Will Medicare Slash Reimbursement In 2006?

By Brian McCurdy, Associate Editor

   Congressional legislation has been able to hold off cuts in Medicare reimbursement for the last several years. However, the relief may have been only temporary. If Congress does not take further action beyond the temporary 2004-05 legislative fix, physicians may see a reduction in Medicare reimbursement in 2006.    Without a legislative remedy, podiatrists will see a 5.2 percent reduction in Medicare payments next year, notes Julie K. Letwat, JD, MPH, the Director of Health Policy and Practice Advocacy for the American College of Foot and Ankle Surgeons (ACFAS). Between 2006 and 2013, Medicare reimbursement rates will be slashed by 31 percent, according to Letwat. She adds that if these cuts are not prevented, Medicare payment rates in 2013 will be less than half of 1991 rates, adjusting for inflation.    Medicare physician payments were cut by 5.4 percent in 2002 using the Sustainable Growth Rate (SGR) formula, according to the American Medical Association (AMA). According to the ACFAS, the SGR system is based on estimates by the Centers for Medicare and Medicaid Services (CMS) for the following four factors: inflation; Medicare fee-for-service enrollment; per capita growth in the Gross Domestic Product as adjusted for inflation; and changes in spending due to law and regulation.    The reimbursement formula also takes into account Relative Value Units (RVUs), three sets of which Medicare assigns to each CPT code, according to the ACFAS. The RVUs quantify the value of the physician work, practice expense and malpractice expense associated with providing that service. The ACFAS says Medicare combines the RVU with adjustments for geographic differences in costs and a conversion factor to formulate a fee schedule.

Is The Medicare Payment System Flawed?

   The ACFAS and the AMA advocate changes to the fee system, pointing to flaws in Medicare’s SGR formula.     “Medicare payments are already lagging behind increases in practice costs,” points out Letwat. “The physician community believes payment updates should be based on increases in practice costs instead of the SGR.”    Anthony Poggio, DPM, echoes that concern. He says there is a significant gap between decreasing reimbursements for services and the increasing salaries, overhead and insurance costs of running a practice. He feels having an outside auditing firm look at the actuarial costs of doctors’ offices would correct the problem.    Dr. Poggio, a consultant for several insurance companies, also describes a “backdoor approach” by Medicare of increasing the conversion factor it uses to help formulate fee schedules, but offsetting that with a decrease in the RVU value of the service. What seems to be an increase actually results in doctors only breaking even or taking a loss, according to Dr. Poggio.     “The best reality check would be to have members of Congress and their staff covered by Medicare insurance and not by other private insurances, which offer generous coverage packages and fairly reasonable physician reimbursement rates,” argues Dr. Poggio. “If congressional members had to hunt to find doctors accepting Medicare covered patients, they may get a sense of what the patients and doctors face daily.”    The AMA notes that only physicians are subject to cuts determined by the SGR formula. Hospitals, Medicare Advantage plans and home health plans will continue to receive reimbursement increases based on medical inflation, according to the AMA. In fact, the AMA notes while reimbursements to physicians would decrease by 31 percent between 2006 and 2013, in-patient hospital payments would rise by 32 percent during the same period. The AMA notes most medical practices are small businesses which cannot “absorb sustained losses or steep payment cuts” that are part of the SGR system and such a situation will affect patients.    Citing physician surveys, the AMA says “these cuts will make it difficult for new Medicare patients to promptly obtain care, cause significant reductions in services for rural areas and prevent investments in new medical equipment and information technology that promise to improve patient care.”

Can MRIs Help Differentiate Between Neuromas And MTPJ Capsulitis?

By Brian McCurdy, Associate Editor    A new study has found magnetic resonance imaging (MRI) to be useful in distinguishing between interdigital neuroma and MTPJ capsulitis. In some cases, researchers found testing changed the diagnosis and prevented unnecessary surgery.    The study, which was presented as a poster recently at the ACFAS Annual Scientific Meeting, tracked 18 feet in 18 patients, all of whom received MRI exams. For 50 percent of the patients, the MRI results ultimately changed the patients’ treatment outcome, according to the study. In addition, the study notes 22 percent of patients in the study avoided surgery because MRI did not confirm the existence of pathology. For 11 percent of patients, the MRI exam did not prevent the need for surgery but did change the location of the incision, according to study investigators.    Alan Catanzariti, DPM, one of the investigators of the study, says he has used MRI in his practice and notes its effectiveness in helping to differentiate between a neuroma and MTPJ capsulitis.     “It’s just difficult to clinically differentiate one from the other,” says Dr. Catanzariti, a Fellow of the American College of Foot and Ankle Surgeons. He notes patients with capsulitis may have complaints similar to the shooting, burning pain experienced by those with neuromas.    If a patient has a history of neuromas, Dr. Catanzariti will treat him or her with orthotics and injections. However, if the patient does not respond to conservative therapy, he will order a MRI. For patients with an initial diagnosis of MTPJ capsulitis, Dr. Catanzariti will use orthotics, digital splints and injections. He also evaluates the web space region to determine if the nerve is inflamed or enlarged.    While the MRI does have the advantage of being noninvasive, there are some drawbacks to the exam, according to Dr. Catanzariti, the Director of Residency Training in the Division of Foot and Ankle Surgery at Western Pennsylvania Hospital in Pittsburgh. While MRI can be a “real tool” in the hands of a good radiologist, Dr. Catanzariti notes the testing is not as reliable if the facility does not have enough experience in reading MRIs.

