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From: W. David Herbert DPM


I have two cousins who many years ago became dentists. Today, there are individuals called "denturists" in some states who can take dental impressions and make dentures without a dental referral. In a couple of states, dental hygienists can practice privately, and in one state can even fill a tooth without a dentist's supervision. In a number of states, a certified nurse anesthetist may practice independently without medical supervision. Also, in some states, a physical therapist does not have to have a doctor's referral to see a patient.


Any person rendering a service that can be construed as the practice of medicine will be held to a medical standard of care while so doing. This is true in all of the jurisdictions that I am familiar with. I still say it is more important that a podiatrist be defined as a physician than that he or she be granted an unlimited scope of practice. You do not find orthopedic surgeons delivering babies or ophthalmologists performing bunion surgery, even though it is in their technical scope of practice. They are limited primarily because of liability issues.


W. David Herbert, DPM, JD, Billings, MT

Other messages in this thread:



From: Scarlett Kinley, DPM


Liquid Rubber Appliance Laboratory (manufacturer of latex shields) of West Orange, NJ is an “old school” business still making this good device for high pressure and high-risk bone prominences for patients needing or desiring to avoid surgical treatment. They make several devices for nine areas of the foot. They send a paper invoice with the device and the positive cast; payment is by check only, I believe. 


Scarlett Kinley, DPM, Clearwater, FL



From: Steven J. Kaniadakis, DPM


This also seems to be a trend among other generic medications. Try writing as Merpergan Fortis. Although the two are essentially the same, some generics, even brand names, are sending limited to no supplies to pharmacies. For another example, CVS and several pharmacists reported that the manufacturer company named Mylan is not providing its generic supplies of some medications it typically delivers. 


Steven J. Kaniadakis, DPM, Saint Petersburg, FL



From: Charles Lombardi, DPM


1) Half of the dues Dr. Kass speaks of does not go to NYSPMA; it is in-actuality APMA dues we collect for them. 

2) The NYSPMA does NOT have sponsored speakers for lectures. The lectures are based on current areas of interest.

3) NO board member of the NYSPMA gets paid a dime from the Association or dues to meet numerous times a year at great personal expense.

4) NO board member of the foundation gets paid a dime to spend numerous hours coordinating the conference, meeting with legislators and insurance companies to help members and non-members advance the fight for their rights and the podiatry profession as a whole. Members get the conference credits for free because all these things COST MONEY.


Finally, Dr. Kass reminds me of the football fan sitting in the bleachers with a green face, yelling that the players are just bums who don't know what they are doing. He doesn't even have the courtesy to sit on the bench and pay his dues. He yells from the bleachers but benefits from the work the NYSPMA does on advocating on his behalf. 


Charles Lombardi, DPM, President, The Foundation for Podiatric Medicine


Editor's note: This topic is now temporarily closed.



From: Allen Jacobs, DPM


Dr. Kass suggests that “most” podiatrists who are NYSPMA members are so only for access to CME credits. One wonders on what factual basis Dr. Kass draws this conclusion. Has he personally conducted a survey of the membership? 


There are many benefits to APMA membership. While I hold strong personal disagreements with some APMA policies, ultimately, they represent my profession. They are in effect my union. We, as a profession, cannot afford nor withstand divisiveness. If the only reason for membership in the APMA is to access CME credits, it is less expensive not to belong to the APMA, and satisfy the CME requirements while paying the increased "non-member fee." 


Finally, an observation from someone who has invested years of work and lost income and family sacrifice in both the APMA, ACFAS, and has "been around the podiatry block" for many years. The current NYSPMA leadership is as good as I have ever witnessed. In my opinion, the dues money spent by members is well spent. Yes there are problems. The NYSPMA leadership has been addressing those problems. The NYSPMA has also been proactive in identifying the future needs of its membership and working on those needs in order to protect the future needs of our patients and our profession.


