11/29/2022    Paul Kesselman, DPM

Therapeutic Shoes for Diabetics Are Proven to Be Helpful: So Why Aren’t They Prescribed More?

This month's issue of Podiatry Management
contained a very well written article by Dr.
White, detailing the benefits of prescribing and
dispensing therapeutic (not diabetic) shoes to
diabetic patients. I commend him for writing this
article and agree that providing therapeutic shoes
is necessary. Unfortunately and it pains me to say
this, I believe the time may have come where I can
no longer support providing this service.

Lost in this well written article are the main
reasons why multiple types of providers (not just
podiatrists) have voluntarily withdrawn from
providing this valuable service. Increasing audits
by the DME MAC, RAC, SMRC, often conducted by
auditors without clinical expertise, have simply
resulted in both large and small practices and
providers throwing their hands up in frustration.
Practices and rightly so have asked, why put hours
of resources running after little profit when that
same resource could be generating far greater
revenue substantiating higher paid AFO and
prosthetic devices?

Even when I have participated in an audit
successfully defending a practitioner, or the
practitioner has followed the manual I wrote for
a shoe manufacturer and previously had been
reviewed and approved by a CERT auditor, claims
still have failed and there is little if any
accountability to the auditor(s). They simply tell
the provider they can appeal. What practice can
afford to continue to spend the man hours needed
to appeal these claims along with the wait it
takes to appeal?

The ramifications on lost revenue on appealing
claims is astonishing. A recent article in
Experian Health stated: In 2009, the challenges
processing claims “wasted” $210 billion. A decade
later, that amount was estimated at $265 billion."
Furthermore other sources state that one in every
four wasted health care dollars is spent on claims
processing.

Unfortunately what this means is that patients who
can afford to purchase therapeutic shoes will pay
out of pocket and those who cannot may not be able
to obtain a very basic service. In many areas of
the country so many suppliers have quit the
program, leaving long waits for patients to see
suppliers who continue to work within the program.
Other patients simply give up. This is certainly
tragic!

If one were to use an accounting balance sheet the
reality is that saving $40,000 (the acute cost of
one lower limb amputation) or $9,000 the costs
involved in treating one ulcer with CTP, can be
used instead to provide shoes to a great deal of
patients. That message unfortunately is lost at
Medicare. The leaders and policymakers at the DME
MAC contractors care less about what the local
Part B Medicare contractors pay out. The leaders
and policy makers at the Local MAC contractors
also don't care about what the DME MAC pay out.
This is because the expenditures of the Local Part
B program are compartmentalized into each Part B
carrier. The same is true for the DME MAC program.
And never the two shall meet. Each one of these
carriers operates in their own little world, not
caring about the implications of what happens with
the other.

But those policies and payments do matter to us,
the taxpayers and to us as providers who are
frustrated. They should matter to lawmakers as
well. Most providers would want to continue to
provide this valuable service to patients, but it
simply is becoming unaffordable to do so.
I for one am glad I am no longer practicing. But
if I was, even with my expert knowledge and astute
documentation, I would think long and hard about
continuing to provide this service in my practice.
Just the time having to spend accumulating all the
data both prior to and after providing the service
in case an audit seems cringeworthy and just not
worth it!

Paul Kesselman, DPM, Oceanside, NY

Other messages in this thread:

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12/02/2022    Josh White, DPM

Therapeutic Shoes for Diabetics Are Proven to Be Helpful: So Why Aren’t They Prescribed More? (Bryan C. Markinson, DPM)

I appreciate the letters written by Drs. Markinson
and Kesselman regarding the article I recently
wrote in Podiatry Management about why diabetic
shoes aren’t prescribed more. While intended as a
“How to” overcome obstacles to ensure patients are
properly fit, it seems to have been perceived more
as “Why not to”, get involved with footwear.

I wholeheartedly agree with Dr. Markinson’s
conclusions that it’s best to have "a high-volume
need", "a dedicated individual in the practice for
the fitting of off-the-shelf shoes and an
available laboratory that will provide true custom
footwear and inserts instead of thin pink foam”.

Every practitioner must decide how to best care
for their patients at risk for diabetic foot
ulceration, whether it is to fit shoes within the
practice or to develop a relationship with a local
qualified shoe fitter. I contend that most
practices have enough patients with diabetes to
enable fitting 10-20 pairs of shoes per month. As
Dr. Markinson and I both state, this is best done
by a trained person who for an hour or two a day,
can expertly recommend appropriate shoe styles and
sizes, procure required compliance documentation
and ensure patients are refit year after year.

Medicare reimbursement for this volume of shoes is
enough to allow such a person to be paid well
while permitting much extra time to assume other
responsibilities. It's important that fitters
reiterate doctors' description of ulcerative risk
and the importance protecting feet both indoors
and out. As Dr. Markinson points out, inserts
must be of adequate quality to effectively
distribute plantar pressure, not the sort that
might be had for $4 or $5 per pair. If patients
are not being refit year after year, something is
wrong either with office protocols connecting
annual ulcerative risk assessment with shoe
prescription or else with how and with what shoe
styles patients are fit with.

