October 19, 2018
One More Time
It has happened again. Another patient came to office after going to the Emergency Room without proper care. Those of you who read this blog know that this is a constant source of frustration.
This is the story. A 36 year old falls through a ceiling on to his heel. He immediately know that it is broken and goes to the ER for treatment. I would do the same thing. They take x-rays and a CT scan which shows a severe fracture of the calcaneus (heel bone). They place him into a splint and send to him to an orthopedist.
The orthopedist sees him and informs the patient that he/she does not treat feet and refers him to his Podiatrist that he saw a few years ago for something else. His Podiatrist does not touch this kind of injury and refers him to me. The patient has now seen the ER and 3 physicians to do absolutely nothing.
There are many problems with this scenario. First, a comminuted, calcaneal fracture ( severe heel fracture) should be treated as soon as possible. After a day, the foot swells and now needs to wait several days before surgery. The ER needs to treat it as urgent like an acute hip fracture if not more urgent. They would not let the hip fracture patient get wheeled out without having the fracture fixed or scheduled to be fixed.
Second, a referral needs to be appropriate. Sending him to an orthopedist who does not treat feet is ridiculous. Fixing this type of fracture is very specialized and not being done by the average orthopedist or podiatrist. You would not send a spinal fracture to a hand surgeon.
I am presently trying to find a specialist that handles this kind of injury on a regular basis. I perform some calcaneal fractures but this seems too extensive. I am not sure if foot pathology is not taken seriously at the ER or they just do not know what physicians perform what procedures. Something needs to be done.
October 4, 2018
Manor Drive is having construction until the Winter. The City of Midland is replacing the water pipes along the entire length of Manor Drive. They are starting on the South End and working toward our office. The stretch from Saginaw to our driveway is open but gravel at this point.
Please use the driveway between the buildings off of Saginaw Street. There are 2 driveways that lead to the parking lot. Please be careful as people come out into the driveways. Please go slow and be aware of pedestrians.
The construction should be completed by the time that the snow falls. Thank you in advance with putting up with the mess.
September 13, 2018
Power is Everything
The last month has been a great example of having influence is everything. Sometimes you feel it is unfair that certain people can get things done quickly while the rest of us struggle. I have a couple of really good examples.
First, I have ended the Gladwin experiment. I was asked by the hospital administration to open the clinic. They had open space since they built a new building for the Family Practice Physicians in Gladwin. They told me that certain doctors wanted a new foot specialist in town to give an alternative. They assured me that they would instruct Doctors to refer patients and that filling up days would be no problem. This was far from the truth.
I was being used as a bargaining chip. When the bargaining was over, I was left with only patients that came from my website and Midland practice. Since the Family Practice Physicians are employed by the hospital, referral can be controlled to a certain extent. Filling up my day would have been easy. The interest went away once the other real negotiations were over.
I have been complaining about the Emergency Room not treating certain foot conditions urgently and sending the patients away. Read this blog and this is a fact for several years. I was sent a patient with a Lis Franc Injury. This is a midfoot injury that can be very serious. The Emergency Room diagnosed the injury and sent the patient for follow up. The Patient winds up in my office through his Primary care. I realize the extent of the injury and schedule surgery and also get him in to see an Orthopedic Foot Specialist who handles more of this kind of trauma.
The Orthopedist agrees with surgery and does the surgery in a couple of days. This would be the usual end of the story. Not this time. I get a letter from the Hospital asking for information concerning this patient. The Orthopedist was annoyed that the patient was not treated properly in the ER and everyone is jumping. If I complained, nothing would happen. Again, power and status matters.
I should get used to the fact that being an independent physician at hospitals where most physicians are employed by the hospital is difficult. I will continue to plug away but it is frustrating.
August 16, 2018
It Never Ends
I have been in practice for 27 years. Over the years, rules change concerning insurances, methods, prescriptions, etc... One of the constants is that the administrations of hospitals and surgical centers have no loyalty to the doctor. They love you bringing in cases until they don't.
Once again, this is the case at Riecker Surgical Center. This is the Surgery Center that is partially owned by the hospital and on the hospital campus in Midland. I have been bringing patients to Riecker for about 3 years and it has been a great experience. It is very efficient and much easier than going through the main hospital. The staff is great and I have not had any complaints until now.
Recently, times have not been available to schedule patients. My staff recently tried to schedule cases and was told that no Tuesday mornings are available until November. We were explained that 10 new Doctors were taken on by the hospital and they now have block time during Tuesday mornings. I was not offered block time or informed of this change. Not one phone call, text, or email. NOT NICE.
It is one more example of unfair treatment of independent physicians in Mid Michigan System. Physicians employed by the hospital have a much easier time getting surgical times. Part of the recruitment is to offer block times. Certain surgeons can call the shots even if they give up their times and want to come back. I understand that it is a business but a little loyalty would be nice. I would be happy to guarantee cases during a block time on Tuesday morning. No one offered or even asked.
I will be using Great Lakes Surgery & Endoscopy Center more on Tuesday mornings as well as taking cases to the main hospital. I am used to the hypocrisy but it still hurts.
July 31, 2018
One More Time
The Emergency Room problem has raised up again. It is again another example of a real problem in the MidMichigan Hospitals ER for patients with Medicaid insurance plans.
A patient stepped on a toothpick that his cat was playing with on the floor. He has complete sensation and knew that the toothpick went into the ball of the foot. It was beneath the skin and could not get it out. He does the right thing and goes to the MidMichigan- Midland ER. He is in the ER for 6 hours while they do x-rays ad work up the problem. So far, so good.
They look at the x-rays and do not see anything. This is expected as wood does not show up on regular x-ray. They then explain that there is nothing that they can do. The ER physician tells the patient that they would not be able to numb up the area since there are so many nerves on the bottom of the foot. They also tell him that they would not know what direction to push on the toothpick to get it out. I kid you not.
The ER discharges him with the toothpick still in his foot and on oral antibiotics. They refer him to a local Podiatrist. He goes the next day to find put that the Podiatrist does not take his insurance and sends him on his way. They also inform him that it would have been covered in the hospital by the same Doctor since he is employed by the hospital that takes his insurance. Luckily, he comes into our office limping on this foot.
The patient has a puncture wound at the entry point of the toothpick and severe pain to the area. I went on the computer to check the ER records and the X-rays have been discarded from the ER visit. The rest of the story seem accurate based on the notes. Under local anesthetic and a 1.5 cm incision, over 1/2 of a toothpick was removed in less than 15 minutes in the office.
There are so many problems with this story.
1. I would go to the ER immediately if I stepped on a toothpick. You would expect to have the toothpick removed either by the ER physician or call in a Podiatrist.
2. The explanation of why the toothpick could not be removed is laughable. So leave an appendix in because it is hard to numb up.
3. Referral should be made to someone who accepts the insurance. The extra info about coverage in the hospital is pouring salt into the wound.
4. X-rays should never be discarded.
The real truth is that removing a foreign body that does not show up on x-ray is never easy. It can be challanging but must be done. The wood cannot just stay in his foot. The patient had Meridian Medicaid which pays very little for this procedure. No one wanted to be bothered. Pretty sad.
July 24, 2018
The Midland office will be closed for the week of August 6-10 for vacation. It will open Monday, August 13th at 8:45. During the week off, the Emergency number will be still be active and call 734-516-8267 for problems that need to be addressed quickly. Messages left on the voice mail will be answered several times per day.
True emergencies should always go to the Emergency Room or Urgent Care. These include injuries and infections that need to be addressed quickly. Timothy Dailey, D.P.M. in Freeland is available for urgent problems that cannot wait until the office reopens. His office number is 989-695-6788.
No surgeries are being performed the week before vacation. This is quite important as most complications are in the first 5 days after surgery. All surgical patients are seen for their first postoperative visit before the week off. Regular surgical schedule will begin the week of August 13th.
Just an aside. We are scheduling surgeries for the Gladwin date August 23rd. There is availability to perform 2 surgeries and we can expedite the process. We can schedule this date in less than 10 days rather than waiting 4-6 weeks. Let the staff know if this date would work for you.
Have a great summer!!!!!
July 1, 2018
The Gladwin location will start on July, 26th. It will be a once a month clinic at the Mid Michigan- Gladwin professional building. It will run from 10:00-4:00 and offer full service Podiatric Services. It is located in Clinic #7 which you enter through entrance B right next to the Urgent Care.
The idea is to give Gladwin area patients another location for Foot care. Most of the patients will be referred from the Family Practice in Gladwin that is just starting a brand new building just outside of town. Anyone is welcome to visit us at this location but follow up will be more difficult and may require a trip to the Midland office.
Appointments can be made through our Midland office at 989-631-0200 and specify the Gladwin office. I will also be performing 2 surgeries at the hospital next door on the same Thursday morning.
June 14, 2018
Choosing the Right Location
There are many choices for medical care in the Mid Michigan area. The community is served by several hospitals, hundreds of physicians offices and many Urgent Care Centers. It is important to make the right decision for health care. Too often, a patient can get stalled in proper treatment by choosing the wrong location.
The first decision is urgency. Emergency rooms (ER) are just like they sound. Emergency. This service should be utilized when getting treatment immediately is needed. Also, the severity should be high. Too often, the ER is used as a family practice for colds, sprains, etc... The ER is a very expensive way to get health care. They are geared to overkill everything and takes hours to be completed.
Not all Emergency Rooms are created equal. It is worth the trip to go to a larger center for complicated problems. The Midland ER has the availability of specialists for consultation as well as being admitted to a major hospital complex for testing and treatment. The ER in Clare and Gladwin do not have specialists available as easily and has limited hospital services. The ER for Mid Michigan in Mount Pleasant has no hospital attached and cannot admit a patient. All this has a factor.
Urgent Care centers are a nice option. Most take many insurances and allow treatment without an appointment. They also have extended hours. They can handle non life threatening conditions. This is great option for small injuries, colds, flu, etc... when the Doctor's office is not available. They can certainly get the ball rolling with treatment until your normal Doctor has availability.
The best option is still your Doctor. They are familiar with your case and provide the best and most efficient care. If the condition is not Emergent, try to get into your Physician-whether specialist or Primary Care. We try hard to keep appointments open for Foot and Ankle problems that need urgent attention. Many times, patients go to the Emergency Room only to be diagnosed and then sent to our office for treatment. It is much more efficient to come to our office directly.
My best advise is to think about where to go. Choosing wisely is the first step in getting the best treatment.
May 21, 2018
Gladwin a Reality
The Gladwin opportunity is becoming a reality. Starting July 26th, I will be operating a clinic in the Multi-Specialties Clinic at the MId-Michigan /Gladwin Hospital. In addition, I will be performing outpatient surgeries at the hospital in the morning of the clinic. The clinic will be open from 10:00-4:00 and provide full service foot care for the area.
