Rationale for the Preservation of Podiatric Medical Services in Medi-Cal Programs

We dont cover $150 visits to a podiatrist but well cover a $30,000 foot amputation. I mean, there are so many things in our system that have to be rerouted, because right now we spend just over 75 percent of all our health care dollars on chronic diseases. Governor Mike Huckabee

Why do insurance companies pay for an expensive operation to amputate the foot of a diabetic, but wont pay for cheaper preventative visits to a podiatrist that could make surgery unnecessary? Senator Hillary Clinton

Foot disease is the most common complication of diabetes leading to hospitalization, which accounts for up to 20% of admissions. Despite the problems associated with the diabetic foot, it is frequently the most neglected part of a clinic visit or examination, with only 12% to 19% of patients who enter the examining room having their feet inspected.

Diabetic Foot Management; American Association of Clinical Endocrinologists. The total annual cost associated with diabetes foot disease is estimated to be more than $1 billion. This cost does not include surgeons' fees, rehabilitation costs, prostheses, time lost from work, and disability payments. In The Diabetic Foot (5th ed.). Levin ME, O'Neal, Bowker JH, Eds. St. Louis, Mosby-Year Book, 1993

Between 1990 and 1998 the prevalence of diabetes in Californians increased by 67 per cent.

Diabetes trends in the US 1990-1998 - Diabetes Care, September 2000 Patients with advanced diabetes, denied access to podiatry, might more often require foot amputations.

Angela Gillard, Western Center on Law and Poverty. Medi-Cal is an essential source of health care insurance for millions of low-income, elderly, and disabled Californians. Every aspect of this vital program's design and delivery affects many people's health and well-being.

Medi-Cal Policy Institute, California Health Care Foundation Podiatry Services are Critical to Overall Health and, if Untreated, Cause other Heath Problems

A Medi-Cal recipient cannot currently even seek podiatry services for pain unless a physician finds the pain severe enough to warrant a referral. Once a referral is made, recipients of podiatry services are still subject to approval by the state using medical necessity criteria. Therefore, any mistaken assumption that podiatry services are not absolutely essential to those who need them must be dispelled. Many recipients who receive podiatry services are suffering from disabling pain that makes it difficult for them to simply function or to be ambulatory. Elimination of those services would result in those same individuals either seeking more expensive care as their foot problems become worse or going without treatment and thus losing their ability to walk, or function independently without such proper foot care. Some individuals would lose their ability to work and be self-supporting.

Western Center on Law and Poverty

Rationale for the Preservation of Podiatric Medical Services in the Medi-Cal Program 2009-2010 Fiscal Budget Year

1 EXECUTIVE SUMMARY The 2009-2010 California State Budget calls for the elimination of the all Medi-Cal optional healthcare benefits. The California Podiatric Medical Association urges the legislature to retain podiatric services in the benefit structure provided for the Medi-Cal recipients for both the health and welfare of the people and economy of the Golden State. Any cuts to Medi-Cal will have profound negative effects on the lives of patients and on Californias economy. The stated objective of the Medi-Cal program is to provide essential medical care and services to preserve health, alleviate sickness, and mitigate handicapping conditions for individuals or families on public assistance, or whose income is not sufficient to meet their individual needs. The covered services are generally recognized as standard medical services required in the treatment or prevention of diseases, disability, infirmity or impair-ment. (Annual Statistical Report, Medi-Cal Care Statistics Section, Department of Health Services, State of California, Calendar Year 1992.) Based on Title 22, Section 51303 (a), medically necessary health care services are those health care services, which are reasonable and necessary to protect life, to prevent signifi-cant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury. Decisions on medical necessity are based on records and evidence that services requested are consistent with established medical practice meeting the aforementioned definition. A literal interpretation of this definition would include podiatric medical services. Podiatric medical services are medically necessary health care services to the population that Medi-Cal is specifically designed to protect: individuals whose income is not sufficient to meet their individual needs, and who, as a result of their socio-economic status, require stringent efforts to preserve their health, prevent and alleviate sickness, and lessen acute and chronic handicapping conditions. Data in the literature reveals the high toll that being poor can have on health in general and foot health specifically. People with poverty level income are far more likely to have foot problems, particularly those who, when left un-treated, can result in significant acute episodes and, equally as likely, chronic conditions. The California Podiatric Medical Association maintains that the retention of podiatric medical services would yield savings to the state in the provision of cost-effective, clinically appropriate services to the Medi-Cal population, as well as improving the health of those individuals who the Medi-Cal program is specifically designed to protect.

