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12/14/2017    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Venture Capitalists Target the Podiatric World


From: Hal Ornstein, DPM  


 


Corporate America is finally recognizing the value of podiatry. Recently, private equity investors/venture capitalists have taken a very close look at specialty physician groups such as podiatric practices. Many podiatry practices have great growth potential and simply need the guidance and financial backing to significantly increase earnings. Investors are attracted by the prudent, routine medicine practiced in a podiatrist’s office combined with the added benefit of being able to perform profitable elective procedures, such as foot, ankle, and sports medicine surgeries. 


 


Further, there is the potential for ownership of ambulatory surgery centers. By owning and controlling the operating environment, practices are able to function outside hospitals, leading to better physician economics, improved cost containment, and better access to care for patients. From an investor’s perspective, a business model of an efficient successful practice thriving in one location so that it can be replicated elsewhere is very attractive. In fact, the practices that are most attractive to investors are ones that have developed strategic plans to compete against regional health facilities and acquiring smaller practices. By owning and controlling the operating environment, practices are able to function outside hospitals, leading to better physician economics, improved cost-containment, and better access to care.


 


Hal Ornstein, DPM, Howell, NJ

Other messages in this thread:


10/16/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Dragon Voice Dictation


From: Ira Meyers, DPM


 


Every once in a while, someone has a question regarding voice dictation. I have been using Dragon Dictate for 10 years. Up until recently, I found the program to be fair. I recently upgraded to Medical Version 4 and I am pleasantly shocked how well it works. If you have been holding off waiting for an almost perfect dictation program, now is the time. 


 


Ira Meyers, DPM, Huntingdon Valley, PA

10/03/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Warren Joseph, DPM


 



I feel your pain! We were getting our insurance through my wife’s teaching job at a University. After she left the position, we have been on COBRA, which ran out September 30!  We have been looking for decent coverage for months. We found a reasonable “Short Term” catastrophic plan, which will only cover us for 3 months which started today. In the “Marketplace”, the best we could do was a BC/BS PPO Bronze plan at $1,900/mo and a $15,000 out-of-pocket deductible! Of course, there is only one provider, Independence Blue Shield. We hear that come Nov. 1 when Open Enrollment begins, 2 more insurers will enter the fray so maybe, just maybe, there will be some competition. 


 


So, I can’t help you with any suggestions; but I can commiserate. I too would love to hear from anyone who may have some thoughts on obtaining coverage.


 


Warren Joseph, DPM, Hatboro, PA


10/03/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Alicia Ericksen, DPM


 


I'm responding to Dr. Mark Stempler's concern with obtaining affordable health insurance for his family. My family was in the exact same predicament, with similar premium and deductible; absolutely unaffordable. We took a leap and became members of a bill sharing network. A few of my colleagues and patients have done this. There are several out there, and we found the right fit for us.  It has honestly been the best decision, and I cannot foresee making exorbitant payments to a health insurance company ever again.   


 


Alicia Ericksen, DPM, Seneca, NE

09/26/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Richard Adams, DPM


 


I have been using a scribe in my clinic for about three years. The benefits of a scribe are many. The benefits of a virtual scribe include one less body in an already cramped exam room, no necessity to purchase equipment, and no additional employee on your payroll. 


 


The downside of a virtual scribe involves occasional, but rare, IT concerns. In my opinion, if you choose the correct virtual provider, you will be very pleased. 


 


Richard Adams, DPM, Granbury, TX

09/26/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Richard D Wolff, DPM


 


I have not used a virtual scribe, so I cannot offer an opinion about that. Pretty sure Dragon Naturally Speaking, which I have used, is not the same. For years, I have used a scribe and have found it helpful in many ways. Patients have commented about how their other doctors are buried in their computer during the encounter, whereas my patient has my undivided attention the entire time. I ramble off my physical exam quietly to my scribe, who checks it off on "Quicksoap". I speak to the patient about their condition and treatment plan as the scribe writes it down.


 


My scribe will also note if the patient expresses pain with a facial expression, as they don't always tell me as instructed. As I begin my treatment, my scribe is dismissed, and she goes to start the note in the computer at another location. This situation has worked well for me. My scribe has learned to pick up on the subjective part of the note and she relays the follow-up plan to the scheduler.


 


There are additional benefits. Patients have also developed a rapport with my scribe and will ask about her if she is not present on a given day. She has also developed the habit of reviewing the patient's chart. She will let me know if there are any insurance coverage issues and she will let me know if the patient is due for new diabetic shoes, should they desire it. I have found this system to be invaluable.


 


Richard D Wolff, DPM, Oregon, OH

09/05/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Pillars of Our Profession


From: Richard M. Hofacker, DPM


 


A few weeks ago at the KSUCPM awards banquet, Dr. Richard Ransom took this "classic" picture of a couple of our distinguished colleagues. You might say, they are the "Arnold Palmers" of podiatry. 


