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01/02/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Ivar Roth, DPM, MPH
A clarification is needed here. My statement stated that if one took fellowship training, they could do these surgeries. This would not be a weekend course but a real fellowship one or two years. Obviously, sometimes things can get out of hand, and that is when you contact or make the appropriate referral. Why not? Let’s support our own specifically trained podiatric vascular specialist; it will be good for all of us.
Ivar E. Roth DPM, MPH, Newport Beach, CA
Other messages in this thread:
01/15/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Vincent Marino, DPM
I may be reading this incorrectly, but it seems to me with the enactment of this new law, the medical community will no longer be able to go after patients for unpaid medical bills since collection companies will no longer be able to ding the patient’s credit report for outstanding bills. Good luck collecting balances. I suggest everyone start collecting the day of service even if you have to refund the patient.
Vincent Marino, DPM, Novato, CA
01/14/2025
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Allen M. Jacobs, DPM
The reasons for a declining applicant pool to the colleges of podiatric medicine are multifactorial. There is need for some reality discussion. Years ago, there were somewhat limited alternative options for those who desired to enter healthcare as a provider, but were, for whatever reason, not accepted into medical school. There were few island medical schools, few colleges of osteopathic medicine. There were no PAs or NPs. There was always dentistry, physical therapy, optometry, chiropractic medicine. Competition to medical school is intense, and there are many excellent individuals who fail to succeed in admission to medical college in the United States.
It is not a matter of failure, it's a matter of numbers. Those who argue that diminishing reimbursement for services is the reason for declining applicants should ask why this factor has not reduced applications to...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
12/19/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Robert Kornfeld, DPM
Dr. Jacobs’ definition of podiatry, should it be the majority opinion, will surely lead to the death of podiatry. If all we do is look at the foot, focus on the foot and treat the foot regardless of the underlying immune burdens (as if the foot is independent of the body it is attached to), we will surely be replaced by NPs and PAs in the coming years. We are already a profession that is slowly being usurped by these new professions. Dr. Jacobs and I are from the older generation that began the battle for parity through better surgical skills.
But will that sustain us? I say absolutely not. I feel that our schools need to provide more comprehensive training in what creates an inefficient immune system that is part and parcel of most of the pathology we treat. Are we not allowed to advance our skills once in practice? Or are we only allowed to practice what we learn in...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
10/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Marco A Vargas, DPM
It seems that after the pandemic, it has been very difficult to find and retain staff. Salaries have increased dramatically and there is a significant amount of staff turnover which creates disruption and is very costly for the practice. Therefore, after limited success with two virtual assistant companies for my own practice, I decided to start my own podiatry-specific virtual assistant company based in Medellin, Colombia.
We specialize in training podiatry virtual assistants in-office duties such as answering phones, appointment scheduling, insurance verification, and prior authorizations among other tasks. We also provide in-room translation services for Spanish speaking patients. All virtual assistants are bilingual, college graduates with podiatry experience, and cost less than half of what an on-site employee does and with less turnover.
Marco A Vargas, DPM, Sugar Land, TX
09/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3B
From: Lawrence Rubin, DPM
Dr. Udell has posted that expecting the APMA to invest millions of dollars into national advertisements is a great idea but in reality it boils down to a pipe dream. I agree with Dr. Udell. We cannot expect APMA to invest millions of dollars into national advertisements. But, although it may require a modest increase in the costs of special human and outsourced resources, it would not cost APMA anything even close to millions of dollars to expand its efforts to put podiatry in the public limelight by employing "guerilla marketing" tactics (Getting great marketing results with minimal expense through advertising creativity).
This creative guerilla marketing could include launching an easily promoted Internet newsroom especially for news and feature reporters and healthcare media copywriters. It can have interesting news releases and feature stories that highlight why podiatrists are best educated and equipped to improve the lives of our footsore public. There could also be collaborations with nonprofit health groups in order to to create and distribute social media PSA print and videos (Public Service Announcements at no charge by the publisher) that present podiatrists as the nation's preferred foot care physicians. These PSAs are not prohibitively expensive to generate and can be easily emailed to literally thousands of national media. And, we could also include these PSAs on our individual websites.