The cost for preventative services is approximately $288 per patient per year, as compared with one incidence of hospitalization for a diabetic or other circulatory-related disorder patient, which averages $30,000 per episode of care.

2 PODIATRIC MEDICINE AND PREVENTIVE CARE Administration of the states Medi-Cal program is a dynamic and evolutionary process; most significant was the State efforts towards shifting Medi-Cal enrollees into a managed care delivery. In August of 2001 more than half (2.9 million of 5.6 million Medi-Cal eligibles) were enrolled in managed care organizations (source: Legislative Analysts office: Analysis of the 2002-2003 Budget Bill). Studies show that primary care physicians infrequently perform foot examination in diabetic patients during routine office visits.1, 2 And, the feet of hospitalized diabetics may also be inadequately evaluated when there are no podiatrists on staff.3 Over a decade ago Department of Health Services Managed Care Work Group transmittal included podiatry as part of the recommended managed care provider network. The framework for Medi-Cal managed care is clear, and inclusion of podiatry as part of the building blocks with which to construct this structural change is imperative. Case management is perhaps the most significant aspect of Medi-Cal managed care. The Department of Health Services has adopted the following definition of case management:

Case management means coordination of medically necessary health care services, assuring the provision of preventive services in accordance with established standards and periodicity schedules and ensuring continuity of care for Medi-Cal enrollees. It includes health risk assessment, treatment planning, coordination, referral, follow-up, and monitoring of appropriate services and resources required to meet an individuals health care needs for the attainment of quality and cost-effective care.

Perhaps the most persuasive example of the podiatric physician as case manager is exemplified by the clinical pathway of a patient with diabetes. There are more than one-quarter million diabetes-related hospitalizations in California every year. Twenty per cent of those admissions are for foot problems and related compli-cations. Timely clinical intervention by a podiatric physician could effectively decrease this per-centage. 1 Assessment of documented foot examinations for patients with diabetes in inner-city clinics 199.; 2 Patterns of foot examination in a diabetes clini. 3 The Acutely infected diabetic foot is not adequately evaluated in an inpatient setting 1993.

Medi-Cal patients often utilize the emergency room as an inappropriate, and costly, source of primary care for foot ulceration. Data has shown that a sequence of visits to the emergency room for this type of intervention will be thousands of dollars more than if provided by a doctor of podiatric medicine (DPM).

3 Preventive care for diabetics consists of examination, treatment of lesions that might produce ulceration (corns, calluses, ingrown toenails, bunions and other foot deformities), accommodative devices to reduce abnormal weight-bearing pressures that might cause ulcerations, and patient education and information as to how to prevent ulcerations and other problems.

Medi-Cal currently pays about $24 for a typical office visit, the 42nd lowest Medicaid reimbursement rate in the county. Preventive visits for patients at risk are at six-week intervals. The cost for preventive services is $288 per patient per year, as compared with one incidence of hospitalization for a diabetic or other circulatory-related disorder, which averages $30,000 per episode of care. When ulcerations of the foot occur, podiatric physicians treat them on an out-patient basis, and routinely are successful in healing a high percentage of these lesions and preventing them from leading to osteomyelitis, a serious and debilitating infection of bone marrow and/or bone structures. Although this condition may be treated by other medical practitioners, podiatric physicians are the only providers of care who employ a treatment plan that includes preventive care. Medi-Cal patients often utilize the emergency room as an inappropriate, and costly, source of primary care for this condition. The average cost of treatment in the emergency setting is over $800 per episode of care, as compared with a professional charge of $65 for a partial debridement in a podiatrists office, or $85 for a full debridement. If X-ray films are needed, they are taken at the podiatrists office at a lower cost ($85 for a complete view of the foot) as compared with the cost of a film in the E.R. by a radiologist. Data has shown that a sequence of visits to the emergency room for this type of intervention will be at least $1,500 more than if provided by a podiatric physician. In addition, an E.R. is not capable of prescribing and fabricating an accommodative biomechanical device that can prevent future recurrences of the ulceration. In addition to preventive foot care, podiatric physicians play a significant role in the early detection and diagnosis of diabetes because the early symptoms often appear first in the feet. The podiatric physician can also diagnose early circulatory problems that are likely to lead to an increase in the risk of amputation (even in non-diabetics) that might result from trivial foot trauma rather than abnormal weight bearing pressures.

