The Voice of Podiatrists

Serving Over 11,000 Podiatrists Daily

October 22, 2008 #3,380 Editor-Barry Block, DPM, JD

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Stem Cell Injections May Help Heal Diabetic Ulcers: MA Podiatrist

An on-going clinical research trial using adult stem cells may help to improve blood flow and heal chronic sores for millions of people with diabetes who develop peripheral arterial disease (PAD) and critical limb ischemia (CLI). During the procedure, adult stem cells are carefully extracted from the blood of a patient affected with CLI and injected directly into the same patient's calf muscle. Early research shows that the stem cells work to replenish blood vessels in the lower legs – a process known as angiogenesis. Once the new blood vessels begin restoring proper blood flow, typically experienced several weeks after injection, many patients soon begin to see and feel improvement in overall lower limb circulation, and increased healing in any diabetic foot ulcerations present.

Dr. Vickie R. Driver

According to Vickie R. Driver, DPM, MS, member of the American Podiatric Medical Association (APMA), and Director of Clinical Research Foot Care, Endovascular and Vascular Services at Boston Medical Center, the treatment in the initial clinical trials positively impacted cells in the body that are affected by PAD and CLI.“ Many patients are not eligible to undergo typical surgical procedures that reestablish blood flow, or have had a procedure that was not completely successful.

That’s why stem cell treatments such as this, which are minimally invasive by comparison, are so critically important to further develop,” said Dr. Driver, who is the principal investigator of the trial at Boston University Medical Center. The novel clinical trial, sponsored by Northwestern University, also has several other test sites set up nationally.

Source: APMA

Dr. Homer Appointed Director of Kern Residency

Brian E. Homer, DPM, was recently appointed Director of Residency Education of the Kern Residency Program at Southeast Michigan Surgical Hospital in Warren, Michigan. The program is a PM&S-36 which has its roots from Civic Hospital dating back to 1956. As our profession's very first podiatric surgical residency program, its legacy is vast, as many of our podiatric leaders graduated from this fine program.

Dr. Brian E. Homer

Dr. Homer is a 1991 graduate of the W.M. Scholl College of Podiatric Medicine and a 1993 graduate of the Cambridge Health Alliance Podiatric Medicine & Surgery Residency, a Harvard Medical School Teaching Affiliate. He is ABPS Certified and past Clinical Director at the Southeast Michigan Surgical Hospital.

MA Sets Minimum Health Insurance Standards

Starting Jan. 1, Massachusetts residents who do not have health insurance that meets minimum standards set by state regulators could face a hefty tax penalty. A state board voted unanimously yesterday to proceed with the new requirements, drafted in 2007. But the panel added exemptions for an individual, union, or employer who can show that their plan - while not one authorized by the state - has comparable benefits.

In general, to meet the test, a plan must offer coverage for prescription drugs, preventive and primary care, hospitalization, mental health and substance abuse services, and emergency services.

Currently, the state's universal healthcare law requires most residents to have insurance or face a tax penalty of up to $912 per year. But the rules do not mandate what the coverage must include. Regulators said yesterday that the penalty in 2009 would probably be higher than $912.

Source: Kay Lazar, Boston Globe [10/18/08]

OIG Unveils 5-Point Plan to Combat Healthcare Fraud

A top official with the HHS Office of Inspector General (OIG) recently unveiled a five-point strategy for fighting fraud and abuse in anticipation of the transition to a Barack Obama or John McCain presidential administration. “What we have been doing is putting together a comprehensive strategy for combating fraud, waste and abuse,” Robert K. DeConti, chief of OIG’s Administrative and Civil Remedies Branch, said Oct. 6 at the Fraud and Compliance Forum in Baltimore sponsored by the American Health Lawyers Assn. and Health Care Compliance Assn. “These are enduring principles — it’s an effective strategy regardless of who implements it.” The five “pillars” are:

(1) Scrutinize who is allowed to bill before enrollment.
(2) Establish reasonable and responsive payment methodologies.
(3) Help the industry adopt practices that promote compliance.
(4) Vigilantly monitor claims for payment.
(5) Respond quickly to detected fraud.

Source: Report On Medicare Compliance [10/20/08]

Positive Emphasis

Never begin your response to an employee's request with the word "No." That word taints everything else that follows.

Better: Ask a probing question to discover the reasons behind the question or request. Then suggest alternative ways you might be able to deliver what the person really wants.

