Two Federal Bills Seek To Define Physicians As DPMs Under Medicaid

By Brian McCurdy, Associate Editor

   Since Medicaid does not recognize podiatrists as physicians, beneficiaries of the federal program may not receive podiatric care for their foot and ankle conditions. However, recent bills in the Senate and House aim to define podiatrists as physicians under Medicaid. The bills’ proponents, including the American Podiatric Medical Association (APMA), say the change will enhance preventive patient care and possibly prevent states from making cuts in podiatric services during budget crises.    Foot and ankle care provided by a MD or DO is covered as a “physician service” under Medicaid but similar care provided by a podiatric physician may not be covered.    If podiatrists are not considered physicians under Medicaid, Michael Downey, DPM, believes there may be negative consequences for patients as they would not be able to see podiatrists for foot and ankle emergencies. He says this would be a particular problem in emergency rooms or for diabetic patients, especially in urban areas, where many Medicaid patients who require podiatric services would either be referred to other physicians or not receive care. Podiatrists see many Medicaid patients in hospital ERs when other medical specialists will not, adds Dr. Downey, the Chief of the Division of Podiatric Surgery at the University of Pennsylvania Medical Center-Presbyterian in Philadelphia.    Podiatrists provide the majority of foot care to high-risk Medicaid patients such as diabetics, according to Dr. Downey. If these patients cannot have access to podiatrists, Dr. Downey says this could lead to a rise in amputations and other problems that arise from not receiving proper diabetic foot care. Both he and Ronald Jensen, DPM, believe such a lack of care would actually increase Medicaid costs over time. However, Dr. Jensen, the Chairman of the Legislative Committee of the APMA, points out the cost of including the estimated 15,000 DPMs as physicians under the Medicaid definition would be nominal.

Can Redefinition Under Medicaid Protect DPMs From Budget Cuts?

   Despite the fact that Medicaid does not classify podiatrists as physicians, Dr. Jensen notes 46 states and the District of Columbia do reimburse podiatrists for physicians’ services under Medicaid. However, he expresses concern that during a budget crisis, states may modify or eliminate services provided by podiatrists as these services are considered “optional” by Medicaid. However, Dr. Jensen notes that no such cuts can be made to services provided by “physicians” as defined by Medicaid. Dr. Jensen says defining DPMs as physicians may prevent cutbacks or elimination of podiatric services to Medicaid beneficiaries.    Dr. Jensen’s concern has become a reality. Although most cost reductions have been in fees, prescription benefits and other areas, Dr. Downey notes some states are eliminating podiatry services as part of their budget cuts. He points out that New York and Missouri have recently proposed excluding podiatrists from Medicaid to save money. Dr. Downey believes other states will follow suit to save money unless Medicaid redefines podiatrists as physicians.    Defining podiatrists as physicians also would affect reimbursement as DPMs would continue to see Medicaid patients, according to Dr. Downey. While he notes that Medicaid reimbursement is low compared to that for Medicare or private insurance, Dr. Downey says podiatrists would prefer low reimbursement to no reimbursement and many DPMs wish to serve the Medicaid population. (Medicare does define DPMs as “physicians.”)    Dr. Downey, a Fellow of the American College of Foot and Ankle Surgeons, also foresees a negative impact on residency programs as Medicaid patients comprise the majority of patients with severe deformities, emergency room visits and diabetic foot conditions. If the Medicaid issue is not resolved, Dr. Downey says residency programs will “suffer significantly.”     “It is inconsistent for Medicaid to cover essential foot care services but not allow those services to be provided by highly qualified and specially trained podiatric physicians,” says Dr. Jensen.

