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RE: The American Board of Wound Medicine and Surgery 

From: Joseph G. Smith, DPM 


I see there is a new wound care certification board called The American Board of Wound Medicine and Surgery for MDs/DOs, but not for DPMs. Do our leaders plan to fight this?


Joseph G. Smith, DPM, Virginia Beach, VA

Other messages in this thread:



RE: Misinformation About Cartiva

From: Craig Breslauer, DPM


I have been performing Cartiva with positive results since its inception. I have performed over 20 thus far. Compared to most surgeries we do, it is technically easy and quick.The purpose of my post is to garner opinions regarding how to, or not, handle some of the comments I have encountered regarding podiatrists vs. foot orthos doing this procedure. I became aware of a Cartiva Facebook page and have read quite a bit. The majority of the posters have used orthos and many recommended only using a foot ortho. Furthermore, there is a foot ortho who acts as a moderator. I do not know if he is affiliated with Cartiva as a company or sanctioned as a moderator.


If the company supports the propagation of such misinformation, I think our profession needs to address it. I know I see poor outcomes/complications of both fellow podiatrists and foot orthos as I am certain they see some of mine. 


Craig Breslauer, DPM, Stuart, FL



From: Joseph Borreggine, DPM


Dr. Williams, I must sorely disagree with your premise statement with respect to the theme of this article and how the patient was “victimized” by the physician assistant and the pharmacy. This is nothing more than the “drive by media” producing a sensational “fake news” story on how big pharma is destroying healthcare by “overcharging” patients for medication that they may or may not actually need. 


The author of this article makes the reader believe that this patient who seemingly is a well-to-do retiree based on her aforementioned resident geographic locale on “Capitol Hill” was taken advantage of without...


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



From: Elliot Udell, DPM


The story as referenced by Dr. Williams is not about a compounded drug, but is about  Kerydin, which is a brand name drug widely available for the treatment of onychomycosis. It is applied topically and it became available at roughly the same time as Jublia, another topical antifungal. These medications are not only expensive but if used properly, only last a month. What is even worse is that the clinical success data provided by these companies does not rate them as panaceas for the treatment of  fungal nails. They are by no means gold standards. 


In our practice, after fungal testing, we might prescribe these medications, but only if the patient's insurance company combined with company incentives make them affordable. If the patients are going to have to pay over a thousand dollars for a month's supply, we will offer them a choice of several new antifungals which not only can be dispensed from the office but have been shown to be clinically effective. 


Elliot Udell, DPM, Hicksville, NY



From: Michael L. Rahn, DPM


I had to chuckle when I read Dr. Luongo's posting about meeting a resident from the late 1990s and he referred to the recent meeting as "so many years later.


Drs. Enrique Spiegler and Michael Rahn


Last year, I met a newly arrived "resident" at a retirement facility where I provide care. He introduced himself and told me that he had taught at NYCPM. I was so delighted to get re-acquainted with vascular surgeon, Dr. Enrique Spiegler, who taught us at NYCPM. The last time I had seen him was in 1969. 


Michael L. Rahn, DPM, McLean, VA



From: Bill Beaton, DPM


In conversations with my billing company E-Professional Technologies, we have researched this situation and, yes, this is a national issue and we are equally outraged. We can still obtain information on Medicare deductibles for regular beneficiaries. However, there is a fairly new program for Medicare/Medicaid beneficiaries called Qualified Medicare Beneficiary (QMB). 


For QMB patients, providers are not permitted to charge the patient anything. So the government, in their infinite wisdom, has decided we are not entitled to know how much we are paying on behalf of each patient! If we can't collect the money, then essentially we are paying the bill on their behalf. Is it $1 or is it the entire $183 deductible? We are not allowed to know. If you see 100 patients at a nursing home in one week, that could mean $18,300!


I called First Coast Service Options (which is the Medicare MAC for Florida) and asked them how we could determine the amount that we would be responsible for, and I was told we are not allowed to know. I have written my congressman about this. It is literally outrageous that a doctor is responsible for paying a patient's deductible and they are not allowed to know how much is at stake. I am now playing a game of holding all QMB claims until I see that all other patients have met their deductible and I'm going to assume they have too, but that's not very accurate.


Bill Beaton, DPM, Saint Petersburg, FL



RE: The Importance of Challenging Medicare

From: Amy Schunemeyer, DPM


So, I noticed that my Medicare allowable was less than the Novitas website posted allowables for my claims coming back for 2018. There is a Novitas mistake that they were following the WRONG fee schedule up to 2/23/18, and they are working on resubmitting corrected claims. This is one problem fixed. 


And, I notice that the increased payment adjustment is in the form of a positive ($xx.xx) adjustment on our EMRs. This is quite a software accounting nightmare. How are others handling this? These are a few of my questions because I am NOT receiving increased payment from the many, many....


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



From: Connie Lee Bills, DPM


Yes! We have the same problem in Michigan. I am not a Medicaid provider, so I face “eating” the deductible and being paid $0 for services. I am contemplating not seeing any Medicare patient that is categorized “QMB”. These are the only ones you can’t see the deductible for.


