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From: Jack Ressler, DPM


I am very interested to find out the amount of time that passed between when the podiatrist passed away and when the practice was put on the market. I'm sure the deceased podiatrist had an excellent relationship with his patients that probably could not be duplicated by the revolving door of podiatrists who pitched in to help in this unfortunate situation. It led to a perfect storm for that other podiatrist. Although grief and shock by the family of the sudden death of their loved one probably prevented the practice from being put up for sale earlier, that delay cost them a very marketable practice. 


The other podiatrist who opened was very fortunate/underhanded to be able to take advantage of a unique and sad scenario that rarely occurs. I do not believe Dr. Name Withheld’s conclusion about a practice not having inherent value. A thriving modern up-to-date practice should have a good marketable value, especially if the seller takes the time and markets it properly. I worked very hard in my practice for many years and was able to sell it. I took the time to market it properly and got a nice return for my hard work.


Jack Ressler, DPM, Delray Beach, FL

Other messages in this thread:



From: Brant McCartan DPM, MBA, MS


Great MIS recap and points. I am “the younger DPM”, finishing a 3-year residency in 2013. To answer some of your questions, I have noticed about fifty older generation doctors who have never given up MIS - and have been doing so for 30+ years. They are anxious to teach and happy that MIS has a growing acceptance, despite being more so internationally as opposed to locally. I believe the appearance of a resurgence is more due to the industry “getting in the game” (nominally Wright and Trilliant; maybe more companies making screws specifically for MIS style bunion correction).


This is interesting because the originators of the MIS bunion-style surgeries rarely use any hardware, if any, in their procedures! But now that industry is involved, it instantly becomes interesting, and a more acceptable, viable option or technique. Show me the percentages of established lecturers or board members in any medical organization who consult for at least one company, likely more. Money talks.


Brant McCartan DPM, MBA, MS



From: Burton Jay Katzen, DPM


The answers to Dr. Borreggine's questions are long and complicated ones dating back approximately 60 years. Minimally invasive surgery is now the standard of care in many countries throughout the world. However, I can say that resurgence of MIS in the United States can be traced, in no small part, to the exceptional outcomes our surgeons are seeing. This includes less patient downtime and the maximum use of the surgeon’s time and the ability to perform many of our procedures in an office setting or an outpatient ambulatory surgical center.


I believe that the future of MIS lies in the ability to teach the procedures in the schools and the residency programs. I am happy to note that the next Academy Of Minimally Invasive Foot and Ankle Surgery LSU lecture cadaver seminar to be held in New Orleans on May 31, June 1, and June 2 will include several residents from programs throughout the United States.


Burton Jay Katzen, DPM, Temple Hills, MD



From: Bill Beaton, DPM


I would like to comment on Dr. Richard Simmons' post in regard to "non-medically licensed" personnel performing routine foot care and that procedure is billed as if the DPM personally performed the procedure. In Florida, it is against the Florida Podiatry Practice Act for anyone not licensed to perform any procedure that falls under the definition of the Practice of Podiatry.


Florida Statutes 461.003(5) states that "Practice of podiatric medicine" means the diagnosis or medical, surgical, palliative, and mechanical treeatment of ailments of the human foot and leg. The surgical treatment of ailments of the human foot and leg shall be limited to that part below the anterior tibial tubercle.


In my opinion, anyone other than a licensed podiatrist providing palliative foot care or a podiatrist that is supervising a non-medically licensed person is in violation of the Florida Podiatry Statutes and subject to penalties under Statute 461.012(2)(d).


Bill Beaton, DPM, Saint Petersburg, FL



From: Richard A. Simmons, DPM


Dr. Forman wrote: “I received notification from Medicare that 33% of my visits submitted included an E/M charge. I was told it was above the average.” To me, there are two issues here: 1) do you really want to go toe-to-toe with Medicare defending your E&Ms and 2) I am surprised that 33% is above average. I know that some doctors will challenge Medicare personally and spend a lot of time and effort defending their claims. If your office is equipped to handle this, then go for it. The 33% number seems low and may be something that APMA could look into. 


That said, there may be a lot of practices where “non-medically licensed” personnel are trimming toenails, corns, and calluses, and these offices may simply have a high turnover of procedures without examinations. On a side note, if a PA (physican assistant) or NP (registered nurse practitioner) submits a bill to Medicare, it is paid at a lower fee profile than if submitted by an MD, DO, or DPM; however, when “non-medically licensed” personnel perform routine foot care, that procedure is billed as if the DPM personally performed the procedure. Even though Dr. Forman may be practicing good medicine, it appears that the numbers may simply be against him.


