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From: Janet McCormick


Every time I hear discussions about nurses taking over podiatry, I think of how wayyy-back-when dentists said to each other "hummm, this may happen." The difference between them and podiatrists is the dentists organized to make certain it didn't. Thus, was borne the dental hygienist (the legislation snatched it away from the potential of nurses doing this work without the dentists) who does the work the dentists do not want to do, are educated to do it correctly, and are legally the only ones who can (other than dentists). But these dental hygienists CANNOT under legislative law do so in any state (that I know of) except under the direct supervision of a dentist. And it was all put through by the state dental associations. I have discussed this with many podiatrists over the years, even suggested organizing and getting the restriction developed, but they never got it!! So, now, it is too late. 


Think about this: no patient can have their teeth cleaned, have x-rays, etc. EXCEPT in a dental office or clinic - wherever, they must have a dentist on staff. And the patients have no choice of where to have this work performed. Wouldn't you love that? But alas, you are too late, I fear.


Janet McCormick, Frostproof, FL

Other messages in this thread:



From: Richard J. Manolian, DPM


I for one would not want to be the doctor who gets inspected and has to then prove how much of this product I bought to match the patient load and requirements of changing it on a 2 to 4 week basis depending on whom you listen to.


In addition, I would then have to show proper paperwork as to the change in schedule and process of how instruments were utilized in the setting. Gas or steam sterilization seems to me a more definite way to avoid this quagmire with any board of any state.


Richard J. Manolian, DPM, Cambridge, MA



From: Brian Kiel, DPM


First of all, if one is to publicly praise and justify the actions of Joseph McCarthy, why are you ashamed to let us know who you are. He was publicly disgraced and proven to be a liar and was the precursor to the same political hate game we are seeing today. This "withheld" person is looking for ghosts under every bed and is obviously a proponent of the extreme right wing political persuasion. I disagree with his basic premise, but he has every right to espouse it, just don't do it behind a curtain. What are you ashamed of if not your views?


Brian Kiel, DPM, Memphis, TN



RE: ABFAS Board Exam Pass Rate is Disparaging (Joseph Borreggine, DPM)

From:  Name Withheld


I am glad that there is some discussion about the ridiculously poor pass rate of the ABFAS Exam. The objective data posted comparing our pass rates with our orthopedic colleagues absolutely should be taken into consideration. I attended a great residency program where I obtained solid training, both didactically and practically, with surgical requirements more than tripled in all categories. I never had difficulty with any of the board exams taken through podiatry school. I have established myself in my community quickly and built up a practice with good referral sources and the respect of my fellow medical colleagues at the facilities I am an attending at. 


I passed 3 of the 4 ABFAS Part 1 exams on my first attempt, but had to retake the forefoot computer-based problem solving exam 5 times. In this period of time, I studied specifically for the format of the CBPS exam, spoke to the staff of ABFAS administering the exam (who to their credit was very responsive and open to helping in any ethical way they could). I am almost to the portion of submitting cases which, after hearing other examples of respectable surgeons who have failed this portion, makes me very nervous.


The system needs an overhaul which would absolutely cost ABFAS money since it did cost me thousands of dollars to even get to this point with the many retakes of CBPS. It's an excellent business strategy for ABFAS to continue to fail that many people, but unfortunately it is at the expense of the next generation of our profession. 


Name Withheld



From: Name Withheld 


This certifying board is a bit of a monopoly that every podiatry student has to deal with to progress to the next level of their career. This certification process is exorbitantly expensive and arbitrary. The rules continually change which apply to everyone except those already certified? I passed all the written exams and (first time every exam) and interviewed well at the time the decision was made that new applicants would no longer be allowed to select their cases to submit for certification. It was at that same time the decision was made that applicants would log their cases as is done in residency. 


I played the game and paid the small fortune over the years only to be told that my cases that they selected were not up to their standards. I was told that I could pay more money next year and hope they pick better cases. I continually see plenty of cases from providers certified by this board which have resulted in suboptimal outcomes. I will often end up doing the revisions to improve the health and welfare of the public. There are other boards who value your dollar and I recommend that route for those who value their time and money. In closing, I have seen some excellent work from colleagues with many different certifications. I have no hard feelings toward ABFAS and I am happy that I chose a different certifying board.


