The Voice of Podiatrists

Serving Over 9,000 Podiatrists Daily

November 17, 2006 #2,743 Editor-Barry Block, DPM, JD

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AZ Podiatrist (and Family) Cycle Together

Dr. Scott Evans, 47, a podiatrist with the Tucson Orthopedic Institute, understands the health benefits that come from preparing for and riding in the El Tour. "The reason we want to do it every year is especially for the kids," Evans said. "Not all exercises can be done for a whole life but this is something that can. This is something that can get them into exercise habit, whatever it is - biking, jogging - and enjoy the exercise."

Dr. Evans & Family

"It's the pageantry, the fun,'" Scott Evans said of El Tour, "all the people, the colored bike jerseys, getting medals, the aid stations. . . . They're so well done and stocked. "And I love going from Saguaro (National Park) to around the Catalinas and Rancho Vistoso and beyond to Silverbell (Road). It's so beautiful." This year, four Evans children ages 6 to 14 will ride, joining their parents and Emily's brother, Dale Oldham, who will be competing in the top group of riders.

Scott is entered in his sixth El Tour and although he is intent on lowering his time for the 109-mile big event (five hours, 34 minutes last year), he will break off this year at mile 74. He then will go to the start of the 35-mile event and ride the rest of the way with his family, including on the tandem with son Michael, 6.

This year, Scott's institute is a minor sponsor and the Evanses have a corporate jersey. "Exercise," Scott Evans said, "is the 'silent insulin.' It helps control blood sugar and if they do things like biking and basketball, it helps control the disease."

Source: Bryan Lee, Tucson Citizen [11/16/06] Gary Gaynor (photo)

NJ Podiatristis WWII Re-enactor

William Anania, 46, of Middletown does not have a direct connection to World War II, but he said he is fascinated with the period. "I am a history buff," Anania said.

Dr. Willian Anania

Anania is a podiatrist. He also is a World War II re-enactor. The group he represents is the 102nd Calvary Re-enactors Association, based in Middletown, NJ. "I started with Civil War re-enactments about 20 years ago, then switched to World War II," he said.

Anania was not in the service. However, he is a member of the Coast Guard Auxiliary based on Sandy Hook. His group of actors dressed in World War II uniforms helped entertain the guests by selling raffle tickets and helped to distribute the auctioned gifts.

Source: Terry Gauthier Muessig, Asbury Park Press [11/16/06]

Thompson Might Seek GOP Presidential Nomination

Former HHS Secretary Tommy Thompson on Wednesday in Iowa said that he might seek the 2008 Republican presidential nomination and predicted that health care and energy would become the top two issues in the presidential race, the Des Moines Register reports. In an interview after a speech for Iowans for Wellness and Prevention, Thompson, who served as governor of Wisconsin from 1987 through 2001, said he will establish an exploratory committee and will make a decision next spring about whether to seek the nomination. Thompson said, "I don't think anybody's got a better handle on healthcare than me."

Tommy Thompson

During the speech, which Pfizer sponsored, Thompson said the U.S. healthcare system would implode by 2013 without major reforms. He also promoted campaigns to fight smoking and obesity and to prevent and manage chronic diseases, such as diabetes.

Source: Tony Leys, Des Moines Register via American Health Line [11/16/06]

AAMC Aims to Boost Minority Docs

The Association of American Medical Colleges launched a national campaign to encourage minorities to apply to medical school. AAMC President Darrell Kirch said attracting more blacks, Hispanics and Native Americans to the nation’s 125 medical schools is “one of the most pressing healthcare challenges we face.” Kirch and other officials said there is an “untapped pool” of top-flight minority students, primarily majoring in biology, who are passing up medical school for other careers.

Between 1993 and 2004, the number of minority students graduating with undergraduate degrees in biology almost doubled for blacks, Hispanics and Native Americans. At the same time, the percentage of those students who applied to medical schools dropped significantly -- by as much as about 40 percentage points in the case of blacks. The AAMC, which has called for a 30% increase in overall medical student enrollment by 2015, said key factors were students’ concerns about doing well on application tests and about financing medical school.