Richard A. Simmons, DPM, Rockledge, FL



From: Thomas Graziano, DPM, MD


With all due respect to Dr. Lipkin, the decision to drop out of the insurance networks is not a "knee jerk" reaction as he implied. And as he said, "thinking with your head, and not your heart", is exactly why he and others should drop out. If anyone in solo practice thinks they are going to negotiate better fees with any of these insurance companies, they suffer from delusional personality disorder. It's not going to happen. If you think its all right to devalue your services on one hand to get thrown some crumbs for another service, then continue to practice that way. 


But if you're looking for real solutions, put your big boy pants on and stop putting up with it. I remember some time ago the late Neal Frankel, DPM met with our division in NJ and told us something that stuck with me. He said the CEO of one of the larger insurance companies told him and I quote, "why should we pay podiatrists more when we know they'll work for less."  That statement continues to resonate, and its one of the reasons I'm out-of-network today. I only wish I had done it sooner.


Thomas Graziano, DPM, MD, Clifton, NJ



From: Allen Jacobs, DPM


I wanted to share some thoughts with regard to the issue of what to do when individuals present to an office with orthotics made at Costco, the Good Feet Store, or similar non-podiatric facilities. 


Simply stated, you have completed undergraduate and post-graduate training, including training in biomechanics and kinesiology. Your decision as to the nature and type of orthotics to be utilized, and the specific corrections to be utilized in those orthotics, are unique and individualized based upon an examination of that patient and a determination of multi-variant factors resulting in...


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



From: Doug Richie, DPM


Nine years ago, I posted a blog documenting my experience with a patient who had purchased "custom" foot orthotics from Costco.


To my surprise, this blog posting became the most popular blog entry ever posted on the Podiatry Today website, primarily due to the readership of the general public. Today, over 116,000 people have read the post. The comments on this blog are also interesting, but my own message is still valid today. Commercial entities who provide low cost, ineffective foot orthoses will only increase awareness and motivate the general public to seek quality foot care interventions provided by qualified podiatric physicians.   


Doug Richie, DPM, Seal Beach, CA



From: Joseph Borreggine, DPM


Dr. Williams, I must sorely disagree with your premise statement with respect to the theme of this article and how the patient was “victimized” by the physician assistant and the pharmacy. This is nothing more than the “drive by media” producing a sensational “fake news” story on how big pharma is destroying healthcare by “overcharging” patients for medication that they may or may not actually need. 


The author of this article makes the reader believe that this patient who seemingly is a well-to-do retiree based on her aforementioned resident geographic locale on “Capitol Hill” was taken advantage of without...


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



From: Bill Beaton, DPM


In conversations with my billing company E-Professional Technologies, we have researched this situation and, yes, this is a national issue and we are equally outraged. We can still obtain information on Medicare deductibles for regular beneficiaries. However, there is a fairly new program for Medicare/Medicaid beneficiaries called Qualified Medicare Beneficiary (QMB). 


For QMB patients, providers are not permitted to charge the patient anything. So the government, in their infinite wisdom, has decided we are not entitled to know how much we are paying on behalf of each patient! If we can't collect the money, then essentially we are paying the bill on their behalf. Is it $1 or is it the entire $183 deductible? We are not allowed to know. If you see 100 patients at a nursing home in one week, that could mean $18,300!


I called First Coast Service Options (which is the Medicare MAC for Florida) and asked them how we could determine the amount that we would be responsible for, and I was told we are not allowed to know. I have written my congressman about this. It is literally outrageous that a doctor is responsible for paying a patient's deductible and they are not allowed to know how much is at stake. I am now playing a game of holding all QMB claims until I see that all other patients have met their deductible and I'm going to assume they have too, but that's not very accurate.


Bill Beaton, DPM, Saint Petersburg, FL



From: Stephen Doms, DPM


I, too, have asked this question. When I completed my surgical residency in 1981, it was a requirement that residents, individually or as a team, write an article suitable for publication to the Journal of the American Podiatry Association (JAPA). We three residents wrote and published our article in JAPA for the February 1982 issue. Is this no longer a requirement of podiatric residencies?  If not, I think it should be.


Stephen Doms, DPM, Hopkins, MN



RE: Lack of Podiatric Authors in Our Journals (Joseph Borreggine, DPM)

From: Leonard A. Levy, DPM, MPH


I agree with the remarks of Joseph Borreggine, DPM about the lack of podiatric authors in our journals, a phenomenon that I believe needs some attention. To accomplish that, more emphasis needs to be made in the education and training of podiatric physicians in the research process at the level of both residency and undergraduate podiatric medical education. Expanding that emphasis could result in an increase in the production of a critical mass of podiatric medical research and scholarly articles reporting on such activities.