Name Withheld 



From: Jengyu Lai, DPM


I took both CMET and American Board of Wound Healing exams. Even though both exams are for physicians, CMET questions are generated and beta tested by physicians - MDs/DOs/DPMs. Additionally, since CMET does not offer exams for mid-levels, nurses or allied professionals, you can wholeheartedly trust that this certificate is for physicians. It is not carved out from a pool of questions for all levels of professionals. It gives me the confidence when I present the certificates to other providers and patients.


Even though ABWH seems to be endorsed by the American Professional Wound Care Association and American College of Hyperbaric Medicine, those are two sister organizations. CMET is recognized by the Academy of Physicians in Wound Healing (the only wound care organization exclusively for physicians - MDs/DOs/DPMs), American College of Lower Extremity Surgeons, and the Israel Wound Care Society.


I don't think it would hurt to have more certificates. But if you plan to take only one exam in wound care, CMET should be the choice.


Jengyu Lai, DPM, Rochester, MN



From: Elliot Udell, DPM


I have used them for several years and have been happy with their service. They always supply the forms I need for hospitals and insurance companies. It's like leasing a car. You have to shop for the best deal and that can change from year to year.


Elliot Udell, DPM, Hicksville, NY  



From: Simon Young, DPM


I am in full agreement with Dr. Markinson. His remarks are so true and germane. 10 minutes for a bilateral significant osseous procedures is ludicrous and riddled with potential poor results, and we wonder why malpractice premiums are so high. Can you envision what a lawyer in court would say?


Furthermore, it's infantile behavior to brag about OR time, and gives insurers more reason to trivialize our worth and pay us less.  No other specialist brags about such insignificance, even if it's true in their sphere. Shame on us.


Simon Young, DPM, NY, NY



From: Scott Grodman, DPM


I agree with both Pam Thompson and Dr. Rubin, wholeheartedly. Instead of the constant "doom and gloom", here are finally some respectful ways to improve our offices, not how they will be destroyed.


Pam definitely put the information in an accurate, concise purposeful direction to either plug in your numbers, or simply as Dr. Rubin related, dollars into smarter areas.


Scott Grodman, DPM, Taylor, MI



From: John Moglia, DPM


Since waiting for parity with MD/DO is the equivalent of Waiting for Godot, why not take the easier path to physician assistant (PA) or RN practitioner? - Either in the schools of podiatry as a combined degree, work study program, or by whatever practical means. I have seen podiatry reimbursements diminish to the point where I would gladly take a secure steady income with potential for a raise instead of a penalty under the MACRA plan.


John Moglia, DPM, Berkeley Hts, NJ



From: Joseph Borreggine, DPM


I have to agree very little with Dr. Jacobs on his recent posting with respect to the "prosper" list and for the future of podiatric medicine. However, I cannot agree at all with the response from "Name Withheld". 


First, Dr. Jacobs' list is quite complete and makes total sense. But what are the current percentages of podiatrists who hold these positions? I do not know if we have exact statistics from any of our profession organizations on this subject matter. It would be interesting to see the actual number of podiatrists who are employed. The number of private practice podiatrists still outnumbers the ones who are...


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



From: Thomas Graziano, DPM, MD


Dr. Borreggine's predictive words are telling to say the least. Right now, PAs and NPs are being trained to handle the routine foot complaints most of us see on a daily basis. Will they do it better? Probably not, but insurance carriers don't care. It will be "adequate." Money, whether we like it or not, is the driving force in all of it. Greedy insurers, unethical lawyers and doctors are all driven by it. That fact will never change. The issue will be whether or not you as a physician are willing to accept it.  


My bet is podiatrists will accept whatever is paid out to them. Years ago, the late and insightful Dr. Neal Frankel told me that he met with the CEO of a major insurance carrier who told him, "Why should we pay podiatrists more when we know they'll take less?" MACRA is coming with private insurance carriers to follow. You can either bend over and take it or stand up and rekindle some of the pride and integrity you had when you decided to enter podiatry school and get into this "business."


Thomas Graziano, DPM, MD, Clifton, NJ



From: Dan Klein, DPM


I have come to learn that any profession works like a business. As such, businesses are in the business of making money, even at the expense of its employees. When I began my life as a podiatrist, I agreed to join an existing practice. I was offered a buy-in to the practice at a certain dollar figure, to which I couldn't afford. I was given the option of 'sweat equity'. I agreed to a nice salary with bonus after meeting baseline income for the practice. The sweat equity was 25% of buy-in costs over the next 4 years. This agreement was not in writing, but by a handshake, a naivety I deeply regretted years later. 


