August 2013

Study Looks At Impact Of Medicaid Cuts On Podiatry In Arizona

By Brian McCurdy, Senior Editor

Changes in Medicaid reimbursement in Arizona have led to adverse consequences for patients with diabetes, according to an abstract recently presented at the American Diabetes Association annual meeting.

   In 2010, Arizona began cancelling Medicaid reimbursement coverage of podiatry visits to reduce healthcare costs. The abstract authors examined inpatient discharge records from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project from 2006 to 2010, observing 3,845 inpatients with diabetic foot infections (DFIs). After the Medicaid reimbursement change, researchers discovered there were 56.3 percent more hospital admissions, lengths of stay were 42.1 percent longer, state inpatient charges were 52.1 percent higher, and there were 86.1 percent more severe aggregate outcomes.

   The abstract authors concluded that the changes to the Medicaid program spurred a “marked worsening of patient care.” They added that “Restricting access to preventive care among people with diabetes may manifest in serious unintended consequences, particularly among the poor and underserved.”

   Bruce Werber, DPM, notes that the long-term consequences of the change in reimbursement include an increase in emergency room visits, increase in hospitalizations, higher cost of wound care centers and more amputations with all of their associated costs. “The ultimate outcome is increased cost to the system and increased morbidity for the patients,” says Dr. Werber, who is in private practice in Scottsdale, Ariz.

   Dr. Werber supports educating podiatrists in the Medicaid system so they can practice to the full scope of their license and their training. Calling broad cuts to podiatry “a mistake,” he suggests that instead, there could have been cuts in the scope of services such as non-emergent services for patients at minimal risk. He explains this would have cut services for conditions like bunion repair, hammertoe repair, heel pain, chronic nail issues and sports type injuries, but allowed treatment for patients with infections, wounds, fractures, diabetic renal disease or peripheral arterial disease. Dr. Werber says such cuts ultimately would have saved the system money.

   “It is great that the appeals court in California found that Medicaid should include dentistry and podiatry, but ultimately our profession needs to be recognized as physicians and the need for our services is essential to the well being of all Americans,” says Dr. Werber, a Fellow of the American College of Foot and Ankle Surgeons.

For a related story, see “Favorable Ruling ...” at right.

Study Questions Partial First Ray Amputations In Patients With DPN

By Brian McCurdy, Senior Editor

A recent study in the Journal of Foot and Ankle Surgery reveals that nearly half of patients with diabetic peripheral neuropathy who had a partial first ray amputation progressed to a subsequent, more proximal amputation.

   The authors performed an 11-year retrospective review of 59 patients with a mean follow-up of 33.8 months. Despite the fact that all patients experienced initial amputation incision healing, 69 percent subsequently developed a mean of 3.1 foot ulcerations and 25 patients required a more proximal repeat amputation at a mean of 25 months after the initial partial first ray amputation.

   The authors suggest that in this high-risk patient population, an initial proximal level amputation, such as a balanced transmetatarsal amputation, might provide a better functional and reliable residual weightbearing foot than a first ray amputation in this high-risk patient population.

   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.

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