Not only are there a lack of articles reporting on research findings in podiatric medical journals, but also in journals of other medical specialties that would find such information useful as well and result in expanding the awareness of other health professionals about the depth and role of our profession.  


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL 



From: John V. Guiliana, DPM, MS


I wholeheartedly agree with Dr. Kashan and Dr. Ressler. It saddens me when I hear physicians state that "their practice has no value and they will someday just close the doors". Surprisingly, I hear this quite a bit.


A practice is a living and breathing entity. It needs to be continuously nourished and maintained. Marketing, continuous quality control, investment in technologies, optimizing processes, etc. all create inherent value throughout the years. In the end, the fair market value can be computed through various techniques which often revolve around net earnings and an applicable capitalization rate. Leave that to the experts. But there are buyers out there, so please take good care of your practice and it will certainly provide you with post-retirement income. 


John V. Guiliana, DPM, MS, Little Egg Harbor, NJ



From: Steven Kravitz, DPM


Dr. Markinson makes some very salient points that podiatrists should consider. There is no turning back the clock; physician extenders are here to stay. But the good news is that there has been a change in podiatry recognition of this aspect of delivery care over the past 3 to 4 years. Assessment of the membership of a well-established physician (MD and DPM) only wound healing association provides interesting data on a dramatic shift with podiatric perspective on NPs and PAs. 


Four to five years ago, there was much more concern about competition with these practitioners and therefore a conflict of interest. But over the past two to three years, more and more podiatrists are working with...


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



From: Neil H Hecht, DPM


I have read the recent posts regarding the ABFAS Board Exam pass/fail rates. I looked up the American Board of Orthopedic Surgery statistics in an attempt to compare. Although the MD/DO residency in orthopedics is 5 years, their scope is the whole body, and therefore it seems to me that 3 years of post-doctoral foot and ankle residency training would be appropriately rigorous and adequate for our DPM graduates.


The American Board of Orthopaedic Surgery posts these statistics on their website:


2013       86%        pass       593/689 candidates passed

2014       93%        pass       713/770 passed

2015       95%        pass       707/747 passed

2016       96%        pass       700/729 passed

2017       93%        pass       689/743 passed


Statistics can be difficult to interpret, but certainly more than 90% of our 3-year residency-trained post-doctoral DPM candidates should be able to pass “our” certification examination. If not, either we have poor candidates for foot doctors or something is wrong with the test. I would like to believe that the test needs to be closely re-evaluated and rewritten in order to better reflect the trained doctors who seek to become boarded.


Neil H Hecht, DPM, Tarzana, CA



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

From: Matthew Williams, DPM


The American Board of Foot and Ankle Surgery’s (ABFAS) mission is to protect and improve the health and welfare of the public by the advancement of the art and science of podiatric surgery. As surgeons, we want the best outcomes for our patients, and ABFAS will continue to strive to fulfill our mission to certify high quality surgical candidates for the betterment of the profession. 


The trending of Part I spring exam results for first time takers shows the impact of the three-year surgical residencies. 


ABFAS Part 1 Pass Rates 


Although there is a drop in the pass rate for...


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



From: Larry Kobak, DPM, JD


This email is in response to Dr. Udell's inquiry if you can sue a patient or social media site that posts an untrue review. The answer is sometimes. If the review merely expresses an opinion, that is protected constitutionally. In NY, if the patient goes further and states something that reflects on the podiatrist's ability, such as "(s)he is a butcher", or inaccurately, such as (s)he lost his/her license last year, that is actionable. I have successfully sued the patient for libel in such cases. Please be warned that there is a statute of limitations in such cases. In NY, it is only one year from the time the review was first published.


Larry Kobak, DPM, JD, Senior Counsel, Frier Levitt



From: Lee C. Rogers, DPM, Ed Davis, DPM


The Internet has made education available to everyone with a connection, without unnecessary time and travel expense. I encourage our state boards of podiatry to modernize their CME requirements to take advantage of these advancements in technology and the renaissance that will be the future of learning.


Lee C. Rogers, DPM, Los Angeles, CA


Dr. Sherman is right concerning the issue of certain states restricting online CME. One can go to a "brick and mortar" CME seminar but no one can ensure that attention to the subject matter presented occurs nor that the attendee is even awake. Online CME generally requires that attendees read the material presented and answer questions to ensure learning.


