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RE: The Relationship Between APMA and CPME (Bret Ribotsky, DPM)

From: Keith D. Cook, DPM, Sylvia Virbulis, DPM


Dr. Ribotsky is correct that the Council on Podiatric Medical Education shares office space with APMA and that CPME staff are APMA employees. APMA provides administrative support to CPME. APMA and CPME have never attempted to obfuscate that arrangement. In fact, the CPME bylaws, a public document, clearly outline the relationship between CPME and APMA.


CPME operates as an independent, autonomous organization with a strict firewall between its accreditation activities and APMA. It stringently applies the same requirements to APMA educational activities as it does to other providers’ activities.


The US Department of Education recognizes CPME as the accrediting agency for the schools of podiatric medicine. The Department of Education has clear requirements that CPME operate independently of...


Editor's note: This extended-length response can be read here.

Other messages in this thread:



From: Gregory T. Amarantos, DPM


I must preface my statement with the fact I love my profession and have been both blessed and fortunate over the years. I have the best patients and enjoy practicing. Years ago, I was a podiatrist who knew some business. Now I am a businessman who knows some podiatry. Altruistically, we enter the medical profession to help others, but over the years we have been forced to become businessmen due to the changing Medicare rules, the insurance industry, and the large hospital systems. For them, it is business and one cannot compete in the same arena while thinking like doctors. We need to think like them.


Over the years, I have thought a 2 week “blue-flu” would wake up the nation. Obviously, emergent care would still be provided. It would be incumbent upon the leadership to present a forceful response to the public outcry of...


Editor's note: Dr. Amarantos' extended-length letter can be read here.



From: Lawrence Kassan, DPM


I agree with Dr. Bardfeld's post regarding doctors going on strike. In fact, I recommended it in a post several months ago. Interestingly, there were doctors at a Brooklyn Hospital who went on strike earlier this year. They must have settled the strike VERY quickly because it was in and out of the news within a day. I think it would be interesting for this forum to take a poll as to how many DPMs would be willing to test the water with a one week strike that targets a specific insurance carrier. 


Hopefully, this would serve as a wake-up call to these insurance CEOs making multimillion dollar bonuses that they only exist because we agree to participate with them. Obviously, whatever we have been doing up until this point has not been working. 


Lawrence Kassan, DPM, Philadelphia, PA



From: Ivar E. Roth DPM, MPH


I have been offering routine foot care since I began practicing 38 years ago after completing a 3 year surgical residency program. Lately, and I am not sure why, there has been a huge increase in new patient calls for routine care. I am averaging 4 new patients a day who just want their nails and calluses trimmed. Today again, I had one of those patients request that I make her orthotics after I explained why they would help her. Believe me, routine care is bringing in lots of pathology to my office. Two others wanted to have treatments for their fungus nails. While it has taken years to develop this following, I think that the other podiatrists in town have abandoned this care, and I am now thankfully the recipient.


Lastly, I call my extended care nail techs “podiacurists” as they all are former pedicurists converted to medical nail techs/podiacurists who I have trained to do nails and callus care. I sincerely hope that any podiatrist who want to get busier get the word out that you do routine care; you will not regret that decision.


Ivar E. Roth DPM, MPH, Newport Beach, CA



From: Richard J. Manolian, DPM


This shouldn’t come as a huge surprise to the podiatry community at large. I’ve written about this at least twice before in PM News. Practice economics are real. Look at it from the younger graduate perspective; when you consider the G0127 code for routine foot care.


This code pays about $10 nationally, and if I’m wrong, please correct me. So in order to pay one employee who earns $40,000 and if your practice consists of 25% routine foot care, that’s 20 patients who need to be seen per week just to cover that one expense, which could be one whole day just to cover that person’s salary.


Richard J. Manolian, DPM, Southbridge, MA



From: Elliot Udell, DPM


Dr. Rubin is dead on target when he questions whether podiatrists trained in foot surgery are no longer addressing non-surgical foot problems. This discussion is linked to the ongoing discussion on nurses who are starting foot care clinics. As a profession, we are like ostriches with our heads buried in the sand; we don't want to see that other non-doctoral level professions can and will encroach on all facets of foot care. Those who feel that their professions are secure because they only do surgery have their heads buried deeper in the sand. 


