The Voice of Podiatrists

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January 31, 2008 #3,155 Editor-Barry Block, DPM, JD

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Podiatrists Differ on Safety of Silicon Injections For Diabetic Ulcers

An off-label technique used to prevent diabetic ulcers entails injecting small amounts of liquid silicone into the balls of the feet to replace eroding fatty tissue. Although the method still hasn't been cleared by the Food and Drug Administration for this purpose, it's used for treating retinal detachment. By reducing the risk that a pain-free diabetic will walk right through his or her skin, advocates say, the procedure lowers the likelihood that ulcers will form.

Dr. Sol Balkin

"It's criminal it's not approved," says Sol Balkin, 82, a retired podiatrist and pioneer in using injectable liquid silicone to treat foot ailments. He estimates that in 40 years of practice he's administered more than 30,000 injections. Balkin and a U.S. company are currently working to gain approval to market this treatment in Europe.

Dr. Stephen Kominsky

Some specialists have qualms. "It's potentially dangerous," says Stephen Kominsky, a podiatric surgeon and diabetic foot expert at Washington Hospital Center in D.C. "Patients with diabetes are compromised, so injecting them with a foreign substance might trigger a negative reaction." In healthy patients—the procedure is often used to relieve pain and pressure in normally aging people losing the fatty padding in their feet—injecting silicone "makes all the sense in the world," Kominsky says. To heal foot ulcers before infection strikes, Kominsky uses a technique that he finds particularly effective: the application of living skin grown in laboratories from neonatal foreskins saved during circumcisions. The skin is placed atop clean ulcers to promote new tissue growth.

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

VA Podiatrist Returns to Help Abandoned Patients

Dr. Margaret Meredith sees patients she hasn't seen since she sold her practice three months ago and started working out of state. "I just felt compelled to come back and see some patients that really needed to be seen," she said. The doors to her old Blacksburg office are locked. The doctor she sold it to is missing. Patients show up not knowing Dr. Robert Knox isn't here and hasn't been here for more than a month. "He hasn't been in contact with me since early December so I can't really comment on what's going on," Meredith explained. "I really don't know."

Meredith doesn't know where Knox is either. She says he has yet to pay for the two podiatry offices she handed over. "He hasn't come through on his financial obligations as well as his professional obligations," she said.

Dr. Meredith says she can't work in her old office but she was able to get space in a free clinic of the New River Valley Wednesday to help some of her former patients. "My biggest concern is the patients and their care. They're left here without a doctor."

Source: Dawn Jeffries, WSLS-10 TV (VA) [1/30/08]

Many Health Systems Are Adopting Strict Policies on Vendor Gifts to Physicians and Key Employees

After months of discussion and consensus building, Hartford Hospital embraced a near-zero tolerance policy for vendor gifts. Physicians and key employees accepting gifts of any substance is just too risky when it comes to medical decision making, says Nickie Braxton, the compliance officer for Hartford Hospital and Hartford Healthcare Corp.

So from now on, all employees and non-employed paid physicians working on behalf of the hospital cannot solicit personal gifts, business courtesies or services from any patient, visitor, vendor or contractor, according to Hartford Hospital's new policy. Only unsolicited gifts of relatively little value — a total of $50 or less each year from any vendor — are allowed. That figure comes straight from the OIG compliance-program guidance, Braxton says.

Hartford Hospital is far from alone. Many health care systems, such as Henry Ford Health System in Detroit and the University of California, are cracking down on vendor gifts to their physicians and other employees and are limiting vendor access to their facilities. Breaking the cycle of vendor largesse is a significant culture change, but experts say now is the time, given mounting evidence that both small and large gifts have distorted medical, prescribing, purchasing and other decisions. Some institutions are banning gifts from medical, surgical and pharmaceutical vendors altogether.

Source: Report on Medicare Compliance, [1/28/08]

Query: Medial Deviation of 2nd Digit

I am interested in surgical ideas to assist in the correction of the second digit on this x-ray This is a 56 year old, fairly active female. There is no history of trauma, but has noted progressive medial deviation of the 2nd digit over the past couple of months.

Medial Deviation of 2nd Digit

Her medical history is unremarkable except for hypertension. The dorsal MPJ region is clinically swollen. There is tenderness on dorsal and plantar palpation. Attempts to immobilize the area and the use of NSAID's have proven unsuccessful.

Wayne C. Gould, DPM, Dover, NH

RE: Recurring Pigmented Villonodular Synovitis (Ivar Roth, DPM, MPH)
From: Amol Saxena, DPM

Recurrence is not uncommon. I reported on 10 cases , 2004 Foot & Ankle Int, (& have seen 9 more since) in which good results were obtained if bone defects were grafted & soft-tissue is irrigated with H2O2. Radiation is an option, but can cause osteopenia & more collapse. Verifying the lesion is PVNS & not Giant Cell tumor is paramount. Though the two are used interchangeably, GCT has a higher incidence of malignant degeneration.

Amol Saxena, DPM, Palo Alto, CA, HeySax@aol.com

RE: Reimbursement and Quality of Care (Richard Boone, Esq.)
From: Multiple Respondents

Attorney Boone writes "It may be time for some podiatric organization to put its money where its mouth is and pursue such a case."

The Connecticut Podiatric Medical Association has done just that. Five years ago we began to legally battle for fee parity. After expending significant monies and effort we were able to make a large insurance company see the error of their ways. Each member of the association has recouped their expenses and realized a yearly financial gain. Unfortunately, Health Net has presented a more difficult struggle. Three years ago CPMA filed suit against Health Net for fee discrimination. Each member of our society has spent thousands of dollars in this battle. We are confident that we will prevail. If more state associations would take up a similar battle, we all will see an end to fee discrimination.

Michael Fein, DPM, Bethel, CT, mzfein@gmail.com

I have discussed this issue at great length and have addressed this in an article in PM Magazine and believe have found the solution. The only way to legally have a voice to the insurance companies is to contract as a group. By legally, I mean under one tax ID#. Our group in Chicago is now 85 podiatrists and growing strong. I have talked to podiatrists and traveled to Wisconsin, Indiana, Ohio, Florida, Georgia, etc. at my own expense and everyone complains and moans on how little they are getting paid yet they keep on taking it. I have tried to get these doctors organized but all they do is worry about the petty crap, i.e.; "why should our group of four have to pay a fee for each doc to contract a contract specialist when a single guy pays a single fee, or, I don't want him in the group since he practices a mile from my office., etc."

In the end no one could get together to be willing to work together. The problem is if you keep accepting 90 then 80 then 70 then 60% of Medicare you will keep spiraling down until you cannot afford to see patients. Even if you unite at 50% of Medicare you will have a hard road to climb to get to a fair rate. The orthopods don't have this problem. When is the last time you saw an Ortho group less than 10 doctors? In Chicago all of the Orthos merged to form two or three groups, each with around 100 docs. I do agree that the time is right for litigation, but if the doctors can't get together to contract and are worried about having to put up a few thousand dollars to get paid fairly than how would you expect these guys to stand up against an insurer?

Neal Frankel, DPM, Chicago, IL, drnrf@aol.com

Editor’s Note: An extended-length note by Dr. Kesselman appears at: http://www.podiatrym.com/letters2.cfm?id=17714&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

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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