June 15, 2006 #2,606 Editor-Barry Block, DPM, JD

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We just posted a CME from the June issue of Podiatry Management titled “Applying Biomechanical Principles to the Diabetic Foot” by Robert D. Phillips, DPM.

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One Third of My Patients are Seen Pro Bono: CT DPM

Doctors, nurses, insurers, and healthcare reform advocates gathered at North Haven’s Anthem Blue Cross & Blue Shield Tuesday morning to take in scrambled eggs, French toast, and the hard truth about our “stressed and possibly broken American healthcare system.”

Podiatrist Jonathan Key knows that when he performs foot surgery on patients without insurance, he doesn’t get paid. “Thirty-three percent of what I did last year was pro bono. I can’t say to the ER physician when someone’s got two black toes, What kind of insurance do they have? I go in, I do the surgery, and I don’t get paid.”

Jonathan Key, DPM

Source: Tess Wheelwright, New Haven Independent, [6/13/06]

Alleged Misdiagnosis of Posterior Tibial Tendon Dysfunction - Unnecessary Triple Arthrodesis and Medial Column Fusion Performed (NY)

Facts: The female plaintiff, age 50 at the time of the alleged deviation in 1997, who visited the defendant podiatrist with complaints relating to a bunion, contended that the defendant negligently diagnosed a condition known as posterior tibial tendon dysfunction and performed unnecessary surgery that entailed a triple arthrodesis. The plaintiff further contended that there was insufficient evidence of pathology to support the diagnosis and that the because of the fusion, she will permanently suffer a significant loss of motion. The plaintiff maintained that a bunionectomy only should have been performed.

The defendant contended that the records and x-rays supported the validity of the diagnosis. The defendant maintained that the condition resulted in a progressive collapse of the arch and that the condition was also the cause of the bunion. The defendant also pointed to the plaintiff's deposition in which she indicated that she had been suffering progressive pain for a two-year period and that the pain was becoming sufficiently severe that it interfered with her ability to work. The defendant maintained that the surgery alleviated the pain and contended that the surgery was indicated.

Result: Defendant's verdict.

Plaintiff Experts: Myron Boxer, DPM, Woodmere, N.Y.

Defendant Experts: Thomas DeLauro, DPM, Staten Island, N.Y. and Charles Wolff, DPM, Nyack, N.Y.

Source: Medical Litigation Review, Volume 14, Issue 5

Most Health Savings Accounts Are Staying Empty

Many consumers simply aren't funding the health savings accounts or HSAs linked to their high-deductible health insurance, say several new studies, calling into question whether the impact of so-called consumer-directed health plans is all it's cracked up to be. As of January, about 3.2 million Americans were enrolled in high-deductible plans, but only 820,000 of them, or 26%, had opened and funded an HSA, according to data from Inside Consumer-Directed Care, a newsletter. Some observers say many consumers can't afford to fund HSAs, don't benefit from their tax-advantaged aspects or are confused by the variety of options.

Source: San Francisco Business Times, [6/13/06]

Friday July 14- Sunday July 16, 2006.

See The Samoset Resort Website http://www.samosetresort.com/ for beautiful photos of the golf course directly on the Atlantic Ocean. 18.5 CME hours pending with focus on Diabetic Foot Care and Surgery. Come join Dr. G. Jolly, Dr. P. Flanigan, Dr. D. Shavelson, Dr. L. Harkless and others. Contact Dr. John Perry at drperry@atlanticfootankle.com or call 207-773-5800 for more details.

For a list of all meetings go to: www.podiatrym.com/meetings.pdf

Query: X-Ray Machine Space Requirements

If I want to place an x-ray machine in a treatment room, how much larger than the standard 8'x10' space should I have?

Jay Kerner, DPM, Baldwin, NY, aikiman44@aol.com

Query: In-Office Testing by an Outside Company

We have an agreement with a company who comes to the office and performs electrodiagnostic testing services, but rather than paying us rent, they give us the coding information and we file the claim for the patient. We have to have a physician on site when the tests are being done. Once the claim pays, we then pay the company 60% of what is collected.

The only billing glitch we have come across thus far is that several of the tests are not covered by Medicare when they are provided by a podiatrist. Otherwise, they are being paid without problems. There are quite a few practices in the area using this company, and all have the same agreement. Is this type of arrangement problematic?

Name Withheld by Moderator

Response: Interestingly, I also have a client in Arizona who has been approached by what sounds like the same company. There is no problem with the rental approach -- in fact, I think it is the proper way. The rental, however, must be fair market value, taking in to account all that is being provided by both sides.

When I challenged the company about their fair market value calculation (they wanted to pay my client $20/hour), they initially blustered about a big law firm having given an opinion on the matter. When I asked for the calculations, however, they finally conceded they had not done one.

I told my client to sign nothing until a fair market calculation for the rent has been done and that amount is part of a written lease that meets Stark and Kickback requirements.