 













Seated are Dr. and Mrs. Alan Spencer.  Standing is Dr. Ray Suppan, Sr.



 


Just about everyone in this profession has been taught, consulted, or helped in some way by Drs. Spencer and Suppan. Podiatry owes a great deal to these fine pillars of our profession.


 


Richard M. Hofacker, DPM, Akron, OH  

09/04/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Pedicure Drill for Podiatry


From: Robert D Teitelbaum, DPM


 


For several years, I have been using an incredibly inexpensive ($3.00 or less) pedicurist drill in each of my treatment rooms and in my ALF/NH bag. I found them just by searching for "Pedicure Drills" on my laptop and getting multiple ebay sites with these drills that use 2 AA batteries. First, you discard all the multiple heads that are supplied. Then, you can use dental (that's right--dental) burrs from Henry Schein's Dental division - which is older and much larger than the podiatry section. I had my dentist order S.S. White stainless steel burrs that come in a ten pack and are 1.5 mm in diameter. They are not expensive. These burrs fit right into this drill by a friction lock--as do the accessories that come with it.  


 


Why this little drill is better than a 120 volt rheostat-driven one is exactly because it is not that powerful. When you have nail borders that cannot be curetted easily or painlessly, it is precisely the instrument to use. You can de-bulk a hypertrophied border to the point that you can then do an angled cut to give your patients relief. These burrs are very sharp and effective, so the constant, moderate speed helps to keep you in control. Along with this find, I discovered many smaller 120 volt drills that each of our suppliers offer, but at major price reductions. This confirms the old idea that "if it used by a 'doctor', we can double the price."


 


Robert D Teitelbaum, DPM, Naples, FL

09/03/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Drug Pricing Insanity  


From: Robert D. Teitelbaum DPM


                                                                                                                                          


I was interested in prescribing Ertaczo cream for my patients, as it seems to be effective for dermatophytic and candidial organisms. When I searched for it on Google, I was taken aback by the amazing prices. For a 60 gram tube, the average price was $830. Even in real estate, they deal in "comparables" for recently sold homes. How many of you out there prescribe antifungal cream in this range? I was told some years ago by a pharmacy tech here at my CVS store in Naples that, "Medicine is a racket." How true, how true.  By the way, my practice does not support that point of view. And this example can only enhance one's suspicion, of "Big pharma."


 


Robert D Teitelbaum DPM, Naples FL

08/31/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Vito Rizzo, DPM


 



As a healthcare professional and now having the distinct advantage of serving in the U.S Congress, Brad Wenstrup should be leading the charge in reforming healthcare and advocating to put medical professionals back in charge. He should take no contributions from insurance companies that have a record of putting profits before patients and should be focused on eliminating the channeling of healthcare dollars into any other purpose than patient care. He should never stand behind or support policies that undermine the protection of the sick and less fortunate. Being a representative can be easy if certain principled actions are followed.


 


Vito Rizzo, DPM, Bay Shore, NY


08/27/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Dan Michaels, DPM, MS


 


With all doctors on a salary and all employed by the government, you would also have several very bad consequences. As in England, doctors would have their day job with the government and have their private practice that is all cash on the side. If someone needed surgery, there would be a 6-month or more wait with the government practice and their private cash practice would be able to deal with the surgery immediately.


 


This would create a tiered healthcare system that would favor the wealthy. There would be a lot more conservative care and much more web surfing by the employed physicians just doing the minimum to get by, and of course the really smart people would leave the field. This single payer system fails everywhere it is implemented. Socialism fails always (e.g. Venezuela). We have the best healthcare in the world.


 


Dan Michaels, DPM, MS, Frederick, Hagerstown, MD

08/27/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Jon Purdy, DPM


 



I couldn’t sit idle after reading Dr. Kass’ comment promoting universal healthcare with salaried positions. There are reasons monopolism in a free market society is not tolerated in the private sector; the reasons being stifling of ingenuity, lack of price competition, and the elimination of free choice to name a few. To promote it in the public sector is the antithesis of what drives this country’s greatness.


 


Imagine for a minute, a doctor who has no incentive to keep a patient a satisfied returning customer, or to direct staff to provide a welcoming environment. There may be minimum outcomes to obtain, but anything difficult or time-consuming could be written off as a loss. Certainly, one could “hope” all doctors practice to their fullest ability, but that is not reality and an unfortunate consequence of human nature in the absence of incentive.


 


When the government controls the livelihood of individuals and their freedom of pursuit, especially after going through training 99% of humanity is unable or unwilling to do, it will no doubt create a catastrophic physician shortage. If a singular controlling entity wishes to eliminate podiatry, it could do so next week. Take a moment and imagine yourself as a patient in that environment with a serious condition. I certainly can’t. There is corruption in all walks of life including the government or any other controlling body. I am not willing to sell my freedom of individual pursuit because of the actions of others.