In my local hospital, PAs working in the operating room have told me that the general surgeons often allow them to do procedures "skin to skin." It is a matter of training and we could see future clinics run by physician assistants, trained by orthopedists and podiatrists, delivering high levels of foot care without the need of a podiatrist. It's only a matter of time until this happens. We have had many discussions over the years about non-podiatrists casting for and dispensing orthotics. It hit home when I witnessed my own physical therapist taking impressions for and ordering orthotics for his patient and the order was placed at a lab that promotes itself to our profession. What is the solution? Until there are legal statutes put into place, we simply have to love and be good at taking care of feet, and happy patients will refer others to podiatrists for foot and ankle care. 


Elliot Udell, DPM, Hicksville, NY 



From: David Secord, DPM


Every one of the points presented by Dr. Kass is legitimate, concerning, and continues to degrade our profession. The solution would be a class action lawsuit and would portend a leveling of the playing field if we had about 10 million to spend on a retainer and associated billable hours to fight this clearly illegal discrimination. Although a few people have offered a solution in operating as a concierge practice, the fear of the unknown and the questionable economic strata makes that a difficult choice for most. 


The salient question—as I see it—is “how do they get away with this?” The answer is “because they can and we let them.” The fix is in legally, as any organized pushback on this by our organized profession (en masse) refusing to take insurance anymore could lead to charges under the provisions of the Sherman-Taft Antitrust statute from 1890. We envy the dental profession, in that they were able to organize and largely avoid the strictures of the insurance companies, but as long as a majority of our providers take falling reimbursement in an age of rising costs, they will continue to stick it to us with impunity. It reminds me of the Pogo cartoon, wherein the character states, “We have met the enemy, and he is us.” 


David Secord, DPM, McAllen, TX



From: Jeffrey Kass, DPM


6) Eliminate the “mafia MIPS tax” - I have yet to hear how this information was collected and used in any meaningful way. All this does is create an unnecessary burden on the doctor. It is nothing more than a legal way to steal a doctor’s income. 

7) Medicare payment reductions must end - I am sick and tired of being threatened every year that Medicare is reducing payment to physicians. I believe this upcoming year, the threat is a 3.4% reduction. The medical profession needs a mouthpiece to scream from the rooftops that doctors require an 8% increase. 


I know of no other occupation whose salaries consistently get reduced. Threats of reductions are happily met with payment freezes, and this is considered a victory. This is nonsense. Physician reimbursements are not keeping up with inflation. All office supplies have skyrocketed since covid. Minimum wage keeps rising. Gov’t raises taxes and makes up new ones every so often. 


I understand that some of these issues mentioned aren’t podiatric-specific. But, podiatry as a profession should help in some form of round table discussion with the other medical disciplines to help solve these issues. Doctors really need to find a way to unionize.


Jeffrey Kass, DPM, Forest Hills, NY



From: Paul Kesselman, DPM


Some corrections are required to clarify the DM, ultrasound, and CTP issues:


1) Same or Similar and DME: APMA has been very proactive since the date this policy reared its ugly head. APMA has met with every medical association involved with DME. We have submitted multiple rounds of documentation to attempt to resolve this. I have worked with AOPA on their bill to be sure it would not be harmful to DPMs and rather be supportive. APMA has been calling for a ban on drop ship orthotics for years and this is now part of the proposed legislation.


2) APMA has a seat on the DME Medicare MAC councils which meets with all four DME MACs. Having this ability we have made sure that...


Editor's note: Dr. Kesselman's extended-length letter can be read here.



From: Eddie Davis, DPM


Dr. Rubin asked me to suggest means by which APMA can improve its overall value. Dr. Rosenblatt opined that APMA has done as well, if not better than AMA and “their specialty Boards.”