Allen Jacobs, DPM, St. Louis, MO



From:  Ken Meisler, DPM


I agree with Dr. Kass that the NYSPMA meeting is not really "free" for members but paid for by our dues. However, I disagree with Dr. Kass saying that most people belong to the NYSPMA because they see value of getting their CME in one weekend. We belong to our state societies and the APMA because these are the groups that fight for us at the state and national level. Without these societies, I think we all know that we would be much worse off. A great example is the recent proposed changes in Medicare E&M codes that the APMA stopped from being implemented. 


The NYSPMA annual meeting is much more than just "getting your CME in one weekend". Nowhere can you see so many podiatry exhibitors in one place. Seeing many of these same companies on line is not the same. Plus, being around thousands of podiatrists is an exciting and informative experience and only possible at a few meetings a year. 


Most importantly, we should ALL join our local and state societies. Those of us that are not members benefit from the hard work of those groups. However, they also miss out on a lot of benefits they could get. If more people joined, the dues would go down also. Your state and local dues are monies well spent.


Ken Meisler, DPM, NY, NY



RE: Payment Disparity Between DPMs and MDs

From: Jeff Kittay, DPM


Though I have been out of practice for more than three years, I do read PM News regularly and am thrilled that I no longer have to deal with the myriad governmental intrusions and regulations that active practitioners must endure in attempting to make a living. That said, the argument made in several recent letters regarding the “payment parity” issue existed before I went in to practice in 1979 and apparently persists. No DPM, no matter how good his/her training, will ever receive the same payment for the same billed level of service as MD/DO trained physicians, and they should stop dreaming about “parity”. 


Until the degree students receive says MD/DO, insurers will assume, right or not, fair or not, that the level of training and expertise is NOT equivalent. How many DPMs are expert at...


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



RE: Payment Disparity Between DPMs and MDs

From: Tom Silver, DPM


It's sad to hear the responses to my initial post regarding MDs across the board getting paid a lot more for new and established office visits than the same visit codes I submit as a DPM. There had been a lot of prior discussion regarding when to use a level 3 or 4 visit for patients, but it still doesn't make much difference when MDs are getting up to 3 times what we get for every office visit!  


I did an analysis of insurance payments on all office visit codes for 2018, and we were paid approximately $95K for visits. And MDs would have been paid up to an additional $190K more for the same visit codes!  This is no small difference, especially for a solo practitioner and would really add up for group practices!


I don't think we can "just accept this because we don't have an MD degree" or are part of a large group that can negotiate fees. Hopefully, the APMA and state associations can work together for us to by putting the "group practice" pressure on insurance providers that is needed to change this gross discrepancy and gain some payment parity for us!


Tom Silver, DPM, Golden Valley, MN



RE: Payment Disparity Between DPMs and MDs

From: Dan Klein, DPM


I have read from many podiatrists that they are upset about the difference in pay by insurers. When will podiatrists realize that as a podiatrist, you will never share the same turf as our counterparts and therefore not be recognized as such. Podiatrists have and will always be classified as allied health providers. Until MDs and DOs cannot provide our services, you will never see us providing a unique service. We will gladly be accepted into hospitals for our services, but the patient is not classified as a podiatry patient versus a medical patient. The reimbursement rates to the hospital are the same.


If you are unhappy with the podiatry reimbursement fees, you must get an MD or DO degree. This appears to be the only avenue open to us for equal pay! This is our future, love it or leave it!


Dan Klein, DPM, Fort Smith, AR



RE: Payment Disparity Between DPMs and MDs

From: Ira Baum, DPM


When I founded and participated in a podiatric LLC,  Florida Foot and Ankle Associates in the early 2000s, two fellow board members and I had the opportunity to meet with the president of one of the major healthcare insurance companies. At the meeting, we were given a lesson in rudimentary business practice, supply and demand. There we learned about a podiatrist’s place on the ladder of importance of our service compared to other specialties. 


Due to our position, negotiating improved reimbursements was not successful. Pleading our case based on our cost-saving quality of care, even offering an internal review committee to ensure the objectives, fell on deaf ears. Even adding in the concept of critical mass did not move the needle. Maybe things have changed for single specialty podiatric groups, but even if they have succeeded, unless all podiatrists are positively impacted, it does nothing to improve the podiatric profession as a whole and, in fact, will fractionalize it over time. In other words, the key to success of large podiatric groups is inclusivity, not exclusivity. Bad apples will be identified quickly and easily, and they will learn to conform to standards or be excluded from the group.