Source: Communications and Briefings [December 2008]

Query: Mistake by Employee

Recently, an employee mistakenly told a patient that we accept the patient’s insurance for bunion surgery. Because I was unaware of this mis-statement, I went ahead and booked, and later performed the surgery. We have now received a paltry check from her insurance company. We explained the situation to the patient and asked her to pay the difference between what the insurance paid and our normal fee. She has refused, stating that we would not have had the surgery if she know how much she would have to pay. What legal recourse do we have?

Name Withheld

Editor’s comment: PM News does not provide legal advice. There is a fundamental principle in law known as “respondeat superior” which states that employers are responsible for the actions of their employees while performing within the scope of employment.

Additionally, another legal doctrine exists in contract is known as “reliance,” which is essentially the argument stated by your patient. Combining these two legal concepts favors a “slam dunk” case for your patient. The lesson learned is to include billing issues as part of your informed consent.

Query: DME Accreditation

I have recently read that DPMs and other healthcare practitioners are exempt from the DME accreditation process. That said, I will be re-activating my NSC number.

I currently reassign my Medicare checks to my LLC with the new rules for electronic funds transfer. Does the LLC need its own NSC number for benefit reassignment? Is the LLC exempt from the accreditation process as it is owned by a DPM?

Hal Abrahamson, DPM, Plainview, NY

Response: I would suggest you have the LLC obtain its own NSC number since the OIG is looking into providers who reassign their Medicare checks to another tax identity. The LLC would be exempt from accreditation requirements if the doctors are only providing DME within the scope of your podiatric license.

If, however, you are using the LLC's NSC number to provide other DME equipment to patients other than your own and for equipment not pertinent to podiatric practice, you would be required to have the LLC accredited.

Paul Kesselman, DPM, Woodside, NY

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RE: Mid-Arch and Met Pain (Kel Sherkin, DPM)
From: Mr. Jeff Root

Dr. Sherkin indicated that he has a 36 y.o. female patient whose most recent “Root type” orthoses are causing mid-arch and met pain. One of the most common causes of orthosis-induced medial arch discomfort is irritation of the plantar fascia. Prior to ordering custom foot orthoses, all patients should be evaluated for bowstringing of the plantar fascia. This quick test is done by dorsi-flexing the hallux and then visually evaluating and palpating the fascia for bowstringing. If it is plantarly prominent, and especially if it is also firm on palpation, it should be marked on the cast and accommodated in the orthotic shell (typically 2 to 5 millimeters).

Without knowing more information about this case, including the exact location of the met pain, it is difficult to make recommendations. However, Dr. Sherkin indicated that the patient has a 4 degree forefoot valgus and a history of functional hallux limitus on the left foot. Is the orthosis causing jamming at the base of the 1st met (dorsal pain at base of 1st)? You might want to try cutting out the 1st met (shell) and adding a reverse Morton’s extension to improve 1st ray function motion and encourage hallux dorsi-flexion. You should also rule out supination of the midtarsal joint during casting as a possible cause since this can increase the medial arch height and can result in arch irritation unless you use a very flexible shell.

Mr. Jeff Root, President, Root Lab, jroot@root-lab.com

RE: Monofiliments Not an Accurate Test of Neuropathy (Peter J. Bregman, DPM)
From: Allen Jacobs, DPM, Peter J. Bregman, DPM

PSSD is NOT the most sensitive means to detect small fiber neuropathy. Intraepidermal nerve fiber density testing is the most sensitive means to diagnose and quantitate small fiber neuropathy. PSSD remains contoversial and does have a CNS component. PSSD is not helpful for peripheral autonomic or motor neuropathy. IENFD testing may preceed positive EMG/NCV testing and PSSD testing for affirmartion of neuropathy by as much as 3-10 years.

The suggestion that retained 10 gram filament perception may be present in the presence of an ulceration is correct. That is why the examination should also include a 128 tuning fork, light touch, 2- point discrimination, reflexes, neuropad testing, manual muscle testing, questioning and observation. Small fiber neuropathy and large fiber neuropathy may cause symptoms without demonstrable office examination findings.

According to the guidlines of the ADA (January 2008-Diabetes Care), diabetic neuropathy can be diagnosed in 87% of cases WITHOUT the need for advanced diagnostic testing.

