News and Trends

CMS To Begin Competitive Bidding Process For DME

   Changes are underway at the federal level to the durable medical equipment (DME) system for Medicare patients and may have an effect on podiatry practices and patient care. The Center for Medicare and Medicaid Services (CMS) proposes a system that will open up the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) system to competitive bidding. As part of the plan, only those suppliers chosen through the bidding will be permitted to supply items to Medicare beneficiaries in product areas covered by competitive bidding.    The rule applies to physicians as well as larger DME suppliers, according to an American Podiatric Medical Association (APMA) e-news update. The CMS will designate certain product categories for bidding, such as high-volume products and those that have the highest potential cost savings for Medicare, according to the APMA. The CMS will then choose winning bids for each category in certain metropolitan areas and set a single price for each product in the category.    The CMS will begin phasing in the plan next year, starting with the 10 largest metropolitan areas, continuing in 2009 with the next 80 biggest areas and concluding after 2009 with the remaining areas, according to the Federal Register. It notes the CMS will initially exclude the New York City, Los Angeles and Chicago areas from the program until it has more experience with implementing competitive bids. The Register also anticipates that DME bids will start this year and prices will take effect in October 2007.    The CMS lists the top 20 eligible DME policy groups and among those are diabetic supplies and equipment, orthotics (excluding custom orthotics), walkers and negative pressure wound therapy. Although the CMS notes it has not yet chosen the products affected by competitive bidding, it notes that the products will probably be chosen from the top 20 DME groups, according to the Federal Register. The CMS foresees the DMEPOS suppliers to be “significantly affected” by the policy but notes that only companies that supply products in at least one category selected for competitive bidding will be affected.

How Will Competitive Bids Affect Patients And DPMs?

   When it comes to patient care, the CMS predicts that although the number of DME suppliers will decrease, there will be a sufficient number of suppliers to ensure access for patients. As the Register notes, CMS expects an improvement in quality because it will more closely scrutinize the suppliers throughout the program. The government’s analysis of the program showed “minimal adverse results” on patient access to care and quality, notes the Register.    In contrast, William McCann, DPM, feels competitive bidding will negatively affect patient care, particularly if physician practices are included in the process. As he notes, about 3 percent of physicians participate in the DMERC program, which he says demonstrates the small number of healthcare providers who require durable medical equipment. Furthermore, Dr. McCann feels that physicians can now carry a small selection of high-quality DME in the office for patients with a wide range of conditions.     “This is critical in practices such as podiatry and orthopedics. Removing our ability to have durable goods available for patients when medically necessary can seriously jeopardize a desired outcome,” says Dr. McCann, the President of the American Academy of Podiatric Practice Management.    While Bret Ribotsky, DPM, says patients will still be able to receive durable medical equipment, he suggests that some patients may ask why they should turn to podiatrists since they will be able to get the equipment from doctors in other disciplines. He believes the competitive bidding program will set up a potential situation in which DPMs are not perceived as being at the level of other doctors. “We have made an extra burdensome step for patients to go to podiatrists,” asserts Dr. Ribotsky, a Fellow of the American College of Foot and Ankle Surgeons. “We are kind of in a situation that it is not very effective for us to survive in.”    With competitive bidding, DPMs will find it difficult to treat patients properly if they need durable medical equipment, opines Dr. McCann. Podiatrists will need more time to ensure patients get the suitable DME and he also notes a loss of autonomy regarding selecting an appropriate device. Dr. McCann says the same factors that affect private practice will affect the profession in general. Durable medical equipment is a standard inclusion for immobilization/splintage in many treatment protocols and clinical pathways, notes Dr. McCann.     “Placing this into the hands of a third party puts physicians at risk from a medical/legal perspective and crosses the line of any quality care initiative,” says Dr. McCann. “In our practice, placing durable medical equipment in a competitive bidding process would be no different than removing stethoscopes from internal medicine practices.”    Dr. Ribotsky notes the program will change the cash flow in his practice and possibly affect employee and staff bonuses. He says if MDs are exempt from competitive bidding, he would bring an MD into his practice to remain competitive.

An ‘Alarming Indifference’

   Dr. McCann says feedback from fellow DPMs on this development has been “alarmingly indifferent,” noting he has spoken at several conferences since the government announced the competitive bidding plan. He speculates that some podiatrists do not understand the ramifications of the plan for their practices and their patients. Dr. McCann notes that education programs are occurring and podiatrists can alter the initiative by corresponding with the CMS. Dr. Ribotsky concurs, noting an attitude of passivity among podiatrists regarding the bidding rule.     “The proposed rule is of significant concern to podiatric physicians and, as written, APMA believes it would compromise members’ ability to treat Medicare beneficiaries. APMA recognizes the rule’s potential harm to members and their patients, and the Association is actively and aggressively addressing this issue,” notes the association’s e-news.

