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08/20/2015    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Joel Lang, DPM


 


If you are paying 4.5% in credit card charges that amount to $5,000 per year, you are therefore receiving more than $110,000 in credit card payments per year. You should celebrate that. For one thing, when added to cash, check and insurance payments, you are operating a practice well into the mid 6 figures in income. Even if your credit card payments represent 50% of your total income (which is unlikely), the $5,000 will represent only 2% of your income. To be certain of immediate payment instead of hoping for a future payment, the 2% is well spent.


 


I think many of your colleagues would be most pleased to have your problem. In addition, when credit card payments are made more burdensome for patients, they may opt to say “send me a bill”. Then you incur billing costs, delayed payments, and a probable increase in uncollected accounts receivable. Worse yet, you may lose the patient altogether. If you want to save $5,000, drive your present car one more year. Pay the 4.5% and be happy you are earning a good living. We sometimes see our glass as half-empty when it should be viewed as half-full.


 


Joel Lang, DPM (retired), Cheverly, MD

Other messages in this thread:


01/16/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Noridian Medicare's Portal for Checking Patient Eligibility or Deductible


From: David L. Kahan, DPM


 


Just a head’s up to those that utilize the Noridian Medicare portal for checking patient eligibility or deductible status. The site will NO LONGER show you the deductible status of those patients who are considered “special needs”, i.e. Medicare and Medicaid (SNP). In the past, you may have held claims until deductibles had been met so you did not have to eat the deductibles. Now you will have to just guess or ask the patients when they come in whether they have been to the doctor and estimate the deductible remaining. 


  


David L. Kahan, DPM, Sacramento, CA

01/15/2018    

RESPONSES/COMMENTS (NON-CLINICAL)


RE: Difficulty Getting Local Anesthetics (Sam Bell, DPM)


From: Nick Turner, Joshua Kaye, DPM


 


While many local anesthetics specifically with epinephrine are out of stock nationwide, DocShop Pro - a podiatry distributor serving offices nationwide - has various sizes and types of Marcaine, Carbocaine, and lidocaine/Xylocaine (including Xylocaine 1% with EPI) available and in stock.


 


Nick Turner, Managing Director - DocShop Pro 


 


As many of you probably know, currently you cannot purchase lidocaine with epinephrine due to a so-called shortage of the product. Plain lidocaine is readily available from all suppliers.  One can also readily purchase 1 cc vials of epinephrine in a concentration of 1 mg / cc, which is available from local pharmacies, hospital pharmacies, and your usual medical suppliers. If you would like the usual 1% or 2% lidocaine with 1:100,000 epinephrine, simply draw up the 1 cc of 1 mg/cc of epinephrine into a 1 cc syringe, and inject 0.5 cc into the common 50 ml vial of lidocaine plain, and you will have your usual mixture of lidocaine with epinephrine.


 


So this "so-called" shortage really begs the question of why couldn’t the drug companies produce the usual lidocaine with epinephrine when the components are readily available? Does this have any similarity to the shortage of colchicine and the subsequent current increase of its price by about 2,000%, or the current enormous price increase of Atenalol?


 


Joshua Kaye, DPM, Los Angeles, CA

01/12/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: William D. Spielfogel, DPM, Vito J. Rizzo, DPM


 



This is an excellent initiative by NYSPMA and it is great that the Board of Trustees is being proactive in its advocacy for podiatry. They are an example of an organization advocating for its membership and trying to get a seat at the table.


 


William D. Spielfogel, DPM, NY, NY 



 


In our rapidly changing healthcare delivery paradigm, it is imperative that there be opportunities to help define what a particular category of healthcare provider can offer to contribute to the problems facing our population. Policymakers need to be educated on the facts as they relate to outcome statistics and verified cost factors. Many of these policy considerations are determined in a federal or centralized system. Podiatry’s first advocate should be the APMA. As experience has demonstrated, podiatry seems to be not permitted “a seat at the table”, and this profession is often caught needing to try to fix policy shortcomings after the fact. This has proven to be bad policy. 


 


I applaud the effort of the NYSPMA, which has been the leading advocate for progressive healthcare policy specifically as it relates to podiatry and to the communities we serve. NYSPMA led the charge, resulting in the Thompson Reuters Study which demonstrated the value of podiatry in the care of lower extremity manifestation of diabetes. NYSPMA has been trying for years to have care measurements developed specifically for podiatry, which could then force payers to better consider podiatry as a key partner in many healthcare scenarios. This effort in population health is the next phase of what has been a multi-year and ongoing effort to demonstrate the need for podiatry’s inclusion in a myriad of ongoing and pressing healthcare issues. The opioid crisis, fall risk, and the ever present concern with the ever rising costs of managing the effects of diabetes are areas where it has once again been shown that with podiatry on the team better outcomes and lower costs result. 


