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From: Janet McCormick, MS


The EPA-approved label on Benz-All says weekly. It does not say, however, if Benz-All is rendered ineffective by bioburden, meaning it might or probably needs to be changed earlier. The EPA requires that hospital disinfectants kill certain benchmark microbes and Benz-All does that. Many disinfectants, however, are tested for further levels of kill, and these are added to the label as "label dressing" since no disinfectant at this level kills everything. In other words, it's designed to improve sales. Keep in mind that there are many organisms it does not kill, but that is true of every disinfectant, no matter the brand. Only sterilization kills them all = use of an autoclave.


There are those that say disinfection is the okay-level of care for podiatry instruments unless you are performing invasive treatments. But any treatment can cause any level of invasion by instruments (in any type of care - podiatry or otherwise), even by accident, so any procedure must be performed under aseptic conditions Doesn't that call for sterilization of instruments in podiatry? Even in the offices? I am always shocked when I go into a podiatry office and there is no autoclave! But it happens way too often! In a survey of podiatry offices in my area, 4 out of 6 offices did not have an autoclave. 


Janet McCormick, MS, Frostproof, FL

Other messages in this thread:



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: 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: CMS' Discrimination Against Podiatrists

From: Lawrence M. Rubin, DPM


The decision of the CMS policy-making gurus to try to save some federal dollars by cutting payment for E & M medical care provided by podiatrists is, to say the least, ill-founded and discriminatory. I believe in healthcare cost-containment measures, but only if they conform to existing rules and regulations. This proposed rule does not do this. For it to conform, Medicare would have to first change its definition of the word "physicians." 


APMA is expertly representing us in its efforts to maintain parity with the other professionals designated by Medicare as physicians – MDs, DOs, optometrists, and chiropractors. With this in mind, I believe what CMS is attempting to do with podiatry should be a “Heads Up!” to optometrists and chiropractors. If CMS gets its way with podiatry, I bet optometrists and chiropractors will be next on its attack list. I hope APMA is keeping this in mind and discussing this issue with the optometric and chiropractic national professional organizations. Together, we could be stronger. We could be a united force in trying to convince Medicare to maintain present Medicare parity regulations.  


Lawrence M. Rubin, DPM, Las Vegas, NV



From: Jeffrey Kass, DPM


I agree with Dr. Siegal's comments regarding seeking equal pay for equal work. I also feel this should not be limited to Medicare and their particular payment system. It is ludicrous that all other payers do not have a standard payment system. Different providers within the same specialties are paid at different rates. This is something the medical community at large should have stopped dead in its tracks when it first started.


Jeffrey Kass, DPM, Forest Hills, NY



From: Len La Russa, DPM


We, as podiatrists, are all worried about the dwindling number of pre-med applicants applying to podiatry school. Could part of the problem have anything at all to do with the 50% passing rate for ABPS certification? Orthopods don't have that problem. Or is it possibly the chance that there might not be a position available for residency? The low passing rate is much easier to fix than the residency crisis, which is less of a crisis now. Another impediment to getting talent to apply to podiatry school could easily be addressed by increasing the pass rate so that it is no longer such an embarrassment. 


Len La Russa, DPM, Americus, GA



From: Brian Kiel, DPM


I, just like many podiatrists, see patients who have been treated by Costco and urgent care facilities. I, like Dr. Jacobs, will not deal with devices that others have made. I explain that it is a useless device and I cannot and will not take responsibility for them. On the other hand, if someone comes into my office with a boot and a fracture, or an improperly treated condition of the foot, I don't feel that we can or should refuse them. If another facility screwed it up in the first place, then they probably won't get it any better the second. It is our responsibility to do everything we can to help that patient. Of course, proper charting regarding the prior care is critical, but we have an ethical responsibility to care for those patients.