In addition to this, there could be an inexpensive complex hub website that could provide information for the public and even lead potential patients directly to podiatry practices. APMA is without doubt doing a good job with its allocated marketing financial resources. We just have to find ways to modestly but significantly increase those financial resources in order to better reach our goals.
Lawrence Rubin, DPM, Las Vegas, NV
09/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3A
From: Robert Scott Steinberg, DPM)
Dr. Udell's comment underscores our problem—old thinking. Who said anything about a million-dollar ad campaign? I suggested using much of the costs put aside for the HOD on an advertising campaign. And if states only sent the president and president-elect to the much smaller HOD, states would have money to advertise, as well.
Robert Scott Steinberg, DPM, Schaumburg, IL
08/28/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
RE: Who Decides Who is a Physician? (Rod Tomczak, DPM, MD, EdD)
From: Paul Kesselman, DPM
This is a very interesting topic considering that on this very day 47 years ago, I attended my first classes at what was then referred to as the Illinois College of Podiatric Medicine (ICPM) and which is now part of the Rosalind Franklin University (RFU). Almost fifty years later, ICPM has been incorporated into the "mainstream" medical educational system. For those who are unaware, RFU hosts the Chicago Medical School, Scholl College of Podiatric Medicine, School of Nursing, Pharmacy, and several other programs in the medical field.
During my undergraduate podiatry rotations, whether at the VA or Naval Hospitals, there was no distinction for medical (MD) vs. podiatry (DPM) vs. DO students. We all were treated in the same tough manner. Not once during those rotations did I ever hear, "Oh, you are a podiatry student; we don't expect you to ...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
05/21/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Alan Sherman, DPM
A correction is needed in the Elliot Udell comment on concierge practices. I'm sure it was just a typo. The concierge doctor that is charging the $2,000 annual fee to 1,000 patients is making $2,000,000 before submitting their first insurance claim, not $200,000. Concierge practice magnificently improves the business model for running an internal medicine practice. It's brilliant.
Most limit their practices to no more than 600 patients ($1,200,000) so that they can provide good high quality service to them all. Here in Boca Raton, Florida, it has gotten hard to find an internist who is not concierge. This was all a solution for and a reaction to the poor service that high volume internists were generally delivering to patients before the concierge model evolved.
Alan Sherman, DPM, Boca Raton, FL
05/20/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3A
From: Elliot Udell, DPM
Concierge practices are not always direct-pay practices. My doctor flipped his practice into a concierge practice. The deal is you pay an annual fee for the honor of being a patient but have to pay or have your insurance pay for each visit. The annual fee may be 2K a year. If the doctor has 1,000 patients in the practice, the doctor makes $200,000 a year before turning the key in his door. The rest is gravy.
I visited an eye center for a cataract procedure. They let me know that my insurance would cover the procedure, but the laser they use to open the capsule would cost me 2K out-of-pocket.
Elliot Udell, DPM, Hicksville, NY
01/29/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Michael King, DPM
Dr. Rubin, thank you for highlighting this important issue of value-based healthcare. The provider group for which I am the Chief Medical Officer of Podiatry, Upperline Health, is embracing the Value-Based Care model. In fact, Upperline Health is the nation’s largest provider dedicated to specialty value-based care. Upperline Plus, part of the ACO Reach program developed by the innovation department of CMS, is changing the paradigm of healthcare with DPMs at the lead.
Through frequent visits and strong credibility with patients, DPMs are uniquely positioned to recognize chronic conditions. Now with the extended Upperline Plus care team to support us, we can help our patients better manage their overall health. Finally, someone is recognizing what we have been saying for years: we see the disease more than anyone and know how to manage its care.
Michael King, DPM, Nashville, TN
01/26/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Cynthia Cernak, DPM
I was one of the fortunate ones to be able to receive the training and continual association with Dr. Lee Dellon over the last 20 years, in association with AENS. The Pressure Specified Sensory Device (PSSD)TM machine was always taught to be billed as a non-covered service. $300 is what I charged the patient, with an ABN completely filled out. It was not a billable item to Medicare as far as I know.