 


I encourage APMA, and all of its individual components, to carefully consider and then support the work of NYSPMA as a national effort. In the big picture, it will help podiatrists and their patients throughout the nation, and not just in New York.


 


Vito J. Rizzo, DPM, Bay Shore, NY

01/12/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Brian Kiel, DPM, Paul Busman DPM, RN


 


There is a national shortage. I was told that much of this was made in Puerto Rico and because of the hurricane damage there is none being made. I can't be absolutely sure of this as the reason but I do know it is a national problem.


 


Brian Kiel, DPM, Memphis, TN


 


I have a somewhat cynical theory about that. The drug companies make up a "shortage" of common but essential items (I once saw a shortage of 3L bags of saline!), let providers stew a while without it, then manage to meet the "shortage" and return the product to the market. Providers are so happy to get it back that they don't gripe about the fact that the manufacturers have raised the price significantly. This probably isn't true, but these days nothing surprises me. 


 


Paul Busman DPM, RN, Frederick MD

01/10/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Historical Perspective on Podiatry


From: Bruce Lebowitz, DPM


 


Since retiring, I have become a docent at a Johns Hopkins museum. As such, I have learned a great deal of history. When I entered classes at MJ Lewi Podiatry school, I learned that in 1912 organized medicine had ignored the foot. Dr. Lewi helped create the school in order to fill the gap. I’ve now learned more about the state of medical care in the late 19th and early 20th centuries.


 


Johns Hopkins University and medical school were founded at the end of the 19th century as a result of Mr. Hopkins' will which allotted some 71/2 million dollars toward that end. Nevertheless, the U.S. economy took a fall at the same time, making it impossible to get the school off the ground. As it turned out, the Hopkins board found a donor willing to shell out the extra millions. Mrs. Garrett, a wealthy philanthropist, donated the funds with a couple of strings attached. One, women would have to be admitted every year. Second, there would have to be students accepted who had achieved academically in college.


 


She did this because she well knew the state of medical care in this country was awful. She knew too that there were American medical schools graduating doctors who could not read or write. So, podiatry began out of need around the same time as academic medicine did. How’s that for parity? 


 


Bruce Lebowitz, DPM, Baltimore, MD

01/10/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: The Passing of Ivan Abrahamson, DPM



I had the pleasure and privilege, back in the mid to late '70s and beyond, to participate and work with Ivan and the Queens County Podiatry Society. We even co-authored a published article on minimal incison removal of a dorsal talar exostosis. Dr. Abrahamson was always a gentleman. He was a kind and caring man who was a credit to the profession of podiatry. He will be missed.



Larry Kobak, DPM, JD


01/08/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Brian Kiel, DPM


 


First of all, if one is to publicly praise and justify the actions of Joseph McCarthy, why are you ashamed to let us know who you are. He was publicly disgraced and proven to be a liar and was the precursor to the same political hate game we are seeing today. This "withheld" person is looking for ghosts under every bed and is obviously a proponent of the extreme right wing political persuasion. I disagree with his basic premise, but he has every right to espouse it, just don't do it behind a curtain. What are you ashamed of if not your views?


 


Brian Kiel, DPM, Memphis, TN

01/08/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Mike Kempski


 


I work on the insurance side of medical malpractice and have twenty five years of experience. In the early years of the Data Bank, the doctors had great concerns about entries against them. The concern was so intense that the carriers responded by changing their policy language as it relates to the settlement of claims. The change was the policies stated they won’t settle a claim without your consent to do so. However, I don’t think there was much reason to be worried. There’s very limited access to the Data Bank. For example, the general public (your patients) can’t access it. Medical malpractice insurance carriers can’t. Hospitals can. But they’re always very reluctant to revoke privileges. How has it hurt physicians?