Brian Kiel, DPM, Memphis, TN



From: Mike Kempski


I work on the insurance side of medical malpractice and have twenty five years of experience. In the early years of the Data Bank, the doctors had great concerns about entries against them. The concern was so intense that the carriers responded by changing their policy language as it relates to the settlement of claims. The change was the policies stated they won’t settle a claim without your consent to do so. However, I don’t think there was much reason to be worried. There’s very limited access to the Data Bank. For example, the general public (your patients) can’t access it. Medical malpractice insurance carriers can’t. Hospitals can. But they’re always very reluctant to revoke privileges. How has it hurt physicians?


Mike Kempski, Plymouth Meeting, PA



From: Don Steinfeld, DPM


Kudos to Brian Markinson. We should all remember that every interaction we have is an opportunity to promote podiatry as a profession and ourselves. What a positive outlook he has. It’s so easy to fall in step with negative thinking and negative thoughts. This is a great way for all of us to start the new year on a positive note. 


Don Steinfeld, DPM, Farmingdale, NJ



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

From: Don Peacock, DPM


The complaints regarding the ABFAS board certification process are completely unwarranted. I say this not to be elitist but to recognize that we all should strive to remain independent. I feel empathy for anyone going through the board certification process. I remember it well and it was challenging. However, I do not feel sorry for anyone complaining about it. The experience should be difficult and will make you more knowledgeable in the end. Complaining about it is silly and serves no purpose. You should prepare and do your best; and like a boxer, you need to be strong enough to give and take a punch. 


I will be taking the recertification exam in 2018 and I plan to study and pass it. If I do not...


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



From: Adam Siegel, DPM


Dr. Williams mentions that we must “not be inferior to that of our MD colleagues.” So I suppose the solution is to do what most podiatrists seem to do: overcompensate in an effort to unnecessarily prove something to an audience that does not exist. If orthopods see a suitable pass rate as 90%, podiatrists should aim to set our pass rate at a comparable level. After all, it is completely up to the board to determine what arbitrary score is considered “proficient.”


Adam Siegel, DPM, Lutz, FL



From: Harry Penny, DPM


CMET has the only physician-specific organization certifying all prescribing MDs, DOs, and DPMs. CMET is different from the other certifying bodies in that they do not certify physical therapists, CNPs, or nurses in wound care. CMET certification is well accepted and respected, and an important certification for hospital and wound center privileges. If you want, you can go to the website for the Academy of Physicians in Wound Healing and sign up for their review course before sitting for the exam. 


Harry Penny, DPM, Altoona, PA



From: David P. Luongo, DPM


I have had Coverys professional liability coverage through Beneficial Insurance. I have had no problems at all. The rep is great.  


David P. Luongo, DPM, NY, NY



From: Elliot Udell, DPM


Dr. Hurchik is correct. There is massive money to be made by not only podiatrists doing these biopsies but by numerous pathology labs that are promoting these tests at our conventions and in journal ads.


At a seminar I attended, there was a med mal defense attorney lecturing about a case he was defending where the podiatrist was sued for doing a nerve biopsy on a diabetic who subsequently developed a severe infection from the wound created by the test. One of the questions asked of the defendant was why he needed to do the test in the first place and could the information it provided have been acquired from lesser invasive tests. Could the patients clinical history combined with nerve conduction studies have provided the same clinical information?


There is a time and a place for these biopsies, but we must all ask whether the benefit of doing them on every diabetic patient with neuropathy and/or reduced vascularity outweighs the risk.


Elliot Udell, DPM, Hicksville, NY



From: John Guiliana, DPM, MS


Chess is a game, the strategy of which many people enjoy. The same "gamesmanship" attitude must be applied to our podiatry practices regarding MACRA. MACRA is nothing more than yet another business decision that deserves some analysis. I agree with Pam Thompson in many regards. There is no doubt a cost associated with MACRA compliance. But a thorough understanding of the initiative as well as a practice's micro-economics will help providers avoid a complete abandonment of the program, along with the consequential fee schedule breakdowns.