Ira Baum, DPM, Naples, FL



From: Jeffrey Kass, DPM


Dr. Hamilton’s story of his medical group’s ability to demand a higher payment for him no doubt occurred because of the “threat” of the group at large withdrawing from the particular insurance plan. I have never heard of an insurance company caving in to a solo practitioner. I agree with Dr. Hamilton that there is power in numbers, but I also believe that each CPT code should be paid the same rate to whomever is doing the procedure.


It is just wrong for Dr. X from a large group to get paid a higher rate than Dr. O the solo practitioner for the same exact CPT code. When I was a member, I brought this up at a state society meeting. The response given to me by the president was that I needed to negotiate a better contract. Out of curiosity, has any solo practitioner colleague had such success and is willing to share their secret? I thought equal pay for equal CPT was a worthy fight for the profession, and medicine at large.  


Jeffrey Kass, DPM, Forest Hills, NY, Forest Hills, NY



RE: Payment Disparity Between DPMs and MDs

From: Jarrett Hamilton, DPM


12 years ago, I was fresh out of residency and chose to join a multi-specialty group. As part of the credentialing process, my new group was trying to get me on the Humana panel in our community. At first, I was told flat out “we have enough podiatrists. We don’t need/want you.” -  to which our group said all or nothing! (Meaning they threatened to pull all the other physicians in our group if I wasn’t credentialed).  


Humana caved in and tendered me a contract. Unfortunately, the contract tendered was at below Medicare rates of reimbursement (All the doctors in our group got 115% of Medicare from Humana). So once again, our CEO said, "if you want any of our doctors, you will pay all of them at 115% of Medicare." They once again caved in to our demands. To me, this experience highlighted the need to be part of a larger organization early on in a career.   


Jarrett Hamilton, DPM, Sierra Vista, AZ



RE: 10 Rules for Reducing Non-Traumatic Amputations in Diabetics

From: Allen Jacobs, DPM


1. We cannot stop non-adherence of diabetics in preventive foot care. As podiatrists, we can educate, we can advise. We cannot enforce. Non-compliance is the number one cause of amputation.


2. Many patients cannot afford indicated therapies, from office visit co-payments to emollients, from deductibles to oral medications. 


3. Amputation reduction should be an ongoing process, not restricted to once yearly...


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



From: Jeffrey Kass, DPM


Dr. Rettig - larger groups getting paid higher rates due to bargaining power over a solo practitioner may not just be a bummer, it may violate Sherman Antitrust Law. Railroads used to monopolize businesses due to their “bargaining power”. Is this really any different? 


The argument “they negotiated a better rate” doesn’t seem plausible to me when there are no solo practitioners with the same rate. On the surface, this seems highly illegal. The issue in my mind is the lack of any form of “protection” we have within this profession. 


Jeffrey Kass, DPM, Forest Hills, NY



From: Elliot Udell, DPM


Kudos to Dr. Jacobs for apprising us of the ADA's recommendation for an annual diabetic foot examination.


Many patients come to our office for this annual evaluation, and in most cases are sent by their family doctors. The problem is that there is no clear consensus among podiatrists as to what should constitute a diabetic foot examination. At an executive board meeting of the American Society of Podiatric Medicine, we once discussed what should constitute a diabetic foot examination. When discussing just the vascular portion of the exam, opinions ranged from some saying that all that is needed is to palpate pulses and manually test capillary return, to others saying that plethysmography and Doppler studies must be included. The only consistency was that each doctor felt that his or her protocol was the right way to do it and any other way was wrong. Each participant was not only in private practice, but was in some aspect of podiatric academia.


Because of the ADA recommendations and the fact that people are coming to us for diabetic foot exams, perhaps the APMA could conduct a study and clearly define what tests should and should not comprise a routine diabetic foot examination.