After 2 years, I felt that since I was generating a lot more money, I would ask for a small increase in my percentage bonus. I was denied this and was told that my services would no longer be needed. When I asked about the 2 years of sweat equity I was entitled to, the owners denied ever making this agreement. I was angry and realized if it isn't written, it doesn't exist. So much for trust. 


In today's practices, a new resident must utilize a lawyer to review contracts and ensure that, over time, what you expect... i.e. raises, etc. are written in the contract. Don't be intimidated and don't sell yourself and your self-esteem to the devil.


Dan Klein, DPM (retired), Fort Smith, AR



From: David N. Helfman, DPM


I have been quiet over the past couple of years for many personal reasons, but mainly because I was focusing on transforming our industry, testing new concepts and truly enhancing the group model experience. I always find it interesting when doctors ask, "How much should a new associate make?” How much should a partner make? 


To truly answer this question, it’s imperative new doctors and established doctors realize that this answer is truly a moving target and most statistics you read about salary usually have a small sample size. Therefore, the data you obtain is probably not the most accurate number. The reality is that most very high earning doctors aren’t...


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



From: Jengyu Lai, DPM


I do not invest in companies with products that are harmful to our health, such as soft drinks and tobacco. Even though I like to support local companies, I clearly told my financial adviser that I will not invest in Hormel, General Mills, or Kellogg.  


Consider poor lifestyle choices like smoking decades ago when doctors were smoking and even prescribed smoking. It took 7,000 scientific publications for the government to say that smoking is harmful to the health. How many people died of related problems waiting for the government to act on it? If we as physicians cannot recognize and adopt the concept, how do we educate patients? Developing new surgical techniques and medical technology to treat diabetic ulcers will not help if patients keep eating unhealthy foods.


Jengyu Lai, DPM, Rochester, MN



From: Name Withheld 


The biggest issue here is that no longer are candidates allowed to select which cases they would like to submit. This change does not affect anyone who is already certified by this board/club. Nowadays, all cases performed have to be logged and the cases are picked for the applicant. This was not the case 5 years ago. I continually see the work of some of these diplomates who were grandfathered in and it is really nothing special.  


The cost associated with this podiatry board is exorbitant. There are other boards out there that are much more reasonable and inclusive (MD, DO, DPM). Honestly, anyone who says they don't have cases that didn't turn out exactly as planned is either a liar or doesn't do enough cases. 


Name Withheld  



From: Thomas Graziano, DPM, MD,  Matthew Loudis, DPM


The definition of healthcare insanity is staying in the networks. There is a simple solution but it takes a bit of testicular fortitude. Drop out of the networks. Get paid for your work. Stop the whining and do something about it.


Thomas Graziano, DPM, MD, Clifton, NJ


Two words for you Dr. Kass: pizza shop. I live near a small town of about 5,000. There are four different pizza shops here for at least twenty years, and they're all still going.


Seems to me it's a lot more fun to do something you love without all of the extraneous crap; maybe that's a definition of sanity? I don't think the pizza guy is whipping out their customer's chart to document that they ordered a...


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



From: Joe DeTrano


Having worked for two billing services over the course of the last 23 years, and signing up hundreds of DPMs to the companies I worked for, I can give two pieces of advice.  I also do not have a "horse in the race", so I am not looking for business.


1) You get what you pay for! If you are paying a crazy small percentage and get "Free EMR", don't be surprised when you are having trouble getting paid and you are on the phone with someone in a foreign country at 1 AM screaming Dx codes into the phone.


2) Make sure they handle podiatry. Get references. Make sure they are current. Even if the firm is very small and has 10 clients, if they handle podiatry, give them a shot.


Joe DeTrano, Great Neck, NY



From: Alan Sherman, DPM


Dale Feinberg, DPM wrote a nostalgic message entitled “Gone With the Wind” about the demise of podiatry as we knew it, and compared the demise with the recent criticism of the confederate flag that we’ve all seen in the news. His thesis is that there was something virtuous in each institution and we are “letting” them wither away. Dr. Feinberg and I were roommates freshman year at CCPM in 1978, and shared a few important life experiences together. I think his feelings are sentimental and yes, I can be sentimental at times as well. But fundamentally, I have believed for 20 years that the private practice fee for service model that we all enjoyed during these years was doomed to be replaced by a system with much different payment dynamics. 


Frankly, I hated billing insurance companies for services. I never felt empowered in that situation, and always felt like I was going to Dad for money, only to have him judge whether my “claim” was worthy to be paid. I felt I had done the correct service for the patient, but that’s not what got me paid. Submitting...