Source: Michael Romano, Modern Healthcare [11/16/06]

Query: Hydroxyurea Side-Effect

A 17 year old girl presented complaining of numbness in her toes for the past few months. She has sickle cell disease, and is taking hydroxyurea, an antineoplastic drug. Chemotheraputic neuropathy is somewhat common, and some brief research on the Internet confirmed my suspicions as this is a known side-effect. Are there are any effective treatments for this? I referred her back to the pediatric hematologist for further care suggesting this in my report.

Ira Weiner, DPM, Las Vegas, NV, vegasfootdoc2005@yahoo.com

Query: Medicare as a Secondary Payer

An HMO (primary payer) refuses to pay podiatrists or orthopedists for performing diagnostic musculoskeletal ultrasound, CPT 76880, on a patient, but will pay for in-office x-rays. Diagnostic ultrasound services jhappen to be one of several capitated diagnostic services assigned to be performed at a specific radiology facility.

If Medicare is a patient's secondary payer, would it be obligated to pay for this procedure - presuming it was medically necessary - when the explanation of benefit from the HMO (primary) states, "This provider is not credentialed for this procedure"?

Paul Kesselman, DPM, Woodside, NY

Response: According to the Medicare Secondary Payer Manual, Medicare makes secondary payment when the primary payer doesn't pay in full, or because the *services* are not covered.

In this case, you as the physician (and apparently a contracted one) are fully aware of the fact that the HMO does cover the services, but not when you provide them. Your contract most likely requires you to refer patients to one or more contracted facilities, and may even hold you financially liable should you choose to perform the services yourself. If that is true, you might find yourself in trouble with Medicare for billing services to them that you are financially liable.

HMOs contract this way for financial as well as other reasons. A radiology group or center can perform all types of plain films and ultrasounds - and like most products - the HMO can obtain savings by "buying in bulk." As to the other reasons, an HMO *must* have a network capable of performing all medically necessary services, and they must prove that yearly to regulators (state, federal or both). Building and proving a network is easier and more efficient if the providers can do a wider array of services. Not all physicians have the ability to do their own ultrasounds (or even plain films), and each ancillary service must be credentialed and submitted to the regulator. Credentialing one or two or even three radiology centers to perform thousands of studies is clearly easier than credentialing thousands of doctors to do one or two (or even ten) procedures each.

Your post indicates that the HMO won't allow podiatrists and orthopedists to do these ultrasounds. I think that is merely a by-product of the fact that ALL doctors are required to refer these ultrasounds to the contracted (and capitated) facility -- but by nature of the service, podiatrists and orthopedists order them more than other specialists.

Stacey Hernandez, CCS-P, Placentia, CA

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RE: EPF Complication (Daniel Tellum, DPM)
From: Multiple Respondents

Dr. Tellum’s patient very well may have a lateral plantar nerve entrapment, but also check to see that the sural nerve (lateral dorsal cutaneous nerve) is not entrapped in your lateral portal site. Try a diagnostic sural nerve block and also a PT nerve block at different times to see which nerve is affected (or possibly both). NCV studies are not great at picking up damage to these nerves within the foot. Proceed with neurolysis after you determine which nerves are affected.

Jim Giannakaros, DPM, Manahawkin, NJ, Jimpody3@aol.com

The EPF procedure is well known to cause destabilization of the midfoot. Subluxation of the midtarsal region in any or all planes is an unintended but not uncommon consequence of sectioning the band. For this reason some section all but the lateral most portion of the band so as not to cause what you now describe- pain over the dorsal and/or lateral midfoot. There may be neurological issues which co-exist relating to this impingement or operative technique. Still, the solution would seem to lie in restoration of the pre-operative footprint.

Although it was mentioned that orthoses had been used unsuccessfully, it is not stated whether these are new devices and if they are designed around the new pathology. I would suggest that neurolysis will only compound the problem. Far better now to step back and approach the degraded mechanics with a device which may restore stability. Such a device might incorporate extra deep heel cup, an appropriate and generous rearfoot post, laterally extended flange, possibly a medial flange, and successful resolution of pertinent forefoot issues such as limitus through cut-out, etc.

Robert Eckles, DPM, New York, NY, reckles@nycpm.edu

One of the complications of an EPF can be if the incision is made too deep and there is muscle belly bleeding. You should know if this occurred because you would see it on the monitor. Of course, you can always get soft tissue swelling as well.