Cynthia Cernak, DPM, Kenosha, WI
01/25/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
RE: New PSSD Diagnostic Device
From: Robert S. Mullin, DPM
I’m wondering how many of you were invited to train at Johns Hopkins with Lee Dellon, MD, a neurosurgeon and plastic surgeon? He was featured on Good Morning America, and has written over 450 peer-reviewed medical and surgical articles both in the U.S. and internationally. Stephen Barrett, DPM worked with Dr. Dellon to market this breakthrough new PSSD diagnostic device that detects peripheral neuropathy, claiming 50 percent more sensitivity as compared to the gold standard of the EMG which was invented in 1933. Most importantly, EMG misses 50% of all peripheral neuropathy, because the nerves in the lower leg and foot are much smaller in diameter. The PSSD neurosensory diagnostic device costs $65,000 with a $5,000 mandatory training session in Baltimore with Dr. Dellon.
After purchasing the advanced peripheral neuropathy diagnostic device, the next step is to come back and train with Dr. Dellon in surgery and be taught a very specific surgical technique that can reverse diabetic neuropathy that is caused by a double crush syndrome.
Robert S. Mullin, DPM, Minneapolis, MN
01/23/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
RE: Kudos to NY Clinical Conference
From: Daniel Chaskin, DPM
I attended the NYSPMA conference. It was so much fun. I understand that a tremendous amount of work went into organizing this wonderful event.
Regarding the leadership of NYSPMA, I would like to thank Sandro Frasca, DPM, president of NYSPMA and let him know he, as well as the entire board of trustees, are appreciated for all the time and hard work they spend trying to help members. I am proud to be a member of NYSPMA and APMA.
Daniel Chaskin, DPM, Ridgewood, NY
01/02/2024
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Khurram Khan, DPM
To piggyback on Dr. Pressman's note, we recently published a case report utilizing a modified Allen test. The patient presented with increasing pain, swelling, and numbness in her bilateral hallux toes for 2 weeks duration. We employed a modified lower-extremity Allen test when we heard an irregularity in vascular perfusion in the foot after a difference in pitch between the dorsalis pedis artery and the posterior tibial artery was heard using a hand-held Doppler.
Non-invasive vascular studies were unremarkable and did not suggest peripheral artery disease. Further angiographic testing revealed occlusions at multiple levels of the lower extremity. The simplified lower-extremity Allen test allowed for efficient bedside assessment of the relative vascular contribution to the foot and can be an important tool in the clinical diagnosis of peripheral artery disease.
Khurram Khan, DPM, Philadelphia, PA
09/26/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Frank Louis Lepore, DPM, MBA
Dear Dr. Christina and Dr. Virbulis,
I am writing to you today as the President of the American Board of Multiple Specialties in Podiatry to discuss our future. Recently, multiple meetings concerning Boards have been held without resolution. These meetings ranged from the CPME and SBRC, multiple meetings behind closed doors of leadership to which we were not invited, Board Summits in 2015 and 2023, and hearings that we have had on the subject of Boards. One of the “recognized” Boards held a Town Hall on Board Certification in 2023, which APMA did its very best to thwart.
It is clear that the APMA, CPME, SBRC, ABFAS, and other organizations are conspiring to keep the...
Editor's note: Dr. Lepore's extended-length letter can be read here.
09/13/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Fred Ferlic, MD
From my experience (retired orthopedic surgeon and now Chief Medical Officer of TayCo Brace), the way to approach patient care is to focus on having the patient gain trust in your professional capabilities. In podiatry, this entails "routine foot care." Use this as part of a treatment program to create a thriving, satisfying practice.
I suggest two plans:
1 - a progression-of-care algorithm encompassing his/her expertise in all diagnoses the doctor was trained to treat. This involves minor to major treatments, from routine foot care (which involves orthotics) to major surgery (AAFD/PTTD reconstruction, etc.). Discuss with the patient your professional background and training.
