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07/02/2024 Paul Kesselman, DPM
Victory! AMA Removes Offensive Social Media Post
In reviewing some email today, I came across an advertisement for a rather large orthopedic summit not affiliated with AMA, AAOS or AOFAS. Within the foot/ankle tract, there were at least 3 DPMs listed as faculty members. This tract was among many orthopedic sections, with dozens of national and international orthopedic surgeons. It was great to see that three DPMs were lecturing on sophisticated surgical topics.
This trend of DPMs speaking at major orthopedic conferences is not new to me and surely not to others. Additionally, several orthopedic surgeons I have either worked with or been friends with for years have all told me the same thing. They are not members of AMA, they don't read AMA materials or care what AMA thinks, and they often disagree with what their national associations think and believe they are also out of touch with the membership.. Sound familiar?
So the question for AMA, AAOS and AOFAS is similar to what many in this forum are asking of APMA.
Are you also out of touch with many if not most of your membership?
Are you too sending out false and biased messages to the public in the quest to desperately hold onto a market share which clearly you are not solely entitled to?
If those running highly intellectual meetings are inviting highly qualified podiatrists to speak at their meetings (and within some of the topics actually serving as the moderator), then what is all the fuss about? If many major orthopedic practices, affiliated with MD/DO medical schools have podiatrists as part of the foot/ankle section of the practices and often running this section, again, what is all the fuss about?
Yes there are still a few hospitals where podiatrists have a tough time gaining surgical privileges, but that is far less problematic than 43 years ago during an initial attempt to seek staff privileges after completing my post graduate training.
With young DPMs and MD/DO working together in hospitals as residents and growing up in medicine and gaining mutual respect for one another, the real question is what if any impact anything AMA says or does will have?
I do agree that a retraction from AMA would be nice and is well deserved. And what if AMA refuses?
Threatening to take legal action against AMA and then not doing so would basically make APMA a paper tiger in the eyes of AMA and just set the stage for the next time. Not doing anything, well again, same thing.
Perhaps a poll should be taken by APMA to see if the membership is really interested in pursuing legal action against AMA before APMA starts spending hundreds of thousands if not millions of dollars, in our dues money, which even if successful may have questionable impact on the public's opinion.
As many have stated there is probably a better way for APMA to be an advocate for our profession and certainly only enriching attorneys may not be the right way to go.
Paul Kesselman, DPM, Oceanside, NY
Other messages in this thread:
07/04/2024 Daniel Chaskin, DPM
RE: Victory! AMA Removes Offensive Social Media Post (Allen Jacobs, DPM_
I have a difference of opinion than Allen Jacobs, DPM
1. Podiatric Medicine mandates knowledge beyond the foot. Podiatrists who specialize in Podiatric Medicine act as gatekeepers similar to internists so long as physical evaluations are in conjunction with the provision of podiatric treatment. Both an internist and podiatrist can treat a foot condition, find the underlying cause of this foot condition and make a referral to the correct specialist to treat the underlying systemic cause.
2. The way medicine is practiced today is not in the best interest of patients. Podiatrists should have knowledge beyond their own specialty. For example, a podiatrist could serve as a primary point of contact for individuals with kidney problems. For example, a podiatrist might order renal function tests to check kidney function. Kidney issues could be the underlying cause of toenail conditions, swollen feet, etc.... The podiatrist can then decide if it's necessary to refer the patient directly to a nephrologist or a different specialist.
3. If a patient's foot symptoms suggest possible heart failure, a podiatrist can arrange for an electrocardiogram (EKG) and blood tests to see if a cardiologist should be consulted.
4. It's important to note that not every patient will have a medical doctor (MD) to refer them to. Moreover, if a podiatrist needs to refer the patient to the correct specialist, it might be beneficial for the podiatrist to first conduct all the necessary tests to accurately diagnose the systemic causes of foot symptoms. The patient receives the most appropriate care and is referred to the right specialist. This is one major reason why a podiatrist should have knowledge beyond the foot.
