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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: Elliot Udell, DPM


I feel Dr. Borreggine's frustration and anger when a patient walks out of the door and never pays his or her bill and, in some cases, has no intention of ever paying it. We had one patient who not only told me that the check would be in the mail, but he took a whole bunch of foot creams and never paid for them either. I physically and emotionally write off these cases by saying to myself that I took an oath to be a healer and that money is secondary.


What got me really angry was when that patient who never paid for the visit nor the foot creams popped up in my office a month later demanding that I give him a copy of the x-rays so that he can go to another doctor. Legally, I had to give him his records and x-rays. I suspect he probably travels from doctor to doctor doing the same thing.


Elliot Udell, DPM, Hicksville, NY



From: Brian Kiel, DPM


We use Dragon Medical and it does an excellent job of accuracy at normal to fast talking. It also learns new words. For accuracy's sake, I read on the screen as I type and I am able to pick up any discrepancies . 


Brian Kiel, DPM, Memphis, TN



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



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



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



From: Andrew Shapiro, DPM


Dr. Kass appropriately recognizes Dr. Dennis Frisch and the APMA for their efforts, but he should also thank the more than 12,000 united APMA members who have invested in their national and component organizations. Without  the advocacy and work of the APMA and its state and division components, there would be no voice to defend and support the podiatric profession. ATTENTION NON-MEMBERS: It's time you stop relying on others to save your profession. Step up and join now, and be a part of the solution, not the problem!


Andrew Shapiro, DPM, Valley Stream, NY



From: Eric J. Lullove, DPM 


I don’t want to sound like a broken record in this post. I cannot stress how important this issue is to all of us. Basically, whether you pay for APMA dues or not, this is as of right now, the most important battle we as DPMs are ever going to fight. I have seen the direct result of how advocacy and involvement at the public policy level works for the day-to-day practicing podiatric physician.


It is this very time that EVERY DPM in this country access the APMA e-Advocacy website and send your customized letter to your members of Congress as well as CMS Administrator Seema Verma to immediately close the...


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



From:  Dennis R. Frisch, DPM


Dr. Kass asks if there is a course of action to ensure the profession is not short-changed when it comes to the changes to E/M codes included in the proposed rule for the Medicare Physician Fee Schedule. In short, yes: Visit the APMA eAdvocacy site today to send a pre-populated, customizable message to CMS. Physicians must send a comment by September 10 to be on the record on this critical issue.


APMA has actively communicated with members since the release of the proposed rule and is asking every member, state component, and affiliate to take part in this profession-wide call to action. We encourage non-members to...


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



From: Stephen Doms, DPM 


While podiatrists are defined as physicians, so are optometrists. When I go to my OD for examination and management of my glaucoma, the doctor writes me a prescription for eye drops. He bills for and receives payment for CPT 99213. Should CMS also carve out a new set of codes for optometrists? They certainly have a smaller anatomical area to care for compared to a podiatrist. Why are we being singled out?


I just looked at the pre-publication PDF of the Federal Register for the CMS proposed changes. You can search for CMS, Federal Register, July 27, 2018. The podiatry information starts on page 359. If my math is correct, these are the calculation of fees for 2019: The "conversion factor" for Medicare in 2019 is 36.0463. The proposed new patient podiatry code has an RVU of 1.35 and an added dollar input of $22.53, resulting in an allowable charge of $72.19. For an established patient, the RVU is .85 with an added dollar input of $17.07, resulting in an allowable charge of $47.71. I hope that my math is way off.


Stephen Doms, DPM, Hopkins, MN



From: Ayne Furman,DPM


I understand that the query was asking for surgical advice, but I would like to offer a few conservative care treatment suggestions that I used successfully in my practice that may not have been tried for symptomatic posterior insertional retro-calcaneal exostosis:


1. D/C all Achilles tendon stretching or any exercise that heel drops below the level of the forefoot during the symptomatic stage. It has been my experience that PTs often will give patients aggressive stretching programs for almost any type of foot pathology.

2. Start on modified Alfredson exercises. Do not allow the heel drop below the level of the forefoot.

3. Make sure the posterior heel is off-loaded when the patient is watching TV or reading. Alert the patient not to rest the posterior heel on a coffee table or foot stool.

4. Modify a night time splitting so the heel is off-loaded in bed. Most of my patients noticed significant improvement in their heel pain doing the above (sometimes with the help of a NSAID) within 3-4 weeks.


Ayne Furman, DPM (retired),  Alexandria, VA



From: Joseph Borreggine, DPM


I do not know if this individual is an outlier or is the typical norm for an ABFAS candidate, but it should raise eyebrows for the entire profession if this issue is a frequent problem. The facts are plain and simple... the cost and time involved to reach this pinnacle of certification may be in excess based on the supposed high quality education and training that every podiatric student receives prior to this achievement.


It is my understanding that podiatry is equal to allopathic and osteopathic medicine less a few educational courses and post-graduate rotations. And as a specialty requiring all DPMs to be trained as “foot and surgeons”, passing of said exam should be a piece of cake. Alas, it is not. The pass rate the first time a candidate takes this exam is much less than 50%. 


The second or third time it is taken, the results are appreciably higher, but these multiple attempts to pass an exam which should reflect the candidate’s aptitude is unnecessary. Our orthopedic colleagues seemingly take a similar exam and have a much higher first pass rate as compared to our comparative board exam. 


I find this disheartening in light of the fact that podiatry is and has been fighting for parity. This concern from this ABFAS Diplomate is valid and should be investigated. If not, then it should fe explained so that prospective ABFAS candidates can understand more thoroughly how this process really works.


Joseph Borreggine, DPM, Charleston, IL



From: Marshall Feldman, DPM


Are you kidding? You should thank your lucky stars that you can even sit for the Board. Because of the men and women that came before you, you are now able to provide the most  comprehensive treatment of foot and ankle disorders in our country. I am not going to waste my time by describing how practicing our profession was like prior to the advent of ABFAS.  Nor will I waste my time to explain how other medical professionals perceived our profession, again prior to the Board's creation.  However, I will say that you should count your lucky stars that the leaders of our profession determined that it was paramount to create a substantial and esteemed panel that would properly ascertain the qualifications of a potential applicant.


To that end, yes the cost is not cheap in order to be able to complete the required certificate. Yes, you were not able to buy into an out-patient surgical center of your choice nor attain hospital staff privileges or even retain them due to the fact that you were not "boarded". You should get down on your knees in order to thank those who came before you and opened the doors for you to enter these institutions with the knowledge and I hope ability that you have attained.


On another note, why the heck does it matter that the ABFAS headquarters are in California?


Marshall Feldman, DPM, Rahway, NJ



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