2 - provide a holistic program with personal pamphlets involving weight reduction and an age-related exercise program. I realize the compliance issue, but at least you are attempting to treat the "whole person."
Communicate these two actions to the patient - it shows your professionalism. Your practice will grow exponentially. This, to me, is the art of medicine. Incidentally, I started out taking everyone's night call, seeing every patient that presented with a musculoskeletal problem - starting at the bottom. I was relentless in every patient's treatment 24/7. Because of this approach, in my last decades of practice I had a very large practice, and gained tremendous satisfaction from my professional duties.
Fred Ferlic, MD
09/12/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Allen Jacobs, DPM
Many podiatrists now work within orthopedic groups. Many podiatrists are employed by medical care groups. Many podiatrists are employed by hospitals. Many podiatrists are fully engaged in wound and diabetic foot care. There are many podiatrists fully engaged in surgical management of trauma, deformity correction, and discretionary surgery. Many podiatrists are employed by medical colleges as faculty members. There are many podiatrists employed in the VA system. Many, if not most, podiatrists are on staff at hospitals, on ED call, and receive in-hospital patient consultations.
There are many podiatrists paid hundreds of thousand and, in some cases, one million or more dollars as consultants to corporations. Many (not all) podiatrists receive extraordinary residency and fellowship training in surgery. These individuals are capable and competent surgeons. This was absolutely NOT the scenario when I graduated PCPM in 1973. The expanded...
Editor's note: Dr. Jacobs' extended-length can be read here.
08/25/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Robert Kornfeld, DPM
Dr. Rubin states, "all these insurance hassles and stresses can be put on the shoulders of a competent billing company." Dr. Rubin, how does a billing company (who are also decreasing your income by whatever they charge you) eliminate all the stresses of insurance? You will still be subject to ever-decreasing reimbursements, more stringent guidelines, prior authorizations, claim delays, claim denials, high deductibles and co-pays, the need to run a high volume practice, super high expenses, etc.! If you truly believe that all of the hassles of insurance-dependency magically disappear with a billing company, you are believing in your own fantasy. If you understand direct-pay as you say, then you would understand that ALL of the hassles with insurance absolutely disappear!
In direct-pay, we are never subject to ever-decreasing payments, more stringent guidelines, prior authorizations, claim delays, claim denials, high deductibles and co-pays, high volume, and high expenses. We get paid at the time of the visit. We have the right to charge what WE believe to be a fair fee based on our training, expertise, and expenses. My expenses went from 70% of gross to 20%. I went from 55-60 patients daily to 8 and I make a lot more money than I made when accepting insurance. Plus, there is infinitely less stress, deeper and more potent doctor-patient relationships (since you have the time to cultivate them) and a lot more time to enjoy things outside of your practice (not to mention more family time - no pajama charting). I fail to see what is puzzling you.
Robert Kornfeld, DPM, NY, NY
08/11/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Robert D Teitelbaum, DPM
I was around in the mid-eighties when the nail avulsion guidelines were established. Right then, I knew there was a problem. The issue was one of enforced overtreatment. To get paid to relieve a potentially dangerous condition, especially in geriatric and diabetic patients, was to make one or more injections to a toe with local anesthesia, when freeze spray anesthesia was often adequate. Using freeze spray also cut the time to a fraction of the other procedure. And when you are dealing with an anxious patient, time is trauma.
Also, strange requirements were made to incise eponychial tissue that seemed to be 'make work' type of actions that were not clearly correlated to the issue that was causing the pain and incipient infection. In other words, I was on the razor's edge of 'assault and battery'. All that was required was removal of 'the offending spicule" and...
Editor's note: Dr. Teitelbaums' extended-length letter can be read here.
08/03/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: John V. Guiliana, DPM, MS
Kudos to Dr. Jacobs, who always seems to have his finger on the pulse of professional challenges. He has again accurately identified a problem that translates into needless infections, hospitalizations, amputations, and death in our diabetic population, estimated to cost approximately $80 billion annually.