Elliot Udell, DPM, Hicksville, NY



From: Desmond Bell, DPM


Thanks to Drs. Levy and Jacobs, et al., in their recent letters, for calling attention to several issues surrounding the increasing number of non-traumatic amputations occurring in the U.S.


We have an aging population, and most importantly, the number of diabetics in our country (and pretty much everywhere else) continues to increase. During my first year of residency, 1995-96, there were approximately 16 million diabetics among our population, whereas we are now at approximately 30 million. While the amputation rates may have gone down for a sample of time, the present upsurge in amputations should not...


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



From: Estelle Albright, DPM


First, let me say that I entirely agree with Dr. Jacobs’ post. There are other factors that are important in preventing amputations:


1. The fact that virtually every packaged, prepared, canned and fast food item contains sugar. Labelling as to actual sugar content is hidden by manufacturers by listing ingredients in descending order with highest first, BUT, they list the various sugars each separately, instead of as sugar. Examples: High fructose corn syrup, glucose, mannose, fructose, ...


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



RE: Comprehensive Diabetic Foot Exam and 2019 ADA Guidelines

From: Allen Jacobs, DPM


The new 2019 ADA guidelines recommend once yearly foot examinations unless a patient is determined to be very high risk for ulceration. The problem is who determines "very high risk." You can only diagnose and risk stratify that which you examine for. There is more to risk stratification than feeling for a pulse and using a monofilament or tuning fork, or dispensing diabetic shoes.


The PA, NP, PCP, RN, PT, cannot perform a comprehensive examination any more than a DPM can complete a detailed cardiac examination. Many Medicare advantage plans and medical managed plans profit primary care providers who do not refer.


When the opportunity arises, be certain to actually perform a complete and comprehensive diabetic foot examination. Risk stratify the patient. Educate the patient and family. Document appropriately. Communicate your findings and recommendations to the non-DPMs. This is the opportunity to grow recognition of your specialty. It is the opportunity to demonstrate the depth and breadth of you education and value to the healthcare team. Others may try, but you can succeed.


Allen Jacobs, DPM, St. Louis, MO



From: David S. Wolf, DPM


Patients don’t care if you wear a tie or a starched white lab coat. Patients want to know that you care.


David S. Wolf, DPM, Retired


Editor's note: This topic is now closed. 



From: Arden Smith, DPM


I think that many of you are missing my point. It's not about your sleeves and ties picking up "little feckies". It's not about your patients loving you even if you come to the office in your underwear. It's not about the pragmatic issue of your laundry bill.


The question was simply, "Is one more productive with a tie?" I am not a big fan of wearing a tie either, as my neck has gotten larger over the years, but it seems to work in our large 4 office, 10 doctor practice, covering 3 counties.


Arden Smith, DPM, Manhasset, NY



RE: Dealing with Pay Reductions for Multiple Procedures

From: Allen Jacobs, DPM


There is actually a CMS rule that addresses performing procedures on multiple days to increase reimbursement. It is in Chapter I (Page 8) General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. “Physicians shall not inconvenience beneficiaries nor increase risks to beneficiaries by performing services on different dates of service to avoid MUE or NCCI PTP edits”. 


Even though this is CMS/Medicare policy, many insurance companies utilize these guidelines.  


Allen Jacobs, DPM, St. Louis, MO



From: Ira Baum, DPM


I’m taking an opposing position than most of the previous posts. I think there is a place for altruism, but I believe podiatrists must be pragmatic. I don’t think that the decision to perform multiple procedures in one session based on one variable is appropriate. Podiatrists and healthcare providers dependent on third-party payors have been financially battered with no real potential recourse. So, if patients depend on a third-party paying for their care, then by implication, they should also expect the care their payors are willing to pay.


Podiatrists have overhead responsibilities. If those obligations can’t be met, then I don’t see how this benefits anyone. I am not a proponent of putting patients at increased risk, but I am also sensitive to the financial predicament put on our providers.  