Ed Davis, DPM, San Antonio, TX



RE: Why Do Some State Boards of Podiatry Still Limit Online CME? (Alan Sherman, DPM)

From: Larry Aronberg, DPM

I completely agree with Dr. Sherman. When I go to a bottoms-in-the-chairs seminar, people wander in and out, tune out the lecture, etc. You just have to sign in and sign out for credit. With online, there is a test you have to pass. You have to learn the material to get the credits. When you also consider travel, lodging, and time away from your practice when attending a seminar, online seems even more logical. I love the hands-on courses at seminars, but would much prefer most of my credits online with just an occasional trip for a distant seminar.


Larry Aronberg, DPM, Lake Worth, FL



From: Bryan C. Markinson, DPM


My friend Dr. Robert Hatcher is absolutely dead on about "working smarter, not harder." There is no question that we should all strive for life balance and more efficiency in our practices. But "working smarter, not harder" is predominantly an empty sentiment....but only us old timers get it. I teach students, residents, and young colleagues on a regular basis. One of my most common points is "the days of 9-5 are long gone." If you want to coach little league and catch every ballet recital, and go to "mommy and me", you may need to settle for a three bedroom house instead of a 5 bedroom house. If you don't get what I am saying, advice on office efficiency and life balance is wasted on you.


Bryan C. Markinson, DPM, NY, NY



From: Martin G. Miller, DPM


I went to the website that Dr. Kesselman referenced in his response, and after putting in my NPI, it correctly identified me and my specialty (podiatry), but it only said revalidation: TBD. I assume this means "To Be Determined". I guess I have to keep checking back to see if any date actually shows up. It would be far more helpful if the actual date was given.  


Martin G. Miller, DPM, Freeport, NY



RE: Enough Already with Time-Consuming Chart Requests (David P. Luongo, DPM)

From: Matthew B. Richins, DPM, Cynthia Ferrelli, DPM


When we get a request, my office manager charges a fee for our supplies and her time to the companies, to be paid in advance. Most pay. Others ask to send a representative out to make the copies. We tell them to bring their own paper, printer, and ink - and they do!


Matthew B. Richins, DPM, Joplin, MO



From: Lynn Homisak


I believe you are asking ‘should you bill a new patient you haven’t even seen yet?’ and ‘should you collect their credit card information prior to their appointment?' Instead of applying a Band-aid on an obvious problem and sending a negative message to patients before you even meet them, why not try to determine the reason WHY new patient cancellations are such an issue for you? 


Yes, new patients must occasionally cancel an appointment. It happens. It is not typical, however, to have a new patient cancellation "problem"; unless of course, new patients are scheduled so far out that...


Editor's note: Lynn Homisak's extended-length letter can be read here



From: Paul Kesselman, DPM 


There is no simple solution to this and there are multiple factors here. On one hand, asking for a credit card deposit on the phone does set a bad tone, but with high deductibles and co-payments and tight schedules, last minute cancellations are also unfair to other patients who otherwise would have been able to obtain care sooner. 


I agree that calling the patient the day before to confirm is far better than collecting a credit card "deposit" on the potential new patient. However, the reality is that tight schedules and last minute (24 hours is last minute) cancellations are unfair to...


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



From: Ivar Roth, DPM, MPH


Missed first appointments were a continuing source of irritation in my practice. We now take a credit card from all first time patients and bill a nominal amount to make sure the card is real. This amount is deducted from their visit if they come in. We send a confirmation email immediately after they call with a copy of our policy so there is NO miscommunication.  


This has worked well for us. Those who refuse to give us a credit card do not get an appointment. This is a real simple solution. We only charge $75 if they fail to show up or give notice. This policy is really to keep the new patient mindful that our time is valuable when they book an appointment.


Ivar Roth, DPM, MPH, Newport Beach, CA



From: Elliot Udell, DPM


Dr. Secord shines a light on the fact that the exorbitant price of brand name medications charged by pharmaceutical companies to U.S. citizens could not be totally justified by the cost of research. Much of this research, as Dr. Secord points out, is done at institutions funded by taxpayers.


Even if we want to give an inch to big pharm's argument that research expenses are at the heart of why Americans pay so much more than "Canadians" for pharmaceuticals, it by no means explains how drug companies have cornered generics and raised the prices to astronomical levels. All of us are aware of how big pharm was able to exploit a legal loophole and start charging over ten dollars a pill for Colchicine when as a generic it sold for pennies for a tablet.


Econazole cream which is a generic antifungal, used to cost less than two dollars for an 85 gram tube. Somehow, the pharmaceutical firms were able to corner that market and raise the price to over $250 dollars for the same product. The ingredients in the EpiPen for which the company charges over $650 dollars (which we all have in our emergency crash carts) are available for less than $2 dollars. The bottom line is that the American citizens deserve close government scrutiny of what is going on and laws to protect its interests.


Elliot Udell, DPM, Hicksville, NY