The idea of the Gladwin clinic is to provide foot care for a under served population. The University of Michigan- Mid Michigan /Gladwin Hospital is ran by the same organization that manages Midland, Clare, and Gratiot Hospitals. The Gladwin location is a 25 bed hospital that has full operating room areas. Patients' will mainly be by referral from the Primary Care Physicians in the hospital as well as other specialties. The Midland office will not be making the appointments for this location.
Surgeries will be scheduled through the Midland office. All Gladwin clinic patients will have surgeries performed in Gladwin to eliminate the need to leave the community for foot surgery. More advanced cases may be performed at other locations. I will expand the days and hours based on the patient load.
Like anything else, there will be a learning curve. The exact details need to be worked out, but it should be an exciting venture. Call the Midland office if you wish to have surgery in Gladwin as an option. We are presently perfoming surgery at MidMichigan Clare, Midland, & Gladwin, Reicker Surgery Center, Great Lakes Bay Endoscopy and Surgery Center, and Genesys Regional Medical Center.
April 13, 2018
Custom orthotic devices have been used for a very long time. They are used in cases of plantar fasciitis, flat feet, metatarsal pain, and arthritis. They can serve a variety of purposes. One is reduce the pressure in an area such as the ball of the foot. Another, is the alter someones gait and make the foot function better. This is the case in plantar fasciitis and flat feet. The problem is proving it.
Several recent studies have been published that show no statistical benefit of custom orthotics over an OTC insole. Why is this important? Insurances demand independent research to have items covered. This would allow insurances to deny coverage of orthotics.
Clinically, custom orthotics work. They treat many conditions very well and do alter the biomechanics of the foot. Most patients avoid surgical release of the fascia in heel spur syndrome based on the orthotic devices. Just the fact that the devices last several years and never flatten out gives a significant advantage over an OTC device. If you purchase an OTC every 3 months ( once it looses it shape), it would be more expensive than the custom device.
The same argument could be true about eyeglasses. An OTC pair with an appropriate lens could produce adequate results for most patients. However, Rx eyeglasses are better and hence covered by insurance plans. The optics business has been much better at stating their case than the foot business.
It is time that the Podiatric community prove what we all know. We need to get a double blind study performed at a major center. Pick one specific problem and treat it with custom devices vs. no device vs. OTC device. A gait analysis could be easily done on all the patients showing the effect. It's just the items being investigated that are wrong, not the concept. The problem is that Podiatry is not a research oriented field. Allopathic medicine is full of MD/PhD people who would jump on this problem and get funding. Podiatry has very few such instances.
I will continue to promote custom orthotics in my office. They are cost effective and patients get better at a high percentage. They also avoid allow patients to avoid surgery which in good for the patient and cost effective for the insurance company. A pair of custom orthotics is $300. The cost of an endoscopic release of the fascia is over $5000 including the hospital cost. You do the math.
April 5, 2018
An opportunity has emerged to start participating in the Mid Michigan Specialty Clinic in Gladwin, Michigan. The Hospital is opening a new Primary Care Center and has opened up more space in the existing clinic. The clinic building is directly adjacent to the hospital.
The clinic would be opened one Thursday per month to start and would be mainly based on referrals from the physicians already in the Gladwin family practice and specialty clinics. I would also be performing surgical procedures in the Gladwin Hospital on the same day. This service is not being utilized at present.
Gladwin is an underserved community. We already see a great deal of the Gladwin community in the Midland office as it is only a half hour away. A local presence would allow more people to get treated for their foot problems. The office would use the existing X-ray and laboratory facilities at the hospital and could have patients' follow up in the Midland office if necessary.
I am only in the preliminary planning stages and is in no way a done deal. Please let me know opinions concerning this opportunity. I am always concerned about the follow up in a once a month situation. I am also concerned about hurting the Midland location. It also means more driving for me which is always a concern.
March 14, 2018
It Happened Again
Once again, a patient came in with an interesting story. A middle aged healthy male stepped on a piece of glass in his kitchen. He tried to get it out but cannot get the whole piece and left it for a few days. He starts getting pain and goes to the Emergency Room (ER).
The Emergency Room gets a x-rays and can actually see a a 4 mm foreign object just below the skin in the area. This is not very common as only leaded or stained glass will show up on x-ray. So far, so good. At this point, the Physician Assistant in the ER informs him that she is not qualified to remove the glass and to go see his family doctor. No calling a specialist. No calling an ER physician. No referral to someone who is qualified. Just basically go away.
The ramification is interesting. An ER should be able to handle emergencies much better than a Primary Care Physician. You would not want to go to your family practice with a gunshot wound. They should be able to call in a specialist when the problem cannot be handled by normal staff. Something is just wrong.
The patient went to his family doctor after almost a month who sent him to our office. The puncture area was infected beneath the skin and the glass was still there. I removed the glass and drained the infection under local anesthetic. The patient should be fine but went through a month of discomfort even though he did the right thing in seeking medical attention.
I understand the Physician's Assistant not trying to open the foot. The mistake is not calling in someone who can. At least refer them to the proper place. It just makes no sense.
February 11, 2018
Upcoming Days Off
This an updating of certain days that the office will be closed this Winter and Spring. Please make these notes and plan surgeries accordingly. I have arranged for Timothy Dailey, DPM in Freeland to handle patients that can not wait to see get in and are not emergent. Emergencies can go Urgent Care or the Emergency Room.
March 29-April 2
I can still be reached for Emergencies by phone at 734-516-8267. Voice mail at 989-631-0200 will still be answered in a timely manor.
The office has a new phone system and members of the staff can be reached directly at their extension. I hope this makes calling the office a better experience. In addition, hold music is placed while you wait. I am trying jazz to relax by. Let me know how it sounds and suggestions for the music.
January 25, 2018
Health Care Changes
The recent new budget changed health care regulations for 2018. The fine for not having insurance is no longer in effect. Ordinarily, I like taking fines away. This is a different case.
Under the Affordable Care Act, a person would pay a $1200 fine on their taxes for not having health insurance for the tax year. This is why the 1040 form had so many questions about health. I've had patients who try to consider the better financial outcome of paying the fine, but this is not the point. The point is to get everyone to have insurance.
The Affordable Care Act makes it financially possible to have a health plan. Why? Health care is too expensive for people to pay out of pocket. It also spreads the risk like any other insurance. Young people do not require as much health care but they still have to enroll. This lowers the risk and lower premiums. Without a plan, young person with appendicitis would need to shell out $40,000 out of their pocket.
The weakest argument is that I rather have the money in my pocket. A plan is based on your income and could be a few hundred dollars a month. If one gets sick, the plan covers a percentage of the cost and makes it feasible that you can survive the illness financially. Without a plan, the hospital and doctors do not get money and the patient goes bankrupt or takes a huge credit hit. In the end, our taxes will wind up paying for the bill or the hospital will go out of business. It is not a few hundred in your pocket vs. nothing. It is a few hundred in your pocket vs. financial collapse.
I really hope that everyone continues to get insurance. Preventative care is a must. A healthy population that can afford health care is not too much to ask. Shop www.healthcare.gov the next time the enrollment period opens. It is simple and gives a whole choice of plans.
January 15, 2018
ER Does It Again
I wrote a few month ago about a number a patients that had foreign bodies in their foot that were taken taken care of in the Emergency Room and Urgent Care Centers. A new case with greater implications came to my office about 10 days ago. The risks for this patient were much higher and can lead to greater risks.
I am changing some of the specifics for HIPPA reasons. A middle age diabetic male presented to the ER with a swollen, painful right foot. This patent is diabetic and has almost no sensation to his feet. In addition, he has a history of Charcot foot ( a severe arthritis seen in diabetics), diabetic ulcers, and previous toe amputations to the other foot. He was replacing ceramic tile and thinks that he might have stepped on something.
The patient had puncture wound to the right foot and some drainage from the area. The puncture was in the middle of the foot in an area where the foot has collapsed from the Charcot foot deformity. The xrays show a metallic object in the soft tissue in the area of the puncture wound. The ER physician attempts to remove the object with a hemostat through the puncture wound but cannot do so. This is where things go wrong. He tells the patient that it probably dissolve and sends him home with oral antibiotics.
Are you kidding? A high risk patient has a metal object in their foot that is already starting to get infected and they are sent home.
I saw it the next day and had to remove the metal object under fluoroscope. It already was being degraded by the body and has a pus pocket in the area. What is the problem?
1. Taking out foreign bodies seems easy but it is not. If it is not visible, it can be very frustrating. The fluoroscope for metallic objects works well.
2. Insurance reimbursement for removal of foreign bodies is poor. I think the perception is that it is easy and low risk.
3. Once again, this patient had Medicaid.
Proper treatment would have been calling a Podiatrist into the ER to remove the object ASAP. It was not going to dissolve and would have not just popped out as it got pushed down to the bone by the time I removed it. The patient saved his foot by calling his Primary Care and getting referred to have it removed. The question is "Why do you go to the Emergency Room in the first place?". That is a really good question.
December 2, 2017
Orthotic devices have always been a difficult item for insurances to handle. They are an expensive initial investment but avoid surgery in many circumstances. Conditions such an tendinitis, and plantar fasciitis respond well to custom foot inserts. The news is good in many ways.
Medicaid policies managed by Molina and Meridian are now covering custom foot orthotics. This is a wonderful change and shows that insurances are finally determining that orthotics save money and are necessity. More Blue Cross/Blue Shield policies and Aetna have begun expanding coverage as well. Medicare has not jumped on board.
Custom foot orthoses are fabricated from a model of the foot. The foot is casted to develop a negative model of the foot. The model is then scanned into a computer system and basically makes digital model of the foot. The model is then modified and a devices is milled based on the model. The result in a device that fits only your foot and is adjusted for you distinct problem.
The cash charge for most orthotic devices in our office is $300. This is very competitive with other specialists in the Mid Michigan Area. Insurances will cover most of the cost, sometimes without a copay. Ask about custom orthotics next visit.
September 28, 2017
Makes No Sense
There has been a big problem that I have noticed in the last few weeks. I have written before about the issue of providing health insurance that no providers will take. This is my whole issue with the Medicaid program through Obamacare(ACA). This issue has pointed out to be dangerous in the last few weeks.. The culprits are the Emergency Romms at several local hospitals.
I have had 2 examples in my office in the last week. The first was a healthy patient that was shot in the fifth toe with a BB gun. She presented to the MIdland ER like any normal person would. The BB was still in the toe and it bled all over the place. This is a true Podiatric Emergency. The ER Xrays the toe, provided a tetanus vaccine and attempts to remove the BB from the toe under local anesthetic. This all seems good as the Xray show the BB lodged in the outer part of the toe.. Here comes the problem. The anesthetic is not done correctly as the patient is screaming as the procedure is being perfomed. In addition, the ER physician is trying to push the BB out of the entry point with pressure. Anyone who has removed foreign bodies will know that this just does not work.
This is not really the problem yet. I do not expect the ER physician to be able to do my job. At this point, someone like me should have been called to remove the BB. Instead, she was appointed to a physician who cannot see her for weeks in the future. In addition, the physician does not take her insurance. She leaves the ER with the BB in her toe and no means of having it removed. She has gone through pain and a huge bill.