J. Kevin West, Esq., Boise, ID

Other responses appear at www.codingline.com

Codingline subscription information can be found at
http://www.codingline.com/subscribe.htm

RE: Inexpensive Nail Nippers (Barry Finkelstein, DPM)
From: Multiple Respondents

I am not disagreeing with Dr. Finklestein’s overall comments, however, when you see nail clippers being sold in a pharmacy for less than $10.00 does one know if they are chrome-plated? Made in Pakistan? German stainless costs way more than $10.00 as I was partner in an instrument company and a quality pair of nippers costs us much more than that at our cost. I do not think we can compare apples to apples here. Do you get a lifetime warranty with the instruments? Will someone be able to sharpen them? These are all factors that add into the cost of top quality instruments. My advice is to be knowledgeable as to what you are really getting!

Steven H. Goldstein, DPM, Livingston, NJ, Stevefootdr1@cs.com

Do you really think they are selling the same grade of equipment in Walgreen's designed to be put under the daily stress we as medical professional apply? When I was in PCPM, many, many years ago, I was given the responsibility to arranging for my class the purchase of podiatry instruments to aid us in the clinical years. I learned a lot about the manufacturing and metallurgy of the instruments we depend on daily. Cheap Pakistani instruments are very different from German instruments in durability, holding a sharp edge, etc.

I have many nail cutting instruments that get autoclaved daily. This rapid heating and cooling must clearly affect the metal characteristics. I am sure if you have been in practice long enough, you have broken a nipper. Just think if the sharp edge of the cutter was propelled into the eye of your patient (lawsuit, of course). Now if you purchased a Miltex-like instrument there is a large company to be charged with the responsibility. If you got the instruments at Walgreen's, I wonder how well you will look to the jury.

The point is, professional-grade instruments cost more. They are (should be) better manufactured and be responsible incase of failure. Just think of craftsman tools from Sears, Quality lasts.

Bret M. Ribotsky, DPM, Boca Raton, FL, ribotsky@doctorbret.com

When I first opened my practice, I priced a stainless steel kick bucket on wheels at a medical supply house for about $100. Before I placed my order, I found myself driving through Pennsylvania farm country, and I passed a dairy farm that had well over a hundred of those buckets stacked up along the side of a barn. I found the farmer and asked him if they were stainlesssteel. They were. He sold me one for $5. I then went to the local Electrolux store and got a used circular canister that the bucket fit perfectly into for another $5. That was almost 30 years ago, and it's still in perfect condition.

Slap a caduceus on a piece of equipment, and you can multiply the price by at least 10 times. Doctors are rich. They can pass along all costs to the patient and still come out ahead. Right?

Howard R. Fox, DPM, Staten Island, NY foxhr@yahoo.com

ASSOCIATE POSITION - PITTSBURGH, PA AREA

Excellent opportunity for a hard working, surgically trained podiatrist to join a well-established, high volume, multi/location practice in the suburbs of Pittsburgh. Must be willing to perform all aspects of podiatry. Incentive-based salary, compensation package, with potential for partnership. Must presently have Pennsylvania license. Would like to fill position asap. Fax resume to 412-831-2115.

ASSOCIATE POSITION - MINNESOTA – MINNEAPOLIS SUBURB

Busy, well-established, full-scope podiatry practice, seeking highly motivated podiatrist for a full-time position with buy-in opportunity. Looking for PSR 24/36 trained individual, to help increase surgical volume. Excellent opportunity for long-term growth with unlimited income potential. E-mail CV to employment@associatedpodiatrists.com or fax to (612) 866-5875 Attn. Jennifer.

RESIDENCY POSITION - HOUSTON, TX

RPR, PSR-24, Houston Podiatric Foundation, Starting ASAP. Must have successfully completed PARTS 1 & 2 of National Boards. Contact: Dr. Randal M. Lepow, Director (281-348-3338) (713-725-8988)

PRACTICE FOR SALE - COLUMBUS, OHIO AREA

Fully furnished practice, open ONLY 14 hours a week with an average yearly gross of 235K. 75% primary care, 20% surgical, 5% Nails. Plenty of opportunity for growth and surgery. Changing locations. Financials available upon request. Kyle_DPM@Yahoo.com

ASSOCIATE POSITION- NEW ENGLAND

Terrific Opportunity Now Available in growing New England practice. Well established and respected practice with new, large office space, latest technology, very helpful staff, loyal patients and solid referral base. Close proximity to hospitals with modern surgical suites. Opportunity for shared ownership. Prefer 24 month PSR with clinical practice experience or an experienced doctor looking to improve their situation. E-mail CV and particulars to NEAFC3@aol.com

EQUIPMENT FOR SALE - ESWT

If you are using or thinking of using ESWT, I have a new machine that has only been used twice. There is no Orbasone in the country priced like this one. Will provide training and installation. Take a look at http://www.orbasone.com Call 1-856-229-2939.

PM&S-36 POSITION – SAN ANTONIO, TEXAS

The University of Texas Health Science Center at San Antonio. Contact Program Director, Javier La Fontaine, DPM at (210) 567-5174 or e-mail casteele@uthscsa.edu

ASSOCIATE POSITION - PHILADELPHIA, PA

Full time associate to join large 6-doctor group. PSR-24 trained with excellent people skills. Competitive salary/benefits package. Fax CV and introduction (215) 742-3902.

RESIDENCY POSITION – NORTHERN VIRGINIA

One Year Foot and Ankle/Rearfoot Surgical Fellowship with excellent salary/benefits available July 1, 2006. If you are finishing a PSR24 and don't have a job yet, this is an excellent way to learn additional surgical and business skills. Please fax resume to 703-491-9994.

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