For the most part, some of the components of MACRA are no longer an "all or none", "pass or fail" type program, like Meaningful Use and PQRS were in the past. As such, I frequently guide podiatrists to understand the process of cost allocation, and arrive at a MACRA "cost-compliance balance" that's best suited for their unique practice's workflow, skill level, staffing, etc. By doing this, penalties can be reduced or mitigated without great suffering to what matters most...attention to patient care. Checkmate! 


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



From:  Michael M. Rosenblatt, DPM


I agree with Dr. James Christina, Executive Director of APMA who said that MACRA does not mean the "end" of podiatry. Dr. Christina correctly points out that many previous "attacks" against private practice have fallen aside. "Managed care and capitation" were high on that list, as well as various Medicare pay cuts. None had any effect on me. And I was not alone. We have seen these fads come and go like wind-blown clouds. One humorous example comes to mind many years ago when BC/BS decided to "require" that any treatment over 100 dollars obtain a second opinion. Apparently their bean-counters believed that most medical care was "unnecessary." 


You can guess the outcome: Second opinion practices bloomed like flowers in the desert and BC/BS ended up paying for...


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



From: James R. Christina, DPM


Please allow me to provide some background, as well as some information about what APMA members can expect with regard to MACRA and its potential effect on podiatrists. Members can also visit to access all our resources on this topic. 


MACRA is legislation that was passed by Congress and signed by the president. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the sustainable growth rate (SGR) and replaced it with the Merit-based Incentive Payment Systems (MIPS) and Alternative Payment Models (APMs), among many other programs the legislation addressed. Once Congress passes a law, the implementation of the law falls to regulatory agencies, and in this case...


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



From: Allen Jacobs, DPM


The impending MACRA implementation may be the canary in the coal mine for private practices of all types. MACRA is certainly a cause for concern. However, the Death Star scenario proposed by some may not prove to be entirely accurate. 


1. Institutionally-based podiatrists will continue to prosper; 

2. VA based podiatrists will continue to prosper; 

3. Military podiatrists will continue to...


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



From: Brian Kiel, DPM


Let's see - $750,000 gross charges means approximately 55-58% will be allowed, which is $430,000. Of that $430,000, approximately 55% goes to overhead which includes malpractice, meetings, etc. That leaves $193,500. Dr. Withheld makes about $150,000. Is his malpractice paid? Without the exact $ amount involved, I can't be absolute, but based on this, his "non-salary" is not way out of line. A bonus system would obviously be indicated and not having paid vacation is unacceptable, but the salary is not outrageous. Also, why would surgery be paid any differently? When you are in the OR, you are not in the office producing income; and in today's environment, you are probably making less in the OR than in the office.


The key to being successful is increasing the utilization of services such as ultrasound, EPAT, Topaz, and DME such as braces and AFOs, and increasing the volume of patients seen. Based on this, I can't imagine that the volume of patients you could see is maxed out. If one is unable to do these things and/or is unable to increase their income to their satisfaction, looking for another position is the best thing to do. 


Brian Kiel, DPM, Memphis, TN



From: Name Withheld


I am 4 years out from residency. I gross $750k by myself for my practice 5 days a week. I make about $150k.This is not a salary, as I have no salary, no bonus, no incentive. My health insurance is not fully covered, and I have no paid vacation days. All talks to discuss a reasonable increase in pay have failed for 4 years. I have even tried to negotiate increases in % compensation for surgery and hospital consults, because, in my opinion, these services are done on my own time, with no use of office resources or overhead. These attempts, unfortunately, have also failed. My compensation and contract are identical to that of newly hired associates, after four years. Sadly, the notion that older podiatrists "eat their young", and see them as work slaves, is true. 


Yes, I signed the contract 4 years ago. There were none better that I could find at the time as a resident. I have maxed out my patient load and feel that there is no higher I can go. I cannot fathom where all of that extra money goes. It cannot go just to overhead and staff.  


A word of advice. If it sounds shady, then it is shady. Many of you will tell me to find a new place to work. Well, you're probably right, but it's easier said than done. Oh, and Dr. Sullivan: Some of us want to make more than just to "get by." Inflation is higher than it was 27 years ago. 