Allen Jacobs, DPM, St. Louis, MO, allenthepod@sbcglobal.net

Editor’s note: Dr. Bregman’s extended=length response can be read at: http://www.podiatrym.com/letters2.cfm?id=22654&start=1

RE: Shoe Screener at Airports

I thought this was interesting in light of previous discussions regarding removing shoes at airports.

Shoe Screening Device at Israeli Airport

“An Israeli woman stands on a step-on scanner during a security check at Ben Gurion airport near Tel Aviv, October 12, 2008. Israel has introduced a step-on scanner that spares airline travelers the nuisance of having to remove their shoes so they can be x-rayed for hidden weapons, though the new device cannot yet sniff out explosives.”

Source: Gil Cohen Magen/Reuters)

Submitted By Neil H Hecht, DPM, Sherman Oaks, CA

ASSOCIATE POSITION - NORTHERN VIRGINIA/DC SUBURB

Excellent associate practice opportunity leading to partnership for PSR 24-36 foot and ankle surgically-trained physician. Currently 4-doctor/2 office practice in fast-growing area, expanding to 5 doctors. Hard working, personable, highly-motivated individuals needed. Great opportunity with excellent salary and benefits. No nursing homes.Top hospitals. Fax CV with references to 703-491-9994

SUBLET SPACE WANTED - NORTHERN NEW JERSEY

Busy multi-specialty podiatry group looking to hire a motivated individual to work part-time, including weekends as a podiatric hospitalist. Immediate opening available. NYS license a must. Applicant should be well-trained in all aspects of surgical and wound care and have completed a 24-36 month residency. If interested please send CV to docbunion@yahoo.com

CASE CONSULTING

Dennis Shavelson, DPM is now accepting referrals of difficult cases involving biomechanics, surgical complications, non-healing wounds diagnostic and treatment dilemma’s and subtalar stenting from DPM’S. Full reporting with second opinion only, rapid return after care and assumption of care options. Medicare and Out-of-Network Only. (212) 288-3668 or drsha@lifestylepodiatry.com

ASSOCIATE POSITION - CHICAGO AREA

Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for full-time podiatrist in a multi practice location in the Chicagoland and Northwest Indiana area. Must have two years of surgical residency. Please e-mail resume to d-kitchens@footexperts.com

SURGICAL EQUIPMENT FOR SALE

One Storz-Ergo Surgical Kit - Oscillating and reciprocating plus K-Wire driver. In very good operating condition. $4,500.00 Complete set of surgical instruments for any type of foot surgery. Includes osteotomes, implant prep osteotomes, hemostats, rongeurs, Allis clamps, retracters, bone forceps, etc, in excellent condition. Approximately 80 instruments. $1,500.00. e-mail Marstubass@aol.com

SURGICAL PODIATRIST - CONNECTICUT

Connecticut Surgical Group, one of the largest multi-specialty surgical group practices in New England, is seeking a Board-Certified podiatrist to add to our four-physician podiatry division based in Hartford. This podiatrist will provide all aspects of podiatric care with a focus on wound and surgical care to a well-established patient base. We require PSR-36 training and bc/be. Competitive salary and productivity bonus, partnership opportunities, excellent benefits, and reasonable overhead. Please apply online or via our website , or fax your CV to 860-524-2653. No phone calls, please. EOE

Wanted to buy – Used New Style (not pressure cooker) desktop digital autoclave (e.g. Midmark Ritter) and 2 waiting room chairs. Call 212-724-4457 or e-mail frottenberg@juno.com

Texas Home Footcare Associates, a podiatry exclusive company specializing in house calls and visits to facilities for the elderly, is looking to hire podiatrists. We are located in the Dallas area. Full and part-time positions are available. Immediate Openings Available. Must have a Current Texas license. Competitive Compensation Package. If interested fax curriculum vitae to 972 931-4819 or e-mail gjmdpm@tx.rr.com. For further information, call 972-380-8028.

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PRACTICE FOR SALE - FLORIDA—CENTRAL/SOUTH

turn-key operation grossing $570,000 annually based on one full-time doctor; practice is in a growing retirement area in the center of the state. Option to purchase or lease real estate. Great opportunity for growing the top-line. Surgery is only 14% of the professional man-hours, so it can significantly increase income. Medicare makes up 64% of revenues. Seller will assist with transition. Call 863-688-1725 for details and ask for Lee.

ASSOCIATE WANTED - SOUTH JERSEY

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