5. The APMA should advertise podiatrists as being in a position of a gatekeeper with knowledge beyond the foot.
Daniel Chaskin, DPM, Ridgewood, NY
07/03/2024 Jon Purdy, DPM
Victory! AMA Removes Offensive Social Media Post (Robert Steinberg, DPM)
This topic once again spurs the question of degree change, or should I say augmentation. Going through the rigors of years of training, dedication and the ever rising expense of getting a DPM degree, does make one wonder why we are swimming upstream. My father was a podiatrist. He was not as well trained as I, nor did he have the privileges today’s podiatrists enjoy. He also had a fraction of the debt we face, minimal insurance interference, and did not have to deal with EHR or the myriad of other government regulatory and overhead expenses current podiatrists deal with. He was able to treat his patients well and enjoyed an income probably far better than most of today’s podiatrists, and did so seeing less patients. In short, his return on investment was far greater than today’s podiatrist. So while we pat ourselves on the back for having achieved more inclusion, we are not reaping the benefits of our colleagues. As a matter of fact, we have more restrictions than other degrees that do half the training and incur half the expense. Most states allow PAs to practice independently with physician oversight. Some states do not even require physician oversight for an NP to open their own practice, and be able to do more than a DPM! We’re ok with this? Podiatrists are limited in far more than scope. We see disparities in reimbursements. We are not able to employ ancillary medical staff without physician oversight. We do not have the option of alternative income from oversight of programs such as home health, hospice or other medical providing companies. There are many other aspects of medicine we are not entitled to participate in, which may just be paramount in the case of injury or illness not allowing us to continue our current practice situations. We cannot supplement our retirement is ways an MD or DO could using the alternative revenue streams. Our training has changed, the medical environment has changed, and we are being left behind while lesser trained ancillary medical providers out pace us. Jon Purdy, DPM, New Iberia, LA
07/03/2024 Lawrence A. Santi, DPM
Victory! AMA Removes Offensive Social Media Post (Robert Scott Steinberg, DPM)
Dr. Steinberg asks what our APMA has done to put money back in members’ pockets. In addition to defending our members’ reputations from scurrilous attacks that could have a legitimate impact on their patient volume, our APMA is the leading organization protecting members from fee cuts, onerous payer policies, and more, all of which affect your bottom line.
Following advocacy by our APMA and others to change office and other outpatient E&M level selection methodology and advocacy to increase payment associated with those services, in 2022, podiatrists submitted approximately 530,000 more Level 4 and 5 office and other outpatient E/M services than in 2018, resulting in approximately $76.8 million more paid to podiatric physicians. That alone is roughly $4,600 per practicing podiatric physician, about five times the cost of full, active member dues. In addition, this figure does not account for the additional many millions of dollars we kept in podiatrists’ pockets when we successfully advocated against the 2018 podiatry- specific G codes proposal.
APMA’s tireless work on that proposal and the -59 modifier and -25 modifier alone has saved members hundreds of millions of dollars. These savings have easily covered the cost of APMA dues and more. Just last week, our APMA announced that after more than a year of advocacy efforts, our association succeeded in advocating for Novitas and First Coast Part B MACs to allow submission of medically necessary repeat nail avulsions and excisions with a KX Modifier appended when the medical record specifies the indication. Our APMA is looking to extend this practice to the other five MACs as well.
In addition, our payer advocacy has averted multiple significant cuts for podiatrists in the Medicare Physician Fee Schedule. Every year, our APMA immediately evaluates and responds to the Medicare Physician Fee Schedule Proposed Rule, strenuously opposing proposals that would negatively impact our members. This year, we avoided a 3.4-percent cut. The proposed rule for 2025 should be coming out next month.
Our APMA also provides outstanding tools to support your practice in saving money. Our APMA Business Mastercard offers 5% cashback on medical supplies and equipment and 2.25% cashback on everything else. Combine it with the savings through our relationship with Talar Medical, our preferred GPO, and your practice could save thousands. Participants in the APMA Registry who reported for MIPS during the past seven performance years saved a minimum of $3.7 million in negative payment adjustments.
Finally, our APMA is the only organization representing podiatrists at the AMA RUC, the body that provides physician recommendations to CMS about the value of codes, meaning we are the leading voice for podiatrists in determining the value of every service you submit for payment to Medicare.
So, in short, the answer is that our APMA is putting money back in your pocket every day. You could choose not to pay APMA dues (which have not increased in more than a decade), and you would save several hundred dollars per year. Or you could choose to continue to support the organization that puts tens of thousands of dollars in your wallet every year. That choice has always been clear to me. Lawrence A. Santi, DPM, APMA President
07/03/2024 Allen Jacobs, DPM
RE: Victory! AMA Removes Offensive Social Media Post (Robert Steinberg, DPM)
Quite some years ago, I served as the scientific chairman, assisted by Ray Esper DPM, for the APMA scientific meeting for three years (Disney, California, Las Vegas, and Boston). At that time, the scientific meeting was held concurrently with the House of Delegates. At the Las Vegas meeting, I had invited a number of nationally respected medical school faculty members to lecture. I was rather upset at the fact that it seemed to me that the House of Delegates was receiving priority over my needs for the academic faculty. Although I did not voice my concern, I was indeed upset about this.
James Ganley was one of the individuals I had invited to speak. With his usual insight, he sensed that I was upset. He asked me to take a walk with him through the exhibit hall. He asked me “Allen, you any good at politics?”. I told Dr. Ganley absolutely not. I have an inability to negotiate if I feel someone is wrong and willfully misrepresenting facts or willfully distorting facts. Dr. Ganley looked at me and said “neither am I“. He then said. “you know, neither one of us is good at politics. But we do need politicians. We need them to move the profession forward and to protect the profession. We need good people to do the things that you and I do not do.”