The second example is a young boy who stepped on a foreign object. He could not put any weight on the foot. He goes with his mother to the ER in Clare who is very busy and they tell him to go the Alma where they are not as busy. Alma takes an xray and sees an object in the foot. Rather than try to remove it or call in someone who can, they send him to an outside physician. The mother calls the office and she is told that they cannot see him due to location and the insurance. Once again, the item is still in the foot and a huge ER bill.
The thing that they have in common is the insurance. Both were covered by Medicaid plans. The ACA has given low economic individuals affordable healthcare with no one who will provide the service. A better insured patient would have had a specialist come to ER to perform the relatively simple procedures. This is ethically wrong and dangerous.
Both patients presented to my office through their primary physicians who knew that I would take care of them. The BB was removed in the office in 15 minutes and the forign body removed under local sedation in the hospital a day later. I made almost no money dong the procedures but so what. I resolved their pain and made them functional people again. The treatment in the ER is ridiculous.
Please consider this issue when considering the Hea;lth Care Debate. Providing healthcare is wonderful, but it needs to be funded at a reasonable level. The original plan was to make the Obamacare plans for low income pay Medicare fees. This would eliminate this whole problem.
September 5, 2017
Fall is Here
It is official. School is starting today all over the state. College football started this weekend with both University of Michigan and MSU winning easily. The NFL starts this Thursday and the Jets are terrible once again. Sounds like Fall in Michigan.
Our schedule is changing slightly starting today. Monday will become our late night instead of Tuesday. We will open until 6 pm on Monday and close at 5 pm on Tuesday. It is a subtle difference but still allows office hours after working hours for our patients. It has been very successful to offer early morning and later hours over the years. Nothing is changing in that respect. The change is to accommodate a new charitable endeavor that I am pursuing with my wife.
The fall also brings Thanksgiving. The office will be closed November 22- November 26 for the holiday. I will be leaving the area over the holiday but can be reached on the emergency number.
It is also time to schedule procedures that patients want done before the New Year. We are scheduling surgeries about 4-6 weeks in advance which puts us presently into the end of October. Please try to schedule procedures for 2017 before the middle of Novemnber. There is always a rush to get in procedures in the insurance cycle.
Enjoy the cooler weather. For all the Game of Thrones people, "WINTER IS COMING."
Obamacare Still Here
Congress has not been able to agree on our healthcare problem. Senator McCain has now stopped the whole process ending a very strange place in our history. Repeal and replace is not going to happen anytime soon as well as just repeal is just about dead. Getting away from politics, what does it all mean?
The Affordable Care Act (ACA) did a whole host of things. It allowed adults under the age of 26 to stay on their parents' health plans. It did not allow insurances to use pre-existng conditions as a basis to deny coverage. It mandated that everyone must have insurance or face a tax penalty of $1200. It allowed shopping of insurances to be easier through healthcare.org. The main purpose was to provide affordable healthcare to the poor population. This is where the problem lies.
The original plan for the low-income policies was a federally funded Medicaid program. It was supposed to be based off a Medicare model so Physicians would be happy to accept these patients. Many states have not allowed these funded plans. Michigan has these plans but the reimbursment to the physician is awful. Giving someone health insurance without providers to see them puts the whole process back to the hospitals and Emergency Rooms to provide care. This does not work.
I accept the low income plans as a public serivice. I believe that we all deserve quality care. I recently had a valuation of the office performed that pointed out that accepting.. the Medicaid plans under the ACA makes no financial sense. I would be better off seeing less patients with better insurance coverage. THIS JUST MAKES NO SENSE.
I will continue to accept these plans out of a personal belief. I wish Congress could see the benefit of preventitive care especially with the diabetic patients. THE ACA has saved a lot of feet. People are getting care that never did before. Physicians should not be in this position.
I have just been appointed to the Ethics Committee at Mid-Michigan- Midland for the next 12 months. The Ethics committee is made up of 38 members ranging from Doctors to Nurses to adminstrators at the hospital. It involves patient care procedures and making sure the dignity of the patient is preserved. It has various missions and purposes that I will find out over the next year.
The question is "Why me?". The answer is that "I have no idea". I was asked to participate in a committee and it sounds like a good idea. I have always felt left out of the decision making process especially in Midland. I am one of the few private physicians on staff that is not employed by the hospital. This immediately makes you an outsider. I have always stayed away from this type of activity but now is a good time to get involved.
I hope to give some input toward the ethical medical treatment in the hospital. I look forward to working with the 37 other members in trying to make a diffrence. It might get me that little bit of say at the administration level. I will keep you informed on this blog.
May 25, 2017
We have been conducting our survey on surveymonkey.com for almost a year. Thank you for all the responses. While most of the feedback was positive, I would like to address two areas of concern.
First, people responded to the question about getting into the office for an emergency with a lot of questions. We try to see a true emergency the same day or the next day as much as possible. We leave appointments open each day for this purpose. Surgical patients are given a priority and always seem ASAP if there is a problem. The question comes down to the level of priority. Please voice your disapproval of the appointment time to my staff and we will try to adjust it. We are a small office and try to see patients in a timely fashion. We realize that you have a choice for your foot care needs.
Second, the time to respond to questions when we are not open. This was the most neagtive response. Messages are checked during the day but not at night. The weekends are checked every few hours. My cell phone number (734-516-8267) is always available and can always be reached. I try to return phone calls within a half hour. I cannot help you with appointment scheduling, appointment times or any clerical issues. I do have access to charts after office hours and can issue non-narcotic RX. Let us know how to make it better.
Midland Family Footcare will continue to adapt to the deficiencies spottted on our survey. Please fill out the survey that is linked on the survey page.
March 23, 2017
I have been on staff at Mid-Michigan Midland for over three years. My original purpose was to perform outpatient surgeries at the Reicker Surgery Center. It provides another option for outpatient surgery that is very close to the office. Tuesday mornings have worked out well for this purpose. I really was not planning to do inpatient consultations but it has happened.
It started with sending patients directly through the Emergency Room when a severely infected foot came into the office. I learned that most of the time the ER would consult the Podiatry Groups that handles the hospital even though I called and had them present my office note to consult me. I then learned that I can directly admit a patient with a hospitalist to care for the rest of the patient's problems. This works very well and avoids the whole bureaucracy of the ER.
Doctors and Patients can also request me to be consulted. Simply request that I be consulted and not the Podiatrist on call. I have full privileges and 26 years of experience handling just about any foot problem. I am well versed at dealing with the worst foot infections. My residency at Hines VA/Loyola put me at the front line of the largest Diabetic Foot Clinic in the country at the time. I have continued this specialty since I went into practice.
I also handle traumatic foot injuries. Any type of blunt or sharp trauma, falls, fractures, etc... presents an interesting inpatient problem. I will be happy to take thee cases and enjoy them very much.
To consult me in the hospital:
1. Ask directly for Lawrence Sternberg DPM not just a Podiatrist.
2. Have them call my cell phone: 734-516-8267.
February 24, 2017
I will be lecturing this May at the American College of Lower Extremity Surgeons conference in Livonia, MI. I attended the conference last year but did not lecture. This will be the 4th time that I lectured at this event and am looking forward to it.
This year, I will be discussing "The Use of Collagen Allografts in Foot and Ankle Surgery". These are products that are taken from various sources of cellular material and are modified to provide a matrix to allow cells to grow. I use these products in tendon repair and ankle stabilization procedures. It is basically a patch that I can use as a graft.
The lecture allows the exchange of ideas and information among 200 podiatrists fro all over the country and some internationally. The lectures encompass the netire weekend and run the full scope of practice. There is also a vendors area that allows products to be displayed that have interest to the people attending the event. It is alos a good time to meet up with collegues from all over the place.
It is an honor to lecture to my peers and I take it very seriously. Thanks you to the organizers for allowing me the opportunity.
January 24, 2017
Many people already know what happened on December 30, 2016. I suffered a heart attack and required a stent. I was off for a week after New Years and returned to the office on January 9th. I am feeling well and am very lucky to survive the event. I have many people to thank.
1. Mid Michigan- Clare Hospital: I suffered my heart attack while dong my normal Friday morning surgery at Clare. I have been working with the staff for many years but they went to extreme measures to take care of me. Being a stubborn patient, I waited to get to the emergency room until it was almost too late. The staff not only insisted that I go but walked me past any receptionist to the bed. These people saved my life and I am indebted to them forever. One member of the surgical staff traveled with me in the ambulance to Midland as he is an experienced EMT.
2. Mid-Michigan- Midland: I got great care after the stent on the Progressive Care wing. The staff treated me with respect and care. I now appreciate when patients tell me that they do not get any rest. An EKG at 4:00 am is no fun but I appreciate everyone. The food was quite good as well.
3. Dr. Andrzej Boguszewski: Dr. B was on on call and made me feel very comfortable with the procedure. He was exceptionable with my staff that came in to check on me.
4. Midland Staff: My staff was awesome. They needed to keep the office running with no notice. Two of my staff members came to the hospital to be with me until my wife and daughter arrived. They were able to inform patients that their appointments needed to be changed and handled the whole ordeal well.
5. Dr. Timothy Dailey: Dr. Dailey covered an office day when I recovering and did a great job. It just so happens that his wife was my PA in the hospital and he came to visit me which was a big help. Good luck to him in his new practice in Freeland.
6. My Family: I really have a great wife, great kids, and supportive Mother, Brother and friends. Everyone supported me and I love them very much. Almost 28 years ago, I made the best decision of my life.
Lastly, a great thanks to all my patients that were inconvenienced. Thank you for your good wishes and understanding. I hope 2017 is an easier year.
New Hospital Computer System
Mid Michigan Hospitals is changing the computer system for the the entire system. It is converting to a software package named Epic. This will require teaching the new system to all personnel and Doctors as well as the amount of money to purchase and maintain the system. The main reason, as far as I understand, is that the rest of the University of Michigan System uses this software package. This seems a bit ridiculous.
Implementing an EHR system to a hospital groups is a huge expense. I would guess an over 10 million dollar expense. This is just for the software. The labor costs is learning and training must be large as well. The amount of time to the personnel and lost productivity should also be considered in the cost. I'm sure that there are advantages to the new system, but is it really worth all the hassle.
I am constantly confronted with cost issues at the hospital. Certain instrumentation is too expensive. I am told to make sure that the patient is discharged as early as possible after a foot infection. My surgical times are monitored to make sure that I am cost effective. This is all well and good, but do not spend all this money just to keep up with Ann Arbor.
I am not in the loop of the inner decisions concerning the new system. I realize that 10 million dollars is a drop in the bucket at the hospital. I am sure that the old system is expensive to maintain and upgrade. So I will get my 16 hours of training to redevelop the wheel. Just do not talk to me about being cost effective for awhile.
