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RE: Merz Won't Sell Radiesse® to Podiatrists 

From: Pat Walters, DPM


I went to Dermfoot seminar in October 2016. Merz was one of the sponsors. They now say we aren't real doctors and won't sell Radiesse®  to us. How's that for discrimination to podiatrists? My salesperson said a real doctor, i.e. an MD could buy it because dermatologists, internists, and plastic surgeons all can use cosmetic products. This is so not right.  


Pat Walters, DPM, Tarzana, CA

Other messages in this thread:



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



RE: Formula for Value of a Practice

From: David Helfman, DPM


After reading all the articles on valuations of a practice, I would like to try to summarize the topic to ensure we are all comparing apples to apples. The reality is that everyone has given good input but I would like to offer a simple and concise summary of valuation methodologies that will be easy to understand based on real life experience. 


There really are no rules of thumb anymore, and selling a practice is like selling any other service business, so it’s important to understand who is buying your practice and then you can come up with a logical formula and rationale for valuing your practice. I think the easiest way to 

start this process is to put your practice in one of three buyer buckets. 


1. Buyer: Current associate or new podiatrist wanting to buy...


Editor's Note: Dr. Helfman's extended-length letter can be read here



From: Michael Zapf, DPM


My “back of the envelope” way to evaluate a practice is the lesser of 1) the average of the last 3 years net annual income OR 2) 40% of the average of the annual gross over the last three years PLUS $1000 for ever new patient per month averaged over the last 3 years. If a gross is high because of high advertising, then the net will show the truth. If the overhead is tightly controlled or there is inordinate equipment expensed (those lasers and x-ray systems are costly), then the net will show the truth. 


Location (spare bedroom or medical center), equipment (even three lasers and digital everything), appearance of the front office, and everything else, is accounted for in the income and the new patients, already. New patients are the lifeblood of a practice, so a steady supply of new patients should be rewarded. But if all those new patients came because of heavy advertising, then this will be accounted for in the net value.


Michael Zapf, DPM, Agoura Hills, CA



From: Mark Block, DPM


Generally, there are three different approaches that are used in the valuation of companies: the asset approach, income approach, and market approach. You can learn more about each of these approaches in APMA’s “Quick Reference Guide for the Purchase or Sale of a Podiatry Practice.” I also recommend participating in APMA’s webinar on “What to Know When Purchasing or Selling a Podiatry Practice.” 


This webinar is scheduled for Thursday, February 8, at 8 p.m. EST, and Sean Saari, CPA/ABV, CVA, MBA, a valuation expert, will be the presenter. There will be time at the end to ask questions. If you are an APMA member, you can access the quick guide and sign up for the webinar at  


Mark Block, DPM, Boca Raton, FL



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.



From: Name Withheld 


A few years ago, a well-respected practitioner passed away in an untimely manner. He had a long standing practice that was busy from day until night, a modern office in a building affiliated with a top hospital and well-trained staff. His practice continued in the interim with help from volunteers, but when his family tried to sell it, they could not get a reasonable offer for the practice; not even an unreasonable one.


Instead, someone who purported to be “a friend” opened up a new office in the same building and poached the patients with a blitz of advertising. Setting up the new office and the professional marketing campaign cost maybe 20% of what he would have paid the family. Within a couple of months, he enjoyed the same busy practice, in a modern office, affiliated with a top hospital and with a well-trained staff. And he had paid pennies on the dollar.


I came to believe at that moment, after decades in this business, that a practice has no inherent value. It is no longer the “retirement account” waiting for us. If I had it to do over, I wouldn’t consider buying a practice. I would open one near an older practice and with marketing’s help become the newest, best-trained, most modern option available. Face it. Patients love the next new thing. Only our older patients look for long-term relationships, and they aren’t going to help sustain a practice. Patients these days look on Yelp for ratings to make their healthcare choices!


Name Withheld



From: Robert Fridrich, DPM


In late 1970s, I gave those flu shots due to an epidemic in Cleveland.


Robert Fridrich, DPM Retired, Green Valley, AZ



RE: PC vs. LLC vs. PLLC (Marianna Blokh, DPM)

From: Joseph Borreggine, DPM


I suggest you review these articles that I found through a simple Internet search: Article 1, article 2. And after reading them, then I would decide. But before you do so, know that President Trump’s new tax (law) makes an LLC more attractive than a PC by helping to reduce your pass through income in an LLC by 20%. The corporate tax rate has also dropped from 35 to 21%. 


This article helps explain the new tax rules for 2018 for pass through income: But, when all is said and done, a good CPA and tax attorney must be consulted to secure the best advice.


Joseph Borreggine, DPM, Charleston, IL



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



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



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



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: 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



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



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



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



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: 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



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



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 be ON the other side and become a target yourself. 


Michael M. Rosenblatt, DPM, Henderson, NV  



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