Name Withheld



From: Tip Sullivan, DPM, Steven J. Kaniadakis, DPM


Wow, Stating that smoking is EVIL is pushing it a little for me! We pay taxes (invest in our country). I wonder what “EVIL” is done with that money!


Tip Sullivan, DPM, Jackson, MS


It has become a standard ancillary question on forms, "Do you smoke(?)". Dr. Rosenblatt's post invokes the ancillary answer that even podiatrists should relate to their patients. The podiatrist should tell patients; "Smoking is bad for your health. You should quit." The "you should quit" order will have a powerful impact, and it is the physician's duty. People do not like the rising costs of healthcare. However, under the ACA, all taxpayers are paying the price for people who smoke. I recall a day in risk management when we were instructed that technically the physician who does not "warn" patients about the health risks of smoking is liable. Yes, years later, the patient can allege that you never told him to quit. As a podiatrist, are you investing in the rising costs?


Steven J. Kaniadakis, DPM, St. Petersburg, FL



From: Stephen Musser, DPM, Jerome E. Reeves, DPM


I agree, Dr. Kass. The practice of medicine/podiatry is very difficult with all the rules and contingencies. I feel these issues will defer qualified/perspective students from persuing a career in medicine. To keep my sanity/spirits up, I remind myself I have a career with a purpose, in good health, a roof over my head, and I've never gone to bed hungry.


Stephen Musser, DPM, Cleveland, OH 


Bravo, Dr. Jeffrey Kass, I understand everything mentioned in your reply article. I am still trying to figure out how Empire Blue Cross/Blue Shield of New York can take from my reimbursement for surgery done in an outpatient hospital setting, a facility fee which has absolutely nothing to do with the surgery I performed. Am I able to pass this expense to the patient? The reduction in my fee is pretty extensive. Any help answering that question would be greatly appreciative.


Jerome E. Reeves, DPM, Hollis, NY



From: David Wolf, DPM


I recommend Active Management. They have proven to be reliable, responsive, and effective in podiatric billing and collecting for our office over the last 10 years. Contact Hoda Heinein.


David Wolf, DPM, Houston, TX



From: Todd Rotwein, DPM


Our profession is graced by the presence of a member who combines the moral fortitude necessary to defend a heritage of people owing people with the insight needed to compare that with the general state of medicine. Thank you, Doctor Dale Feinberg.


Todd Rotwein, DPM, Hempstead, NY



From: Neal Houslanger, DPM 


The best way to answer that is to keep records of where your new patients (the life blood of your practice) are coming from. In our area on Long Island, there seems to be many large Yellow Pages that have sprung up, as well a small local Yellow Book. We have found, as I suspect, most practices are getting more new patients from the Internet. Therefore, whave gradually decreased the size of our ads and listings in all these Yellow Pages and local books. I do get some satisfaction from reducing those costs, as the price has gone up each year. We have instead used our marketing budget to invest more in our Internet presence, including updating our Website, which has proven successful. We have also increased our physician referrals.  


Neal Houslanger, DPM, Patchogue, NY



RE: Repeal of the Flawed SGR

From: Jon Purdy, DPM


All the doctors, associations, and money spent over the past couple of decades haven’t made a dent in this issue. Voters hold the power to change the people who hold the power over them. That is why I have crafted a letter on this topic that is handed out to every one of my Medicare patients. This letter contains the contact information of the legislators in my state.


The result has been very interesting. A number of my patients have the cell phone numbers of those legislators and calls were made. Patients were not only scared that they may not have a doctor to go to if they drop Medicare, they were also incensed that doctors were being hit in the pocketbook.


More of a concern were the number of patients who thought Medicare was a “gift” from the government. When the public doesn’t realize that their life’s income has been stripped from their paycheck for the “promise” of a future healthcare plan, it tells me we’re in trouble.


Jon Purdy, DPM, New Iberia, LA