Another consistency-related issue in the scope of practice debate is how practices’ relationships with insurance companies are affected by the lack of uniform scope.
“You could have a medical director from New Jersey sitting with a medical director from the Carolinas,” posits Dr. Ornstein. “The Carolina guy says, ‘We cannot let podiatrists do ankles,’ and that gets the guy from Jersey thinking, ‘Maybe we should not be letting these guys do ankles or pay them to do ankles.’ A more consistent approach to scope of practice will open up more doors versus closing those doors.”
“One of the issues in San Antonio that came up with the legislation was that foot and ankle orthopedists were not on HMOs,” notes Dr. Pollak. “There wasn’t a foot and ankle orthopedist on an HMO in San Antonio. If I had a patient who uses an HMO and had an ankle fracture or an Achilles tendon tear—something that requires surgery—there are no foot and ankle orthopedists who are willing to take on the case. You have orthopedists pretending to take on all the pathology, saying you do not need podiatrists. Yet they will not take HMOs, they will not take Medicaid. There is a need.”
Scope Of Practice: Where Things Stand
Ambiguity and inconsistency seem to reign when it comes to the podiatric scope of practice in different states. This author consults leading DPMs in the legal battles over podiatric scope of practice and whether a uniform national scope of practice can be a viable solution.
You are visiting family in Sumter, S.C., and, as usually happens at such get-togethers, a backyard basketball game breaks out. It is late in the game and your team is down by one. You notice a clear lane to the basket and go in for the layup. Of course, you are not as spry as you once were. By the time you are in the air hurtling toward the basket, that weasel cousin Marty bumps you and sends you sprawling, causing you to land awkwardly on your ankle. The accompanying pain leads you to believe you have broken your ankle. As expected, Marty insists it was a clean block and clearly feels no remorse.
You want to be treated by a podiatrist but this is a problem in South Carolina. While podiatrists can diagnose ankle injuries and disorders, their state law prohibits them from performing ankle surgery.
As you writhe on the backyard court, someone produces a map and the family ponders your fate. You could take the Myrtle Beach Highway to I-95 North and head up to North Carolina where a podiatrist could treat your ankle and its related soft tissue structures. However, podiatrists in this state cannot perform surgical procedures for the ankle unless you are “in a hospital licensed under Article 5 of Chapter 131E of the General Statutes or in a multispecialty ambulatory surgical facility that is not a licensed office setting, and that is licensed under Part D of Article 6 of Chapter 131E of the General Statutes” (according to North Carolina General Statute 90-202.2).
Conversely, you could hop on 521 South and take I-95 down to Georgia, where podiatrists can perform surgery on your ankle provided that general anesthesia (if needed) is “administered under the direction of a duly licensed physician” (according to Georgia state law—Title 43, Chapter 35).
An Example Of Ambiguity: Scope Of Practice In South Carolina
Such border conflicts are made possible by the lack of uniformity in the scope of podiatric practice from state to state. This, in turn, affects any number of issues from the education and training of podiatry residents to insurance regulations and billing once those residents graduate and start practicing. However, the ultimate losers might just be the patients who depend on DPMs for their foot care.
Excessively limiting scope-of-practice laws drive a podiatrist like Michelle Butterworth, DPM, up the proverbial wall. She is the President of the South Carolina Podiatric Medicine Association and a tireless combatant in the scope wars between South Carolina podiatrists and their opponents in orthopedics and other fields.
“South Carolina is one of the most restrictive states in the nation,” she notes from her clinic in Kingstree, S.C. “We cannot perform ankle surgery nor can we perform multiple digital amputations, according to our state law.”
The reasons behind the limited scope simply do not add up to Dr. Butterworth. “An amputation is technically not that difficult to do compared to some of the other reconstructive surgeries we do,” she says. “It is a little frustrating that we cannot do something relatively simple like an amputation but we are able to do a major foot reconstruction. It does not make sense.”
Dr. Butterworth has seen her share of political wrangling in the South Carolina state government over scope of practice, coming tantalizingly close in 2006 to broadening allowable procedures for podiatrists.