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



From: John V. Guiliana, DPM, MS


I completely agree with Dr. Kashan's assessment of the decision. I would like to add to this discussion by using my love affair with micro-economics. As Dr. Kashan already emphasized, what I am going to discuss necessitates diligent monitoring and measuring. But why would we hesitate to do that when there's so much at stake with our valuable resources? 


The Yellow Pages present one marketing opportunity which needs to be compared to other potential choices. Whenever we are faced with choices of allocating valuable resources, it's only obvious that as we allocate towards one choice, we...


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



RE: Repeal of the Flawed SGR

From: Lawrence M. Rubin, DPM


Now that we know what lies ahead, I think that any podiatrist in solo or small group practice who has not already done so has to begin adapting his or her practice to survive the future. A gradual severe reduction and probable elimination of the fee-for-service reimbursement system over the next few years appears inevitable. 


Lawrence M. Rubin, DPM, Las Vegas, NV 



From: Ira M. Baum, DPM


Dr. Graziano articulated well the dilemma facing podiatrists regarding reimbursement for services, surgery in particular. From my perspective, the key statement, when drilled down, was the insurance companies' position to “pay the lowest amount that the suppliers will accept.” The historical cause why podiatrists initially accepted low reimbursement is speculative. Did we accept discounted fees because podiatrists aren’t as smart as other specialists, or because the supply of podiatrists was and is greater than the demand, or that opportunistic podiatrists took advantage of the “opportunity to be the podiatrist on the panel of a sequestered population of patients,” leaving other podiatrists to fend for themselves? Who knows?  


The question is “Is there a solution?" Socioeconomic conditions and foot and ankle orthopedists don’t seem to be helpful in conjuring up a solution. However, the paths of extensive and lengthy training and the financial rewards are divergent and unsustainable. The temporary fix by some podiatrists joining orthopedic surgeons will not last and, in effect, works against a solution for the profession. Maybe, ACOs could present a window of opportunity. The shared risk model of an ACO may afford podiatrists involved equal pay as with all other physician members of a particular ACO. I leave you with this - if a viable solution is unattainable, I predict an attrition of podiatrists in the field and in applicants to podiatry schools. This will also impact on the training of podiatrists. The latter makes me sad, because I think giving up ground that has been conquered does no good.


Ira Baum, DPM, Miami, FL



From: Martin V. Sloan, DPM


I, too, was sickened when I reviewed the reimbursement for patients insured with another HMO, Blue Cross Advantage, a less-expensive "Obamacare" product. Even our revenue cycle manager noted it's the first plan he has seen that pays less than MEDICAID. I was flattered when all the PCPs started sending these patients to me, until I discovered I am the ONLY provider listed on their plan within a reasonable geographical distance.


The only way we can avoid these ridiculously low reimbursements is to not sign the contracts to participate. Under our current system, I only see the problem worsening. And, frankly, we brought this problem upon ourselves the day we agreed to "accept assignment" from Medicare and all the private insurance carriers. Dentists and veterinarians, who as a group, maintained their autonomy, continue to thrive and prosper. 


Martin V. Sloan, DPM, Rockwall, TX



From: Paul Kesselman, DPM


Any patient who protests about paying their deductible and co-pays is not worth having as a patient. You may want to check your contract with the third-party payer as there may be nothing wrong with collecting something from the patient as a "down payment" on their deductible. 


Anyone who has such a high deductible ($3K), and has not met any of it, certainly is going to have to pay something. If you have the fee schedule, it is certainly much easier to...


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



From: Michael M. Rosenblatt, DPM


Dr. Alan Bloch wrote that he had a patient with a 3,000 dollar deductible who was reluctant to charge a hundred dollar "good faith" payment for his first office call, but eventually did. The patient subsequently called his insurance company and was told that "it was not customary" to be charged an up-front billing by a doctor. The patient is now seeking to remove the payment. 


Dr. Bloch asked an interesting question about the Advance Beneficiary Notice Form. He posits that if the patient signed the form, the patient is "acknowledging" by signature that he/she is responsible for...


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



From: Joseph Borreggine, DPM


This code can only be billed when billing for orthopedic shoes and the shoes must be attached to a brace; therefore, you were paid incorrectly by mistake. Therefore, refund the money to Medicare.


Joseph Borreggine, DPM, Charleston, IL
Orthotics CadCam