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06/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: AI and Podiatry
From: Lawrence Rubin, DPM
As podiatry board certification matters are bringing the profession closer and closer to there being mainly surgery limited practices, we'd better figure out a way to combat present and future bad AI public information. Let's say a footsore person gives AI this question: "Where can I go to get this big, red, sore bunion taken care of?"
It surely will not be to the benefit of the patient or podiatric surgeon for the AI answer to be, "Go to the Walgreens store nearest you. Ask the pharmacist where you can find bunion shields to reduce pain and inflammation caused by shoes and also Tylenol for bouts of intense pain." Forewarned Is Forearmed. We have to prepare ourselves to deal with AI. It’s good to see that APMA will have a lecture on AI at its August meeting.
Lawrence Rubin, DPM, Las Vegas, NV
Other messages in this thread:
09/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Robert Kornfeld, DPM
I thoroughly enjoyed reading Dr. Tomczak's post about how exciting it is to have a new APMA administration that finally understands what is happening and is going to do something about it. Well, I am a 1980 graduate of NYCPM. If you do the math, I graduated 44 years ago. And during all 4 1/2 decades that I have been a podiatrist, APMA has been "working" on making things better for us. Sometimes, they work "hard" at making things better. Yet, in all these years, not only has it not gotten better, it has gotten so much worse.
I won't go into details about my personal issue with my own NYSPMA which I quit many years ago, but what I will say is if anyone out there wants to make things better, you need to stop counting on APMA and do it yourself. When I realized that nothing was changing for the better, I decided to do it myself. And to be honest, my efforts to improve my professional experience all paid off without dues to an organization that is always working hard for us but never seems to accomplish what they promise.
I'm sure I'll catch some backlash for this, but my career is nearly over and I don't care what they have to say about me and my opinions. Of course, what I have already heard is if I'm not a dues-paying member, then I'm part of the problem. Nah. My career was amazing in spite of, not thanks to, APMA.
Robert Kornfeld, DPM, NY, NY
09/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Jon Purdy, DPM
Regarding the post from Dr. Tomczak, I did find that very amusing. I don’t intend to do a back and forth on this, but suffice it to say, I never put someone’s name in print without their permission. I’m sure that person would have been fine with it had I asked.
All associations post-covid have struggled, which necessitated change. As treasurer of the American Academy of Podiatric Practice Management, there has been change required of our own organization. We welcome constructive criticism, as it helps us improve and grow. It’s no different for the APMA. Time will tell, but I like the vibe they are currently putting out, and its leaders seem to be in tune with positive change.
Jon Purdy, DPM, New Iberia, LA
09/26/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Rod Tomczak, DPM, MD, EdD
I wonder if Jon’s letter was written tongue in cheek. If accurate, Jon’s report about a recent encounter with a secret agent from APMA who assured Jon there are changes a comin’ at APMA headquarters gives cause for celebration. That’s tongue in cheek. If what Jon was told is indeed true, and why should we doubt anything out of the mouth of an unnamed secret APMA leader, then I am grateful that the spirit of Deep Throat is alive and well in Washington, DC. One difference between the original Deep Throat and the APMA Deep Throat is that the current mole is wearing old Rohadur orthotics posted to the casts to throw off younger potential trackers.
But there is a disparity between these new APMA promises and those made in the waning moments of the Nixon administration. Deep Throat’s assertions proved to be true. Both the current APMA Deep Throat and the Watergate Deep Throat were accurate when they presently advised Purdy and in...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
09/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Kathleen Neuhoff, DPM
I have always found it interesting that when gabapentin was only available as Neurontin, insurance companies would not pay for it because it was off-label use. Then Lyrica came on with it on-label used for diabetic neuropathy, but at a high cost. So, the insurance companies would decline Lyrica until the patient had tried and failed gabapentin, which was still off-label.
We all know that cost is never considered an adequate reason for choosing a drug, so when my patients would decline Lyrica, I had them sign a consent form advising them that we were using gabapentin in an off-label manner, and that they had declined my recommendation for Lyrica.
I do the same thing when I am using something off-label for surgeries. For example, I use cryoablation for most of my neuromas with very good success, but I have the patient sign a form telling them that the instrument I’m using was not designed for neuromas. Many of my colleagues thought I was a bit paranoid, but maybe I was not!