The Federal Centers for Disease Control (CDC) estimates that up to 85% of diabetic foot and leg amputations can be prevented with proper foot care.

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Californias Medi-Cal population encompasses a high percentage of diabetics because the cost of treating the disease is one reason these individuals must apply for state-assisted medical aid. PODIATRIC MEDICINE AND CLINICAL INTERVENTION IN DIABETES AND DIABETES-RELATED AMPUTATIONS The Federal Center for Disease Control estimates that up to 85% of diabetic foot and leg amputations can be prevented with proper foot care. Diabetes causes disabling complications, among them diabetic neuropathy, a vascular disease, which, if not properly treated, can lead to foot disorders and amputations. For persons with diabetes, ordinary foot problems, such as ingrown toenails and calluses, can quickly escalate into serious and painful complications. Without the availability of podiatric services, many of these patients will require hospitalization, and extensive surgical intervention. The treatment protocols utilized by podiatric physicians tend to be limb preservation and generally conservative with regard to costly surgical intervention, as compared to the approach of most orthopedic surgeons. Research facts and data highlight the severity of this problem: The total annual cost associated with diabetes foot disease is estimated to be more

than $1 billion. This figure excludes surgeons fee, rehabilitation cost, prostheses, loss of future earning power, disability payments, and increased reliance on social programs.

2.8 million Californians are estimated to have diabetes, only 50% of which are diagnosed.

Twenty percent of all diabetic hospital admissions are for foot problems and related complications.

Fifty-five percent of all lower extremity amputations (LEAs) are performed on people with diabetes.

Cost of care estimates for lower limb amputations in 1992 range from $24,000 to $27,000 and from $14,500 to $21,500 for rehabilitation. This figure excludes loss of future earning power, and increased reliance on social programs

After an amputation, the chance of another amputation on the same extremity or of the opposite extremity within 6 years is as high as 50%. The 5-year mortality rate after lower extremity amputation ranges from 39% to 68%.

The amputation incidence in California is highest among African Americans with

diabetes; this patient population also has a morality rate of 56.7% per 1,000 amputees.

If podiatric services become unavailable to Medi-Cal Program beneficiaries, the rate of amputations for those beneficiaries with diabetes will increase dramatically.

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If podiatric services become unavailable to Medi-Cal program beneficiaries, the rate of amputations for those beneficiaries with diabetes

will increase dramatically.

Analysis of a statewide California hospital discharge database indicated that in 1991, the age-adjusted incidence of diabetes-related lower extremity amputations per 10,000 people with diabetes was 95.3 in African Americans, 56.0 in non-Hispanic whites, and 44.4 in Hispanics. Amputations were 1.72 and 2.17 times more likely in African Americans compared with non-Hispanic whites and Hispanics, respectively. Hispanics had a higher proportion of amputations (82.7 percent) associated with diabetes as opposed to other causes of amputation, than did African Americans (61.6 percent) or non-Hispanic whites (56.8 percent)1.

Another study showed Texas (which has a population makeup similar to that of California) amputation rates to be 66.5 per 10,000 for whites, 120.1 per 10,000 for Mexican Americans, and 181.2 per 10,000 for African Americans. The incidence of amputations for Native Americans living on the Gila River Indian Reservation was 24.1 per 1,000 person-years compared to 6.5 per 1,000 person-years for the overall U.S. population with diabetes.2

Foot and lower leg amputation is not an inevitable consequence of diabetic foot problems. In most cases, the patient and the podiatrist can influence the course of this malady and help prevent its occurrence. In many cases, an amputation for a patient with diabetes can be viewed as a failure of the health system to provide appropriate services. Efforts should be directed as much toward prevention as toward treatment. The American Diabetes Association recommends that persons with diabetes have a foot care specialist (podiatrist) available to assist them when medically indicated. Elimination of podiatry services for persons on Medi-Cal will have devastating consequences for those suffering from diabetes or other disabling conditions. The cost of caring for person with complications from diabetes, such as the performance of life-threatening amputations, would clearly be much greater than the cost of podiatric services utilized by those same individuals in order to avoid such devastating health consequences. 1. Lavery LA, Ashry HR, van Houtun W, Pugh JA, Harkless LB, Basu S: Variation in the incidence and proportion of diabetes-related amputations in minorities. Diabetes Care 1996. 2. Lavery L, et al: Lower extremity amputations in San Antonio, Texas. Abstract, 2nd International Foot Conference, Netherlands, 1995.

