Will Tough Fiscal Choices In Arizona Hamper Patient Access To Podiatric Care?

David G. Armstrong DPM MD PhD

I was asked by the editorial staff of Podiatry Today to summarize our thoughts regarding recent fiscal rulings to reduce the weight of the Arizona Health Care Cost Containment System (AHCCCS) on the state of Arizona’s budget. One of those rulings eliminated all state Medicaid coverage of foot care provided by podiatrists.

This figure, which amounts to approximately one million dollars (out of the several billion dollar AHCCCS budget), makes sense philosophically. It is a line item on a budget and it is a conceptually superfluous item. After all, people do not die from hammertoes, bunions, ingrown nails or heel pain. However, what gets missed in this discussion is that many of these patients — a disproportionate amount — are at high risk for severe complications of diabetes, including ulceration and amputation. Now that bunion or hammertoe — or tight fitting shoe — becomes something slightly less superfluous. About half of people with diabetes at any given time may have reductions in sensation that put them at risk for skin ulcers, infections and amputations.

This current discussion seems remarkably prescient. Two robust, large-scale nationwide studies (see http://www.ncbi.nlm.nih.gov/pubmed and http://tinyurl.com/2u2td3n ) have just been published and they describe the very convincing role of podiatric foot care in preventing amputations.1,2 These studies have confirmed many other regional and local studies reporting the same trend toward prevention.

This preventative effect is particularly potent when podiatrists team up with other generalists and specialists. This team approach, which we have coined the “toe and flow,” is featured in a historic and first of its kind dual issue of the Journal of Vascular Surgery (JVS) and Journal of the American Podiatric Medical Association (JAPMA), which will debut next month.

Judging by the amount of mail that we receive and that has been posted to stories on the issue, we know that many patients and clinicians are angry about this budgetary deletion. I would urge people to consider tempering this approach. I am convinced that this cut is not any sort of nefarious scheme to limit access. This is something done by well-intentioned folks who want to make sure that a state-funded agency remains fiscally viable. That being said, this is a real opportunity not to scream and yell, but to educate. This is one of those few areas encountered where all data point in one direction, namely that podiatric care helps people with diabetes.

In the state of Arizona, for instance, the aforementioned one million dollars that can be saved by simply deleting podiatric care in AHCCCS may seem like a real and immediate savings, and it is. However, if preventative podiatric care prevents just 10 or 20 people from undergoing amputation over the course of the year for the entire state (not to mention the loss of productivity, additional emergency department visits, re-admission to hospital or any other softer figures), then that million dollars vanishes fairly quickly.

I think it can be safely and very conservatively estimated that most podiatrists have easily that many high-risk patients showing up in their clinic next week and just as many with open wounds teetering on the brink of limb loss.

This is the beginning of a logical discussion that can be had not only up and down the state, but around the country or worldwide. This is especially true since, in the time it takes you to read this brief missive (even if you are a speed reader), six or eight people will have lost their legs due to diabetes around the world.

Let us make a difference but let us do it together as patients, as doctors, and as federal healthcare agencies.

References

1. Sloan FA, Feinglos MN, Grossman DS. Receipt of care and reduction of lower extremity amputations in a nationally representative sample of U.S. elderly. Health Serv Res. 2010 Aug 16 (Epub ahead of print).

2. Gibson T, Bagalman E, Wang S, Christina J, Driver D, Garoufalis M, Defrancis W, Wrobel JS. Podiatrist care and likelihood of amputation or hospitalization for patients with diabetes and foot ulcer. Late breaking abstract poster presentation, American Diabetes Association’s Scientific Sessions, June 2010, Orlando, FL. Diabetes 2010; 59(suppl1).

This blog has been adapted with permission. It originally appeared at www.diabeticfootonline.blogspot.com

Comments

David: I agree in principle with your editorial. AHCCCS cut our services at the direction of the legislators. It was my understanding that all Democrats voted to keep our profession included. It was the Republicans who controlled our destiny with only one voting to maintain our services.

The public hearings were not well attended and therefore, the education of our services was not adequately represented. The reasons we were cut are obvious: budget and lack of education, which has always been an issue within our profession.

Now to find out that AHCCCS will accept treatment of podiatric problems rendered by PAs and NPs is an insult. AHCCCS is also well aware that many wound clinics and hospitals may try to employ DPMs, which could result in denial of claims and fines.

AJT

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