The Best Laid Plans
The recent Presidential Election was a shocking result. Many doctors are cheering the Trump upset as an end to Obamacare and higher reimbursements. My advice is to be careful what you wished for.
I have been altering my practce for the last 4-6 years to comply with the Affordable Care Act.(ACA) I have always enjoyed treating a variety of patients with a variety of insurances. I have also expanded hours to fit more people into a week. The ACA allowed 20 million who were previously uninsured to have some kind of coverage. I am have been able to be reimbursed less per patient because there is a larger patient volume. This may not be the case if Obamacare is overturned..
Some of the other inititatives have bipartisan support. The dreaded "MACRA" which will penalize physicians for not reporting criteria to the government is not going to go away. A Trump Presidency and a Republican Congress will tighten tax money to programs such as MI Child and Medicaid type programs. The working poor will once again go uninsured. This puts a burden on the Emergency Rooms who have to treat the patient and the taxes must bale it out eventually. My practice will once again have to put people in debt or perform procedures gratis as the people cannot afford the money.
Before the Physicians celebrate, be careful. I wish the new President luck. I hope he remembers that 20 million Americans benefitted from the ACA. Please modify it, but keep people insured.
New Medicare Regulations
Medicare is now requiring more information for certain procedures to be covered. It is considered part of ensuring that people are going to a primary care physician on a regular basis. We must provide the name of your Primary Care Physician and the last seen date. It must be exactly right or the claim will be denied.
I appreciate that ensuring that a patient is seen for a physical every six months is probably a good idea. It would seem that giving the month of the visit should be more than enough. The other problem is that it must be exact physician not just what office. If a PA sees you, this is the treating practitioner. It is very difficult to get all this information on every patient.
Please come to the office with the information. We are leaving this in the message when we call for a reminder. The patient is ultimately responsible for the bill. We will bill the patient if the claim gets rejected and let the patient provide the information to Medicare. This is one more headache. We will be happy to allow you to call your physician's office from our office if there is a problem.
September 22, 2016
The Holidays Are Coming
The summer is over and fall is here. It is not too long that Thanksgiving and Christmas will be upon us. This brings up several issues with the office.
1. Office Closings: We will be closed the Wednesday and Friday of the Thansgiving Weekend.( November 23-27 ) This makes this week very busy, so make appointments early for this week. We will also be off December 26 and 27th. Christmas is a Sunday this year. This allows a long weekend for us to enjoy the holiday and travel to our family.
2. Insurance End of the Year: Many insurances end their year on December 31st. Patients want to have surgeries before the new deductible kicks in. Please plan accordingly. Surgeries for 2016 should be scheduled by early November. It gets busy and we even add some surgery dates. Do not come in December 20th and expect elective surgery by New Years Eve.
3. Slippery Conditions: The white stuff will start falling in a few months. Please be careful in the parking lot. The handicapped ramp is the safest way to get in on a slippery day. We sweep it several times during a snowy day. It also has a handrail on both sides.
4. Insurance Changes: Many companies change plans to start to start the year. Make sure that we have the changes. Benefits also change from year to year. We have started just sending a statement if the insurance is incorrect. This is your opportunitiy to call and give us the right information. No response make you responsible for the entire bill.
Thanks to everyone for keeping Midland Family Footcare in business since 1994. We are happy to be seeing some of Dr. Young's patients. He decided to only practice in his Mount Pleasant office. We wish him luck as always.
September 6, 2016
Arthroscopy Priviileges Renewed
Mid-Michigan Hospital- Clare has reistated my arthroscopy privileges. After months of administrative issues, the Medical Execituive committee has chosen to allow the procedure to be done again. While I am glad that this was done, it was ridiculous from the outset.
As I have stated in other blog entries, the whole situtation is 2 fold. First, University of Michigan Hospital has no idea what to do with Podiatrists. They have no surgical Podiatrists in Ann Arbor. The Podiatrists on staff in Ann Arbor strictly do ulcer care. Second, the University of Michigan Hospital administration wants common privileges throughout the MId Michigan Hospital System. Midland does not want ankle arthroscopies to be performed at their hospital. Thus, a conundrum.
The solution was to stop the privilege and then let each hospital decide on exceptions. It is simply a way to get around University of Michigan wanting uniform privileges. I was strictly a casualty of administrative chaos.
I am starting to perform Ankle Arthroscopies again at Clare but not in Midland. I still am perforing them at Genesys Health Park as well.
July, 21, 2016
More Government Regulation
People who have been reading this blog know that I am in the minority of Doctors. I have been supportive of the Affordable Care Act. It has provided insurance to the lower income group that needed something.. It is hardly a perfect solution but it did something. Leaving the lower economics groups that cannot qualify for Medicaid uninsured made no sense. I also alos a minority being an independent practitioner that is not owned by a hospital or large group. This is becomming a rarity. I am becomming annoyed at the present climate in both these stances.
New legislation that that passed in 2015 will hurt my practice a great deal. First, I will penalized 20% by Medicare for taking analog xrays. The thought is to reduce patient xray exposure. The digital xray is a 35K investment which is considerable for a private practitioner. The amount of radiation that I am using is negligible even with an analog system. I was going to convert to digital xray anyway in the next few years but a 20% penalty seems excessive. It favors larger groups and hospitals as a 35K investment is meaningless.
Second, there is a shift toward an outcome driven reimbursement plan. You will hear the term "MACRA" in the next few years. I idea is to reward good outcomes and penalize poor outcomes. Physicians that provide better care would increase revenue. This replaces a "fee for service" concept that has been the standard. This sounds great. The problem is how to monitor an outcome. The method will be reporting items of the chart note through EMR that have nothing to do with an outcome. Simply, a good note taker will be a better outcome. Hospitals will have consultants who automatically have the computer system report the right data. This has nothing to do with the patient outcome. Private practices do not have the resources to report all the items to get the increase. This makes no sense.
I have been very tolerant to change over the years. It is getting harder to survive in the present climate. Look for the new xray unit to be activated by New Year
June 28, 2016
This summer has been a hot one thus far. This last week was one of the hotter spells that we have had in years. The warm, humid weather leads to dehydration. Dehydration can be very dangerous and even lead to death. It poses some specific concerns to the feet and legs.
First, cramping is directly related to dehydration. Why are athletes constantly drinking water? The answer is to prevent cramping. As you perspire, the body is losing water. One of the first effects is cramping to the feet and legs. The cramps can be small or severe. The calves are one of the most common muscles to cramp. The answer is to drink water and to stretch the muscle. Realize that this is a good warning sign to get into air conditioning and hydrate.
Second, gout is caused by dehydration is many instances. Gout is an increase in uric acid in the blood. The uric acid causes crystals to be formed in the joints. The joints swells up like a balloon and becomes extremely painful. When one is dehydrated, the urine become concentrated and increased uric acid is one of the products. If the urine becomes brown and not clear, you are probably dehydrated. One a gout attack occurs, hydrating alone will not stop it.
Third, skin tears become common. The skin needs water to keep its texture. If the skin thins and tears, this is chronic dehydration. Skin tears and friable skin can lead to sores and infection.
Please drink a great deal of water this time of year. The foot effects are not dangerous in the log term. The systemic effects can lead to confusion, kidney failure and death. When you stop sweating, danger should be noted. Enjoy the summer.
June 16, 2016
The process is still moving at the MId MIchigan Hospital System. Going back to the blog of May 4, 2016, the privileges for ankle arthroscopy have been on hold for several Podiatrists at all the Mid-Michigan Hospitals. The idea is that the University of Michigan Hospital system wants to centralize the credentialing system so that the Doctor has the same privileges at every hospital. At least that is what I was told.
The new idea is to allow physicians that do not meet new criteria ask for a waiver to the individual hospital. The new criteria is explianed in the previous blog. Think about this. The whole reason for changing was to centralize, but the solution was to break apart the system with the waiver. So now, one hospital can grant the waiver and the other hospital refuse. It makes no sense.
I am complying with the new regulations. I have requested a waiver from MidMichigan -Clare and expect to start doing Ankle Arthroscopies soon. I can still perform the procedure in the Flint area.. Hospitals move slowly so I have no time frame in mind.
May 24, 2016
The surgery schedule has become very busy this Spring. When the weather gets warm, patients seems to need more surgery on their feet, This a phenomenon that occurs every year after the last snow flake falls. While I am not sure of the exact cause, we are trying to cater to the increased demand for foot surgery.
Over the years, we have tried to schedule surgeries no more than 6-8 weeks in advance. Any longer timeframe has led to a high rate of cancellations. People just have a hard time planning time off and recovery so far in advance. We are going to be adding a few all day surgery days at University of Michigan Hospital - Clare this summer and fall. The idea is to still not schedule more than 8 weeks ahead and adding the extra surgery time seems like the answer. We have done this at times and have had success.
There are drawbacks to this arrangement. First, the hospital has to schedule more staff and allow more surgical time for the day. Cancellations will cost the hospital money. Second, it does allow normal patient hours on that day. This causes appointments to be delayed which has its own set of challenges.
My advice to patients is:
1. Figure at least a 4 week lead time to have surgery. Do not expect a hospital based surgery to be scheduled next week.
2. Make sure that the date for the surgery works. Canceling a surgery within the last week before the surgery date takes up a useful spot. Of course, emergencies happen.
3. Consider in office surgery for minor procedures. It is much less expensive for your insurance carrier and has the same success rate. The infection rate is actually lower.
4 Be patient. My staff works very hard getting everything scheduled and approved. Many insurances require prior authorization. This delays scheduling the surgery as well.
Thank you for trusting Midland Family Footcare for your surgical needs. We will try to make the experience as easy as possible.
May 5, 2016
University of Michigan- Health Systems has decided to temporarily suspend the ankle arthroscopy privileges of several Podiatrists in their network. This affects me immediately and have had to refer several patients to other physicians or take the patient to Genesys Health Park in Grand Blanc. Michigan. The decision is administrative and is said to be a way of standardizing the credentiling procedures among all the Mid-Michigan Hospitals. There was no notice or discussion about the ruling. It points to recredentialing the parties affected but gives no such date. It also links other procedures to the arthroscopy such as Total Ankle replacement that no one in the groups of physcians affected performs.. It is all confusing nonsense.
The "administrative ruling." conveniently only effects older Podiatrists. Presently, all Podiatrists in Michigan have to have a 3 year surgical residency to practice in the state. When I did my residency in 1991, there were only three 3 year programs in the entire country. I believe even these programs were not all 3 years of surgery training. Most programs were 1 year and a few 2 year programs available. It is ridiculous to hold me to the same residency standard 25 years later. I have the same Board Certification and a whole lot more experience.
I have been performing Ankle Arhroscopies for over 10 years and have a very good results history. Dr. Michael Holland in Alma has been performing arthroscopy for a longer period of time with also great results. He also falls into this umbrella. We worked very hard to get training for this procedure and show our competency to hospital staffs many years ago. It is not fair to take this away with no explanation.