 


Jon Purdy, DPM, New Iberia, LA


08/24/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Justin Sussner, DPM


 


Another problem that we see in our office is many of the ER and urgent care foot pathology patients are seen by a lower level practitioner who has no idea or training regarding what they are looking at. And they almost never consult with the MD who is supposed to be supervising them. 


 


This is not meant to be a jab against PAs or NPs, I know quite a few who work for my PCP and my dermatologist, but they have been properly trained and supervised. 


 


Justin Sussner, DPM, Suffern, NY

08/23/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Podiatrists vs. MDs as Foot Specialists 


From: Jeffrey Bean, DPM


 


An emergency physician called me today for guidance on a patient with a foot injury. The doctor told me, “It looks like the patient has a fracture of the first "METACARPAL" that might also involve the "HELIX of the SESSAMO". Should I be concerned about a Lisfranc injury?” I had the physician repeat this several times, and was told the same thing repeatedly. I felt it was futile to begin by teaching this MD kindergarten anatomy (leg bone connected to the foot bone). 


 


I told him to apply a fracture boot and send the patient to me or any other podiatrist for appropriate treatment. No wonder I see so many patients with disabling neglected foot and ankle injuries. Most were seen by multiple physicians who...


 


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

08/22/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Paul Kesselman, DPM 


 


This is an extremely complex matter fraught with many mine fields. While the suggestions which have been made might sound appealing, they may not be the best path for you to take. In fact, I’m concerned they may not be the correct way to go at all. I suggest you find an attorney very experienced in anti-kickback statutes and Stark. While the latter may be more familiar to most and possibly only affects your business and Medicare, the former may be less familiar yet applies across the board to all patients, Medicare, other third-party payments, and even self-paying ones.


 


The mere appearance that your salary is somehow tied to the number of your DME referrals and volume of DME your group provides to patients may constitute incentives that some experts may feel is problematic. The best and only advice I can offer is to spend the time and no doubt some money on a healthcare attorney who can safely navigate you through some very complex regulations.


 


Paul Kesselman. DPM, Woodside, NY

08/22/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Ron Werter DPM


 


Dr. Hofacker's comments remind me of something that a new patient's daughter related to me recently. A 92 year old gentleman brought in by his daughter came to me because they were outraged with the billing of the previous doctor. She received 2 checks from Anthem Insurance for the one visit of the previous podiatrist of her father totaling $1,550. She told me that she had taken her father to the other podiatrist for the past 6 years for nails and corns. On the last visit to this other podiatrist, when dad was called into the room as usual, she remained in the waiting room. He returned to her after his treatment 15 minutes later and said there's a different doctor. She found that peculiar since there was no notice that the other doctor had left or retired.


 


The father has an insurance plan that pays both in and out-of-network; out-of-net is 60/40. When she called the doctor’s office about the received checks, she was told to...


 


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

08/21/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Name Withheld


 


Welcome to the world of wRVUs! I’ve been working in this model for the last 5 years. Long story short, my hospital has no interest whatsoever in doing DME. Early on, I tried to explain to a C-Suite member that in my previous group I had collected over 90k in DME. They still balked at any DME. That said, I am compensated well for my time. My production (wRVUs) is at the 50th percentile, as is my compensation (based on MGMA benchmarks). So, at the end of the day, I’m a highly compensated employee who does what my employer wants me to do (see patients and fill my OR block).   


 


Name Withheld

08/20/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Stacy A. Resnick, DPM, Hyim Baronofsky, DPM


 


Along with my RVU-based pay, I receive 55% of what was collected on custom molded orthotics, Arizona and Richie braces, and diabetic shoes. I do not receive compensation for CAMwalkers, ankle braces, or any other DME products.


 


Stacy A. Resnick, DPM, Bethlehem, PA


 


I work for a multi-specialty group and I am paid based on RVU production. When I informed my employer that if a patient has fascitiis and is following up for orthotic casting/scanning at times, I cannot even bill an E&M code. Thus, the visit has no compensation value for me. When I explained to them the only alternative would be to send out all orthotics, DME, etc., they quickly assigned an RVU value for both the casting and orthotic codes so they would not lose that revenue stream.


 


This problem is not exclusive to podiatry and DME. Groups often assign RVU values for medical services that lack them. Our dermatologist has several services that are cash payment and the group has assigned them RVU values as well.


