June 24, 2006 #2,614 Editor-Barry Block, DPM, JD

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DPM’s Provide Advice on Blisters

"A lot of blistering is caused by rubbing and moisture buildup on the surface of the foot," says Dr. Joshua Kaye, a podiatrist with a private practice in Los Angeles. "Non-cotton socks wick more sweat away from the foot during activities, especially during sports."

"A very common blister this time of year is in the right arch, behind the bunion bone," says Dr. Greg Cohen, a podiatrist at Long Island College Hospital in Brooklyn, N.Y. "The reason why that happens is because when a person wears sandals, the foot rolls inward, and that strap cuts right across the foot."

Of course, even with precautions, everyone is almost guaranteed to get at least one blister. If that happens, Kaye says, you can drain it, but if it doesn’t hurt, then simply leave it be. "It’s just fluid buildup, and there’s no real urgency to take the liquid out."

For those who can’t keep their fingers off of their blisters, Ronald D. Worley, a podiatrist in private practice in La Jolla, Calif., says you should never remove the layer of skin covering the blister. "It can cause infection that may require time off your feet and even antibiotics," he says.

Source: Susan Yara, Forbes [6/22/06]

Armstrong Chairs Session at Oxford Wound Healing Symposium

Specialists from 21 nations converged on Oxford University for the 11th annual Wound Healing Summer School. David G. Armstrong, DPM, PhD, Professor of Surgery at Scholl's Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Science in Chicago, chaired and addressed the introductory symposium on advances in wound healing.

"I am in debt not only to Dr. George Cherry and Prof. Terence Ryan, the renowned conference co-chairs, but also to Dr. Alan Cantor and Ivan Bristow, two clinicians who have been real ambassadors for podiatry at this meeting. They are largely responsible for attracting foot and ankle specialists from around the globe to this gathering," said Armstrong.

The annual event is held in a venue adjacent to Oxford's Radcliffe Infirmary, where penicillin was first used in 1941.

CMS Proposal Could Lessen Cuts For Some Docs

The CMS' proposal to increase payments for evaluation and management services under the physician fee schedule could lessen the blow of an expected across-the-board cut to Medicare payments to physicians in 2007 -- at least for some specialties. The forthcoming proposed rule would revise physician work "relative value units" for more than 400 evaluation and management services to better reflect the work required by physicians in performing procedures, evaluating a patient's condition and proposing a course of treatment.

Overall, Medicare physician payments are set to decrease by 4.7% next year because of a flaw in the way the payment formula is calculated. If that cut takes effect, specialties such as primary care that provide evaluation and management services most frequently could see a smaller overall reduction compared with other physicians, a CMS spokeswoman said. The CMS is also proposing changing the methodology for calculating direct and indirect costs for practice expenses, using procedure-level data for clinical staff times, supplies and equipment instead of calculating practice expenses by specialty. The change would make the methodology more transparent and easier to understand, according to the CMS.

If adopted, the revisions would be implemented for services provided to Medicare beneficiaries starting in January 2007. A notice on the proposed changes is expected to appear in the June 29 Federal Register.

Source: Jennifer Lubell, Modern Healthcare [6/22/06]

Query: Diabetic Footwear Data

I recently spoke to a physician who doubted the benefits of the Medicare Therapeutic Shoe Program and asked for literature. I searched PubMed for articles, however, I could not find scientific data on how much reduction in ulcer development is achieved by proper footwear. Can someone direct me to a good source for this information?

Jengyu Lai, DPM, Rochester, MN

RE: DME Competitive Bidding
From: Paul Kesselman, DPM

I would urge all readers to review APMA's recent bulletin on the competitive bidding program. It appears that CMS intends to use a more restrictive definition to only include MD and DO's. This would allow them to restrict their competitive bids only to their patients, allowing them to continue to provide DME ancillary services to their patients. Whereas, DPM's will need to competitively bid for a geographic area with large DME suppliers.

While obviously prejudicial to DPM's and our patients, it sets a dangerous precedent for future Medicare policy, and will cause significant harm to many patients. This policy smacks of bias against one profession, while current CMS policy on many levels discourages bias based on professional degree.

One simple example would be patients who had fractured metatarsals. If they sought care from a DPM, they might be required to be transported cross town to obtain their CAM walker. The same patient seeing an MD or DO orthopedist would be able to obtain the CAM walker on the spot. What about the diabetic who needs shoes and inserts. While it is the opinion of several shoe companies that shoes are not included in competitive bidding, there has been no such official written or verbal response from CMS officials.

Regardless of whether you supply your patients with DME or not, the adoption of this policy serves as a dangerous precedent. It allows the exclusion of podiatric patients from accessing healthcare benefits afforded those who seek care from an MD/DO. It is therefore incumbent on every DPM to write a letter to CMS, and their congressional delegation in Washington prior to the June 30 deadline.

Please reference policy # CMS–1270–P, in the mailing address and visit http://www.apma.org/CMSLetterCampaign to access instructions on further instructions on how to submit comments, talking points, and sample letters to CMS.