We "old podiatrists" are in the process of banding together to fight this ruling. Please feel free to contact the credentialing committee at Mid-Michigan ([email protected]) with your concerns. We hope that we can start performing arthroscopes in the near future.
March 31, 2016
Soft Tissue Masses
There has been an influx of soft tissue masses recently coming into the office. Soft tissue masses can be anywhere on the feet and may or not be painful. Diagnosis can be simple or difficult depending on the mass. The treatment and the outcome depends on the correct diagnosis.
Soft tissue masses can be frightening to the patient. A lump develops and the first thought in cancer. The best news is that the vast majority of foot masses are benign. A primary malignancy in the foot is somewhat rare. Most of the soft tissue masses are benign ( Non-cancerous) but still require treatment. Here are some examples.
Ganglion cyst- These are quite common on the top of the foot along the tendons. They are also common at the elbows and the hands. They are fluid filled and almost look like a hard water balloon under the surface of the skin. They tend to be sore but not very painful. Draining of the mass with a needle is successful in 50% of the cases and the rest are surgically removed. They are not dangerous.
Inclusion cyst- These are harder and can be anywhere on the foot. They are caused by a piece of skin or hair getting under the skin. Surgical excision is the answer and it is very simple. The mass is well contained and comes out easily.
Plantar fibroma- These are hard masses found in the arch of the foot. The tend to be a little more painful and do not move as much. They also my be more than one in the same general area. A steroid injection may shrink them but excision is necessary if they are painful. The surgery is more complcated and requires 2 weeks of casting in most cases.
Lipoma- These can be anywhere an the foot and are a fleshy type tumor. They are basically an organized lump of fatty tissue and can be quite large. Excision is a little more complicated tahn a ganglion cyst but similar.
The best advice if a lump pops up is to not panic. It is probably not cancer. Make an appointment and get it evaluated. Normally, we will have a good guess as to the diagnosis very quickly.
March 15, 2016
Patient Portal Started
The patient portal on the Electronic Medical Record (EMR) is now working.. This will allow a patient to access their record directly with a password. Lab tests and other results can also be obtained directly.
Midland Family Footcare has been using "Amazing Charts' as a EMR software for over 2 years. There was a learning curve at the beginning but has been a positive experience. This is the computer stuff that you see all of us going to during your visit. The idea is to complete the note directly while the patient is being seen, Lab reports, insurance cards, and other items are scanned into the system. It is very efficient if not time consuming. The patient portal allows assess to only the individual patient's chart.
All it takes is an email address. Provide your email address and we will email you a specific password to access your account. For security reasons, we will require ID in the office and/or ask for information on the phone or email to identify the patient. You do not have to call us for lab results anymore. Just look them up.
This is one more addition to make an easier experience for the patient. The patient information forms are avalable as well on this website. It is under "New Patient". Let us know how you like the patient portal on your next visit.
March 1, 2016
A new problem has arisen in the last few months. We have more patients cancelling surgeries or just no showing up. This presents a problem to us and the surgical facility. I am not really sure the reason behind it.
We normally schedule hospital based surgery 4-6 weeks ahead of the surgery date. The patient needs to comply with a physical and come in a week before the surgery for preop visit and lab work. This gives a 3-4 week period of time to make sure that the surgery date works with a schedule. Cancelling the surgery several weeks before the date is not that big of a problem. The surgery patient is taking away from another patient that may need surgery but I understand that things happen. The problem is cancelling within the week of surgery or not showing up the day of surgery.
Cancelling at the last minute does not allow us to reschedule the time. Normally, we can add a patient to the spot or start office hours earlier with some notice. The biggest problem is the hospital. They schedule OR staff and equpment based on the number of surgeries. There have been times that equipment was delivered overnight to acommodate a patient who does not show up. This is a waste of resources and money.
Most of our cases are elective. Please make sure that the surgery date works before scheduling. Our policy only allows for one late minute cancellation. A patient that cancels late twice just will not be rescheduled. Patent's that do not show up will not be rescheduled.
Slippery Parking Lot
We had a patent fall this week in the parking lot on a slippery day. Luckily, the patient was not hurt. This brings up a few interesting suggestions and information.
We all know that Michigan is going to have ice and snow in the winter. The plowing service for the office come early in the morning. Snow that falls during the day or ice that forms from the melting snow will not be cleared until the following day unless it is a large amount. We clear the sidewalks leading to the building periodically during the day when it is snowing. It is impossible to avoid all weather related problems.
Since the fall on Monday, we will try to keep the handicap ramp and couple parking spots by the ramp clear of ice and snow during the day. Realize that it still be slippery depending on the weather. The ramp will be less difficult for most patients on a slippery day. Water collects at the end of the ramp, so be careful!!
Here a couple of tips:
1. Call from your car and we can assist you into the building. We have a wheelchair available and it sits by the handicapped entrance.
2. Bring someone to assist you if you are unsteady in the winter conditions.
3. Reschedule your appointment if the conditions are terrible unless it is an emergency.
4. Wear appropriate shoegear for the weather. Make sure your shoes and boots have a good tread for the conditions.
Medicaid plans have been explanding since the Affordable Care Act went into effect. More companies are starting a Medicaid option and this is presenting a billing problem in the office. Not all Medicaid plans are the same.
The problem is that many plans change every month. Patients start with one provider and then get transferred to another. This sounds fine to the patient since it is a Medicaid plan. The problem from a billing standpoint is it a whole other insurance. The statements do not transfer from one company to another. We get rejected for the service and have to completely rebill the other company. This whole process can take over 3 months. So basically, the office is getting no payment for service for 3 months and getting Medicaid reimbursement with is less than 1/2 of a private insurer. This is not a recipe for success.
One other problem is that certain providers do not link to a general website. We use a state website to check Medicaid coverage. Meridian Health informs us that they do not link to this site. WHY??? No idea. This makes us have to check the individual company's website which is more time consuming for my staff.
Patients need to remember the following:
1. Your insurance is yours. You need to provide the correct information or you will be billed for services directly.
2. Medicaid is not all the same. The perception is that if you have Medicaid that is all you need to know. We need the correct health insurance provider and ID number on a monthly basis. Molina, Meridian, and now United Health Care are totally separate and have different rules for coverage. Please know your company.
3. We will our best to bill correctly but the ultimate responsibility is yours. You are responsible for the charges and wrong information transform you into a cash patient.
4. This is VERY IMPORTANT. We accept Medicaid patients and provide quality care. The harder that it becomes to get reimbursed for care with these plans, the less likely that we will continue to participate. I try very hard to consider the big picture of healthcare. I feel that everyone deserves quality care and am happy to allow the Affordable Care Act to function for low income patients. The problems make it harder to see the big picture.
January 21, 2016
Feedback is Important
We had two interesting situations in the office this week. One was good and one was bad. Both are important to reacting to our patient's needs.
First, we had a patient requiring a surgical procedure as several courses of conservative treatment had failed. The patient came on a very busy morning and had to wait for awhile until she was seen. The appointment went visibly well and she scheduled surgery. There was no complaints or problems and the day went on. After a few days,, the patient cancelled the surgery explaining that while the doctor was fine, the staff was rude during the visit. We had no idea that this patient had a bad experience or why the experience took place. We were able to apologize and save the relationship.
Second, was an icy day experience. The cold weather has refrozen the parking lot and certain areas are very slippery. A patient entered the office normally through the ramp entrance and was seen in a timely manor. After the appointment, the patient seemed troubled ablut leaving. The real truth is that she was scared to death. She had parked in the middle of an icy area, and was frightened that she would fall on the way out. This little piece of knowledge allowed us to take her out by wheelchair and help her into the car.
These are two examples of knowledge being a wonderful thing. Please feel free to let us know if you need help or that we did not perform our job during your visit. Things happen that we are not aware of during the course of business. Our goal is to provide quality foot care in a safe and friendly environment. Let us know either during the visit or later if you had a problem. Feel free to go to our survey.
January 14, 2016
The New Year is Upon Us
Welcome to 2016 in Mid-Michigan. We had a very warm late fall/early winter, but the cold temperatures have taken over. This is normally a slower time of year at Midland Family Footcare. It is a good time to install new procedures and item to the practice. This website was conceived on a snowl January day many years ago. It is the time to try new things.
First, 2015 was an excellent year. The practice grew more this year than in any other year. The website continues to grow in its scope and in viewership. The new patient documents are available thanks to Jen Clark and are being accessed This helps new patients fill out their paperwork better and faster. Adding surgical times at Riecker Surgical Center is still growing and allowing less of a wait time for surgery. Adding the extra assistant allows a faster flow in the office with less wait time for xrays and procedures. We re surviving the Affordable Care Act (Obamacare) and succeeding to provide more patients quality care.
What is the plan for 2016?
1. We will be adding a patient portal. Patient's will be able to look up lab tests and notes directly and request RX refills. This will take time but should get done this year.
2. We are going to try not to schedule surgeries outside of a 6 week timeframe. We were backed up this fall past 8 weeks and too many people cancel procedures with this long of a wait. Lesson learned.
3. We are now participating in Healthnet. The VA system is overburdened and is allowing veterans to seek private care at the cost of the VA. This requires VA approval to the patient and is unclear as to the rate of reimbursement. Stay tuned.
4. We are continuing to experience changes in Medicare policies. ICD-10 was implemented in October and Medicare decided that it was a good time to redefine certain billing codes. This is still a work in progress.
5. We will continue to try to get email adresses and text numbers to remind people of appointments electronically. It is much more efficient for our computer savvy patients. So far, it has been a failure.
Thank you Mid-Michigan for allowing us to provide footcare since 1994.
December 1, 2015
Artificial Skin Grafts for Diabetic Ulcers
There are various products that are being used to help heal diabetic ulcers more quickly. The biologics are a group of products that are used to cover the wound like a skin graft. There are many types and each is slightly different. The idea is the same. Speed up the healing process.
Diabetic ulcers are a difficult problem. Ulcers are caused by too much pressure in an area of the foot resulting in an open sore. Diabetic neuropathy does not allow the patient to compensate to the added pressure so the sore becomes deep and past the layers of the skin. A patient with normal sensation would feel pain and stop walking on the spot. Initial treatment is to apply dressings to the wound and deweight the area. The ulcer should close from the inside out and at a consistent rate. Biologics are used when the healing stops.
We are prently using dermaspan as the major product. It is made of processed cadaver skin. It is processed so that no diseases can be transmitted from the host. Consider it a patch to cover the wound. The ulcer is cleaned in a sterile setting and the patch is stitched into place. There can be no weight on the dermaspan for about 2 weeks while it adheres to the wound. It than becomes a layer of skin to close the wound. It is simple and at very low risk..
The major complications of dermaspan is the cost and failure. It does not always work and is quite expensive. It is still a lot cheaper than a diabetic ulcer getting worse and needing surgery. Look up the diabetic ulcer section on this site or on any other site for more information. Ask about DERMASPAN on your next visit.