 


Hyim Baronofsky, DPM, Mount Prospect, IL

08/15/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: It's Time to Clean Up Our Act 


From: Joseph Borreggine, DPM


 


Having previously been on the Illinois Podiatry Licensing board for the last 5 years and serving as its chair for three of those years, I had the opportunity to review a number of cases that were initially brought to the board as patient complaints. I could only opine that these patient complaints were driven by possible perceived high fees for medical services with outcomes that did not solve the patient’s problem. Therefore, with the basis of this type of complaint, not much could be done. But, many cases with similar complaints were more frequent than one would think. 


 


The reason that nothing could be done was due to the inability to “restrict someone’s trade.” Hence, it did not allow me or the board to make any judgment against these podiatrists. So, the complainants were usually just left without any...


 


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

08/14/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Elliot Udell, DPM


 


Dr Kass is correct. When it comes to anatomic locations of ulcerations, the determination of what is and what is not in scope for a podiatrist in NYS is absurd. I would love to see how insurance companies would handle a case of an ulceration that was half in scope and half out, and if the podiatrist would treat half of the ulcer and a "dermatolgist" would treat the upper half of the same ulcer.


 


That being said, there is a greater area of scope of practice that our state society should not ignore. Last year, we saw a miserable flu season with many deaths as a result. If pharmacists can give flu shots, why not podiatrists who give injections all day long? Since we treat geriatric patients, this would make sense from a public health perspective.


 


Elliot Udell, DPM, Hicksville, NY

08/13/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Relaxing Scope of Practice Restrictions


From: Jeffrey Kass, DPM


 


Medpage Today reported this week that Health and Human Services Secretary Alex Azar said that states should consider relaxing scope of practice restrictions as this impedes healthcare competition, raises healthcare costs for patients, and deprives them of choices. I could not agree more. There are some states where the scope of practice is absurd, New York being one of them. 


 


In a personal communication with the NY State Podiatry Board, I asked if I were treating a leg ulcer contiguous with a foot ulcer and the leg ulcer healed, could I continue to treat the leg ulcer? The response was (paraphrased) ”if I was treating it before, common sense would dictate I could continue to treat it.” I responded with a follow-up. Wouldn't common sense also dictate, if I can treat a leg ulcer with the healed foot ulcer, I could treat the leg ulcer without the foot ulcer ever existing? The Board has yet to issue a response. 


 


With the comments made by Alex Azar, every state with ludicrous scope issues should capitalize on these comments, agree with them, and invoke change. If not now, when?


 


Jeffrey Kass, DPM, Forest Hills, NY

08/10/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: 20 Years with Sammy


From: Christopher A. Orlando, DPM


 


August 8, 2018 marked 20 years with Sammy. On 8/8/98, Ken himself came to my office to install Sammy. At the time, it was DOS-based! It was the best business decision I ever made. Ken Katz and company have exceeded my expectations and have kept up with all the insane insurance changes and demands. Thanks to Ken and his excellent support staff.


 


Christopher A. Orlando, DPM, Hartsdale, NY 

08/09/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Medicare Unmasked Revisited


From: Joseph Borreggine, DPM


 


The website: https://graphics.wsj.com/medicare-billing/ came out in 2013 in the Wall Street Journal and shows how doctors and other providers compare with peers in their state and nationwide. This information, I believe, is accurate since it came from CMS; most importantly it is public information. I do not think there is any further data beyond 2015 since CMS now has a "physiciancompare.gov" site which is much harder to navigate to find the same data. I tried. 


 


I recommend that my colleagues investigate the WSJ site and see their own data and consider how they compare to their associates in their own community with respect to how much they were paid by Medicare from 2012-2015. You may be surprised to see...


 


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

08/08/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1



From: Darryl Burns, DPM


 


They can be found at: www.medid.com


 


Darryl Burns, DPM, Salinas, CA 

08/06/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: David E Gurvis, DPM


 


I respectfully disagree with Dr. Al Musella. My most frequent code for a new patient is CPT 99203. I also frequently use 99201 and 99203. On occasion, if the time has been spent in counseling - 99204. I have a similar distribution on established patient visits... 99212 and 99213, for the most part.


 


When appropriate, I do a complete LE neurological, muscle strength and testing, ROM, integument and nails, along with musculoskeletal. I read and document that I have read and gone over with the patient the family history, social history, and ROS. At times, a patient who has waited too long to come in presents with 4 or 5 complaints, and each requires an...


 


Editor's Note: Dr. Gurvis' extended-length letter can be read here.

08/04/2018    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Al Musella, DPM


 


Take a look at the proposed rules before making comments. They specifically ask about something that is not addressed in the APMA letter. They specifically say on page 345: "We are soliciting public comment on what that total time would be for payment of the proposed new podiatry G-codes. The typical times for these proposed codes are 22 minutes for an established patient and 28 minutes for a new patient, and we could use these times."


 


I think that is reasonable. They predict that the changes will result in a net loss of 2% of our...


 


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