Dual Degrees On The Schedule At Barry University

By Brian McCurdy, Associate Editor    Earning a DPM degree is a challenge in itself and Barry University offers its students a chance to take on additional challenges to earn degrees in related fields. Barry’s first students with DPM and MBA degrees will graduate this spring.    While studying podiatric medicine, these students took an extra graduate course each semester at Barry’s accredited Andreas School of Business, according to Chet Evans, DPM, MS, Associate Vice President and Dean of Graduate Medical Sciences at Barry University. Dr. Evans says while the majority of other programs require an additional year or two of study to earn a MBA, the Barry graduates earned both degrees in four years.    Next year, Dr. Evans says the university’s first DPM/MPH students will graduate without requiring additional years of education. The school offers an MPH track in health services administration and Dr. Evans emphasizes the importance of earning MBA or MPH degrees.     “With these degrees, they may choose to go into hospital or nursing home administration, corporate medicine or simply be more effective managers in the business of their solo medical or group practice,” says Dr. Evans. “These are options that I had wished I had in podiatric medical school and am pleased to have developed these programs for our students here at Barry.”    The extra tuition for students earning extra degrees is $12,000, which is spread out over four years. Dr. Evans notes Barry University is also exploring a program for earning a DPM/JD degree with the new School of Law.    Barry University is also developing its fifth Barry Foot and Ankle Institute site at North Shore Hospital in North Miami. This clinical site provides additional clincial exposure for students to a severely disadvantaged and underserved heterogenous minority community, according to Dr. Evans. The institute has been in existence since 1985 and has provided $15 million in charitable care to Miami’s poor population, according to Robert McKinlay, MPS, Director of Program Development.     “The establishment of the Barry University Institute of Community Health and Minority Medicine comes at a time when we need to provide more community health services to the underserved,” offers McKinlay. “We want to broaden education to a new generation of podiatric physicians with an emphasis on service to culturally diverse populations and research of the health conditions of the minority population who have previously been overlooked.”

Study Says Emerging ESWT Device Is Effective For Plantar Fasciitis

By Brian McCurdy, Associate Editor    While extracorporeal shockwave therapy (ESWT) has been in the spotlight in recent years as a treatment for plantar fasciitis, only a few devices have been on the market. However, a new study has examined the safety and efficacy of a device that the Food And Drug Administration (FDA) approved on April 1 for sale and use in the United States.    The study, which was presented as a poster at the ACFAS Annual Scientific Meeting and as a lecture at the recent Podiatry Institute Update meeting in Atlanta, examined the safety and efficacy of Orthospec in treating proximal plantar fasciitis in patients who had failed conservative treatment strategies. The primary outcome under investigation was the blinded investigator’s assessment of the participants’ heel pain, using a standardized pressure applicator and a visual analog scale (VAS).    Researchers concluded Orthospec was safe and effective for this condition, noting that 77.3 percent of patients in the Orthospec group had a significantly greater mean reduction in heel pain (via the VAS) than the placebo group. The Orthospec patients also showed significant reductions in the self-assessment of heel pain and the use of analgesic medications for heel pain, according to the study.    The multicenter, randomized study involved 172 patients, who either received a treatment with Orthospec or a placebo. Patients received one 25-minute application of a continuously increasing level of shockwave energy for a total of 3,800 shocks. Investigators followed patients at one, two and three months after treatment to determine efficacy and also reevaluated them at six and 12 months for a safety assessment.    Principal investigator D. Scot Malay, DPM, says Orthospec offers the advantage of having just one treatment session for patients and there is no need for any local anesthetic or sedation. Citing the device’s safety, Dr. Malay says the study noted no serious or lasting adverse events among the participants.    Orthospec, which is manufactured by Medispec, utilizes an electrohydraulic spark gap, which creates shockwaves based on ESWT lithotripsy, according to the study. Dr. Malay says the product’s unique design allows shockwaves to be accurately delivered to the target tissues while remaining well tolerated by the recipient.     “In my own practice, this form of ESWT has replaced surgical interventions when non-surgical methods have failed to satisfactorily alleviate the patient’s symptoms,” says Dr. Malay, the Director of Podiatric Research at the University of Pennsylvania Medical Center-Presbyterian in Philadelphia.

In Brief

   Apex Foot Health Industries is rebranding its company name as Aetrex Worldwide, Inc., effective May 1. Aetrex will also offer Apex Healthcare Products and Aetrex Technology & Education. All Apex products, including Ambulators, Ariyas, Lyncos and Anti-Shox, will remain in the company line.    The FDA has given permission to Ortec International, Inc. to begin a trial to evaluate OrCel® to treat diabetic foot ulcers. The trial is expected to be conducted at up to 25 clinical centers and involve about 200 patients, according to the company.

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