November 18, 2015
Manning has Torn Plantar Fascia
Peyton Mannng, quarterback for the Denver Broncos, has a torn plantar fascia. Manning has been struggling this season with a host of injuries and still has the fused neck from several years ago. It is the torn plantar fascia that finally has put him on the sidelines.
The plantar fascia is the tissue that attaches from the front of the heel and extends to the toes. It effectively holds the arch up and very very commonly strained. Plantar fasciitis ( heel spur syndrome) is the more common entity in which the fascia gets stretched. The stretching of the fascia causes pain to the front of the heel. This is one of the more common problems that walks in the door everyday. A torn plantar fascia is a different story.
The fascia is made up of strands of fibrous tissue. If the fascia is stretched too much,, it will tear the fibers in the tissue. This will lead pain and swelling in the area. There will be a defect in the tissue that can be palpated. The pain will be more severe than plantar fasciitis and take longer to heel. It will be difficult to put pressure on the foot. If you watched Denver this weekend, Manning could barely move in the pocket.
Treatment at this point is rest. The fascia must heal and reattach. Ice and PT help, but time is the best cure. He is probably in a removable cast at this point with crutches. The danger is that it will continue to tear and become a complete care. This would mean the entire season. In rare instances, it must be surgically repaired if it tears completely.
Good luck to Peyton. Take your time coming back.
November 12, 2015
Holiday Office Closings
The holidays are around the corner. The office will have altered hours during this festive time.
The office will be closed Wednesday, November 23rd- Sunday November 29th. We will reopen with regular hours on Monday, November 30th.
The office will close at 1: 00 on December 22nd and will reopen on January 4th after New Year. We will be open 1 day on December 30th to see emergent and surgical patients. New patients will be seen but only emergent conditions that need treatment quickly. We will be open on December 30th from 8:00 to 6:00.
Have a great holiday season. Our new calandars for 2016 are available in the office. There are 3 different styles to choose from. They have always been a hit with our patients.
October 20, 2015
New Medicare Criteria
Medicare has changed billing for fungal toenails. It puts a burden on the patient and the office. What does this mean to you?
Nail care for fungal toenails now requires the doctor to provide the patient's Primary Care Physician(PCP) and the last date that the patient was seen. For a long time, "Routine Foot Care" needed this information, but now the treatment of fungal toenails needs the same information. The idea is to make sure that the Medicare patient is being seen for their systemic problems every 6 months. The thought is that preventive care by the PCP will provide better care and save the system money. I have no problem with this thought process if it was the real reason.
The real reason is the save money by denying claims. Many podiatrists will not follow this new criteria and thus the Medicare system saves a ton of money. Even if 5% of the fungal nail claims are denied, this mean millions of dollars in savings. I have no problem collecting the information, but notice would have been nice. I never received any direct notices concerning the change. There was no huge release in the Medicare bulletins. It was sprung on the Podiatrist through claims denials. THIS IS WRONG.
Fungal nail patients need to keep track of their last visit with their PCP. It needs to be within 6 months of your visit with Midland Family Footcare.. We will be helping in collecting the information by researching the NPI numbers for the PCP and confirming the visit. This takes a great deal of time. We are considering not accepting any new fungal nail patients or eliminating insurance coverage for this procedure. Please be aware of this change.
October 7, 2015
Winter is Coming
Where has the year gone? We are less than 3 months until Christmas and New Years. The leaves on changing and the mornings are getting cooler in Midland. I though I would take this opportunity to update the changes at Midland Family Footcare.
1. The expanded hours on Wednesday afternoon are working very well. The office is busy throughout Wednesday afternoon up to 4:30 and beyond. Adding the extra hours allow us to treat about 15 more patients a week which has opened more New Patient appointment times. The lifeblood of a practice is New Patients and we are trying hard to open 1 New Patient spot per hour. Our goal is always to see New Patients within a 1 to 2 week timeframe.
2. Utilizing University of Michigan Health Systems- Midland is still a transition. Riecker Surgical Center is being used mainly on Tuesday morning or on some Fridays. I am not pursuing consultations at the hospital unless it is a present patient with an active problem. My schedule does not allow seing inpatients as quickly as needed. An additional problem with U of M- Midland is the History and Physical. The History & Physical on all patients must be completed by a physician that is on staff at the hospital. This presents a definite limitation that we do not encounter at U of M- Clare or at the Great Lakes Surgery and Endoscopy Center. We treat a large geographical area and many of our patients have physicians from other groups and other areas. We are still working on a solution.
3. The patient forms are finally online. Please download the forms to be filled out before the visit. It will you and us time in the office.
4. A new rule is being enforced by Medicare. Treatment of mycotic nails now requires us to provide the patient's Primary Care Physician and the last date seen by the physician. It does not seem difficult, but the amount of information can be alarming. Please provide us with this information for our fungal toenail patients. This change has made us consider not seeing any new mycotic nail patients other than an initial evaluation. Please be aware of this new rule.
5. We will be closed over Thanksgiving from Wednesday to the Monday after the holiday. We will be closed Christmas eve and Christmas day as always.
Enjoy the fall. It is a pretty time of year and the best time for a sports nut like me.
September 24, 2015
Dez Bryant Update
Low and behold, I was somewhat right from last week. The injury has been clarified as a fifth metatarsal fracture and not an inside metatarsal fracture as last reported. The recovery time has been extended greatly in the press to 8-12 weeks. See my Kevin Durrant stuff during basketball season to get a true perspective.
The key at this point is where the fracture is on the 5th metatarsal. A base fracture (avulsion fracture) is much easier fracture to heal. The blood supply is better and it is much more stable. This would require a simple screw insertion. A Jones Fracture (midshaft fracture) is a much harder injury to heal and has a very high refracture rate. A metarasal head fracture heals the easiest and carries the best prognosis.
The 8-12 week recovery seems appropriate for the base and at head fracture. I would put it 8 weeks for a head fracture and 10 weeks for a base fracture. The Jones fracture- FORGET ABOUT THIS SEASON. Kevin Durrant required 3 surgeries for this injury and is just getting ready for the NBA season now. Bryant should be careful not to return too fast from all of these possibilities. He a young player with a great career ahead of him. Again, Good luck to Dez.
September 17, 2015
Dez Bryant Foot Injury
Football has started and thus injuries are going to happen. The Dallas Cowboys suffered a huge blow with a foot fracture to their best wide receiver Dez Bryant. The organization is keeping the exact nature of the injury a secret, but expect a 4 week abscence. Probably not.
The injury to Bryants foot sounds like a middle metatarsal fracture. The 2nd, 3rd, or 4th metatarsals are in the front of the foot. The injury required surgery meaning that it was not a stress fracture. The bone was completely fractured and may have had some separation or movement of the two fragments. The break was probably clean and not fragmented given the nature of the play. This still will require more than 4 weeks to heal.
Surgery would consist of pitting the 2 ends together with either screws, plates, or wires. We refer to this as fixating the fracture. A normal person would be walking without a cast in about 4-6 weeks. A Wide Receiver in the NFL need to jump and plant on the foot. The impact for such activities needs a longer healing time and also the time to get beck into football shape. 4 weeks is too soon.
Professional athletes are great healers and will get the best treatment from the start. However, I would suspect 6-8 week recovery to be a better guess. This would be the earliest. Again, this is just speculation given the information that has been provided. Good luck to Dez Bryant is his recovery.
September 10, 2015
Forms Online and Survey
We are in the process of providing the new patient information forms to be either downloaded from this site or filled out and sent electronically to the office. This would allow new patients to avoid the time to fill them out before the appointment. I always feel rushed at a doctor's office when filling out forms. Patients are stressed just finding the office. You could fill out the information in the privacy of your home at anytime before the appointment.
We have resisted doing this in the past. It is very easy to provide this service from an internet standpoint, but we thought that it might confuse patients or lead to problems such as the forms not downloading to the office and never being received. While I'm sure that there will be some glitches, the process should help in the patient experience.
The survey has been a positive experience. While it is presently a very small sampling, most responses have been positive. I am surprised that no one has had a negative response to wait time. I worry that we get behind too much in the office, but maybe I am worrying for no reason. Please take the survey when you get a few minutes.
August 27, 2015
School starts in a few weeks. High school football games start this weekend. Our teenagers will come home with sore feet and legs from various activities that they encounter at school. This is a good time to go over a few of the problems.
1. Calcaneal Apophysitis ( Sever's Disease): This is pain to the back of the heel mainly after sporting activities. The back of the heel will be warm and tender. The person will have trouble in certain shoes and cannot put weight on their heel. It normally occurs from ages 11-15. The growth plate in the back of the heel is just starting to close and this causes pain in many adolescents. The good news is that it will go away in about 6 months but may need treatment in the meantime. Try anti-inflammatories and icing as the first step.
2. Ankle Sprain: The outside of the ankle will be swollen and painful after a twist of the ankle. If the patient is able to put weight on it, it is probably not fractured. First home treatment is to rest, ice, wrap it, and elevate to ankle. In young people, the swelling and pain should be better in a few days. If not, they should get xrays and treatment.
3. Plantar Fasciitis: This is a condition mainly seen in adults but does happen to teenagers as they get bigger. The bottom of the heel will be sore and tender. They will complain of pain first thing in the morning and at the end of the day. The fascia that holds up the arch stretched too much and gets painful Icing, stretching of the achilles tendon, and good supportive shoes usually help.
4: Achilles tendonitis: This is pain to the back of the heel and can be easily confused with calcaneal apohysisits. The diffence is that the bone does not hurt, just the tendon to the back of the heel. The patient will sometimes remember a trauma to the foot and may be tender along the achilles tendon as well as the attachment to the bone. Try the same things as apophysitis.
5. Stress Fracture: This is usually in the ball of the foot and presents with swelling and pain for no apparent reason. A stress fracture is a bone that get a little crack that does not break all the way through the bone. Treat this the same as an ankle sprain ony concertrating the ice and wrap to the front of the foot.
The good news is that young people normally heal quickly. General rules should be that any severe bruising of blackening of the skin should be looked at by a medical professional. If weight cannot be placed on the injured part, go see someone. Lastly, the injury should be a little better by the next day or go see someone. We make an effort to keep appointments open for these problems.
August 18, 2015
Tendoachilles Tear in Football Lineman
I have always written about sports injuries of the stars of the sport. Atlhlete's such as Kevin Durant and Derek Jeter have a great deal of fame, so I have written about the injuries on this blog. My new subject is a less known player but equally as interesting and important to his team. His name is Phil Loadholt.
Phil Loadholt is the right tackle for the Minnesota Vikings. He torn his achilles tendon in practice a few days ago and will be out for the season. I have written about a torn achilles tendon before but the type of athlete is interesting. A torn achilles tendon is usually seen in an athlete that jumps or gets off the ground. The best example is that of Kobe Bryant who leaps 35 inches in a vertical leap. Loadholt is over 300 pounds and certainly does not jump 35 inches off the ground. A right tackle must be able to move laterally and have power to block the opposing player. Weakness in the achilles tendon could impact the power off the ball.