Ira Baum, DPM, Naples, FL



From: Hal Ornstein, DPM, Tip Sullivan, DPM


I agree with Dr. Jacobs to always tell the patient the truth when it comes to performing all services. In teaching practice management most of my career, I have always professed what we call “The Mother Test”, doing what one would simply do if the patient were their mother. What many successful practices have in common is that they are always driven by what is best for the patient. Our podiatric oath should be out guiding light to do what is best and safest for the patient and not driven by what one gets paid. Whether one believes in this or not, our actions come full circle and karma can be quite rewarding.


Hal Ornstein, DPM, Howell, NJ 


I agree with Dr. Jacobs. The truth will set you free, but if you are not doing multiple procedures (if they are needed) just because you don't want your payment diminished, then your heart is not in the right place. To make a patient go through multiple surgeries and the associated surgical risks of each surgical intervention is wrong. Your financial gain does not come before the patient’s well-being. I can remember when I would see patients who would tell me that their previous hammertoe surgery was done one toe at a time at different times. I am certainly not against staging procedures when the decision is based on the patient’s welfare and not financial compensation of the physician.


Tip Sullivan, DPM, Jackson, MS



From: Dieter Fellner, DPM


I empathize deeply with Dr. McCormick and his frustrations. The problem is, however, much more pervasive. Primary certification, with this exam is frankly absurd. I have over 30 years’ experience. I know my 'stuff' and I keep up-to-date. In 2016, I sat for their exams, as required. The system is flawed. I want to challenge those sitting comfortably on their lifetime certificate to submit to the same process (without cheating). 


Let me be quite plain: the computer simulation is ridiculous. The marking of answers is inherently biased against the examinee. The hapless test taker is required to search frantically for those elusive buzz words that resonate with the marking. Doctors: that has nothing to do with clinical and surgical competency. The computer systems also tend to malfunction. 


I have practiced surgery for decades. I have never been sued. I know of exam-taking superstars who get sued repeatedly. So, what exactly does the Board Certification provide? It is not clearly a yardstick for surgical competence. In England, where I first practiced, we have a system of periodic peer review. Assigned podiatric surgeons will visit the facility every two years for an on-site evaluation of surgical practice. This is a supportive function, as much as it is an audit. After 4 years of school and 3 years of residency and endless exams, when will America have confidence to allow their doctors to be doctors? 


Dieter Fellner, DPM, NY, NY



From: Vincent Marino, DPM


I have been treating Workers Compensation patients as well as performing medical legal evaluations on them for the past 25 years in California. However, the federal government Workers Compensation laws (for which a postal worker falls under) are quite different than any of the state laws. What you need to determine is whether or not the occupation of this postal worker acts as an aggravating factor rather than as an exacerbating factor.


In other words, does the employment simply temporarily increase the symptoms or does the employment increase the symptoms requiring further treatments and accommodations? If it is the latter, then it is considered an industrial injury. In your case, most likely your patient will have a legitimate industrial injury since weight-bearing is such a large part of their job requirements - regardless of weight, pronation, equinus, etc. Even for these to be the CAUSES, the person needs to be weight-bearing. I hope this helps explain the issues.


Vincent Marino, DPM, San Francisco, CA



From: Danae L. Lowell, DPM


It’s important to note that data quoted from and the annual PM survey are anecdotal and do not in any way accurately reflect current salary ranges. If we are going to have an educated discussion on current salaries, data from MGMA and Sullivan Cotter should be utilized. This is officially validated data that provides accurate salary ranges in quartiles and most importantly delineates between surgical and non-surgical practices. It also goes beyond solo practitioners and includes hospital appointments, group practices, and VA salaries. 


Quoting an annual median income for solo practitioner of $123,250 does nothing to promote the practice of podiatry. Indeed, it negatively represents the field. The true scope of practice possibilities and financial prosperity available to today’s podiatrist far exceed the solo practitioner making $123,250. Podiatrists completing a 3-year PMSR, PMSR/RRA residency and advanced fellowship programs have training worthy of much higher salaries and they are getting them.  


Regarding the relatively new associate, the $192,738 is within the range of validated data depending on quartile and scope of practice. Pay him what he is worth according to validated data and performance.


Danae L. Lowell, DPM, Cleveland, OH