Connie Lee Bills, DPM, Mt. Pleasant, MI



RE: Inability to Verify Satisfaction of Deductibles

From: Ira Cohen, DPM


For years, we have been able to verify benefits and deductible satisfied on all of our Medicare patients via NaviNet, Office Ally, or directly through Medicare Portal (in our case Noridan Southern California). We would hold claims until their Medicare deductible was satisfied on the Medicare-Medical portal to avoid lower reimbursement from Medi-Cal.


Recently ,we discovered that on the Medicare-Medi-Cal portal only, we can no longer see if their deductible is satisfied. We called Noridian and they told us, "You don't need to know that information because the patient is not responsible for deductibles anyway - Medi-Cal is. This is outrageous and unfair. My guess is that they have worked out a deal with the state(s) to reimburse us less. Is anyone else experiencing this? If this is a national issue?


Ira Cohen, DPM, Downey CA



From: Simon Young, DPM


With 3-year residencies programs, a publishable, even collaborative, paper should be a requirement for graduation.  So much research can be done over their tenure as residents and they should recruit their podiatric director, administration, and other specialties in neurology, orthopaedics, ER, medicine, endocrinology, dermatology, podiatry, rheumatology, infectious diseases, biomechanics, physical therapy, etc. What a plethora of topics available to be researched and put us on the map. We need to show the other professions that foot pathology is more than nails and callosities.


When I was a residency director, it was difficult to impossible to get my residents to publish or offer research ideas. I did have the cooperation of administration and some specialties but not all. The ER was willing so I was able to get one research paper published.


NYCPM has a relationship with Ireland Podiatry School and they present more research than our graduating 3-year residents. What are they doing right?


Simon Young, DPM, NY, NY



From: Brian Carpenter, DPM


I think this is a very important question/observation by Dr. Borreggine. Dr. Saxena mentions George Liu, DPM recently ran for the ACFAS board (and won) on the platform that DPMs need to do more research and start maintaining registries which I 100% agree with. 


One thing that Dr. Saxena did not mention is that we have a very large and powerful society, The American College of Foot and Ankle Surgeons, which states that part of its mission/vision “is to advance and improve standards of education.” The college has over 300 volunteer leaders serving on committees and serving on educational faculties. One of their strategic initiatives is to “advance scientific and clinical research to maintain leading edge competency among our members“ and “deliver superior continuing medical education to enhance competency at every level of professional training.” 


Just as with the residency programs, the College is rewarding those with little to no academic experience or background and placing them into leadership and educational roles. Good examples of this are at the Annual Scientific Meeting in Memphis next month. They have 12 speakers who have never published in the Journal of Foot and Ankle Surgery (JFAS), the College's own journal. There are currently 4 members on the Board of Directors and 52 committee members who also have not published in the JFAS. For us to truly gain parity in medicine, we have to be doing the work of the other medical professions, and research and publishing are at the top of the list that we are lacking in.


Brian Carpenter, DPM, Fort Worth, TX



From: Stephen Doms, DPM


I, too, have asked this question. When I completed my surgical residency in 1981, it was a requirement that residents, individually or as a team, write an article suitable for publication to the Journal of the American Podiatry Association (JAPA). We three residents wrote and published our article in JAPA for the February 1982 issue. Is this no longer a requirement of podiatric residencies?  If not, I think it should be.


Stephen Doms, DPM, Hopkins, MN



RE: Lack of Podiatric Authors in Our Journals (Joseph Borreggine, DPM)

From: Leonard A. Levy, DPM, MPH


I agree with the remarks of Joseph Borreggine, DPM about the lack of podiatric authors in our journals, a phenomenon that I believe needs some attention. To accomplish that, more emphasis needs to be made in the education and training of podiatric physicians in the research process at the level of both residency and undergraduate podiatric medical education. Expanding that emphasis could result in an increase in the production of a critical mass of podiatric medical research and scholarly articles reporting on such activities.


Not only are there a lack of articles reporting on research findings in podiatric medical journals, but also in journals of other medical specialties that would find such information useful as well and result in expanding the awareness of other health professionals about the depth and role of our profession.  


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL 



RE: Lack of Podiatric Authors in Our Journals (Joseph Borreggine, DPM)

From: Amol Saxena, DPM


There are many reasons for the lack of DPM-produced research and more non-DPMs publishing in our journals. 


Most podiatric students and residents are not required to actually complete written and publishable research during their training. There may be less "perceived value or need". As I interview fellowship candidates, I am able to see how much research they are actually required to complete. Most are case studies. There was a time where podiatrists were trying to document their cases and show the pathology they were capable of seeing. Publishing was the only way to...


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



RE: Lack of Podiatric Authors in Our Journals

From: Joseph Borreggine, DPM


Can anyone explain why the authors of most of the articles in our podiatric journals are now written by mostly non-DPMs, foreign doctors, and others not in the field of podiatry?