 


Mike Kempski, Plymouth Meeting, PA

01/08/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: The HIPAA Audit


From: Richard B. Willner, DPM


 


One of the by-products of the passage of the HITECH ACT as part of The American Recovery and Reinvestment Act (ARRA) was the mandatory HIPAA Audit with mandatory fines. The passage of these laws were delayed to give time to understand the Regs and to come into compliance. It was not until April 2010 that the Office of Civil Rights (OCR) at the U.S. Dept. of HHS awarded two contracts to Booz Allen Hamilton, Inc. The first contract was for audit consulting support to OCR to help train the auditors. The second contract was to help OCR develop training seminars for state atty generals on HIPAA rules and regs. 


 


The HITECH Act is a subsection of the HIPAA of '96. HITECH Security Act part 2 strengthens many of the rules and regs of HIPAA and can be thought of making it stronger, especially for...


 


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

01/03/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 3


RE: Best Way to Study for 10-Year Forefoot Boards


From: Patrick (Pat) Caputo, DPM


 


I have recertified for foot surgery two times. If you study for foot surgery, you should do fine. Antibiotics, medicine and surgical principles are the same for foot surgery as they are for reconstructive rearfoot/ankle (RRA) surgery.


 


Patrick (Pat) Caputo, DPM, Holmdel, NJ

01/03/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Medical Symbol Misunderstanding 


From: Rick Harris III, DPM


 


Why do we still see the caduceus linked with medical associations instead of the Rod of Asclepius? The confusion seems to stem from the appearance of the caduceus on the chevrons of Army hospital stewards as early as 1856. A misinterpretation led to the caduceus being adopted by the United States Army Medical Department in 1902. It would gain such popularity that it even briefly served as the symbol for the AMA, but would subsequently be replaced by the Rod of Asclepius. 


 


Many believe the caduceus to be inappropriate as it is associated with the Greek god Hermes, who was patron of commerce as well as thieves, liars, and gamblers. Being as that, it is interesting to see its continued usage. There have been a number of recent articles in the medical literature that have highlighted the inappropriateness of the caduceus as a symbol of medicine and have sought to restore the Rod of Asclepius to its rightful place. For historical context, look no further than the first paragraph of the original Hippocratic Oath, “I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea, and by all the gods and goddesses as my witness, that, according to my ability and judgment, I will keep this Oath and this contract."


 


It will be interesting to see if there is a continued shift by academic and health institutions to the single serpent entwined rod wielded by the Greek god of healing and medicine, Asclepius.


 


Rick Harris III, DPM, Jacksonville, FL

01/03/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Regulation for Power over Physicians and Surgeons


From: Michael M. Rosenblatt, DPM,


 


The abuse of physicians is clearly a byproduct of progressive liberal rule of the United States. Ostensibly, it is "couched" in regulation to raise the standard of care and "limit" damage by "incompetent or dangerous physicians." The regulations and their promulgators always say this is for the public good. It has nothing to do with the public good or protection. It is entirely regulation for POWER over doctors and professionals. It creates "boards of review" who are not qualified in most cases and also exposes physicians to "Star Chamber" procedures and accusations with absolutely no civil rights. 


 


Make no mistake: Regulation is for power. It has no intent or purpose otherwise. It also creates boards and employment for non-professional people and expands government into every aspect of our personal and professional lives. Physicians must be careful for whom they vote. Bigger government means lack of rights without improvement in opportunities. Marxism is a byproduct of big government. This country has been on a rolling slope toward cultural and professional Marxism with Democrats in control. 


 


The "members" of these various committees are fools if they believe they are on the "right side." It is only a short step, under accusation of another person who wishes to take away your rights, your profession, and your money....to be ON the other side and become a target yourself. 


 


Michael M. Rosenblatt, DPM, Henderson, NV  

01/02/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Jack Ressler, DPM


 


We've been using Square in a satellite office for several years. The rates are very competitive and they email you a confirmation of payment within a few minutes of the transaction. You can access reports quickly on-line with relatively easy navigation.


 


Jack Ressler, DPM, Delray Beach, FL

01/02/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Best Way to Study for 10-Year Forefoot Boards


From: Mark L Miller, DPM


 


I just recertified last year for the second (and last) time—the Goldfarb Board Review Course was all I needed. I took the class over a weekend and then took the test the next week. Everything was fresh in my head and the test was not bad at all. As one of the instructors in the course said, "the recertification test is testing what you do every day."