FDA Panel Recommendations: Keep COX-2 Inhibitors On The Market

By Brian McCurdy, Associate Editor    While an FDA panel recently recommended keeping the COX-2 inhibitors rofecoxib (Vioxx), celecoxib (Celebrex) and valdecoxib (Bextra) on the market, podiatrists have seen a mixed range of patient experiences with NSAIDs and COX-2 inhibitors.    Emerging studies and controversy surrounding the side effects from COX-2 inhibitors had erupted in recent months, and resulted in Merck voluntarily pulling Vioxx from the market. Although the FDA panel acknowledged that COX-2 inhibitors do pose potential heart problems for some patients, it recently recommended keeping the drugs on the market with a “black box” warning for patients.    Peter Blume, DPM, has experienced problems treating patients with Vioxx in the past. He recalls one patient who had complications with the drug, resulting in acute tubular necrosis and ongoing issues related to drug therapy. The patient requires long-term prednisone therapy for chronic renal issues, says Dr. Blume, an Assistant Clinical Professor of Surgery, Orthopedics and Rehabilitation, and the Director of Limb Preservation at the Yale School of Medicine.    Dr. Blume notes that several of his patients who have taken Celebrex have had type 2 allergic reactions because of the sulfa ring and cross sensitivity, and another patient had significant GI bleed due to long-term use of Celebrex.    That said, how wary should one be in prescribing NSAIDs and COX-2 inhibitors? Dr. Blume believes DPMs may safely use NSAIDs to treat short-term conditions if they ensure appropriate patient selection. To that end, he says these patients should not have a history of GI bleed or significant reflux. He also cautions DPMs to take into account the patient’s age, weight, comorbidities and concomitant drug therapy before prescribing NSAIDs.     “I think NSAIDs, when used appropriately, can be a safe and appropriate therapy for a variety of musculoskeletal conditions,” notes Dr. Blume. “Overutilization of any drug can be detrimental to a patient population who often need certain drug therapies in order to maintain independent and mobile lifestyles.”    NSAIDs have “gotten a bad rap,” according to Richard Braver, DPM, a Fellow of the American College of Foot and Ankle Surgeons. However, despite the FDA panel’s recommendations, Dr. Braver says patients are still skeptical even when he safely prescribes drugs such as Celebrex. He notes his local hospital has taken Celebrex and Bextra off the formulary.

University Of Texas Emphasizes All-Inclusive Approach To Diabetic Foot

By Brian McCurdy, Associate Editor    Treating patients with diabetes and Charcot foot conditions is an important component of podiatric practice. Before entering practice, residents and students at the University of Texas Health Sciences Center in San Antonio (UTHSCSA) receive a comprehensive education in both.    The university’s podiatric program offers a one-week Diabetic Foot Post-Graduate Course (DFPGC) for practicing physicians, nurses and other healthcare professionals. The 60-hour CME course is is offered four times a year under course director Kathleen Satterfield, DPM. The course facilitates a multidisciplinary environment that gives physicians and surgeons an introduction to medical and surgical treatment of the diabetic foot, according to Thomas Zgonis, DPM, Assistant Professor in the Department of Orthopaedics/ Podiatry. He notes that healthcare professionals taking the course not only have an opportunity to interact with the university’s podiatric team but with vascular surgery, orthopedic surgery, internal medicine, radiology, pathology, prosthetics and hyperbaric medicine services as well.     “An all-inclusive course such as the DFPGC serves to increase one’s awareness of the diabetic foot and increase the quality of care provided to patients,” says Dr. Zgonis. “We believe we are helping to train the next generation of academicians as well as a fine group of clinicians and reconstructive surgeons.”    Over the decades, the UTHSCSA podiatry program has achieved a reputation for being on the cutting edge of diabetic care and Dr. Satterfield notes the program is increasing its emphasis on trauma and reconstruction. To that end, the school has recruited new faculty members, Dr. Zgonis and Javier LaFontaine, DPM, leaders in the field of external fixation, according to Dr. Satterfield, Associate Professor in the Department of Orthopaedics/Podiatry. She notes the university’s other departments turn to the Orthopaedics/Podiatry Department for all matters involving the foot.     “Podiatry is recognized as the authority on the foot here,” says Dr. Satterfield. “We receive consultation requests and the respect that goes with that from every department from internal medicine to cardiology and that is due to the hard work of Lawrence Harkless, DPM.”    The program is also becoming a Charcot center for excellence and Dr. Satterfield says the school plans to add reconstructive surgery fellows this year. In addition to instruction in skeletal reconstruction of the Charcot foot, Dr. Zgonis says the school offers extensive training in surgical topics including lower extremity deformity correction, major rearfoot and ankle reconstructive procedures, and advanced plastic surgery techniques.    In addition, the university has 15 residents and a fellow under the guidance of Dr. Harkless, Director of the Podiatric Residency Training Program. Dr. Zgonis notes the program offers core rotations in podiatric medicine and surgery so over 50 students a year have extensive opportunities to teach. He says students, residents and fellows participate in weekly grand rounds, monthly anatomy labs, journal clubs and conferences on subjects that include orthopaedics and vascular surgery.    Dr. Satterfield notes that interns, from their first day of residency, are recruited to lecture at major conferences. Once the students have graduated, Dr. Satterfield notes they have gone on to take positions of leadership at podiatric colleges and other academic programs.     “Graduates from our program now lead foot and ankle services at major hospitals and medical schools across the country,” adds Dr. Zgonis.