As a profession, we have become so preoccupied with the worry of audits that many forget to look beyond just the nail and callus care in this “at risk” population. Attacking the $80 billion annual price tag involves comprehensive chronic care management, and paramount to our role in this initiative involves maintaining skin integrity. Without skin integrity, the unfortunate and costly “chain of...
Editor's note: Dr. Guiliana's extended-length letter can be read here.
07/25/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: George Jacobson, DPM
It is all about the money! The same goes for limiting the number of CMEs one can get online versus in person. If put to a vote in each state, I am certain that most podiatrists would eliminate the in-person requirement for CMEs. If put to a vote, I am equally certain that most board-certified podiatrists in all boards would want to be granted a recognition (tail) status.
You paid your dues and met requirements your whole career! Imagine if PICA didn't offer a tail after paying your premiuns from day one for 40—50 years. PICA is not quite the same thing, but I think our colleagues get the point. In the end it is ALL ABOUT THE MONEY and nothing to do with what is best for us the practitioners.
George Jacobson, DPM, Hollywood, FL
06/29/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Robert Kornfeld, DPM
Dr. Belanger asserts that, "Not everyone has the ability to have a concierge practice or a holistic practice that does not participate in any insurance plans if someone practices in a relatively low income area." Dr. Belanger - that is simply your own belief. As adults, we have freedom of choice. No one is a victim of circumstance to their own prior decisions. I started my career in a relatively low income, blue collar town. And when it worked for me, it was great. But I had bigger aspirations than to sit around watching self-serving insurance companies whittle away at my income. I was very lucky because insurance companies and Medicare way back in the '90s began to target my practice and deny claims for anything they considered "holistic". So I developed a "hybrid" practice before I ever heard the term.
Yes Dr. Belanger, even in my town, people were willing to pay me directly for...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
06/23/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
RE: Cigna and 20600, 20605 Restrictions
From: Paul Kesselman, DPM
Cigna Health Care recently announced a total limit of four injections for each CPT code 20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (e.g., fingers, toes); without ultrasound guidance) or 20605 (Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); (without ultrasound guidance).
This misguided policy by Cigna Health Services should be the last straw for providers to seriously consider stopping cooperation with any insurance company with misguided policies. How in the world will a hand surgeon know that a DPM or other MD/DO provided an injection to the foot/ankle or...
Editor's note: Dr. Kesselman's extended-length letter can be read here
05/22/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Rod Tomczak, DPM, MD, EdD
I have known Jeff Carnett since 1986 when I became an Assistant Professor of Podiatric Medicine at then UOMHS/CPM. Jeff was selected to be one of the first podiatric residents at UOMHS/CPM when I was the residency director. He was an excellent resident, trained mostly by Vince Hetherington, DPM and me. Jeff married a Chinese national and was led to believe that if he and his wife became residents of China, he would be able to practice podiatry. This promise never came to fruition and Jeff tried to work in various countries in the East doing some wound care here or there but never practicing to the fullness of his training. Of course, he had an Iowa license but he let it lapse with each additional promise from a government.
So now Jeff would like to return to the U.S. He is meeting resistance at the state level because his one year residency does not qualify him for licensure and employment. Thus, he cannot become board certified although he certainly deserves the opportunity and would no doubt pass any exam. The real irony is that the American Board of Podiatric Medicine which wants to offer a certificate of additional qualification to those podiatrists who did not do a surgical residency will not offer a chance to become board certified to an exceptional podiatrist caught in a time warp. A board (ABPM) that wants to ensure everyone the ability to become boarded, isn't.
Rod Tomczak, DPM, MD, EdD, Columbus, OH
02/07/2023
RESPONSES/COMMENTS (NON-CLINICAL) - PART 3
From: Gregory T. Amarantos, DPM
In Illinois, we have been a part of the OPEIU for the past 25 years paying dues of $100/year. Our benefits are similar to the benefits of an AARP member. In a nutshell, we have received “bupkis”.
Gregory T. Amarantos, DPM, Chicago, IL
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