 


Mark L Miller, DPM, McLean, VA

12/28/2017    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Due Process Rights and Peer Review


From: Richard B. Willner, DPM


 


Medical peer review is the process by which a committee of physicians investigates the medical care rendered by a colleague in order to determine whether accepted standards of care have been met. The professional or personal conduct of a physician may also be investigated. If the  committee finds that the physician departed from accepted standards, it may recommend limiting or terminating the physician’s privileges at that institution. If the physician’s privileges are restricted for more than 30 days, federal law requires the peer review committee to report that fact to the National Practitioner Data Bank. 


 


There is no federal statute that requires peer review committees to observe due process, which the Supreme Court has defined as...


 


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

12/28/2017    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Rules of Evidence and Professional Practice


From: W. David Herbert DPM, JD


 


Anyone who is interested in determining who can do what to whom in a medical sense should review the appropriate licensing acts of all medical type providers in states like Montana, Alaska, and Minnesota. I also recommend that they review the scope of practice of naturopaths in states where they are licensed. Not too long ago, I was contacted by several state legislatures about the issue of nurse anesthetists obtaining hospital privileges on hospitals that only employed anesthesiologists. The unlimited scope of practice of nurse anesthetists was not the issue. Only the politics involving who was granted hospital privileges in the larger hospitals was the issue. In states where they are allowed to practice independently, many nurse anesthetists have larger incomes than many primary care physicians.


 


In a medical malpractice case in some states, nurses can testify against physicians and vice versa depending on the issue. In a lawsuit involving medical providers, it will be your malpractice carrier that will determine whether you are covered or not. How it is in Florida is not how it is everywhere when it comes to the practice of anything that might be related to medicine.


 


W. David Herbert DPM, JD, Billings, MT 

12/27/2017    

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



From: Steven Kravitz, DPM


 


Dr. Markinson makes some very salient points that podiatrists should consider. There is no turning back the clock; physician extenders are here to stay. But the good news is that there has been a change in podiatry recognition of this aspect of delivery care over the past 3 to 4 years. Assessment of the membership of a well-established physician (MD and DPM) only wound healing association provides interesting data on a dramatic shift with podiatric perspective on NPs and PAs. 


 


Four to five years ago, there was much more concern about competition with these practitioners and therefore a conflict of interest. But over the past two to three years, more and more podiatrists are working with...


 


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

12/27/2017    

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



From: Janet McCormick, MS


 


As per dental hygienists practicing without supervision, I would truly like to know where that is? I'm thinking that somewhere in the background there is a "dental supervision" requirement, possibly similar to aesthetic spas level peels etc. as long as they are "supervised by a physician." Many of these medical supervisors are not on site, but there is a responsibility there, and they must be within a set distance. And they are financially involved in some way. 


 


I find it doubtful that dental hygienists would escape the supervision of dentists fully. The dental associations are very active in the legislative processes and...


 


Editor's note: Ms. McCormick's extended-length letter can be read here.

12/26/2017    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Lorraine Loretz, DPM 


 


I have been employed in an academic vascular surgery group for the past 10 years. Vascular surgeons do a lot of work with peripheral vascular disease, and depending on where you practice, do most of the amputations for non-reconstructable PAD. I was hired as an NP (I am dually credentialed), but they quickly realized the potential for having a podiatric surgeon in the group, so added me on to the staff with surgical privileges. You will end up doing a lot of limb salvage. If your state permits, they will have you do all the amputations up to the ankle.


 


I found it to be very interesting work and introduced all of the 'toe' aspects of 'toe and flow' to the team. I did the reconstructions, grafts, etc., and did all the follow-up in clinic. I introduced advanced wound care products, TCC, orthotics, etc. to the group and assisted in training their resident team in limb salvage principles. You will learn a lot about the value of vascular reconstruction, non-invasive vascular testing, etc. 


 


Make sure your vascular surgeon does distal bypasses and distal angio work. Like I said, it was very rewarding work, but you need to be sure to negotiate your role in the practice.  A podiatrist will never be replaced by an NP/PA. We have 11 of them, but they can't do the surgeries and don't have the podiatric training to manage post-op salvage to ambulation. Podiatric care is essential to a full scope vascular surgical practice.


 


Lorraine Loretz, NP, DPM, Worcester, MA

12/26/2017    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: W. David Herbert DPM


 


I have two cousins who many years ago became dentists. Today, there are individuals called "denturists" in some states who can take dental impressions and make dentures without a dental referral. In a couple of states, dental hygienists can practice privately, and in one state can even fill a tooth without a dentist's supervision. In a number of states, a certified nurse anesthetist may practice independently without medical supervision. Also, in some states, a physical therapist does not have to have a doctor's referral to see a patient.