Ray Esper and I met with John George, who was either APMA president or on the board of APMA at that time. We spoke to the need to separate the national scientific meeting from the House of Delegates meeting. He agreed, and got the ball rolling.
Recently, we have seen some increasing criticism of the APMA by contributors to p.m. news. I must say at the outset that I am in general agreement with them. However, complaining does not solve the issue of poor political representation by our national or local organizations
Anyone who knows me well knows I am incapable of participating in politics. However, I tell the residents with whom I work that they must get involved and change things. If you are dissatisfied, then you must vote out your current delegates. You must be more involved in your state societies. You must demand action by the officers and board members both locally and nationally or you must take action and remove them. You must get involved if you have the ability to do so. In the “old days“ the APMA officers and presidents were generally individuals academically accomplished, who moved on to politics later in their life. They had established bona fides. They were people like Irv Kanat, Earl Kaplan, Dalton McGlamry, Arthur Helfand. They were academics first and politicians later.
We need good politicians. I agree that in the last number of years we have had individual officers with relatively little or no academic or professional accomplishment. I personally believe it is acceptable to be a full-time politician so long as you do a good job of it, moving the profession forward, academically and politically. I agree with other writers they have failed in this regard. I believe that the APMA has become somewhat self-serving relegating the needs of our profession second to their own personal political and financial needs. Some of the concerns of our membership are beyond the control of the APMA, and are issues which confront all of medicine, just not podiatry.( As an example, reduced payments for services rendered, increasing pre-authorizations). At the local level, as they say, all politics are local. You need to take the time to get involved at the state level. You need to hold your national delegates accountable or remove them. You need to hold your executive directors accountable or remove them. If your seminars fail to provide you with the education you require and fail to satisfy your educational needs vote out the people who are responsible for the construction and content of these meetings. Get involved. The editor of PM Magazine has told you this for years and it is true. If you do not get involved, you do not have the right to complain. hold people accountable. Dr. Ganley said it best, we need good politicians.
Allen Jacobs, DPM, St. Louis, MO
07/02/2024 Allen Jacobs, DPM
RE: Victory! AMA Removes Offensive Social Media Post
There is an old joke that goes something like this: what is the difference between an internist, a surgeon, a psychiatrist, and a pathologist? The answer: an internist knows everything but does nothing, a surgeon does everything but knows nothing, a psychiatrist knows nothing and does nothing, and a pathologist knows everything and does everything, but it is too late.
It is difficult to believe that the AMA position statement, obviously driven by AOFAS, will have any significant impact on your practice. Your medical colleagues who refer to you regularly are well aware that you are not an MD. They are well aware that you did not go to medical school. By virtue of referrals of patients and trusting you with the care of their patients, by action, they respect your diagnostic and therapeutic abilities. Otherwise, they would not refer their patients to you.
This suggestion that we pursue legal action in my opinion is unfounded and likely not supportable. Much of what was stated in the AMA position, whether you want to agree or disagree, was true.
I believe it was about 1968 or so when Bob Dylan released the song “the times they are changing“. Reference has been made to this relevant to medicine in some of the correspondence to PM News. Indeed, the times are changing. Osteopathic physicians are become fully incorporated into medicine. Physician assistants and nurse practitioners have increasingly been increasingly permitted to provide unsupervised diagnostic and therapeutic interventions.
Years ago, when I was a residency director and chairperson of a podiatry service at a relatively large hospital in St. Louis, I served on the credentials committee of that hospital. Controversy arose when a local DO orthopedic surgeon who had a successful sports medicine practice applied to our hospital privileges. The MD orthopedic surgeons were in an uproar. In some ways, I thought it was ironic that here I was, a DPM with full privileges at the hospital, supervising a fully integrated residency program, and a DO with training which was closer to that an MD than was mine was, being subjected to this scrutiny. The chairman of the committee was an Ivy League trained neurologist complete with a bowtie. He pointed out to the committee that the applicant had not graduated. Medical school, did not pass standard medical boards recognized by the MDs, did not complete an MD recognized orthopedic residency, and had an unrecognized certification in orthopedics. He was opposed to the application.
I stupidly interjected my thoughts. I noted that there were very qualified and some unqualified doctors with all degrees, and that in my opinion each individual should be evaluated by their individual competency and experience and not by degree. The chairman looked at me said “Jacobs, you are a podiatrist. I understand that you are good at what you are good at. But you are a technician. Medicine is a learned academic profession “. The osteopathic DO was denied privileges.
