The Voice of Podiatrists

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December 12, 2006 #2,763 Editor-Barry Block, DPM, JD

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IL Podiatrist Uses VAC For Diabetic Ulcers

Podiatrist Stephanie Wu, D.P.M., says a condition called neuropathy prevents many diabetics from feeling pain. As a result, every 30 seconds, someone with diabetes loses a limb. Foot ulcers are the main culprit.

Dr. Stephanie Wu

"Patients who lost the gift of pain will continue walking and not realizing that they are wearing a hole at the bottom of their foot," Dr. Wu, of Rosalind Franklin University of Medicine and Science in North Chicago, tells Ivanhoe. Now, there's a new way to heal those dangerous wounds. So she is using a new therapy -- called vacuum assisted closure, or VAC.

Dr. Wu first covers the wounds. Then, she wraps them with special foam and covers them again. A tube attaches to the foam, sucks out fluids and provides pressure -- almost like a vacuum. The specialized foam interacts with the wound and promotes healing.

Source: Ivanhoe Broadcast News [12/11/06]

Government "RAC"ing it in From Pilot Auditing Program

Federal officials are singing the praises of a Medicare auditing program, heightening the chances that the government will expand it to other states. But physicians have described the initiative as an aggressive form of bounty hunting.

The Centers for Medicare & Medicaid Services in November issued its first progress report on Medicare's recovery audit contractors, or RACs. The three-year pilot project uses private auditing firms to comb through physician, hospital, nursing home and other claims to find instances in which the government paid too much.

Since it launched in the spring of 2005, the program has identified about $290 million in overpayments. Only about $18 million was related to physician services, which are in a group that also includes ambulance and laboratory services, according to CMS. Medicare already has recouped more than $60 million overall and has initiated steps to collect the rest.

The average amount demanded from each physician who received an overpayment notice was $135 in Florida and $216 in California, CMS said. So far, New York contractors have not investigated physician claims.

Source: David Glendinning, AMNews [December 18, 2006}

Medical ID Theft Is Booming

Instances of medical identity theft have grown dramatically over the past year, says Alex Johnson, assistant director of external audit investigations at Regence, which operates Blues plans in Washington state. He blames the increase in this type of fraud on rising healthcare costs and the growing number of the uninsured.

"As insurers, we really are stuck in the middle of identity theft," he says. "We ask providers to return payment. Sometimes their only recourse is to go after the perpetrator."

That has prompted more providers to incorporate procedures to match insurance cards with photo identification. Johnson says Regence is considering health cards that include a photo ID.

Source: The AIS Report on Blue Cross and Blue Shield Plans [November, 2006]

Query: Mosaic Verrucae

A patient of mine has tried numerous topical treatments for a large mosaic verrucae on his heel over the past year or so. His last treatment of applying a soaked gauze of apple cider vinegar to his heel for approx. 4 hours a day has helped improve his condition. Has anyone had success with this treatment or does anyone have any other ideas to treat his heel topically?

Steven Schutzbank DPM, Havertown, PA

Editor’s Comment: Over the last 12 years numerous verruca treatments have been suggested ranging from duct tape to hypnosis. What these treatments share in common is that they all result in some success, yet never in 100% success. As Dr. John Grady recently commented, “the placebo effect” can never be discounted.

RE: Pay Cuts Averted
From: Paul Kesselman, DPM

I am not jumping up and down and rejoicing that the 5% across the board cuts were averted in 2006, 2007 and likely won't be implemented again in 2008. More importantly we also did not get an overall raise and many CPT codes may still be reduced if their R.V.U.'s are lower than that of the previous year.

While Congress and the Federal government are paying more to Medicare Advantage organizations, these same organizations are making further inroads into our traditional Medicare patient base. These organizations pay providers only a percentage of Medicare fees, and are more restrictive in our ability to provide many ancillary services we may provide under traditional fee for service Medicare. The same is true for many private insurance carriers who have lead the way in inventing creative stumbling blocks in our attempts to secure payment for the vital services we provide.

Simultaneously our professional and personal financial dependents demand increases. Other professions only after a four-year college education are paid higher wages with more benefits than health care professionals. Other professions also start making these wages at least 5 to 6 years prior to a healthcare professionals ability often receiving tuition assistance and pay raises from their employers should they chose to obtain an advanced degree.

Until someone in the congress, state legislators, universities and board rooms of America have the wherewithal to address these issues I believe there is little financial incentive for anyone to go into the health care profession. While those who are independently wealthy or those who are altruistic may able to afford to pursue a career as a health professional, I doubt those numbers will be sufficient to care for all of us who will soon be the patients rather than the care givers.