Kathleen Neuhoff, DPM, South Bend, IN
09/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Justin Sussner, DPM
But how often do all of us get a fax or email or phone call that "ABCD" antifungal cream needs pre-approval, all for what may be a $20 generic. Isn't it the insurance companies' fault for not requiring the big ticket items to be pre-authorized first? This doesn't make sense to me. Maybe they just don't trust DPMs, and let the MDs do whatever they want.
Justin Sussner, DPM, Suffern, NY
09/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Ron Werter, DPM
What I don’t understand (and maybe the lawyers among us could explain) is how does the insurance company have the legal right to charge the doctor for writing a prescription. The doctor has no financial stake in the prescription; the patient and the pharmacy are the ones who have financial benefit. Is there something in an insurance company contract that says they can do that?
Ron Werter, DPM, NY, NY
09/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Back to the Future
From: Steven Finer, DPM
Upon reading the new issue of Podiatry Management, I counted ten ads for various creams and lotions pertaining to skin, nails, and pain relief. There were other ads for orthotics and podiatry-related machines. I have a 1962 Journal of the American Podiatry Association. It contains three ads for prescription internal medications. Also there were various ads for skin, nails, and orthotics. I know the various surgical magazines feature countless ads for surgical instruments and devices.
Must we now read internal medicine journals and use the Internet to review the latest medical news. I know everything is segregated in medicine, but this 62 year old journal was ahead of its time.
Steven Finer, DPM, Philadelphia, PA
09/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Recoupment Responsibility for Prescribing Ozempic
From: Paul Kesselman, DPM
While podiatrists rarely if ever prescribe Ozempic, a recent story in my local newspaper (Newsday) yesterday caught my attention sending shivers down my spine. Apparently, some insurers (UHC was named as one) are targeting physicians who prescribe medications off-label. They are now asking the physician for recoupment for the money they had reimbursed for Ozempic when the physician prescribed this off-label. One physician is facing a $125K recoupment merely for writing prescriptions. Interestingly, he is not being accused of falsifying medical records to get patients covered for Ozempic because he never did. He essentially prescribed Ozempic for weight loss and nothing else.
How many physicians (including DPMs) have written off-label prescriptions? I dare say most, if not all. In the podiatry world, prescribing Neurontin for neuropathy or chronic pain and cortisporin otic solution (neomycin and polymyxin B sulfates and hydrocortisone otic solution) post-matrixectomy easily come to mind. There are certainly many examples, all of which set a dangerous precedent if insurers are allowed to recoup money from providers who simply write a prescription for a medication which works, but for a non-FDA-approved purpose.
Medicine must fight this latest incursion to muzzle our independence and thus prevent our ability to provide our patients with the care they deserve. Unfortunately, the insurance companies are often shielded from legal action brought by patients who are denied coverage by their insurance carriers. Now the insurance companies want to sue us for the mere act of prescribing medications for purposes they don't agree with. The playing field is continuing to be unfavorable for physicians and it's high time we put a stop to this.
Paul Kesselman, DPM, Oceanside, NY
09/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Rod Tomczak, DPM, MD, EdD
Allen Jacobs' letter on why one chooses an NP for care piqued my curiosity, but in a tangential direction. I began to wonder about the APMA Seals of Acceptance/Approval. The APMA states it desires to provide information for podiatric physicians, their patients, and the general public to ensure they can make the best possible decisions regarding foot health. On their website the APMA states the Seal is not an endorsement. Shakespeare said it best, “A rose by any other name is still a rose.”
There is a committee that determines which product is fit to use the seal/logo of approval. The members of the committee are confidential according to the APMA website. I understand. God forbid an approved treatment for bromhidrosis does not work for someone. This NSA committee is protected from retribution and the need for Witness Protection, which can get very expensive. The APMA website stresses safety and utility and the need to submit various documents to the APMA proving efficacy. They do not mention if there is a fee for evaluation of a revolutionary flip-flop seeking...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
09/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Ivar E. Roth, DPM, MPH, Jeffrey Trantalis, DPM
Dr. Jacobs is correct. WE the profession, APMA, need to fund a campaign on TV to get the word out about our services. I had a local Dr.’s wife who was treating with an MD orthopod foot and ankle fellowship trained with the usual hands-off approach. The patient had an ulcer that was infected and very callused. When she saw me, the first thing I did was debride the callus which gave her immediate relief and now the ulcer could also drain properly, etc. Let’s make this happen. Good observation Dr. Jacobs.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
Dr. Jacobs is correct in the ability to promote podiatry as a profession. However, because of my experience working for a back surgeon, we as a profession can take it a step further promoting non-surgical care for the lower extremities and lower back. People are not aware of our training and skills in the biomechanics which provides a non-surgical approach to the complete lower extremities and lower back care.
