I have to call Dr. Fullem, on the appearance of bias, when it comes to him recommending Hoka shoes. I have found them very unstable. They do have the unwanted tendency of excessively straining the calf and the Achilles. Because they are unstable, there is unnecessary overuse of certain muscles. Is there anything worse than getting or treating Achilles tendinitis if you are a runner? His use of the word "old", in an attempt to cast doubt on the proven protective properties of the classic 10-12mm drop, stability running shoe, further exposes his bias. Once runners get past the gimmicky nature of fad running shoes, they see the foolishness of some trends.
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.
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.
To echo Dr. Borreggine’s concern, I am currently sitting for my boards in both foot and rearfoot/ankle case reviews. I have the most recent training with the PMSR with the RRA certification. I had my share of failures with the CBPS portion of the exam and I found after speaking with the board that it was not due to my intellectual abilities to reason or make good decisions; it was how I was taking the test which was not explained at the time that I took that portion of the exam. After speaking with them, a video was posted regarding my specific issues that I experienced, which leads me to believe that this was a common problem among candidates.
Once I passed my CBPS portions, I sat for my case review. This was the most frustrating aspect of the process. I was failed based on...
Editor's Note: This extended-length letter can be read here
I graduated from a 3-year residency program in 2013. I passed all my NBPME exams the first time and I passed the ABFAS qualifying exams the first time. Then I bought a non-surgical practice in a small town and set to work. I have spent 4 years building up my case volume and then was able to sit for the exam. I failed both the case studies and the computer-based examination. My hospital says I have to be board certified in a 5 year window. I have one more shot at it in 2018.
During residency, ABFAS lets you take yearly practice tests to be prepared for the qualifying exam, but not after residency. So, I went 4 years not taking a practice test and then finally being able to sit for it and failing it (They used to make you wait until your case volume was built up prior to taking the computer-based exam). Just this year, I heard that ABFAS is allowing candidates to...
Editor's note: Name Withheld's extended-length letter can be read here.
I totally agree with Dr. Udell. Years ago, when a patient didn't want to pay a bill, they threatened to sue. Now-a-days they threaten to post a "nasty review"(because it will cost them money to hire an attorney). The fact that this patient not only wanted the fees removed, but also a DISCOUNT! is absolutely ridiculous. Should you give in, this person sounds like they will write the negative review anyway and say to themselves - "Gotcha".
You have done all of the correct manners and given more than enough time for this patient to pay. At this point my answer would be - It is out of my hands and the collection company has control of your account.
I'm writing in response to Dr. Sherman's comments about online CME. I agree with his comments and support the opinion that online CME should be unlimited in all states. Simply put, the content and delivery is the same, the requirements for proof of viewing is higher than at live conferences, and this delivery method is appropriate for adult learners. The various online CME available allows a physicians to receive rapid answers to topical clinical problems using on-demand education services. This format is innovative and able to change with developing technologies. Allowing online CME to flourish is equivalent in the medical community to the progress of the Internet itself. This system must be allowed to develop.
Disclaimer: Dr. Shapiro writes the column Practice Perfect for PRESENT e-Learning Systems.
I’ll take the counterpoint to my friend and Boca Raton neighbor, Dr. Sherman. Live CME events are best. Not only have I had the opportunity to have lectured in 49 of the 50 states and many 15 different countries, but I have also been the patient for multiple foot operations. For the months after my accident, I spent many months in rehab, unable to walk, and did many online classes. I collected online training certifications in real-estate, insurance, financial planning, securities series 7, 63, and a bunch more. But... there is nothing as good as live learning. And as a physician, there is so much more to learn at a seminar than what is learned in the lecture hall. I have learned so much in the hallways, and at the bar from my colleagues. Meet the Masters was started 8 years before my injuries, with the idea that learning outside of the lecture hall was priceless.
I do enjoy online events, but I would hate to miss the yearly get togethers to learn from and with others. As a patient, I know the difference between great and outstanding care; that it comes from those with exposure to many viewpoints which only a live event can deliver.