Dr. Tellum’s presumptive diagnosis sounds logical. Considering all treatment options that exist - I think the best treatment option for this particular case would be cryotherapy. It seems the post logical. I have looked into the procedure and it seems to best suit this case. The incision would be minimal and the "ice ball" would shrink the inflamed tissue present. I do not know when you say neurolysis if you meant cryo versus open. The reason for cryo over open is that you wouldn't have to make another long incision in the patient.

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

RE: Rape of the Plantar Fascia (Allen Jacobs, DPM)
From: Multiple Respondents

I agree wholeheartedly with Dr. Jacob’s opinion, and also hold
accountable the journal that printed it. We all know that every scumbag plaintiff witness has cut that article out and taped it to their "wall of ridiculous things I can say."

The word "rape" is often used in the vernacular to indicate disrespect, in this case disrespect to the plantar fascia. Rape is a horrible, violent crime. I think it totally inappropriate to use that term for anything other than the awful crime it describes. How offensive that phrase must be to anyone who has ever been, or who has a friend or family member who has ever been a victim of a violent, life-changing crime. I think we can do better!

Peter Smith, DPM, Stony Brook, NY, ps84@bc.edu

I commend Dr. Stephen Barrett for not fearing "thinking outside the box." Too much of what many physicians do they do because that is how they have done it for years. Too timid to try new techniques, and using flimsy excuses like, "It's not proven", or "Where are the double-blind studies", these practitioners are paralyzed in their "art." What is the practice of medicine and surgery if not an ever evolving science?

Robert Scott Steinberg, DPM, Schaumburg, IL, Doc@FootSportsDoc.com

I entirely agree with Dr. Jacobs regarding the need for conservative
care for chronic plantar fascitis. However, as critical as Dr. Weil's article was several years ago, the new rape is actually occurring with over utilization of ESWT therapy. Several companies actually selling ESTW services actually use outrageous numbers cases and revenue generated, surprisingly by, Dr. Weil himself.

As any well trained foot and ankle surgeon will tell you, 6-9 months of ACTIVE treatment is indicated before any surgical or ESWT therapy should be tried. Restraint is warranted, all podiatric physicians need to remember, we are here to treat the patient, not make our wallets fat.

John Levin, DPM, Director Residency Training, JFK Hospital Atlantis, FL, John.Levin@OCPBC.com

I was very taken back with Dr. Barrett's comments with respect to cryosurgery. They are untruthful, biased, and in fact incorrect. He makes mention that it is well documented that cryosurgery can cause neuromas, yet he references an article from 1985 where the procedure was done on horse hoofs. The article does not mention anything about technique or treatment protocols. he then goes on to say it can cause permanent nerve damage and is dangerous. On what does he base this comment as he has never performed any cryosurgery. There should have been a disclaimer that the remarks made were solely of his opinion with no factual evidence to back it up. Could the over 700 patients' I have treated be wrong? This was very disrespectful to the profession as a whole.

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

I have a future column in PM News that addresses the need to scrutinize the sources of information presented in all forms of communication. If someone is professing that everyone with plantar fasciitis needs an EPF, then the sources of that conclusion should be considered. Someone should do a prospective study on 100s on cases of plantar fasciitis and present those findings. Much of that work has actually already been done and seems to indicate that 80% or more cases of PF resolve with simple conservative measures. After 30 years of practice doing lots of surgery and sports medicine, that is consistent with my own findings.

Another point to consider is whether the company,author or speaker has a vested financial interest in the technique being proposed. That will often severely compromise the integrity of the conclusions. Just look at Vioxx and Merck for a great example.

Let's not rape the plantar fascia, let's figure out what works best and profess those standards to all.

Lloyd S. Smith, DPM, Newton Center, MA, lloydpod@yahoo.com

RE: Off-site Access and HIPAA (Pat Caputo, DPM)
From: Ray Posa

Both Gotomypc and Logmein in are safe and secure services that fully meet the requirements of HIPAA.

The way these services work is that they use a cluster of servers called Citrix Farms. What they do is set up relationships with in your account. When you set up the client software on a PC, it sends a signal to the farm saying I am on line and here is where I am right now. When you log into your account it will show all of your register PC's and show you which ones are available online. When you click connect. The farm then opens a portal and joins the two PC's

It is a great productivity tool, easy to use and with 448-bit encryption safe and secure.

Ray Posa, rposa@rfrancis.com

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