DPMs are less likely to use costly inpatient facilities than other physicians.

6 Podiatric intervention in the Medi-Cal population at risk for amputation could yield a significantly different clinical outcome for the patient no amputation and also yield immediate cost savings to the states general fund budget. Podiatric intervention could reduce the cost of amputations in the state by at least 50% translating into an immediate cost savings of millions of dollars.

DPMS DELIVER EFFECTIVE CARE AT LOWER COST Podiatric Physicians traditionally have provided comprehensive care for their patients at less cost than the same service provided by a primary care of osteopathic physician. Medical studies confirm that skilled medical care by doctors of podiatric medicine costs less. One study published in The American Journal of Public Health concluded:

Doctors of podiatric medicine (DPMs) and orthopedic surgeons provide surgical care of the foot, in both inpatient and ambulatory care settingsThe average per procedure charge by an orthopedist was 17% higher than that of a DPM1

Compared with podiatrists, orthopedists were five times as likely to perform a procedure on an inpatient basis, and admitted patients to a hospital had longer stays

DPMs perform a greater number of procedures per episode, but their overall charges during the average foot surgery episode were 30% lower, primarily because of their lower hospitalization rates

each surgical episode treated by a DPM cost approximately two-thirds as much as when provided by an orthopedist

Another study on the economics of foot care verified the cost-effectiveness of doctors of podiatric medicine.2

Approximately one out of every five surgical procedures performed by podiatric physicians [is] handled on an inpatient basis. This is a much lower percentage than for other practitioner[This] makes them extremely cost competitive in comparison with other physicians

Podiatric intervention could reduce the cost

1. American Journal of Public Health, August 1987; Jonathon P. Weiner, Dr.PH, Health Services Research and Development Center. Department of Health Policy and Management, School of Hygiene and Public Health, John Hopkins University; et al

2. The Economics of Foot Care. A Summary of Comparative Research Studies and Analyses fromJohn Hopkins Health Services Research and Development Center, Virginia Polytechnic and State University, ELM Services, Inc.; Lee E Mortenson, MS, and Herbert M. Baum, PhD

Podiatric intervention could reduce amputations and the associated Podiatric intervention could reduce amputations and the associated costs at least 50 per cent translating into immediate cost savings in the millions of dollars.

7 Overall, podiatric physicians were able to perform better than other providers with

respect to cost. The charges for podiatrists were $600+ less than for other providers.

Overall, inclusion of podiatric services in the Medi-Cal program has not promulgated a significant cost increase by the program for the inclusion of the specialty. The scope of practice of a podiatric physician is clearly limited to the conditions and diseases of the foot. Treatment plans prescribed by podiatric physicians are therefore designed to treat the immediate problem and prevent the recurrence of such condition, as well as the occurrence of any co-morbid condition or disease. Continuation of podiatric services as a Medi-Cal program benefit should be based on the efficacy of specific procedures not the category of specialist, as the Medi-Cal budget restrictions propose. The absence of podiatric medicine would leave a substantial gap in the spectrum of outpatient services. PODIATRIC SCOPE OF PRACTICE Podiatric Medicine is that profession of the health sciences which deals with the examination, diagnosis, treatment and prevention of diseases, conditions and malfunctions affecting the human foot and its related or governing structures, by employment of medical, surgical, or other means. The Business and Professions Code of the Medical Practice Act of California further defines podiatric medicine as the diagnosis, medical, surgical, mechanical, manipulative, and electrical treatment of the human foot, including the ankle and tendons that insert into the foot and the nonsurgical treatment of the muscles and tendons of the leg governing the functions of the foot (Article 22, Section 2472).

