Jan-12

Searching For Solutions To The Ongoing Threat Of Medicare Reimbursement Cuts

By Brian McCurdy, Senior Editor

Although Congress acted last month to prevent a 27 percent reimbursement cut for Medicare, questions remain as to ensuring long-term reimbursement stability for podiatric physicians. The House passed HR 3630, which would increase Medicare physician payments by 1 percent each in 2012 and 2013.

   Anthony Poggio, DPM, cites an inherent problem with the Sustainable Growth Rate (SGR) formula that drives Medicare reimbursements. He feels the formula’s accounting principles do not translate well to the real world.

   “No business entity could sustain at 20 percent-plus cut in reimbursement and expect to survive,” maintains Dr. Poggio, a member of the American College of Podiatric Medical Reviewers.

   As Lee C. Rogers, DPM, notes, the Medicare Payment Advisory Commission (MedPAC) voted in October to repeal the SGR and replace it with a 5.9 percent reimbursement cut for specialists each year for three years. Dr. Rogers says this would be followed by a seven-year freeze on reimbursement for specialists. Accompanying the reimbursement changes for specialists would be a 10-year reimbursement freeze for primary care providers, according to Dr. Rogers.

   “This is not a viable option as many specialists have threatened to leave the program,” says Dr. Rogers, the Co-Director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles. “The option which is most fair — and one I would support — replaces the SGR with a yearly adjustment based on inflation and ensures it is properly funded.”

   If a 27 percent reimbursement cut actually happened, Dr. Poggio says there would have been “a huge exodus of Medicare providers” as well as “tremendous pressure” from senior citizen advocates to prevent the cuts. He suggests correcting or disbanding the SGR formula altogether, and using common sense to address this issue.

   “That requires some political backbone on the part on Congress,” adds Dr. Poggio. “Without some Congressional will to address healthcare as a whole, I think we will continue to kick the can down the road and create temporary fixes every year.”

   However, Dr. Rogers notes that the yearly threat of Medicare reimbursement cuts “actually benefits Congress because it fills campaign coffers with donations from doctors around the country trying to stave off drastic cuts in reimbursement. If there was a permanent solution or if it did not become urgent, the money would not flow as easily to Congress.”

   Dr. Rogers, who is running for Congress in California this year, notes that the physician fee schedule for 2012 includes “drastic reductions” for podiatrists who use skin substitutes in the clinic or operating room. He does not predict any meaningful congressional action on Medicare in the foreseeable future.

   “Partisanship is as high as it has ever been and each side is posturing ahead of a bitter campaign season with congressional approval ratings tied for the lowest in history,” says Dr. Rogers.

Podiatry Today Poll: Most DPMs Use Taping in Practice

By Danielle Chicano

A large majority of podiatrists who responded to a recent Podiatry Today online poll say they use taping as part of their treatment armamentarium (see https://bit.ly/ukxGfY ). Out of 378 respondents, 83 percent (315 people) answered “yes” while the remaining 17 percent (63 people) stated they do not use taping in their practice.

   Among those who responded “yes” is Frank Kase, DPM, a Past President of the California Podiatric Medical Association.

   “Taping ‘properly’ is one of the most valuable tools we as podiatric physicians have in our diagnostic and treatment armamentarium,” explains Dr. Kase. “I find it is a better therapeutic modality and diagnostic predictor of the efficacy of a foot orthotic than is a prefabricated orthotic device.”

   Dr. Kase, the President of Burbank Podiatry Associated Group in Burbank, Calif., says taping is especially effective when clinicians use it in conjunction with nonsteroidal anti-inflammatory drugs (NSAIDs), cortisone injections, shoe modifications and stretching exercises.

   In a recent Podiatry Today DPM Blog, Patrick DeHeer, DPM, addresses the issue of taping in podiatric practice (see https://bit.ly/ooJQ0A ). Similar to Dr. Kase, Dr. DeHeer refers to the benefits of taping in combination with other treatment modalities.

   “I may tape two or three times in conjunction with equinus stretching and anti-inflammatories,” notes Dr. DeHeer, a Fellow of the American College of Foot and Ankle Surgeons. “I use it with orthotics to evaluate how a patient will respond to orthoses and also to see if the orthoses need more correction.”

   “With Blue Cross plans only paying about $6 for this service, it is very difficult to continue (taping),” noted one DPM who commented on Dr. DeHeer’s blog. Christopher Corwin, DPM, says cost does play an important factor in deciding on treatment options for patients but he views taping as more practical than costly in some cases. He explains that under the right conditions, taping may actually be cost effective.

   “The ridiculously low reimbursements for some of these effective treatments may dissuade some from continuing (to use taping) but one needs to look at it from a different perspective,” says Dr. Corwin, an Associate of the American College of Foot and Ankle Surgeons. “If used as a test that is successful, (taping) may persuade that patient who is on the fence about orthotics to decide to get them. So instead of missing out on $6 by not taping, you have just picked up a couple of hundred.”

   Dr. Corwin utilizes some taping in his practice, particularly for the treatment of plantar fasciitis, posterior tibial tendonitis and second metatarsophalangeal joint instability.

   “Sometimes taping can be used as a method of putting a structure to rest, adding a little extra support or as a test for orthotic therapy,” adds Dr. Corwin.

Study Says Topical Agent Could Be Beneficial For Mild DFIs

By Brian McCurdy, Senior Editor

A recent study published in the Journal of the American Podiatric Medical Association concludes that a topical, electrolyzed, superoxidized solution is an effective treatment option for mildly infected diabetic foot ulcers.

   Researchers focused on 67 patients with ulcers. Each patient was in one of three treatment groups: irrigation with Microcyn Rx (Oculus Innovative Sciences) alone; oral levofloxacin (Levaquin, Janssen Pharmaceuticals) plus normal saline wound irrigation; and oral levofloxacin plus Microcyn Rx wound irrigation. Two weeks after the end of treatment, the clinical success rate for patients treated with Microcyn Rx alone was 93.3 percent versus 56.3 percent for patients treated with levofloxacin plus saline, according to the study.

   Since Microcyn is a topical agent, patients can avoid complications like stomach upset and allergic reactions, according to lead study author Adam Landsman, DPM, PhD. He also notes that Microcyn is a targeted treatment and can be effective at killing bacteria that are resistant to levofloxacin. In addition, he notes that Microcyn can have a positive effect when one combines it with advanced biologics.

   “By pre-treating the wound with Microcyn, you help to break up the biofilms that may prevent optimal attachment of biologics like Apligraf, DermaGraft or TheraSkin,” says Dr. Landsman, an Assistant Professor of Surgery at Harvard Medical School.

   Dr. Landsman speculates that Microcyn may also be useful in treating more severe diabetic foot infections if one uses the topical agent with oral or intravenous antibiotics, particularly in patients with suboptimal circulation, which would make systemic delivery to the tissues more difficult. He routinely uses Microcyn as part of his wet-to-dry dressing regimen, along with either an oral or IV antibiotic.