Jeffrey Trantalis, DPM, Delray Beach, FL
09/18/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Kathleen Neuhoff, DPM
Sadly, I must agree with Dr. Doms. I was president of the American Animal Hospital Association years ago and we investigated the cost of such a campaign. It was many millions of dollars. At that time, there were about 50,000 veterinarians. It would have required a donation of more than $500 each if EVERY veterinarian contributed. We polled our members and the average they were willing to contribute was $100. And we knew from PAC contribution records that less than 10 percent would actually contribute, so it was not feasible.
The advertising we have been able to do has been primarily supported by our vendors but I suspect the amount of money spent by clients for products such as pet foods, cat litter, flea products, etc. far exceeds the amounts spent by our patients for podiatric-related products. It is certainly possible that some of the podiatrists reading this would be happy to contribute $1,000 each year for a PR campaign, but I suspect most would not.
Kathleen Neuhoff, DPM, South Bend, IN
09/17/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Pete Harvey, DPM, Stephen Doms, DPM
Kudos to Dr. Jacobs for his astute observation of NP advertising! I fervently hope some podiatry entity will pursue this.
Pete Harvey, DPM, Wichita Falls, TX
With all due respect to Dr. Jacobs, the number of nurse practitioners is about 385,000 according the American Association of Nurse Practitioners. They graduate about 39,000 each year (Fact sheet, AANP). With those numbers, they can afford to advertise. We graduate about 500 DPMs each year. They outnumber us by 20 times or more. Our profession is so small we could never compete with their kind of national television advertising.
Stephen Doms, DPM, Hopkins, MN
09/17/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Robert Scott Steinberg, DPM
I can tell you why the APMA doesn't do something similar: money and how they spend it. It is costly to put on the HOD. The budget for the 2024 HOD was $234,000. The Illinois Association of Podiatric Physicians and Surgeons has budgeted $20,000 for the 2025 HOD. Each state could use some of what they budgeted for the HOD to promote our profession. The APMA could do the same.
Nothing Earth-shattering happens at the HOD that necessitates hundreds and hundreds of delegates going to DC. The HOD recently ditched Roberts Rules of Order for Sturges for no practical purpose other than acting like they are the House of Lords. If you go to Facebook and search for plantar fasciitis, you will then be inundated with ads from PTs, DCs, and others who claim to be the experts. I rest my case.
Robert Scott Steinberg, DPM, Schaumburg, IL
09/17/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Howard Bonenberger, DPM
I cannot agree more with Dr. Jacob's letter. I feel secondary embarrassment when reading a post, presumably from social media or print material, quoting a podiatrist about foot odor, Dante's flip-flop hell, shoe selection, and ingrown nails.
I experienced something that may be partially at fault: years ago a local writer asked for an interview. She came with a list of questions which would have produced the very subject matter we are denigrating. I realized that she knew little about our training and skill level. I walked her through a typical week of sports injuries, fracture care, office and hospital surgeries, diabetic care, and C & C. She was a little embarrassed and very grateful for the eye-opening education. She actually became a patient and referred many others over the years.
I suggest that when asked to be interviewed for an article, podiatrists provide a thoughtful, short summary of a typical week and educate the interviewer. Plan ahead, please use spell check and proper grammar. Send them to various health news outlets. I have never read an interview with an orthopedic foot and ankle doctor who is discussing buying junior's shoes. It is because the interviewer would never deem to insult them with such lowly questions, after all...they are seen as well-trained physicians and surgeons. Until we, as a profession, set the table of expectations, not much will change.
Howard Bonenberger, DPM (Retired), Hollis, NH
09/03/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Donald R Blum, DPM, JD
Many years ago, I would have agreed with your hospital. That is the assistant should be as qualified as the primary surgeon. In the past, the assistant surgeon should have been able to give input to the surgeon and opinion during the procedure. However in today’s world a “certified medical assistant” is allowed to assist in surgery and in many cases also bill an assisting fee. Many times, this is out-of-network which greatly benefits the employing surgeon. This is possibly a good argument for allowing the DPM to assist on procedures with the privileged DPM.