 


Any person rendering a service that can be construed as the practice of medicine will be held to a medical standard of care while so doing. This is true in all of the jurisdictions that I am familiar with. I still say it is more important that a podiatrist be defined as a physician than that he or she be granted an unlimited scope of practice. You do not find orthopedic surgeons delivering babies or ophthalmologists performing bunion surgery, even though it is in their technical scope of practice. They are limited primarily because of liability issues.


 


W. David Herbert, DPM, JD, Billings, MT

12/25/2017    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Don Steinfeld, DPM


 


Kudos to Brian Markinson. We should all remember that every interaction we have is an opportunity to promote podiatry as a profession and ourselves. What a positive outlook he has. It’s so easy to fall in step with negative thinking and negative thoughts. This is a great way for all of us to start the new year on a positive note. 


 


Don Steinfeld, DPM, Farmingdale, NJ

12/25/2017    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Janet McCormick


 



Every time I hear discussions about nurses taking over podiatry, I think of how wayyy-back-when dentists said to each other "hummm, this may happen." The difference between them and podiatrists is the dentists organized to make certain it didn't. Thus, was borne the dental hygienist (the legislation snatched it away from the potential of nurses doing this work without the dentists) who does the work the dentists do not want to do, are educated to do it correctly, and are legally the only ones who can (other than dentists). But these dental hygienists CANNOT under legislative law do so in any state (that I know of) except under the direct supervision of a dentist. And it was all put through by the state dental associations. I have discussed this with many podiatrists over the years, even suggested organizing and getting the restriction developed, but they never got it!! So, now, it is too late. 


 


Think about this: no patient can have their teeth cleaned, have x-rays, etc. EXCEPT in a dental office or clinic - wherever, they must have a dentist on staff. And the patients have no choice of where to have this work performed. Wouldn't you love that? But alas, you are too late, I fear.


 


Janet McCormick, Frostproof, FL


12/25/2017    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Joint Venture with Vascular Surgeon


From: Steven J. Kaniadakis, DPM


 


From my practical experience, vascular surgeons, as with the rest of the MD community, will typically employ a physician assistant (PA) . Therefore, I suspect that you will be taking your time training a PA about what we know until the vascular surgeon replaces you with the PA. The solution may be to have a five (5) year contract with some clause on what money you will receive if there is termination for any reason at all (or for no reason at all) short of the time contracted. 


 


Steven J. Kaniadakis, DPM, Saint Petersburg, FL

12/23/2017    

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



From: Eddie Davis, DPM


 



Dr. Borreggine has concerns about the implication for podiatry caused by expansion of ARNP scope. Dr. Herbert, in his response, related an interesting story about a podiatrist who later became a family practice physician, but his hospital did not offer him privileges for foot surgery. We should not view the efforts of other health professions to expand scope as a threat to podiatry. We should, instead, attempt to better define our scope of practice. 


 


Podiatrists, relative to training hours, have the narrowest scope of practice of any health profession. APMA believes that we need to emulate the allopathic model and increase residency training time. How do you tell a prospective podiatry student that he/she will be offered training equivalent to an orthopedic surgeon but that the scope of practice can only be less than 15 percent of that of an orthopedic surgeon and then tell that person that he/she may not be able to call themselves a physician?


 


The dental profession has figured out how to maintain a degree as a “limited licensed practitioner” and make it work. We either emulate the model of dentistry or move toward providing the MD degree. Standing in the middle of the door is not advisable because the door will keep hitting and bruising us.


 


Eddie Davis, DPM, San Antonio, TX


12/23/2017    

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



From: Bryan C. Markinson, DPM


 


Dr. Borreggine's concern is legitimate but not from the perspective of the elimination of podiatry, but that the DPM degree does not allow us full scope. The step up of ancillary providers such as NPs and PAs is a natural extension of the changing environment in medicine that enables patients to get seen and still be economically solvent. There is no turning back from this.


 


The best approach for DPMs by far is to let every full scope nurse practitioner in your community know your availability and what you can do. Even lecture to them at their meetings. From my own personal experience, the one NP who decides to do foot care is completely outnumbered by the rest that will not. Nurse practitioners are a steady consistent source of patients in my practice.


 


All we have to do is show up at the dance! Attend the hospital meetings of dermatology, endocrine, vascular, etc. They will flood your office.


 


Bryan C. Markinson, DPM,  NY, NY
Alma Lasers