The Voice of Podiatrists

Serving Over 10,600 Podiatrists Daily

January 30, 2008 #3,154 Editor-Barry Block, DPM, JD

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Healthy Feet Mean Mobility for Seniors: SD Podiatrist

For senior citizens, mobility can mean independence. Several groups in the area are helping seniors retain their mobility by helping them get their feet healthy. Dr. Dan Conrad, a podiatrist, leads a monthly foot care clinic for the staff and residents at Westhills Village. He stresses the importance of mobility for a senior citizen’s continued independence.

Dr. Dan Conrad

“If you have open sores or pain that keeps you from being able to walk, that limits your mobility and ultimately it limits your independence,” Conrad said. “I can’t tell you how often I have seniors tell me, ‘All I want to do is go out and go for a walk.’”

“I’ve had patients come in with major problems who say, ‘I’ve been to my family doctor three times and he didn’t check my feet,’” Conrad said. Conrad said this may be because family doctors assume that if you have a problem with your feet, you will tell them. General practitioners also may assume that you see a specialist for your foot problems. Furthermore, general wellness checks usually focus on health concerns that affect the longevity of life, rather than the quality of it.

Source: Crystal Hohenthaner, Rapid City Journal [1/29/08]

Most Foot Ulcers are Preventable: Armstrong/Rogers

The economic burden that diabetes and its related complications has placed on the U.S. healthcare system—now $174 billion each year, a 32 percent increase since 2002, according to a study released online last week by the American Diabetes Association—is creating a new urgency. (A related report to be published in the March/April edition of the Journal of the American Podiatric Medical Association estimates that about a fifth of those costs are directly related to diabetic foot ulcers and amputations, says lead author Lee Rogers, an amputation prevention specialist at Broadlawns Medical Center in Iowa.)

Dr. Lee Rogers

"Every 30 seconds, someone in the world is losing a limb to diabetes," says David Armstrong, a podiatric medicine specialist at Rosalind Franklin University of Medicine and Science in North Chicago and the surgeon who treated McGill. "I can't stress enough how sinister this disease is."

Dr. David Armstrong

But research indicates that most foot ulcers are preventable, and become deadly only when neglected, Armstrong says. Several studies, including one published in the American Journal of Medicine in December, have found that daily monitoring of skin temperature is an effective way to stave off ulceration in high-risk diabetics. Wounds heat up before skin breaks down, Armstrong explains. If patients detect an abnormality—a spot on one foot 4 degrees hotter than the corresponding spot on the other foot—conditions might be ripe for an ulcer.

Source: Lindsay Lyon, US News and World Reports [1/28/08]

Congressional Task Force Sets Sights On E-Prescribing

A congressional task force made up of moderate Democrats—part of the New Democrat Coalition—with an eye toward passing “doable” healthcare legislation said it would push for the passage of an electronic-prescribing bill that gives doctors financial incentives to adopt such systems.

Reps. Lois Capps (D-CA), a former nurse, Allyson Schwartz (D-PA), a former healthcare administrator, and Jason Altmire (D-PA), a one-time hospital executive, officially debuted its health reform agenda on Capitol Hill. Health information technology is one part of a broader mission, which the lawmakers said would also include efforts to better coordinate chronic-disease care and bolster pay-for-performance and comparative effectiveness programs.

“The U.S. invests more resources in healthcare than any other country in the world,” Schwartz said in a written statement. “Yet, more than 45 million Americans remain uninsured, and our healthcare delivery system is too often inaccessible and inefficient.”

Source: Matthew DoBias, Modern Healthcare [1/29/08]

Query: Recurring Pigmented Villonodular Synovitis

Four years ago I did an MRI on a lateral ankle suspecting tears of the peroneal tendons which were confirmed on the MRI with a suspected ganglionic mass. During surgery a massive lesion was found that turned out to be PVS in the tendon sheath.

Pigmented Villonodular Synovitis

I cleaned up the area as best I could. Now 4 years later the mass is back not as large as last time with some minor new symptoms of the peroneals. A new MRI has been ordered. The question is: are there any new therapy’s/ surgery for PVS that will avoid a trip to surgery every 5 years or so?

Ivar E. Roth DPM, MPH, Newport Beach, CA

Query: Office Visit and Treatment

How would this scenario be coded? Patient presents with bilateral foot pain, left more symptomatic than right. At that visit, the x-rays taken bilaterally, a lengthy discussion was held, however, treatment was limited to the most symptomatic side.

The patient returned to the office two weeks later, stating marked improvement on left side, however, the right side was increasingly painful. At that visit, a lengthy discussion was held regarding treatment and etiology. Treatment was rendered to the right foot, consisting of a therapeutic injection and taping. Are we entitled to bill for a office visit as well as the treatment?

Lisa, Office of Gary Goodman, DPM, Clearwater, FL

Response: When the evaluation and management service is significant, separately identifiable, you are always entitled to code the E/M service AND the treatment. I have found that carriers usually require that the E/M portion be level 3 or higher to be counted as significant.

Walter Pedowitz, MD, Linden, NJ

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RE: Pinpoint IPK’s at Suture Sites (Rick Burnell, DPM)
From: Evan F. Meltzer, DPM, Jon Purdy, DPM

This is not an uncommon occurrence. The lesions are similar to porokeratoses. After debridement, I apply 75% silver nitrate to the lesions. They may not completely disappear, but they are no longer painful. Repeat this procedure in one month if the first treatment is not successful.

Evan F. Meltzer, DPM, Jackson, MS, Evan.Meltzer@va.gov

I have had a case just like this. After healing of the incision site, I used a moisturizer with off-loading and debridement. When it was well healed, I added a topical steroid with the moisturizer and that solved the problem long-term.