Since this topic has come up again, I would like to remind everyone of a posting that I wrote on 03/05/2016. You can search it in the PM News archives. In a nutshell, here is the main excerpt, "We received a letter from Palmetto GBA stating that they have received information from the National Supplier Clearinghouse (NSC) indicating that we have not billed the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) within the last four consecutive quarters."
George Jacobson, DPM, Hollywood, FL
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
RE: Enough Already with Time-Consuming Chart Requests (David P. Luongo, DPM)
From: Cynthia Ferrelli, DPM
I have experienced the same problem, so I came up with a solution several months ago that has been working fine. When my office is called for a chart review, we say we will comply but that their reps come to my office, will have to pull all the charts themselves, and find what they need in the chart. We tell them that this is how we do it and we set the guidelines. Set your boundaries. You are paying your staff to do work for you, not for the insurance companies. We seem to do enough of that already.
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.
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."
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.
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.
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
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.
Tuesday, there was a fire at Ortho-Rite, my orthotic fabrication and biomechanics cornerstone for 25+ years. Its heart, muscles, and brains - Greg Sands, OP - must process and restore what he has quietly built from scratch. The impact that he has had on the face of biomechanics and orthotics will be recognized while he is doing so.
There is no immediate fix. All involved from the lab to our practices to our patients will be sharing the pain and suffering caused by the shocking event that took place. We will survive and become stronger, wiser, and more successful. I can’t seamlessly transfer my work to a competitor of Ortho-Rite. Greg is the best fabricator of custom foot orthotics from A to Z. Over the years, he has partnered with so many, handling the glitches and snags that exist in the custom foot orthotic marketplace quickly and professionally. His devices outlast and outperform all other labs that I have worked with, visited, and monitored over 40 years.
In order to help Ortho-Rite get back on its feet (pun intended), until I get a sense of how long it will be before Ortho-Rite will again be open for business, I am holding out. I have under-appreciated the importance of Ortho-Rite in my life until Wednesday. I remain available to assist any colleague or vendor that finds his-/herself in shock and unable to deal with the enormity of this event. Join me in offering a quick and coherent rebirth to Ortho-Rite.
Sendinc.com is an excellent resource, providing options such as email destruction after a pre-determined time.
Martin S. Lynn, DPM, Oil City, WA
I use G Suite. It's the paid version of Gmail, Calendar, and Drive. You can sign a BAA with them and they are HIPPA- compliant. Also, it looks more professional, as you'll have email@example.com. Pricing starts at $5/month per user for 30gb of storage, and for another $5/month, storage is unlimited.
Disclosure: I have no financial interest in Google's products.
There are a number of ways to achieve better patient flow in an office. Some are more expensive with installed lights or computerized options within EMR systems. There are less expensive manual colored flags that hang outside patient rooms and used as indicators for what is to occur in that room. I feeltthat the system I have always used in my practice is even more simple and effective.
I have designed a “task sheet” which is a categorical list of our most common diagnostic and therapeutic procedures, dispensed items, medications, and other “tasks” that I perform. This sits in the chart holder outside the patient room. If it is vertical and backward, I know this is the next patient to be seen. I take it in the room and fill out what I need performed for that patient. My assistants then know to orient the task sheet of the next patient to be seen, from horizontal to vertical.
When I walk out of the patient room, I place the task sheet vertical and forward. The assistants perform and prepare what I have checked off, such as x-rays, injections, medications, and bracing, as I walk into the next room, which has a vertical task sheet. By the time I am done with that patient, the tasks I have marked for the previous patient will have been performed and initialed. I can finish up with that patient and mark any additional tasks needed - and the process continues. Of course all HIPAA compliance is followed, so no patient identifiers are visible. Theoretically, one could see and treat patients without ever having to verbally communicate with the well-trained assistant.
As I was reviewing ADA Section 1557, I came across this on the HHS website, which I would like others with more knowledge to comment upon. Is it possible that we in private practices might not be considered a “Covered Entity” according to the definition from the Office of Civil Rights, and hence be excluded from section 1557 compliance?
Civil Rights Obligations of Covered Entities - Nondiscrimination laws enforced by the Office for Civil Rights (OCR) prohibit discrimination and require covered entities to provide individuals an equal opportunity to participate in a program activity, regardless of race, color, national origin, age, disability, or (under certain conditions) religion or sex.
