August 2013

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Favorable Ruling On Podiatric Care For Medi-Cal Beneficiaries

By Brian McCurdy, Senior Editor

The 9th U.S. Circuit Court of Appeals has overturned a California state law that denied Medi-Cal beneficiaries podiatric care at designated rural health clinics and federally-qualified health centers. The California Podiatric Medical Association (CPMA) cautions that the ruling has a limited scope and DPMs are still excluded from standard Medi-Cal fee-for-service.

   Due to this ruling, Lee C. Rogers, DPM, notes that patients in affected rural clinics can now expect to see a specialist for their foot care needs. He explains that Medi-Cal does not exclude foot care but only prohibits foot care from being provided by a podiatrist. Dr. Rogers says the CPMA Board and legal team are still evaluating the impact of the decision.

   As CPMA President Carolyn McAloon, DPM, explains, the court decision is due to the fact that the federal laws mandating rural clinics are distinct from the general Medicaid laws. She notes rural clinic laws specifically incorporate the Medicare definition of “physician” but the definition of physician for general Medicaid coverage does not currently include podiatrists.

   “This decision only affects a minority of California podiatrists,” says Dr. Rogers, the Co-Director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles.

   “The fight continues to ensure that all Californians can see a specialist when they have a foot or ankle problem, some as serious as limb-threatening.”

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   A transmetatarsal amputation provides a contoured, balanced, residual forefoot — without the presence of peak pressure formation — that can routinely fit in a standard shoe with limited need for in-shoe orthosis use, according to study co-author Thomas S. Roukis, DPM, PhD, FACFAS. Furthermore, he says that amputating the toes also removes the digits as a potential source of ulceration, noting this is a common development following an isolated partial first ray amputation.

   “As long as the foot is balanced to resolve any soft tissue ankle equinus or varus/valgus residual forefoot frontal plane deformities, the disadvantages are limited,” says Dr. Roukis of transmetatarsal amputations. “Excellent soft tissue handling, proper contouring of the residual metatarsal parabola and electrocautery of the residual metatarsals will limit wound healing problems, mechanical, pressure-induced wounding and ectopic bone growth respectively.”

   Dr. Roukis, the President-Elect of the American College of Foot and Ankle Surgeons, has not had a patient refuse an initial transmetatarsal, Chopart or Lisfranc amputation instead of a partial first ray amputation. Patients have told him the cost of care is markedly lower following the successful healing of their transmetatarsal amputation in comparison with partial first ray amputation due to fewer office visits, debridements and in-shoe orthosis modifications.

   “Most patients have been through endless rounds of wound care and the ulceration and associated care have disrupted their life to such an extent that they simply desire a foot that they can use again without the development of an ulcer every time they are active,” says Dr. Roukis, who is affiliated with the Department of Orthopedics, Podiatry and Sports Medicine at Gundersen Lutheran Medical Center in La Crosse, Wis.

Study Skeptical Of HBOT For Diabetic Foot Ulcers

By Danielle Chicano, Editorial Associate

A recent study in Diabetes Care concludes that physicians need to reevaluate the usefulness of hyperbaric oxygen therapy (HBOT) in the treatment of diabetic foot ulcers (DFUs).

   The retrospective analysis of data looked at 6,259 patients with diabetes, adequate lower limb arterial perfusion and foot ulcers extending through the dermis. Researchers found that HBOT neither improved the likelihood that a wound might heal nor decreased the likelihood of amputation in patients with DFUs. Researchers also reported that in the propensity score-adjusted models, patients who received HBOT were more likely to undergo amputation and less likely to have healing of their foot wound.

   Caroline Fife, MD, argues against the validity of the findings in this study. She points out that the study did not report the selection criteria for HBOT, making it unclear whether researchers properly analyzed the therapy.

   “The (study’s) retrospective analysis of practice in a single wound care organization does not indicate the effectiveness of HBOT when appropriate clinical practice guidelines are followed,” notes Dr. Fife, who is in private practice in The Woodlands, Texas.

   Although prospective studies have shown that HBOT may increase the likelihood of minor amputations in exchange for decreasing major amputations, Dr. Fife says the Diabetes Care study was unclear about the degree of amputation.

   “The study did not distinguish between minor and major amputations when evaluating outcomes,” notes Dr. Fife, the Chief Medical Officer at Intellicure, Inc.

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