Jon Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com

RE: Hypoallergenic Nail Polish/Remover (Larry Dorman, DPM)
From: Rob Katz, DPM

My group practice has been using a new product called Drs. Remedy Nail Polish (www.remedynails.com). It is new to the market and developed by podiatrists. The company has made the effort to remove some of the more harmful products such as formaldehyde, dibutylphthalate and toluene. They claim many of the natural ingredients used to treat fungus are in the product such as tea tree oil. Time will tell how effective the product will be, but patients have been very happy with the product and the price tag.

Rob Katz, DPM, Bradenton, FL, rkatz@ips-med.com

RE: Reimbursement and Quality of Care (Ken Malkin, DPM)
From: Multiple Respondents

I have done a great deal of legal research about the problem of insurance companies and which pay podiatrists at a lower rate than M.D. providers for equivalent services. The research all involved Virginia law, but it would probably also apply to other states which have equal access laws.

My conclusions were as follows:
1. Paying podiatrists at a lower rate is probably unlawful in those states which have equal access statutes; and,
2. These statutes are NOT pre-empted by ERISA (the Federal statute governing insurance benefits).

Unfortunately, I was never able to find anyone willing to underwrite the cost of that litigation WITH ONE EXCEPTION. At the behest of the Virginia Podiatric Medical Association (VPMA), we filed a lawsuit against a large commercial payer which actually capitulated rather than go through with the discovery involved in the litigation. Unfortunately, the VPMA never wished to pursue the matter with other companies.

I personally believe the issue is ripe for litigation with the right plaintiffs and the right fact pattern. It may be time for some podiatric organization to put its money where its mouth is and pursue such a case. I believe you would find out that you have more legal protection than you ever realized.

Richard W. Boone, Sr., Esq, Fairfax, VA, RWBoone@aol.com

DR. Kase writes "we can no longer accept non-negotiable contracts that contain discriminatory policies, provisions, and fee schedule reimbursements that are different for MD's and DO's".

I don't think anyone disagrees with this. What do you tell a newly graduated resident in debt over 100 thousand dollars? Don't accept that insurance...so what should he/she do? It becomes a matter of survival...if you don't accept the plan, you can't put food on the table. I am so pathetically naive. I actually thought everyone in the medical profession had the same fee schedule. Not only can an orthopedist do a bunion and get paid more for it than a Podiatrist, there are some Podiatrists getting paid more for the same procedures there colleagues are doing. Dr. Giannone from Mt. Kisco pointed this out on a previous posting. These are all horrible things.

I laugh when I get emails from various organizations I belong to informing us how to negotiate better contracts with HMO's but be prepared to walk away. This should not be an individual fight. There is strength in numbers.

I attended the NY conference this weekend. Lectures were filled with hundreds of pods from all over the US. How cool would it be if we all decided straight from the conference (assuming it was a weekday) to march to an insurance company door and asked to speak with the medical director. All of us at once...and bring our EOB's showing that their plan is essentially paying us less than minimum wage...(i.e., a capitated plan where you see a patient with an ulcer and see him once a week..) and say enough is enough. Tear up our contracts TOGETHER...how cool would that be? It's just not as fun tearing it up yourself!!

Jeffrey Kass, DPM, Forest Hills, NY, Jeffckass@aol.com

The circumstance of podiatrists (more than any other specialty) accepting unfair reimbursements has plagued our profession for many years. It was the motivation for third party payers to develop capitated networks for podiatry and continually erode our fees. he slow insidious erosion of fees for podiatry services has shackled our profession with unfair reimbursement. Unfair reimbursement leads to questionable billing practices by providers, over loading patients in their offices to increase volume reducing time available with patients which may lead to poor quality of care, and podiatrists seeking other methods to increase revenues. We who have practiced before and during the transition to managed care know this, but knowledge without action has no value.

There is no simple solution. There are podiatrists that can't become providers even to accept unfair reimbursements. These members are struggling financially. There are podiatrists who have gotten entangled in the web of managed care and now depend on the paltry reimbursements to stay in business or to maintain their life style. Although the simple solution is not to accept reimbursements that are unfair, practically speaking how would you or anyone reading this note recommend we as a profession locally, regionally or nationally tackle this issue?

Ira M. Baum, DPM, Miami, FL, ibaumdpm@bellsouth.net

Editor's Note: An Extended-length note by Dr. Young appears at: http://www.podiatrym.com/letters2.cfm?id=17688&start=1

ASSOCIATE POSITION - VIRGINIA (SOUTHERN)

Immediate full-time and part-time associate position available.
Unlimited income potential. Busy, diverse, 40+yr Hampton Roads practice. Must be compassionate; energetic; and motivated; PSR24/36. Looking for long-term arrangement. Please send letter and CV to dcarrone@cox.net

PARTNER WANTED FOR GROUP PRACTICE LOCATED 1 1/4 HOURS NORTH OF NYC

We can interview prospective partners at the NY Clinical Conference this coming Friday, Sat & Sunday. Feel free to call Dr. Hudes cell at 845-807-8864 to set up a meeting or respond to: mhudes@footcaregroup.com

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City . Currently five (5)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

ASSOCIATE POSITION- CONNECTICUT

Established Practice looking for PSR 24/36 trained surgeon. Must have experience and be responsible for all surgical cases for the practice. EMR and digital x-ray in new 6-treatment room office. Hospital privileges available. Connecticut has a new ankle law for the Properly-trained DPM. Competitive salary, benefits, and bonus. Great area to raise a family. Fax resume to 860 243-5790.

PODIATRISTS NEEDED - CHICAGO --NORTHWEST INDIANA

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