Study Reveals Benefits Of 5-FU For Plantar Warts

By Brian McCurdy, Senior Editor    There is no shortage of treatment options when a patient presents with plantar warts. Possible modalities range from cryotherapy to tape occlusion. Patients may try several types of treatments without success. However, a recent study has given high marks to using the topical 5-fluorouracil (5-FU) to treat warts in patients who had already tried other options.    The randomized study, recently published in the Journal of Drugs and Dermatology, examined 40 patients who received either a combination tape occlusion and 5% 5-FU cream (Efudex, Valeant Pharmaceuticals) or tape occlusion alone. Nineteen of 20 patients who received 5-FU and tape occlusion had complete plantar wart eradication in 12 weeks with the average time to cure at nine weeks, according to the study. Additionally, the study notes that three of 20 patients had a recurrence six months after the end of treatment, making the sustained cure rate 85 percent.    The study notes that patients in both study groups had various treatments for warts, including salicylic acid, cryotherapy, surgical intervention, duct tape, imiquimod cream, oral cimetidine, canthardin and intradermal bleomycin. According to the study, 60 percent of patients had attempted two or more previous treatments without success. Study co-author Thomas J. Chang, DPM, notes other treatment options “may be painful and not as successful.”    The study notes Dr. Chang and co-authors Robert Salk, DPM, Kirk Grogan, DPM, and Walter D’Costa, DPM, have treated over 300 patients with the 5-FU cream. Dr. Chang says his patients have tolerated the medication and it is a safe treatment option. However, one should still consider combination therapy in most patients, such as debridement, tape occlusion, topical medicines, and even some oral options, according to Dr. Chang, a Clinical Professor and Past Chairman of the Department of Podiatric Surgery at the California School of Podiatric Medicine at Samuel Merritt College.

How Effective Is Hyaluronic Acid In Treating Osteoarthritis?

By Brian McCurdy    Can podiatrists find success with using hyaluronic acid to treat ankle osteoarthritis? A recent study in Osteoarthritis and Cartilage suggests patients may find relief from pain and improvement in ankle function.    The prospective clinical trial looked at 75 patients who had unilateral ankle pain for at least six months and had osteoarthritis ranked at grade I or II on the Kellgren-Lawrence scale. Patients received five weekly intraarticular injections of hyaluronic acid (Artz®, Seikagaku, Japan). Researchers detected significant improvement in patients’ ankle/hindfoot scores as measured by the Ankle Osteoarthritis Scale and American Orthopaedic Foot and Ankle Society at one week, one month, three months and six months after the last injection, according to the study. Researchers noted that the patients’ ankle sagittal range of motion did not improve significantly.    Furthermore, every patient related satisfaction at one week and one month, and local adverse events were present in 6.7 percent of patients, according to the study. The study also says after treatment, patients’ acetaminophen consumption was significantly lower.    One DPM has found success in using hyaluronic acid for patients with osteoarthritis. George Vito, DPM, cites an “excellent” experience with using hyaluronic acid, saying he has seen substantial improvement with the regeneration of the articulating surface. “There is a significant improvement in function and a decreased amount of pain,” says Dr. Vito, the Director of the Atlanta Leg Deformity Correction Center in Macon, Ga. While Dr. Vito praises the therapeutic benefit of hyaluronic acid in patients with lower extremity osteoarthritis, he notes that cost can be an issue. In the United States, Smith and Nephew markets the hyaluronic acid Supartz®.

In Brief

   OsteoMed recently launched the Hemi Great Toe Implant as the latest addition to the company’s family of foot and ankle products. The implant is intended for use on the phalangeal base of the first metatarsophalangeal (MPJ) joint. The company says it is ideal for eliminating bone-to-bone contact and alleviating pain associated with inflammatory arthritis, hallux valgus, hallux rigidus and an unstable or painful metatarsophalangeal joint.    PRESENT e-Learning Systems (formerly PRESENT Courseware) debuted its new division, PRESENT Diabetes, at the recent annual American Diabetes Association meeting. PRESENT says the new division will serve the educational needs of the multi-disciplinary diabetes care team, including podiatrists, endocrinologists, internists, nurses, ophthalmologists, vascular surgeons, physicians assistants and pharmacists. For more information, see www.presentdiabetes.com. PRESENT says John Steinberg, DPM, will lead the diabetic foot section.