Additionally, having a podiatrist assist whether trained in the particular procedure or not should decrease the OR time as the primary surgeon will be more efficient, and one could expect better outcomes as a result. Efficiency would occur as the assistant is more knowledgeable of the instrumentation and order of the procedure. Setting up power equipment, aligning a fixation wire or other hardware will be easier with a podiatrist, even one who does not do the procedure on a regular basis. The language and skill of the DPM assistant beats the knowledge of a “PRN” medical tech or a permanent OR medical assistant employed by the hospital but typically does general surgery or non-orthopedic procedures.
An item which the assisting podiatrist needs to check on is whether one's malpractice will cover them for these more involved procedures. Many times a doctor doing non-boney procedures will have a different medical liability coverage than one doing bone and tendon/ligament work.
Donald R Blum, DPM, JD, Dallas, TX
09/03/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Jerry Peterson, DPM
No, you are not missing something. He should be able to assist ANY physician on ANY surgery. In Oregon, a podiatric physician can assist in general surgical procedures, Ortho, Neuro procedures, etc. They are not required to have the privileges to be able to assist. Good luck moving forward.
Jerry Peterson, DPM, West Lynn, OR
08/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Ken Hatch, DPM, Herb Schmirer, DPM
I did get a notice via my state association. I first joined APMA in 1976. I am now a life member. When I tried to vote, it kicked out my password and number. When I called APMA, I was told that LIFE membership did not include voting rights. WE old guys saw the best and worst of podiatric medicine over many years. I guess the current leadership does not need input from our experience.
Ken Hatch, DPM, Annapolis. MD
I join the growing list of APMA life members whose vote is not important to the APMA. If my opinion is not good enough for the APMA, my money will not be either.
Herb Schmirer, DPM (Retired), Port Washington, NY
Editor's note: This topic is now closed.
08/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A
From: Bret Ribotsky, DPM, Lawrence A. Santi, DPM
I’m eagerly awaiting APMA’s response to this issue before I send my check. Please choose wisely.
Bret Ribotsky, DPM, Fort Lauderdale,, FL
APMA values every member and their input, and we apologize to any life member who may feel disenfranchised by the current referendum. As background, eligibility to vote in a referendum is codified in the APMA Bylaws for each member category—the APMA Board of Trustees and staff cannot simply choose to allow life members to vote. The Bylaws, Procedures, and Rules Committee reviewed the privileges afforded each member category as part of its comprehensive review of APMA’s governance documents and included the current privileges that were adopted by the 2019 House of Delegates. Life members are not the only category of members who are ineligible to vote. For more information on eligibility, check out our FAQs about the referendum at www.apma.org/referendum.
The philosophy of the committee has been that members eligible to vote in a referendum are those who are most likely to be affected by the outcomes of a referendum. So, life members, who are retired from practice, would not be affected by language designed to support scope of practice modernization.
I have heard your concerns, and the Bylaws, Procedures, and Rules Committee will consider the feedback we have received from life members at its fall meeting. To be clear, changing the bylaws would require action by the APMA House of Delegates, so any changes will take time. I thank you in advance for your patience and understanding.
Lawrence A. Santi, DPM, President, APMA
Editor's note: This topic is now closed.
08/30/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C
From: Steven J Berlin, DPM, Carl Solomon, DPM
I read that several retired podiatrists have felt slighted by not being able or being denied the opportunity to voice their opinions on current events affecting the profession. That certainly needs to change. I suggest a column of current situations affecting this great profession. We need a special column in the newsletter drafted by senior editors and/or Journal to encourage the opinions of us older podiatrists
Steven J Berlin, DPM
I acknowledge, but don't agree with the philosophy that life members are ineligible to vote because "... members eligible to vote in a referendum are those who are most likely to be affected by the outcomes of a referendum."
That makes about as much sense as not allowing voting rights to members who are employed by a hospital or other institution, because they may not be affected by certain issues that would have a greater impact on private practice docs. Some issues affect everybody and some issues do not affect everybody. We cannot permit our membership to be fragmented like that.
Carl Solomon, DPM, Life Member, APMA
Editor's note: This topic is now closed.
08/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From: Eric J. Lullove, DPM
There are numerous multilayer compression systems on the market for management and treatment of venous leg ulcers. They are not “replacements” of an Unna boot. They are specific for a different diagnosis code set. Multilayer compression systems should be billed with the I87.xxx series ICD-10s. The CPT code for those systems is 29581. The code is not a substitute for making a multi-layer compression from your supplies — this code was designed specifically for the compression system kits that are manufactured by 3M, Urgo, Milliken, Hartmann, et al.