Personally, being an old guy 50 years in practice, I do not believe that an MD degree is required to provide exceptional care of foot and ankle pathology. Someone needs to explain to me how increased knowledge of spasmodic dysphonia will improve my ability to perform a proper bunionectomy. Someone needs to explain to me how increased knowledge of cerebellar pontine angle tumors will improve my ability to manage plantar fasciitis. I would much rather future podiatrists spend extra time learning about peripheral vascular disease, rheumatic disorder manifestations of the foot and ankle, lower extremity dermatological disorders, than spending any time on an obstetrics rotation or gastroenterology rotation.
The times they are indeed changing. Perhaps MD model of education is the former gold standard. In some ways, the podiatry education model is ideal for its intended purposes. Education is intensely focused on various diagnoses and treatments that will constitute the actual practice of podiatry.
Several weeks ago, I happened to have two patients admitted to the hospital in septic shock resulting from diabetic foot infections. One of the patients had multiple significant comorbid conditions. I was called to treat the foot via incision and drainage and eventual amputation. I was sitting in the doctors’ lounge reviewing the chart and a first year podiatry resident walked by. I grabbed him and said let’s look at the chart together. I want to make a point to you. We went over all the medical notes by the various specialists. Each one stayed in their own lane.
Then nephrology notes reflected fluid, and electrolytes and renal function. Not a word about anything else. Ditto infectious disease. The pulmonary specialist made comments restricted to pulmonary function. It went on and on and on. I do not understand why you would expect, the podiatrist to have extraordinary capability or knowledge beyond their own specialty when it is clear that is not a reflection of how medicine in today’s world is practiced. Dr. Kesselman made the point regarding “functional equivalence“ and that is in fact the case. We are functionally equivalent to an MD when it comes down to what it is we do and what it is they do.
I had two patients this week that required below the amputation. I consulted the orthopedic surgeon for the amputations. And again I pointed out to the chief resident the following: the orthopedic surgeon said in his notes essentially when the medical problems are stabilized call me, and I will do the amputation. Not a word about any of the medical problems. Nor was this required.
Some of the residents (not all) coming from the three year programs today are extraordinarily well trained, and I would put them up with any resident in any medical specialty. They know what they do not know, they know when to appropriately refer, they are sensitive to the overall medical status of these patients. They are indeed “functionally equivalent“ to our MD colleagues.
As for the AMA, this will not affect your relationships whatsoever. My first class at PCPM in 1969 was “introduction to Podiatry “. Dr. Jerome Shapiro stated day one “Do not ever forget that MD means my domain “.
Podiatry has come too far even during the 50 years of my practice and observations, to go backwards. That will not happen. You are now on hospital staffs, you are at major teaching hospitals. Should you choose to do so you can participate in orthopedic groups, treat major trauma, and if so inclined, participate in major reconstructive surgical procedures. This is a reflection of the competency which you have demonstrated. Practice good medicine. Continue educating yourself daily. Practice ethical medicine. No statement from the AMA is going to reverse those referrals which you receive so long as you follow these guidelines.
Allen Jacobs, DPM, St. Louis, MO
07/02/2024 Keith L. Gurnick, DPM
RE: Victory! AMA Removes Offensive Social Media Post
When will our national and state associations bring us real victories? I preface this post as a 42 year dues paying member of the APMA, California Podiatric Medical Association and Los Angeles County Podiatry Association. It is always good news when our associations fight for us and win the battles to right the wrongs. Quick action to eliminate the AMA's irresponsible, inaccurate and defamatory social media hit piece against our profession should be commended.
The CPMA recently was victorious against Blue Shield who was planning to cut allowable payment by 50% for an E/M or consultation when billed at the same encounter (same date of service) as a minor procedure. These are two recent actions successfully undertaken where we prevailed. But is not losing the same as winning? We all know there have been tremendous gains for our profession made in the past. Isn't it time, now to try for more gains for our membership, in addition to putting out these irritating forest fires one at a time.
When will these same associations really step up, and get tough and fight for our membership and get us some additional progress and gains?
Hospitals are trying to reduce podiatrists’ privileges at a time when we should be fighting to expand them. Insurances are getting away with reducing payments (with take it or leave it contracts) for services that are so low I do not know how young and other private practice podiatrists can make a profit after paying all the bills we are bombarded with every single day.
Bunion surgery payments of $350-$700 with a 90 day- global. Blue Cross in Los Angeles allows $77 for a "real" toenail avulsion and then has the audacity to send out a "fishing" letter to educate podiatrists about what is and what is not a 11730 or a 11750. We need to get higher reimbursements for what we do to stay in business and to be able to pay our bills. I just did an osteochondroma excision on an 11 year old girl and was allowed $308 by Aetna.
Why are custom foot orthotics not a Medicare covered service, a service we provide that is certainly medically necessary in our aging Medicare population? They pay for a walker boot or a night splint or a drop foot brace when needed, why not a foot orthotics?
Keith L. Gurnick, DPM, Los Angeles, CA
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