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

RE: Schwannoma (Art Hatfield, DPM)
From: Multiple Respondents

There is an entity known as Schwannomatosis, which is currently
considered a variant of neurofibromatosis, of which two distinct types, NF-1 and NF-2 are currently recognized. Multiple lesions of Scwannomatosis tend to stay confined to a particular extremity or segment of the spine, and cause nothing much more than pain which resolves on excision.

Two cases I have had in the past five years both occurred in the muscle belly of the abductor hallucis muscle. Be advised that lesions not involving skin tend to be more typical of scwannomatosis. Although no evidence of multiple lesions existed in both cases, I was encouraged by neurologists to get a MRI of the skull to make sure that we weren't dealing with one of the NF types, which have increased chances of malignancy and vestibular function issues. I therefore recommend that the scwannnoma cases cited in these pages be referred for a neuro consult.

Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@msnyuhealth.org

I took one out from the dorsum of the foot approximately 1 year ago. It was approximately 3 cm. in diameter and approximately 5 cm in length. Dissection was difficult but the patient went on to an uneventful recovery with no recurrence.

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

I excised one approximately 2 months ago on a 65 yo female that was located dorsally over the mid tarsal joint. I actually thought it was a ganglion but the pathologist proved me wrong.

Barrett E Sachs, DPM, Plantation, FL, Uncletenose@aol.com

RE: Neuroma Release Vs. Excision (Peter Bregman, DPM)
From: Marc Katz, DPM

I agree that conservative therapy is a must to start. However, cortisone is a noxious substance. It is injected blindly, and it causes tissue breakdown and blood sugar elevation. When you release an intermetatarsal ligament, you have, in fact burned bridges. You have removed a vital structure that stabilizes the metatarsals. Doing an endoscopic procedure does not guarantee that you will not damage neurovascular structures or cause an infection. It is invasive.

Cryosurgery is no more invasive than endoscopic release. There is no dirty work involved, as we are not cutting ligaments or nerves. We "truly" burn no bridges because the nerve is not actually being destroyed. Rarely, are there complications. It can be repeated without any problem and it has a similar success to what you report with the release.

We all have multiple procedures at our disposal. None of them are perfect, but we should be open to all of them to allow our patients the best possible care. There are multiple papers written by Dr. Goldstein and others on cryosurgery. I can tell you from personal experience that I have had better success using cryo when compared to ligament release, alcohol injections, and nerve excision. I would highly recommend that you educate yourself on the actual treatment and physiology of cryosurgery.

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com

ASSOCIATE POSITION - CENTRAL CALIFORNIA

Central California multi-location practice looking for PSR-36 associate leading to partnership. PSR-36 trained podiatrist with great opportunity for reconstructive surgical practice. Practice has Medicare-approved surgery center. Must have excellent interpersonal skills. Excellent salary and incentive. Respond to: westsidefoot@yahoo.com

ASSOCIATE POSITION - LOS ANGELES/SOUTH BAY AREA

Multi-office, multi-doctor, well-established practice near the beach cities. Seeking a board eligible/certified PSR-24 or PSR-36 trained foot and ankle surgeon. Well-rounded practice requiring knowledge in biomechanics, pediatrics, sports medicine, diabetic wound care, trauma, and reconstructive foot and ankle surgery. Full-time position available immediately with generous compensation and benefits, including malpractice, and health insurance. Two-year commitment required with partnership opportunity. Send CV to akemfoot@sbcglobal.net or fax to (310) 838-0227.

PRACTICE FOR SALE – NEW YORK

20 Year practice by-the-sea in beautiful Long Beach, NY. Excellent Terms. E-mail seashell554@aol.com or (516) 432-7300.

ASSOCIATE POSITION – NEW YORK CITY

Looking for an enthusiastic well-trained foot and ankle surgeon to join busy Manhattan/Brooklyn practice leading to partnership. Candidate must have completed a minimum two-year surgical residency program, demonstrate qualities of self-motivation and have impeccable skills in forefoot and rearfoot surgery. Package includes malpractice ins. health ins. plus salary. Terms negotiable. Email Manfootcare@aol.com or call 917-756-3686

ASSOCIATE POSITION--PHOENIX SUBURB

Attractive opportunity for enthusiastic, proficient, and personable associate. Well-established modern practice with multiple newer spacious offices, technology and equipment. Solid referral base, close to hospitals, knowledgeable certified staff. 22% MCR. Practice and surgical center partnership potential opportunity. Prefer 24-36+ PSR. Send CV: AZpodassociate@aol.com

ASSOCIATE POSITION- MEMPHIS, TN

30 year-old, high volume, multi-office practice in Memphis, looking for 24-36 PSR trained individual. Good opportunity for reconstructive surgery and wound care. No nursing homes or weekends. Potential partnership opportunity. Contact Footdok4@gmail.com.

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