You must document the need for edema control, CEAP or VCSS clinical documentation for a VLU or venous hypertension (or hyper congestion) as well as the failure of conservative therapy of elevation and stockings. You also should as a caveat have a recent ABI dated from the initial onset of the venous event or ulcer and any other additional vascular studies (venography, for example). As always, it’s about documentation, documentation, documentation, especially with wound care services.
Eric J. Lullove, DPM, Coconut Creek, FL
08/27/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: APMA Wants My Money, Not My Vote
From: APMA Member
APMA excludes Life members from voting, then asks for money. I feel quite disappointed that the recent referendum about the new definition for podiatric physician that APMA is seeking approval for has excluded life members from voting. Who better than people who have longitudinal knowledge and experience to be able to shed insight into this process?
And then the same week, I receive a lifetime member contribution form with APMA asking for $150 from me. I have always paid this contribution amount to APMA, but this year I’m refraining from doing so because obviously if my vote doesn’t count, neither does my money.
APMA Member (Verified)
08/26/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: Podiatrists Should be Doing Their Compliance Due Diligence
From: Lawrence Rubin, DPM
Due diligence refers to the reasonable steps that should be taken by a person or business entity in order to satisfy legal requirements. This diligence should include complying with the Medicare Office of the Inspector General (OIG) strong recommendation to have a provider and staff written compliance plan that is implemented and kept up-to-date.
There is no better way to avoid unintentional coding and documentation errors from resulting in an audit that can lead to potentially devastating punitive actions. This is because the OIG is on record for saying: Having a provider and staff (including outsourced billing staff) compliance program can be a mitigating factor in the decision of whether or not we (OIG) effect punitive action.
If you are a solo or small group practice owner or manager and are interested in knowing more about Medicare compliance matters, discuss this with your healthcare attorney or a qualified compliance consultant.
Lawrence Rubin, DPM, Las Vegas, NV
08/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B
From: Steven Finer, DPM
After reading Dr. Tomczak’s post, I reviewed the various boards in Pennsylvania. The Podiatry Board is the only medical one that requires two physicians, save one other. Physical therapists, require one. I have not researched the history of these board hand holdings. Somewhere in our past, podiatrists needed a lot of guidance, lest they stumble and do something idiotic. It seems that chiropractors, optometrists, and dentists do not need any help.
Steven Finer, DPM, Philadelphia, PA
08/15/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
From Paul Kesselman, DPM
Orthotics are custom fabricated, custom fitted, off-the-shelf, etc. Some companies advertise their wares as being able to cure everything and custom fabricated. While not every consumer can sniff out the snake oil salesman as medical providers, it is our job to report those who violate the law! Each state has different board regulations on who can dispense orthotics. If a company is marketing custom fabricated or custom fitted orthotics to the consumer, there are often state laws limiting this activity.
One can identify the 20 or so states which strictly regulate who can provide orthotic devices. By visiting the NPE West contractor at NSC, one can search under tools bar for a particular state's licensure database for all sorts of DME. Here you can find your state's licensure requirements for dispensing all types of orthotic devices. If you find that you practice in a state requiring a licensure and should the orthotic manufacturer be marketing directly to the consumer, this may be a reportable violation of the state’s laws and must be reported. There may be different regulations between custom fit, off-the-shelf and custom fabricated orthotics. So one needs to be careful to check all three benefit categories (OR1 =Custom Fabricated, OR2=Custom Fitted; OR3=Off-the-Shelf).
It is important to note that while this information is available on a Medicare contractor's website, the NPE contractor is using your state's board information and this is updated on a fairly regular basis. Thus, it is both fairly reliable and accurate.
Paul Kesselman, DPM, Oceanside, NY
08/14/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 1
RE: False Advertising about Orthotics? (Vincent Gramuglia, DPM)
From Elliot Udell, DPM
Dr. Gramuglia brings up two issues. One is whether a non-medical professional can prescribe orthotics. The other is whether a provider, professional or non-professional, can promote their product as being a panacea for all sorts of non-pedal ailments.
Anyone can legally sell foot orthotics. We are all aware of the Dr. Scholls machines in Walmarts, and orthotics sold on the internet via Amazon as well as in all sporting goods stores.
Whether a vendor can make a claim that his or her orthotics can cure herniated discs, scoliosis, or other systemic ailments is a legal matter and most states have district attorneys who investigate fraudulent claims made by any vendor selling any sort of product. Perhaps Dr. Gramuglia should call his local DA's office and report the matter.
Elliot Udell, DPM, Hicksville, NY
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