AMA does not have a large membership base. AMA financial support is largely derived from publishing revenues and database sales About 15 to 18 percent of MDs belong to the AMA.


I believe that Dr. Rosenblatt was thinking about...


Editor's note: Dr. Davis' extended-length letter can be read here.



From: Michael M. Rosenblatt, DPM


I am writing this comment in defense of APMA. Although I have been retired for many years, I am aware of their outreach efforts through reading their Journal and Podiatry Management. I recall the years when Congress enacted an enormous attack against physicians of all kinds, “felonizing” hundreds of previously legal business activities. Unfortunately, the major physicians’ political arms did absolutely NOTHING to mitigate the horrible damage done against doctors.


APMA was hardly in any position to fight against Congress. But the AMA and their specialty boards had the power. But they folded like a cheap suit purchased at the now defunct K-Mart. This, despite millions of dollars of dues paid to them by MDs.


If you think any other professional organizations are better than APMA, you are sadly mistaken. APMA is at least as good or better. And I speak as a previous critic of APMA. Continue your dues. They are trying.


Michael M. Rosenblatt, DPM, Henderson, NV



From: Ivar E. Roth, DPM, MPH


Dr. Karulak states that we are not big enough as a profession to institute change to our state scopes of practice. How about if the APMA studies which is the most likely state to expand privileges and focus not only the state association resources, but also the national on this one state? Once we get the first state to upgrade our privileges, work on the next state, and so on with the easiest first. With the mighty power of the national behind a single state, we could make this happen.


Ivar E. Roth, DPM, MPH, Newport Beach, CA



From:  Ben Pearl, DPM


I have always thought of Allen Jacobs, DPM as the Kurt Vonnegut of podiatry. His sharp witted writing and lectures also include similar thoughts on the trajectory of where things are going; in this case CME meetings. I agree that it is not a valuable use of time to have a series of infomercials. I do think that vendors need to have value to support meetings. I would like to see more open discussion and debate within a CME program so it is not just a highlight reel of best cases and scenarios. Industry and technology they represent do have a place on the podium, but it should be done in a thoughtful manner. Science has to be at the core but it is okay to have case studies that have some relevance as part of the discussion. 


To think that many solutions that work will be able to come up with funding for meaningful studies is not living in reality. If it were that easy, there would be more double-blinded randomized controlled studies. That is not to say that these trials are not an important piece, but everything is relative in the practice of medicine. 


Ben Pearl, DPM, Arlington, VA



From:  Allen Jacobs, DPM


The recent commentary regarding the state of post-graduate education for CME is noted. His participation in seminar programs and his products for the betterment of patient health are appreciated. Like Mr. Cioe, I miss the days of the large scientific gatherings such as the great Hershey seminars, the old Connecticut state meetings, and do enjoy the few remaining similar programs such as the NYSPMS annual meeting.


Peter, Paul, and Mary popularized the Bob Dylan song The times they are a changin. So too has podiatry post-graduate education. CHEC is first and foremost to serve the doctor, not the exhibitor. My own seminar, the St. Louis Podiatry Seminar, has increased in registration every year since going...


Editor's note: Dr. Jacobs' extended-length letter can be read here.



From: Steven Finer, DPM


Thank you Dr. Zicherman for writing that detailed analysis of nail surgery. Medicare’s constant changing of the regulation was to stop fraud and lower payments for this procedure. One can argue all day about 8mm.vs.9mm. but this is what it is really about. Medicare guidelines changed it up with the words, ”local anesthesia.”


This simply means the use of an injection to the toe. When some podiatrist makes the fraud headlines, most of these cases are about nail surgery. Around 1976, Dr. Arthur Helfand mentioned to me that one day this billing through Medicare would become problematic.  


Steven Finer, DPM, Philadelphia, PA



From: Michael L. Brody, DPM


I understand and appreciate your comments, but let me pose a few questions regarding how camera  phones would be used and how low-cost digital  cameras would be used. 


1) If you have a low-cost digital camera that does not leave your office, what is the risk of...


Editor's note: Dr. Brody's extended-length letter can be read here.

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