Every patient wears shoes that they have paid for.
The opportunity to get expertly fit with footwear
that can significantly reduce the likelihood of
ulceration, at little to no out of pocket cost, is
an entitlement that many patients can benefit
from. The company I work with, Orthofeet, as well
as others, can provide practical guidance on how
to employ the best practices to ensure that
patients prescribed shoes are properly fit,
whether in the practice or if referred out.

Josh White, DPM, CPed, NY, NY

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12/01/2022    Paul Kesselman, DPM

Therapeutic Shoes for Diabetics Are Proven to Be Helpful: So Why Aren’t They Prescribed More? (Bryan C. Markinson, DPM)

I have to mostly agree with Dr. Markinson
sentiments and publicly want to acknowledge that
many years ago, Dr. Markinson often referred his
patients to my practice for proper evaluation of
shoes/inserts through the Therapeutic Shoe
program, because his practice could not deal with
the bureaucracy of the program. He and I am sure
most, continue to believe the program is
theoretically needed, but from a practical office-
based practice perspective untenable.

Most podiatrists (and others) as opposed to
pedorthists do not offer custom molded inserts
(A5513) simply because they either don’t want to
deal with the increased costs of the custom molded
devices, while still receiving the exact same
reimbursement as for custom milled (A5514)
devices. Most pedorthists and some orthotists
produce their own custom molded inserts in-house.
But they too as was noted during the recent AOPA
National Assembly are also facing increasing
pressures to discontinue their participation in
the shoe program.

The heat molded inserts for most patients as Dr.
Markinson mentioned are for most patients with
significant pathologies, worthless, yet they are
more profitable. In reviewing many of my patients
I encountered over many years, I also found that
custom orthotics, not covered by Medicare, are far
more efficacious for patients with significant
pathologies than any of the custom inserts
(A5513/4) available through a myriad of my
vendors, including private orthotic labs.

Providing custom molded shoes is definitely even
less profitable as producing these types of shoes
properly requires multiple adjustments, remakes,
etc. all of which almost eliminate their
profitability. Many of the pedorthists who work
either individually or for large providers, no
longer accept Medicare assignment for these
devices. Interestingly enough, non-assigned claims
paid by the patient are rarely audited. Thus
possibly becoming a non-participating supplier who
does not accept assignment, but does submit the
claim on behalf of the patient may be one way to
continue to provide shoes for diabetic patients.

For the most part, the reason(s) I have suggested
that this program is no longer tenable for most
providers, is solely the business/financial costs
of having to deal with all of the issues involved.
If the individual podiatrist/pedorthist or
orthotist left it up to their vendor to deal with
the audits, I could almost guarantee that most of
those vendors would shortly find themselves paying
out a significant amount of labor related revenue
to deal with these audits. Also having your vendor
respond to the audit for free, brings up some
rather interesting violations of the anti-
incentive regulations. This could leave both the
provider and the vendor in some legal hot water.

In short, the bean counters at Medicare and even
more important lawmakers must be categorically
shown they are paying out way more money to deal
with the medical/surgical ramifications of
patients not receiving responsible therapeutic
shoes. Once until Medicare and other bureaucrats
are shown that they are paying out $5 or more for
every dollar they would have paid for therapeutic
shoes, the ridiculous audits will continue. Until
Medicare and Congress are shown that the audits
are costing their constituents limbs and lives the
audits will continue. Until the American Diabetes
Association (ADA) and other patient advocate
groups such as AAPR drop their resistance to get
involved in the support of changes to the program
changes, the audits will continue.

It is not that I want to see podiatrist,
pedorthist, orthotist or other responsible
providers discontinue providing therapeutic shoes.
This program can definitely save us the taxpayers’
money by saving limbs and lives. Unfortunately, as
providers, the current program is fiscally
irresponsible for most suppliers.

Hanger and most other large suppliers have
discontinued their participation, in most
locations simply because of the labor costs
associated with dealing with audits and the paper
work nightmare associated with audits. This has
left long waiting lists at practices who can
barely keep up with the demand. However, if I had
the choice between providing routine foot care
(also a hot revenue item being audited) and
therapeutic shoes, it would hands down be routine
foot care. No product cost outlay and minimum to
no reliance on other providers to co-sign or
attest to my medical decisions or medical
documentation.

Most other providers as Dr. Markinson alluded to
(and as I have previously agreed with) cannot
afford to hire a dedicated employee only to deal
with therapeutic shoe issues. Most providers can
adequately staff their offices today, so to
suggest that hiring a dedicated employee only to
deal with shoes I’m sorry to state is no longer
practical. That being said, I agree with Dr.
Markinson, that Dr. White’s article unfortunately
accomplished the opposite of his expectations.

Paul Kesselman, DPM, Oceanside, NY