What is a Covered Entity? - A Covered Entity is any entity that receives federal financial assistance from the Department of Health and Human Services or is covered under Title II of the Americans with Disabilities Act as a program, service, or regulatory activity relating to the provision of health care or social services.
How do you know if you are not a Covered Entity under OCR jurisdiction in its enforcement of nondiscrimination laws? If you receive some type of federal financial assistance from another federal department or agency but it does not include any HHS assistance, you are not a covered entity under OCR’s jurisdiction. You may also not be such a Covered Entity if you are a healthcare professional who accepts only Medicare Part B insurance payment. (Bold and Italics added by me.)
I have a patient who wears a size 17, and I was able to fit him into a Darco Body Armor Walker II. This was the only walking boot I could find that would fit him. Gill carries them in both a high and low model. If that doesn't work, another option would be to put him in a short-leg walking cast, or perhaps a slipper cast.
Robert Wunderlich, DPM, San Antonio, TX
Editor's note: This letter has been reprinted from PM News' archives.
What I have done to solve this problem is copy the LCD from my Medicare carrier and highlighted certain parts. If patients complain about wanting to be seen sooner, I show them the guidelines regulating the 60-day global period. They can pay cash if they want to come sooner. Just like your situation, I will show them what the Medicare guidelines consider RFC - i.e. corns and calluses. If I have a diabetic patient who does not meet the guidelines, I will show the patient the guideline in print, as well as show the covered diagnoses and class/clinical findings required.
If the patient tells me "they" said it would be covered, I tell them to get that person whom they spoke with on the phone to send it to me in writing that they now cover this service and it now supersedes the previous long-standing published LCD. If that doesn't work, I wish them well and tell them they can shop around for another doctor who will do what they want but I am not going to lose my license, be fined, or end up in jail just to make them happy.
This problem goes way beyond having CMS employees telling Medicare patients wrong information about coverage policy. The IRS is famous for giving wrong information on tax rules to the public. I am sure most gov’t agencies have similar deficiencies in transmitting accurate information to the public who are simply trying to understand and comply with the rules.
The routine foot care issue, however, is plagued by so many other confounding problems. For example, the right for regional Medicare carriers to interpret federal CMS guidelines independently. While being on warfarin is a recognized risk factor and acceptable for routine foot care in one part of the country, the same patient’s care is medically unnecessary (and potentially fraud and abuse) in...
Editor's note: Dr. Markinson's extended-length letter can be read here.
The original post and my post were not referring to the utilization of the shoes for runners. They're two separate discussions. I think that all respondents may agree on this and that perhaps we can help some of our patients who are working on their feet for a living. We make our recommendations to individual foot types and pathologies, and we don't want to over- generalize in our discussions.
I don't recommend individual shoes (brands). I educate my patients about what qualities to look for due to their pathology, and have samples of different types of athletic shoes in the office. I also cut some athletic shoes longitudinally in half (sagittal plane) to help with their education and understanding. Some patients say they have good athletic shoes at home and then bring in a flimsy, flexible "sneaker" (Keds). They can intuitively see the difference with my sample.
I am a retired podiatrist who is now a personal trainer/TRX instructor. I had a severe forefoot injury this past winter that required a walking boot for 6 weeks, and I still had significant residual pain. I found Hoka One Shoes and they were like a magic pill. Within about 10 days of use, my forefoot pain had significantly reduced to the point that I could start running again. I resumed my full schedule of teaching and my personal exercise schedule.
The Bondi model is one of the max cushioned models I use. Hoka One also has models for trail running, spikes, and hiking shoes. The main drawback of the Bondi model is that there is very poor lateral stability due to the very thick sole. I do not recommend it for any sport that involves a cutting movement or unstable surfaces. I love these shoes and the fact that I can now run without foot or knee pain.
Disclosure: I do not have any financial relationship with Hoka shoes.
Helen Gentile, DPM, Avondale, PA
Podiatry Management • 10 E. Athens Avenue, Suite 208 • Ardmore, PA 19003 • 610-645-6940