I remember the days when all I ever saw was solely DPMs authoring in these journals that represent this profession. I recognize none of the names of those who are published in these journals. Does this mean that we, as profession, are no longer interested in research and writing about what we do anymore?


Have we just left innovation and outcome studies in the hands of others who have nothing to do with podiatry, or are these journals now just a platform for a totally new and international audience specializing in foot and ankle medicine and surgery?


Joseph Borreggine, DPM, Charleston, IL



From: Brian W.  Zale, DPM


I would like to tell you how the opioid crisis has affected me, my wife, son, family, relatives, and friends. Exactly 11 months ago today, my 31 year old son died in the bathroom sitting on the toilet two weeks before his younger brother got married. At 10:00 am, he asked me if he could use that bathroom as we had had some plumbing issues and I said no problem, we had it repaired. At 11:15 am, he was pronounced dead at St. Luke’s hospital here in Sugar Land, Texas. As per the autopsy report, cause of death, opioid toxicity.  


This is a real crisis. Addiction is a terrible thing, a nightmare for everyone involved. It's like being on a electrical fence, you want to get off but you can't. He knew more about the drugs that I prescribe than I did. It has made me a better doctor. I have no problems telling a patient that I won't give them any more Rxs. I have no problem telling these patients I lost my son to addiction. It’s funny how after I tell them that that, they no longer ask for it.  


My son would have been 32 this Wednesday on Valentine’s Day. It's going to be a tough day for my family and myself. God bless you all.


Brian W.  Zale, DPM, Sugar Land, TX



From: Bret M. Ribotsky, DPM


I have been consulting and advising for the past 18 months in the buying and acquisition market for medical dermatology practices. While I have not specifically worked with the DPM market, the foundations and principals from the hedge funds and private equity people are similar. It’s all a function of EBITA (Earnings before interest, taxes, and amortization. EBITA refers to a company's earnings before the deduction of interest, taxes, and amortization expenses). 


In simple terms, it’s the PROFIT left over after you have removed your ownership from the practice and paid someone (or you) to do the work you have done. For example, if you're a single practitioner and your practice gross is...


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



From: John V. Guiliana, DPM, MS


I wholeheartedly agree with Dr. Kashan and Dr. Ressler. It saddens me when I hear physicians state that "their practice has no value and they will someday just close the doors". Surprisingly, I hear this quite a bit.


A practice is a living and breathing entity. It needs to be continuously nourished and maintained. Marketing, continuous quality control, investment in technologies, optimizing processes, etc. all create inherent value throughout the years. In the end, the fair market value can be computed through various techniques which often revolve around net earnings and an applicable capitalization rate. Leave that to the experts. But there are buyers out there, so please take good care of your practice and it will certainly provide you with post-retirement income. 


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



From: Jack Ressler, DPM


I am very interested to find out the amount of time that passed between when the podiatrist passed away and when the practice was put on the market. I'm sure the deceased podiatrist had an excellent relationship with his patients that probably could not be duplicated by the revolving door of podiatrists who pitched in to help in this unfortunate situation. It led to a perfect storm for that other podiatrist. Although grief and shock by the family of the sudden death of their loved one probably prevented the practice from being put up for sale earlier, that delay cost them a very marketable practice. 


The other podiatrist who opened was very fortunate/underhanded to be able to take advantage of a unique and sad scenario that rarely occurs. I do not believe Dr. Name Withheld’s conclusion about a practice not having inherent value. A thriving modern up-to-date practice should have a good marketable value, especially if the seller takes the time and markets it properly. I worked very hard in my practice for many years and was able to sell it. I took the time to market it properly and got a nice return for my hard work.


Jack Ressler, DPM, Delray Beach, FL



From: Brian Kashan, DPM


I just read the posting by Name Withheld, about how he would choose to open an office next to an older practice instead of purchasing an existing practice. Although the circumstances he describes, with the sudden passing of a doctor is different than the more common scenario of a retirement, there are several similarities. If the practice has been a successful practice and is valued correctly, it should be an attractive opportunity for someone to acquire. 


There are several factors that I feel are being overlooked in the mindset of Name Withheld. Firstly, it is much easier to get a bank loan when...


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



RE: Allowing Podiatrists to Administer Flu Vaccinations

From: Elliot Udell, DPM


This year's flu epidemic is considered the worst in ten years. In NY State, Governor Cuomo has issued a directive to allow pharmacists to give vaccinations to kids as well as adults. If a pharmacist can give a flu shot, even though they do not give injections regularly, why shouldn't podiatrists be allowed to give flu shots? Are there any other professionals who give as many injections as podiatrists do?


Not only are we trained to give injections but because we deal with the elderly population, we would reach people who might not go their pharmacy or primary care doctor and get an injection when necessary. I call on the respective state societies to push their local legislatures to allow podiatrists to administer flu vaccinations.


Elliot Udel. DPM, Hicksville, NY



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



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



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



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. 



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