DPM, MD, DO, and DDS are the only degrees that qualify a person to diagnose, administer medical treatment and prescribe medications for human ailments. Doctors of podiatric medicine may specialize in sports medicine, podiatric orthopedics, biomechanics, podopediatrics or podogeriatrics. Doctors of Podiatric Medicine are the only health professionals who share with Doctors of Medicine, Osteopathy, and Dentistry the legal authority to administer treatment by medical and surgical means including the prescribing of drugs.

The Doctor of Podiatric Medicine is the only medical specialist educated, trained, licensed and certified for exclusive treatment of the foot and ankle.

8 Doctors of Podiatric Medicine are the major providers of foot care in the United States. Podiatrists are less likely to use costly inpatient facilities than other physicians and are the provider of choice and, thus, the acknowledged experts for the following procedures (source: Federal Government 1987 Part B Medicare Annual Data): 82% of all hammer- toe surgery; 71% of all metatarsal surgery; 68% of all bunionectomy surgery; 56% of all rearfoot surgery; and 77% of all foot care. Podiatric physicians contribute to the well-being of patients in the role as primary care provider. By virtue of his or her podiatric medical training, a podiatrist is skilled in the primary diagnosis of systemic diseases that often are indicated symptomatically in the feet and legs; afflictions such as arthritis, diabetes, kidney disorders, circulatory disorders, and bone conditions such as osteoporosis. CONCLUSION The following argument has been presented to the legislature in previous years; however, its content remains significant: The elimination of podiatric services as a Medi-Cal program benefit will not result in monetary savings. For every dollar cut from the General Fund related to Medi-Cal, California will lose $1 federal matching dollar. The State will not only lose on matching dollars, but business activity as well.

In federal fiscal year 2001, California investment in Medi-Cal generated more than a two and a half-fold (255%) return in state economic benefit an increase in business activity of $31.5 billon from a state investment of $12.4 billion. The value of increased business activity from Californias Medi-Cal program spending was the second largest in the county, surpassed only by that of New York. Families USA January 2003 report Medicaid: Good Medicine for Californias Economy. The report also found that Medi-Cal generated at least 291,000 jobs and $11.4 billion in increased wages. Additional findings by Families USA show that the proposed cuts to Medi-Cal will cause an economic loss of $3.2 billion, a loss of approximately 28,000 jobs ($1.2 billion in lost wages.) Furthermore, cuts will promulgate the following resource-intensive and costly actions:

a) Shift patients into emergency rooms which cost at least twice the cost of an office visit to a podiatrist;

b) Shift patients to orthopedic surgeons who charge an average of 15% - 20% more than podiatrists and may be more likely to do surgery; and

c) Encourage patients to neglect chronic and persistent medical conditions.

Doctors of Podiatric Medicine keep Californians on their feet Healthy, Active and Productive

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Hispanics suffer from diabetes at twice the rate of Caucasians. African-Americans have diabetes 50% more frequently. If services are not made available and accessible for these individuals, the resultant cost for acute intervention after a disease or condition has progressed without primary or preventive measures may result in hospitalization, rehabilitation services, and/or increased dependency on public assistance and social services.

The cost-per-patient for the provision of podiatric services in the Medi-Cal program will not decrease. The cost will merely be shifted to a different, more expensive, and perhaps less efficient provider and mode of care. Individuals who require podiatric treatment and care will seek intervention and care from acute care facilities, e.g., the emergency room, and from other providers whose reimbursement schedules tend to exceed those routinely charged by podiatric physicians. If access is limited, medically needy individuals will tend to wait until the condition is so acute as to require more intensive and expensive care than would be required if preventive, primary podiatric services provided by podiatric physicians were maintained as a program benefit. It is the mission of the California Podiatric Medical Association to promote, advance and protect the profession of podiatric medicine, to preserve the rights of

The consequences of unmet medical needs are decreased productivity, efficiency, independence of function and quality of life; increased suffering, severity of condition,

and physical and economic dependency.

PODIATRICMEDICINE IS A HEALING ART

For over 95-years the California Podiatric Medical Association has served the people of California by promoting the science and art of podiatric medicine, protecting the public health, and elevating the standards of medical education.

CPMA has been in the forefront of progress for patients and for podiatric medicine, sponsoring strong licensing provisions and more stringent formal and continuing educational requirements. The Association continues to support strong regulatory procedures and high ethical standards.

CPMA, helping Californias doctors of podiatric medicine keep Californias on their feet, healthy, active and productive.