing a prescription. The doctor has no financial stake in the prescription; the patient and the pharmacy are the ones who have financial benefit. Is there something in an insurance company contract that says they can do that?
Ron Werter, DPM, NY, NY
09/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Back to the Future
From: Steven Finer, DPM
Upon reading the new issue of Podiatry Management, I counted ten ads for various creams and lotions pertaining to skin, nails, and pain relief. There were other ads for orthotics and podiatry-related machines. I have a 1962 Journal of the American Podiatry Association. It contains three ads for prescription internal medications. Also there were various ads for skin, nails, and orthotics. I know the various surgical magazines feature countless ads for surgical instruments and devices.
Must we now read internal medicine journals and use the Internet to review the latest medical news. I know everything is segregated in medicine, but this 62 year old journal was ahead of its time.
Steven Finer, DPM, Philadelphia, PA
09/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Recoupment Responsibility for Prescribing Ozempic
From: Paul Kesselman, DPM
While podiatrists rarely if ever prescribe Ozempic, a recent story in my local newspaper (Newsday) yesterday caught my attention sending shivers down my spine. Apparently, some insurers (UHC was named as one) are targeting physicians who prescribe medications off-label. They are now asking the physician for recoupment for the money they had reimbursed for Ozempic when the physician prescribed this off-label. One physician is facing a $125K recoupment merely for writing prescriptions. Interestingly, he is not being accused of falsifying medical records to get patients covered for Ozempic because he never did. He essentially prescribed Ozempic for weight loss and nothing else.
How many physicians (including DPMs) have written off-label prescriptions? I dare say most, if not all. In the podiatry world, prescribing Neurontin for neuropathy or chronic pain and cortisporin otic solution (neomycin and polymyxin B sulfates and hydrocortisone otic solution) post-matrixectomy easily come to mind. There are certainly many examples, all of which set a dangerous precedent if insurers are allowed to recoup money from providers who simply write a prescription for a medication which works, but for a non-FDA-approved purpose.
Medicine must fight this latest incursion to muzzle our independence and thus prevent our ability to provide our patients with the care they deserve. Unfortunately, the insurance companies are often shielded from legal action brought by patients who are denied coverage by their insurance carriers. Now the insurance companies want to sue us for the mere act of prescribing medications for purposes they don't agree with. The playing field is continuing to be unfavorable for physicians and it's high time we put a stop to this.
Paul Kesselman, DPM, Oceanside, NY
09/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Rod Tomczak, DPM, MD, EdD
Allen Jacobs' letter on why one chooses an NP for care piqued my curiosity, but in a tangential direction. I began to wonder about the APMA Seals of Acceptance/Approval. The APMA states it desires to provide information for podiatric physicians, their patients, and the general public to ensure they can make the best possible decisions regarding foot health. On their website the APMA states the Seal is not an endorsement. Shakespeare said it best, “A rose by any other name is still a rose.”
There is a committee that determines which product is fit to use the seal/logo of approval. The members of the committee are confidential according to the APMA website. I understand. God forbid an approved treatment for bromhidrosis does not work for someone. This NSA committee is protected from retribution and the need for Witness Protection, which can get very expensive. The APMA website stresses safety and utility and the need to submit various documents to the APMA proving efficacy. They do not mention if there is a fee for evaluation of a revolutionary flip-flop seeking...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
09/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Ivar E. Roth, DPM, MPH, Jeffrey Trantalis, DPM
Dr. Jacobs is correct. WE the profession, APMA, need to fund a campaign on TV to get the word out about our services. I had a local Dr.’s wife who was treating with an MD orthopod foot and ankle fellowship trained with the usual hands-off approach. The patient had an ulcer that was infected and very callused. When she saw me, the first thing I did was debride the callus which gave her immediate relief and now the ulcer could also drain properly, etc. Let’s make this happen. Good observation Dr. Jacobs.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
Dr. Jacobs is correct in the ability to promote podiatry as a profession. However, because of my experience working for a back surgeon, we as a profession can take it a step further promoting non-surgical care for the lower extremities and lower back. People are not aware of our training and skills in the biomechanics which provides a non-surgical approach to the complete lower extremities and lower back care.
Jeffrey Trantalis, DPM, Delray Beach, FL
09/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Kathleen Neuhoff, DPM
Sadly, I must agree with Dr. Doms. I was president of the American Animal Hospital Association years ago and we investigated the cost of such a campaign. It was many millions of dollars. At that time, there were about 50,000 veterinarians. It would have required a donation of more than $500 each if EVERY veterinarian contributed. We polled our members and the average they were willing to contribute was $100. And we knew from PAC contribution records that less than 10 percent would actually contribute, so it was not feasible.
The advertising we have been able to do has been primarily supported by our vendors but I suspect the amount of money spent by clients for products such as pet foods, cat litter, flea products, etc. far exceeds the amounts spent by our patients for podiatric-related products. It is certainly possible that some of the podiatrists reading this would be happy to contribute $1,000 each year for a PR campaign, but I suspect most would not.
Kathleen Neuhoff, DPM, South Bend, IN
09/17/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Pete Harvey, DPM, Stephen Doms, DPM
Kudos to Dr. Jacobs for his astute observation of NP advertising! I fervently hope some podiatry entity will pursue this.
Pete Harvey, DPM, Wichita Falls, TX
With all due respect to Dr. Jacobs, the number of nurse practitioners is about 385,000 according the American Association of Nurse Practitioners. They graduate about 39,000 each year (Fact sheet, AANP). With those numbers, they can afford to advertise. We graduate about 500 DPMs each year. They outnumber us by 20 times or more. Our profession is so small we could never compete with their kind of national television advertising.
Stephen Doms, DPM, Hopkins, MN
09/17/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Robert Scott Steinberg, DPM
I can tell you why the APMA doesn't do something similar: money and how they spend it. It is costly to put on the HOD. The budget for the 2024 HOD was $234,000. The Illinois Association of Podiatric Physicians and Surgeons has budgeted $20,000 for the 2025 HOD. Each state could use some of what they budgeted for the HOD to promote our profession. The APMA could do the same.
Nothing Earth-shattering happens at the HOD that necessitates hundreds and hundreds of delegates going to DC. The HOD recently ditched Roberts Rules of Order for Sturges for no practical purpose other than acting like they are the House of Lords. If you go to Facebook and search for plantar fasciitis, you will then be inundated with ads from PTs, DCs, and others who claim to be the experts. I rest my case.
Robert Scott Steinberg, DPM, Schaumburg, IL
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