Can Toe Pressures Predict Lower Extremity Arterial Disease?

By Brian McCurdy, Associate Editor    To detect lower extremity arterial disease (LEAD) in patients with diabetes, DPMs may use a range of indices as screening tools. However, the authors of a new study say screening patients’ toe blood pressure is an effective method of screening for the disease.    The study, published in Angiology, tracked 134 control patients and 303 patients with diabetes and screened their peripheral circulation, including arm, ankle and toe circulations. Twenty-four percent of patients with type 1 diabetes and 31 percent of those with type 2 diabetes had at least one lower limb with a low toe pressure (TP), ankle pressure (AP), toe/arm index (TI), or ankle/arm index (AI), compared to 6 percent of control subjects, according to the study.    Using ankle blood pressure and indices alone to detect lower extremity arterial disease is less efficient than using toe pressures, say study authors. They believe this is due to medial calcinosis in patients with diabetes.    Two podiatrists feel screening toe pressures is effective in detecting LEAD. Leon Brill, DPM, CWS, says the test is reliable while David G. Armstrong, DPM, MSc, PhD, calls the test “relatively simple and inexpensive.” However, both doctors emphasize the use of multiple screening measures in order to obtain a better diagnostic picture.     “One must not throw out the baby with the diagnostic bathwater. (Toe pressures) should be combined with other studies to give a more clear picture of a patient’s vascular status,” cautions Dr. Armstrong, a Professor of Surgery, Chair of Research and Assistant Dean at the William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine in Chicago.    To that end, when Dr. Armstrong performs a physical exam, he checks for signs of ischemia like non-palpable pulses and atrophied skin and skin structures. Dr. Armstrong, a member of the National Board of Directors of the American Diabetes Association, notes the value of additional tests, which may include segmental Doppler studies (such as those identified in the Angiology study), transcutaneous oxygen tension and angiography.    Dr. Brill, a Fellow of the American College of Foot and Ankle Surgeons, also cautions DPMs to use comprehensive hands-on tests to screen for LEAD. He uses ankle-brachial indices (ABI) and waveforms as screening methods. Due to medial calcinosis, Dr. Brill says the ABI alone is not sufficient to interpret a patient’s LEAD status so one must combine the ABI with waveforms from thigh to toes to obtain a good overall indication of vascular perfusion.    As the study notes, up to 30 percent of diabetic patients with no ischemic symptoms may have signs of impaired arterial circulation. Drs. Armstrong and Brill concur, citing neuropathy as a factor. Dr. Brill comments that up to 40 percent of those with palpable popliteal pulses have clinically significant vascular disease. He says some symptoms of vascular disease, such as claudicating pain, reduction of pulses and changes in hair growth and skin, may mimic the effects of neuropathy.     “Most people with profound vascular disease and diabetes do not have any overt symptoms,” notes Dr. Armstrong. “This is due to the silent nature of the disease and the presence of neuropathy.”


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