A right tackle explodes off the ball on running plays. This is similar to a sprinter coming off the starting block in a race. A great deal of pressure is placed on the ankle to move a large amount of weight. Passing plays require stability and lateral movement. This is probably less effected by achilles tendon weakness. Why does this matter?
Loadholt's surgical repair should concentrate on stability. On a smaller athlete that jumps for a living, a shorter achilles tendon would be a problem. The ROM is equally as important as strength. A right tackle would do well with a shortened tendon as long as it is powerful Again, I am not looking at the MRI. I would guessthat the tear could be resected and primarily repaired. I would not be stingly on the resection. I would make sure that the fibers are intact on both sides of the tear. Reinforcement would be done either by artificial graft product or a tendon transfer. The rehab would be the same and require at least until next season.
I wish Phil Loadholt a speedy recovery. He allows Adrian Peterson to run right right for over 5 yards a carry. He also keep Teddy Bridgewater alive as quarterback in the NFL. Unfortunately, he does not get the press of the other two guys.
July 29, 2015
A practice survey is now available through this website and our facebook page. The link directs you to a short survey about the care that you receive in the office. The survey is confidential and does not require any personal information from the patient.
The idea is to get feedback. We have tried various things over the years to enhance the patient experience at Midland Family Footcare. Even things as to how we address the patient has been experimented. Some patients find using their first name warm and others find it too familiar. Responding to the survey can direct improvements to the office and patient care.
I will be the only one examining the results of the survey. No one will be disciplined or fired based on patients' responses. Try to be as honest as possible. Let me know if I am explaining things well. Point out if things feel rushed during your visit. It is your chance to direct changes.
This idea came as a result of my own Family Practice Physician. She is part of a large hospital group, and a survey is sent via email after all tests and appointments. As a small practice, I find it important to keep up with large groups. There are advantages to being a small practice but it is important the minimize the disadvantages. Getting feedback is a very simple way of improving care.
Please take the 5 minutes to respond to the survey. It will be greatly appreciated.
July 23, 2015
This is just an update on things that are happening at Midland Family Footcare (MFFC).
1. Jennifer Clark has been with us since May and is working out well. She has started a Facebook page for the practice and allow us to see more new patients in a more efficient manor. From a personal note, I am no longer bringing home hours of work every weekend to load into our computer system.
2. Utilizing the Midland hospital is working out well. I was just able to treat one of our patients as an inpatient for a diabetic foot infection. I used to have to admit them to Genesys Health Park or U of M Clare. It is much easier for everyone concerned. I am using Riecker Surgery Center at U of M Midland on Tuesday mornings that has also turned out to be a good option for outpatient surgery.
3. MFFC just had it first expanded Wednesday hours last week and was busy all the wqy up o 4:30. The office will be open Wednesday afternoons from 1-4:30 except for 1 Wednesday per month. I will continue to perform surgery at Great Lakes Endoscopy and Surgery Center on that 1 afternoon.
4. We will going on vacation for the first week of August. The office will be closed from Monday, August 3- Monday August 10. I will still be taking emergency phone calls. Patients needing care can go to Dr. Mark Young next door or urgent care. I will give more information next week.
5. We will be starting an E-Newsletter in the next few months. Give us your email address if you would like the newsletter.
6. We are starting to offer email and text notifications rather than just phone. I personally hate phone call reminders and love texts. Let us know if this suits your needs.
Thank you Midland for your continued support. We will continue to improve the practice and provide quality foot care.
July 7, 2015
Big ankle news hit the sports wire yesterday. Rory McIlroy, the number 1 golfer in the world, apparently reported that he has a complete rupture of his ATFL and capsular damage to the ankle. He was playing soccer with some friends and hurt himself. The British open where he is defending champion is only 10 days away. Will he be able to play?
Reports have altered since his original tweet. His injury may not be as severe as first expected, but it does give me a chance to write about the ATFL. The anterior tibiofibular ligament (AFTL) runs between the tip of the lateral malleolus and the lateral side of the talus. Simply, the front part of the outside of the ankle. It is the most commonly injured ligament to the ankle. When someone rolls their ankle, structures start to give. The ATFL is usually the first structure to give.
There are degrees of damage to the ligament.
1. Stage I is the most common. The ligament gets stretched and becomes swollen and painful. The fibers in the ligament do not tear. Usually, the recovery is fairly quick with proper treatment especially in a world class athlete.
2, Stage 2 has some degree of ripping of the fibers and can have some instability to the ankle. The other structures usually get involved to the lateral ankle. There is more swelling and a longer recovery time. Casting may be required.
3. Stage 3 represents a rupture of the ligament and instability of the ankle. The patient would probably not be able to bear weight on the ankle and would swell up like a balloon to the outside ankle. Surgery would probably done on an athlete such as McIlroy.
My answer to the question about McIlroy is questionable. He would not play at "The Open" if it was a grade 3 rupture. He would be enjoying some postop pain as we speak. My guess is that he has a grade 2 injury. They will ice, ultrasound, and rehab like crazy. He will be seen in a removable cast and crutches when not in therapy.
If this was football or basketball, he would not play. Golf? He will give it a try. A good brace and good therapy between rounds and it may work. He will not be 100%.
July 3, 2015
I finally have full privileges at U of M Health Center- Midland. I was granted staff membership almost a year ago. After a year of paperwork, proctoring, medical reviews, etc..., I can provide full care at the hospital. The hospital protocol is not unique to me, but it does make life difficult. I have been on staff at U of M- Clare for 14 years, which has much of the same administration as Midland. It does not seem to matter as I was treated as a new practitioner.
What does this mean to the patient?
1. I will be performing most procedures at Riecker Surgery Center in Midland. I will still be doing surgery every Friday morning in Clare, but it gives patient another option for Tuesday morning.
2. I will be able to treat patients that are in the hospital in Midland. Ask your treating doctor to refer footcare directly to me.
3. I will be able to admit infected feet directly to Midland using a family practice physician for general medical care. Presently, I admit infected feet to Genesys Health Park in Grand Blanc.
4. I will be trying to grow the trauma part of my practice to handle fractures and dislocations now that a closer facility is available. I enjoy working with calcaneal fractures (heel), toe dislocations, and other injuries.
Thank you my staff for putting up with all the paperwork and scheduling problems to make this happen. Let us know which facility works best for you when having surgery. 3 hospital and 3 surgery centers are now available.
June 23, 2015
ICD-10 is going to be a major issue in the near future. This is a system of diagnosies that will universally replace the existing ICD-9 list of diagnoses. This is a major medical issue is mainly a problem for doctors, but it will filter down to the public in several ways.
October 1, 2015 is the start date for the change. The ICD-10 system is used all over the world and provides a much more accurate and specific diagnosis for a particular problem. Other countries use this for statistical purposes and not for a billing issue. The US is going to use this new system for billing purposes and for quality purposes. A doctor will be judged on providing the corrrect information that is used to support the diagnosis. It causes the doctors to change and takes a great deal of time.
I know that the nonmedical reader is now falling asleep, but it will effect everyone in several ways.
1. Patients will take more time in the office and the wait to see physicians will increase.
2. Insurance claims will have a much higher rate of rejections starting in October.
3. The history of the problem that the patient provides can change billing criteria in the hospital immensely.
Midland Family Footcare is going to try very hard to adhere to the new ICD-10 system. My staff will check my coding on each patient and there are very good online refences to convert the codes. Podiatry is effected but the conversion is relatively straight forward. I feel very sorry for family practice physicians. Good luck to all.
June 02, 2015
Midland Family Footcare(MFFC) is continuing to expand. We just added a staff member, Jennifer Clark, to allow us to see more patients in a more efficient manner. Now, we are going to expand both office hours and surgical times.
Starting in August, MFFC will be opening Wednesday afternoons. Presently, the office is only open until 1:00 on Wednesdays. We will be opening 1:00-4:30 to allow for more patients to be seen. We may open a few Wednesday afternoons in July to incorporate more new patients into the practice.
In addition, surgical times will be expanded starting in July. Presently, most hospital surgeries are performed at Mid-Michigan- Clare on Friday mornings as well as Great Lakes Surgery & Endoscopy Center on Wednesday afternoons. We will start utilizing the Riecker Surgery Center more and explanding to Tuesday mornings. The goal is to provide more services in a more convenient manor.
The expansion in patients should change the basis of the practice. MFFC tries very hard to treat each patient in a dedicated and personal approach. Let us know which changes are working when you visit the office.
May 26, 2015
Gout is a condition that is fairly common. The perception is that only rich men get gout. There is some truth to this perception but there is much more to the story.
Gout is an increase in uric acid in the body. This increase in uric acid causes crystals to form inside a single or multiple joints. The joint effectively has an irritant inside the joint as it moves causing severe inflammation and pain. The pain can ensue any time of day and is extreme in nature. The greek term is Padagra which meant curse. The most common joint affected is the great toe followed by the ankle.
The cause is the uric acid increase can be confusing. The typical reason is eating too much red meat and drinking alcohol. The red meat is heavy in purines which cause increase uric acid. The alcohol makes the kidneys work overtime to get rid of the alcohol and not eliminate the uric acid. Other causes are dehydration and other medications that the person is taking. There is also a strong genetic component.
Treatment is fairly easy with medications available to both stop the gout attack and help eliminate uric acid. Colchicine, now Colcrys, is an old medication that stops the inflammatory response to the crystals. Drugs such as allopurinol and uloric lower the uric acid level. A steroid injection reduces inflammation and pain while the medications work.
Here are some tips for someone with a history of gout:
1. Eat less red meat. Try to stick to chicken and turkey.
2. Hydrate. Water will dilute the uric acid concentration and eliminate the material in the kidneys.
3. Avoid alcohol.
4. Avoid foods such as beans and spinach. Food besides red meat can cause an increase in uric acid.
5. Try cherry juice. The is a holostic treatment that many patients swear by.
Remember that gout can be easily treated in the office. A blood test is performed to confirm the diagnosis. Treatment is usually a prescription and a steroid injection into the joint.
May 19, 2015
We have added a new employee to our footcare family. Jennifer Clark has joined our staff as a medical assistant. This is our first new employee in almost 3 years since Debbie Darland joined our staff.
Jennifer will be responsible for our Electronic Medical Records ( EMR) system as well as assisting in patient care. We have had a large amount of new patients join our practice. It became necessary to have someone dedicated to entering information into our system and helping make the introduction of new patients a smooth process. New patients are the life blood of the practice and we did not want to cut back on seeing patients just for paperwork reasons. Jennifer should allow us to continue to welcome new patients on a daily basis.
Ms. Clark will also implement more electronic methods of communication to the practice. Email and text notifications will be implemented in the near future for reminders. She will also be starting a newsletter service for patients through email. We are going to try to update this website more often and become more computer oriented over the next few months.
Please say hello to Jennifer when you come to the office. Please let us know if you want to get reminders electronically. All we need if an email addess or a phone that receives text messages.
