by Jarrod Shapiro, DPM Joined practice July 2006 of John K Throckmorton, DPM Lansing, Michigan

By this point I've written about a variety of topics that I find pertinent to the new podiatric practitioner. Some of it has been critical, but the majority has been, I'd argue, positive. I've experienced countless positive moments in my practice of medicine so far. In the spirit of critical evaluation, though, I'd like to take this time to talk about some of the things I don't like about medicine. Of course, every career has its ups and downs, its good points and bad points. I'd like to separate the minor daily inconveniences from the topics I'll bring up below. What I'd like to discuss are those subjects that significantly affect the day to day quality of practicing modern medicine: health insurance and our litigious society. In this part 1 I'll focus on my beef with health insurance.

As a resident I was blissfully unaware of the intricacies and injustices of the nature of our health insurance system. Then I started practicing medicine in the real world and had to wake up from my pleasant residency dream. As you all know, if you don't have health insurance in the U.S. then you're essentially barred access to quality health care. Try seeing a specialist without insurance much less primary care. You're relegated to obtaining your primary care in an ER. This is the very reason the emergency rooms are overcrowded and getting worse. No wonder patients often wait hours to see a doctor throughout the US.

That's the patient side. How about as a new practitioner? Well, the one thing that bothers me the most is when my treatment regimen is dictated by the patient's insurance. For example, many insurance companies don't pay for custom orthotics. In my area the running price for orthotics is around $400 per pair, which many patients simply cannot afford. I'm then relegated to other methods like over-the-counter inserts which are almost always inferior to orthotics. On the other hand, the insurance companies seem to have no problem paying for surgery, which would be fine if all my patients walked in the door begging for surgery and there was no such thing as malpractice lawsuits! Look, we all know that the standard 6 month therapy regimen for plantar fasciitis is based more on the concern for lawsuits rather than science.

I see the more malignant side of this in my wound care clinic. I've had patients receive denials for multi-podos boots if I have "ulcer" as a diagnosis. I actually have to lie and put "dropfoot" on the script! I bet they'd pay up if I put a kickstand external fixitor on them to offweight their heel ulcer. Most of my patients cannot afford the copay for Apligraf if their insurance only covers part of the cost. Remember, Medicare only pays 80% of the costs. If my patient is unlucky enough not to have a secondary insurance they'll have to pay around $250 or so. That may not seem like much to us, but come to Michigan where the economy is at an all-time low, and $250 is significant.

Do you see Medicaid patients? Medicaid reimburses physicians poorly. In my area it's gotten to the point that most physicians are nonparticipating in Medicaid. They'll see patients in the hospital emergently but will refuse patients in their offices. I have a patient who I've been treating for many months with a venous insufficiency ulceration secondary to postphlebitic syndrome. I sent him to a local vascular surgeon who specializes in veins after the patient failed multiple attempts at compression, debridement, Apligraf, a negative biopsy, and a myriad of other local wound modalities. The surgeon determined my patient required an endovascular venous procedure which required referral to another location (the local hospital didn't have the appropriate surgical instrumentation). Could I find a surgeon in Mid-Michigan to take his Medicaid? Not a chance. What's the plan of care? The patient is going to buy better health insurance and then drop it if this heals after his surgery.

Have you ever heard of this treatment regimen? Wait, I think I saw an article on this treatment in the last JFAS issue! I think it was called "Over-The-Counter Inserts vs. Changing Insurance for the Treatment of Plantar Fasciitis." I must have missed this new modality during my residency.

"Patient X. I'm going to institute today a comprehensive plan of care to consist of compression therapy, local wound care, and a change to your insurance."

I know. It's ridiculous. Welcome to the real world, Shapiro.

I'll ask you one question before I end part 1 of my rant: Who's treating our patients? The doctors or the accountants? By the way, remember that Apligraf you're cutting up and putting on 2 or 3 of your patients? If you do that you're committing fraud. That's right, fraud. If you apply a piece of Apligraf to a patient you'd better throw out the rest of that expensive bioengineered neonatal tissue or you're a crook. Don't you dare help someone else with it or you're taking advantage of the patient's health insurance. Give me a break.

What do you think of our health insurance situation? Write in with your opinions.


Jarrod Shapiro, DPM
PRESENT New Docs Editor
[email protected]