Paul Kesselman, DPM, Woodside, NY, pkesselman@pol.net

RE: Proposed Changes in Medicare Reimbursement for 2007
From: Richard Rettig, DPM

APMA has just announced that CMS has just issued their "Medicare Program: Five-Year Review of Work Relative Value Units Under the Physician Fee Schedule and Proposed Changes to the Practice Expense Methodology."

I have gone to the CMS site and looked over briefly this 605 page document. Relevant pages include 24-25 and 187-190, as well as 337-343 for those who are interested. It seems that CMS has been quite unkind to podiatry with regard to requested reviews for improvements for coding for ulcerations in particular, where they not only overrode the requests for increases, but actually instituted major decreases. I was also surprised to see, and perhaps it has been this way for some time, that the valuation for 28292 (McBride) and 28296 (Austin) are practically identical.

Moreover, after full implementation of the changes, the fee for a McBride will actually exceed that of an Austin with screw fixation! These were not codes where reviews of valuations were even requested. Certainly the report is confusing, and I may be incorrect in my interpretations. I encourage APMA to continue to seek equity in these important coding values. While it appears that podiatry was particularly singled out, I do note that values for total hip arthroplasties as well as total knee arthroplasties were also hit, with THR's taking what looks like a 25% devaluation in work RVU's.

Richard Rettig DPM, Philadelphia, PA, rich.rettig@verizon.net

RE: Off-Label Drug Use Is Common; Lacks Scientific Justification

The statement: "according to a recent journal study that finds most off-label prescribing lacks scientific justification." is quite misleading. When the FDA approves a new drug there are two important criteria which must be met. The drug has an acceptable margin of safety and be efficacious in treating the medical condition it was submitted for. To gain FDA approval, a drug company must submit evidence of massive studies which costs millions of dollars. The entire process can take years. After a pharmaceutical is approved, it is often found that it may have benefits for the treatment of conditions other than what it was originally approved for. To change the specific condition the drug company has to go through the entire process again which may be unaffordable, especially if the drug goes generic.

One such drug is Gabapentin, which was originally approved for the treatment of seizures, later herpetic neuralgia but after numerous scientific papers were published, its main therapeutic purpose became the treatment of neuropathic pain. Another medication that is used off-label is nifedipine for Raynaud’s phenomenon. There are enough clinical studies to justify its use for this purpose and I can vouch that it is a lifesaver for many of my patients who take it from November till April. Many of us use Tagamet for the treatment of verrucae and have had success.

The use of "off-labels is legal" but drug companies are prevented from detailing us on off-label uses. This is where Podiatry Management and other publications are crucial in keeping us abreast on medical developments. We have to educate ourselves on topics that are not always endorsed and funded by companies so that we can learn about treatments such as off label uses of drugs. We cannot rest our continuing education solely on grants from drug manufacturers. The prudent use of off-label pharmaceuticals is legal and is good medical practice.

Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

ASSOCIATE POSITION--NEW YORK CITY

Excellent opportunity for a hard working, surgically trained podiatrist to join a well-established, high volume, multi/location practice in Manhattan and Queens. Must be willing to perform all aspects of podiatry. Must presently have New York license. Position available immediately for the right candidate looking for a future partnership opportunity. Fax resume to 212-753-3521 scottlurie@eastsidepodiatric.com

PSR-24 RESIDENCY POSITION - SOUTHEASTERN MICHIGAN

The P0H Medical Center (POH), Pontiac, MI has an opening in its Podiatric Medicine Residency Program. POH is a major teaching affiliate of Michigan State University College of Osteopathic Medicine. This is an excellent opportunity for a highly focused individual, who just graduated or has already completed a PPMR/RPR and or a PSR-12 program. POH offers an excellent learning environment with three high volume surgical venues and two busy foot/ankle clinics, including a limb salvage and wound clinic; as well as a competitive salary and benefit package. For further information, please contact S.J. Goldstein, DPM, POH Medical Center (248) 338-5392 FAX – (248) 338-5567

ASSOCIATE POSITION - NAPLES- FLORIDA

Great opportunity for PSR- 24/36 BE/BC podiatrist with strong surgical skills. Hospital privileges available at 548 bed hospital system and multiple surgical centers. Candidate should want to perform rearfoot surgery including Charcot reconstruction. Candidate needs to be ethical and motivated and have a current Florida license. Established practitioner or new practitioner OK. Base, percentage, benefits including insurance and 401K. Fax CV to (239) 566-8778.

RESIDENCY POSITION – VIRGINIA

One Year Foot and Ankle/Rearfoot Surgical Fellowship with excellent salary/benefits available July 1, 2006. If you are finishing a PSR-24 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.

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.

EQUIPMENT FOR SALE-X-RAY DEVELOPER

Near-new podiatry/medical x-ray developer for sale. All-Pro Model 2010. Excellent condition. $2500. Call (216) 261-7662 or email: fergusondpm@aol.com

TEMPORARY POSITION – LONG ISLAND

Doctor broke arm and needs a NY-Licensed DPM to cover for a period of time. (516) 637-2671 Mel2222@peoplepc.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.

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