The burden on the healthcare physician is continuing to grow. Electronic Medical Records(EMR) have become the standard for most offices. Health insurance companies want to obtain certain statistics immediately through the EMR systems (PRQS). The Congress is fighting over doctor Medicare reimbursements and facing a 21% cut in benefits. I am the most frustrated that I have been in 24 years of private practice.
I started using an EMR system about a year ago. I was slow to come on board since I am in solo practice. I changed to keep up with the times and not become a dinosaur at 52 years old. I have chosen not to try to get federal incentive payments as this requires time and also opens the practice up to auditing. I believe that my notes are better but it has put a time burden on me. I wind up doing charts on the weekends for many hours just to keep up. I am hiring another staff member to aid with the EMR system. The other solution would be to stop accepting new patients which is something that I do not want to do. New patients grow the practice and make my practice interesting on a daily basis.
Another problem is Obamacare. I was in the minority of doctors that welcomed the Affordable Care Act. It has allowed lower income patients to have health insurance and seek medical care. I am a firm believer that providing the population a better life helps me in the long run. I continue to see Medicaid plans as I want to provide quality footcare regardless of a patient's particular insurance. The problem was in the promise of Obamacare.
The original promise of the Affordable Care Act was that Medicaid plans would be more federally funded. The reimbursements were supposed to be raised somewhere in the neighborhood of Medicare rates. Medicare rates are low but at least make some sense. This has not happened. Medicaid reimbursements continue to be 50% that of the already low Medicare rates. That means that I have to see twice as many Medicaid patents to make the same money as seeing one Medicare patient. Worse, it is a three to one ratio with private insurance patents. I try to ignore his fact, but I am getting tired.
I have toyed with the option of stopping Medicaid patients completely. A few years ago, Michigan Medicaid did not cover Podiatry. I saw less patients, but it provided the same revenue to the practice. The problem is that I would be going against my conscience. For some insurance plans, I am the only provider with the ability to do many procedures. Patients' are already traveling some distance to see me and would need to keep heading South for treatment. I wish someone would provide a solution.
My last present problem is information requests from insurances. I have no problem providing chart notes when asked for them. This is the world we live in. My objection is no feedback. Doctors send chart notes and never get a report. Someone is evaluating the notes but never get back to us. I would appreciate a simple report that helps me in the future. I guess "NO NEWS IS GOOD NEWS" will have to suffice.
April 6, 2015
There has been a shift in testing criteria recently. Insurances are making it difficult to get an MRI for many patients They are allowing a CT scan or diagnostic ultrasound without approval. While I was upset at first, it actually makes sense.
An MRI has become an overused modality. Some physicians order an MRI for anything. I see an MRI ordered for superficial diabetic ulcerations and ganglion cysts, MRI's show a wealth of information but is an overkill in many cases. It is also very expensive. The average lower extremity exam costs about $1300. A CT scan is half the price and shows me the bony structures just as well in most cases. A diagnostic ultrasound is very useful in achilles tendon tears and neuroma evaluation.
Case in point is ankle arhtroscopy. Before performing an arthroscope of the ankle, I would always get an MRI to rule out major pathology in the joint. My rationale is to confirm that I will not run into large bone defects, masses, and unexpected situations. Medicolegally, it also it a good idea. The insurance company suggested a CT scan as an alternative. Since I am not worried about any ligament damage in these cases, it serves the same purpose. This one change saves the healthcare community a great deal of money.
Is the MRI better? YES
Is the CT scan adequate? YES
This is a good example of adapting to a new medical climate. You can fight the change or adapt. I am choosing to adapt. After all, Coach K of Duke just won a National Championship with 4 Freshman Players. This is the same guy who graduated almost all of this seniors back in the Grant Hill days.
March 31, 2015
Kevin Durant is out for the season with a nonunion of a 5th metatarsal fracture. I commented a few month ago concerning the injury. This will be his 3rd surgery and questions need to be addressed. Every " podiatric expert" is giving their 2 cents of the proper procedure. It is now my turn.
Before I begin, I have never seen the xrays or know any more information than every sports fan. It sounds like the original surgery was the placement of a large cancellous screw down the shaft of the bone.. While being an acceptable procedure, it has a major drawback. It sacrifices a great deal of bone stock in the shaft of the bone just by inserting the screw. Failure of this procedure can be devistating as the bone integrity has been violated. I prefer a small cortical screw across the fracture followed by application of a metal plate.
The procedure choice is a matter of opinion. The second surgery to replace the screw after Durant played 28 games is puzzling. The thought was that the head of the screw was irritating Durant while he was playing. The doctors replaced the screw with a headless screw. I cannot figure this out. If the fracture was healed, the screw can be removed completely. The screw head being prominent would be irritating, but I can imagine a professional athlete such as Durant taking time off for an irritant. The fracture must not have been healed at this time.
Now, a bone graft surgery is planned. The thought is that they will take a calcaneal bone graft and place it across the fracture. The will probably use some Platelet Rich Plasma (PRP) product along the fracture. Why not a plate?? Experts are quoting studies that show the success rate of the bone graft surgery. The problem is that there is less studies using surgical plate fixation.
A professional athlete that make tens of million of dollars gets the best treatment possible. Money is just not a factor in his treatment. A bone stimulator can be used from the onset. PT can be done around the clock. The doctors are dealing with a mid 20's world class athlete with no medical problems and great health. This should just not be hard. GOOD LUCK KEVIN!!!!
March 10, 2015
The change in weather has felt great in Mid Michigan.. Februarry was the coldest month on record in the area with an average temperature of less than 11 degrees. The 40 degree temperatures have given us relief and confirm that baseball season is only 3 weeks away. The Spring marks the beginning of our busy season and there are many conditions that require attention.
The Spring means that more people will be active and playing outside. We see a rash of ankle sprains, tendonitis, and foot fractures once the weather changes. People start playing sports, running, jogging, and just doing lawn work. We try to make appointment available quickly for these more emergent problems. These are ailments that require quick attention.
Many patients still go to the Emergency Room, Urgent Care, and to their Family Doctor for these problems. The truth is that these doctors refer many of these problems to us after the initial visit. Most insurances do not require a referral. Midland Family Footcare is fully equipped to handle all of these problems as a primary source. We can diagnose and treat all in one place. We have onsite xray and have the ability to diagnose and even cast within an hour for a new patient.
If the injury requires surgery, we perform surgery quickly at all the major facilities in the area. We have particular interest in ankle injuries and reconstructive ligament repair. Open reduction/Internal fixation of foot fracture is another specific specialty of the practice. The quicker the fracture can be fixated, the faster the recovery time. Patients that wait for weeks before seeing us are just delaying the healing process.
Midland Family Footcare tries to be a primary option for acute foot care. We try every year to increase the number of patients who use us for trauma. We strive to appoint these patients within a few days and provide the best care possible. Please spread the word.
February 27, 2015
I am going to be lecturing again this May. The American College of Lower Extremity Surgery (ACLES) is once again holding its yearly conference in Livonia, Michigan on April 29-May 2. I have been asked to lecture at the conference and is once again an honor to speak.
The conference is attended by severeal hundred Podiatrists from all over the country and some from around the world. It tries to cover a great variety of topics ranging from Surgery to Practice Management. The best part of this particular conference is that new ideas and procedures are welcomed to the format. Many conferences shy away from new topics that may be controversial. The ACLES opens the open exchange of ideas. Topics such as laser nail terapy and Podiatric accupuncture are allowed to present lectures and ideas.
I will be lecturing on "Criteria for Billing Diabetic Shoes". I have always lectured on surgical matters in the past and have decided to lecture on something with a wider appeal. Every year, the criteria improsed by Medicare becomes harder for a podiatry office to comply. We have worked very hard to achieve a small rejection rate on Diabetic shoes and I will try to convey our system to the ACLES conference. The average office is running almost 30% rejection. We are down to about 5% with our system.
I am going to try to lecture at more conferences over the next few years. I enjoy the experience and really enjoy sharing information with my collegues.
February 9, 2015
I have changed the format of the website. I started Midlandfootdoc.com 3 years ago and has been successful in providing information of people in the Mid Michigan area. It serves to attract new patients and educate people in the many facets of my practice. The change represents a freshening of the appearance.
The web hosting company uses a format that can be changed very quickly. The old format made each page present after a large banner. It was necessary to scroll downwards to reach the actual page. The new format allow the content to be seen when the page loads. I also prefer the choice tabs to be on top rather than in the left column. The content does not change with the format.
While I concentrate on promoting to the Mid Michigan area, Midlandfootdoc.com reaches all around the globe. The website gets 20% of its traffic from Brazil. We treat a fair number of people who are from Brazil and working with Dow and Dow Corning. This probably allows news of the website to attract web visitors from this populous country. Some of the information, especially diabetic shoes, reach all over the US as the Diabetic Shoe Program is a national entity.
Please let us know whether the website format change is helpful. Let us know what else should be in the website.
Thanks to everyone for helping Midlandfootdoc.com be a vital part of Midland Family Footcare.
February 3, 2015
Obamacare is in full force. This has allowed more people to be insured and also has allowed people to choose a wider range of health policies. Many people are now choosing insurances that have a higher deductible. Saving money on premiums is fine but be aware that it comes with a cost. More money comes out of the patient's pocket which presents for a problem with the office.
Deductibles of $5000 or above become major medical policies for an office. The patient is not expected to ever have their insurance pay anything. The patient is appeciably cash in regards to a private office. The patient should be aware of this and should pay for procedures the day of treatment.. We can submit the claim to your insurance to go towards the deductible, but at least a partial payment should be made.
Many Podiatry publications are advising using a credit card on file as a solution to this problem. A patient provides a credit card that will be charged once the insurance claim goes to your deductible. My problem is that credit card info will be too available in the office. It would allow an opportunity for credit issues and fraud that I do not want to be responsible for.
Be aware of your deductible. If it is very high, the charges will be billed directly to YOU. Inform my staff of any situation where payment needs to be paid today.
January 26, 2015
The new year always brings a lot of changes to health insurances. Most health insurances change policy on January 1st or July 1st. We try very hard to inform patients' on covered procedures but it is impossible for us to know every change. The biggest problem that we are having is with orthotic devices.
Orthotic devices are traditionally difficult to get covered by insurances. Medicare, Medicaid, and many HMO products automatically reject custom orthotic devices. Some Blue Cross policies will cover a portion of the devices or the whole amount. The policies vary a great amount and it changes constantly.
Custom foot orthotics are just that- CUSTOM. They are casted for the individual patient and therefore non returnable. It is up to the patient to realize that they will be responsible for the cost if insurance rejects the charges.
Our cost for orthotic devices is $300. This includes the entire process of providing foot orthosis including casting, follow up and the devices. This is actually very low compared to other providers in the area. We feel that orthotics are extremely important and try to keep them affordable to most of our patients. We expect $150 to be paid immediately and we can bill the rest of the cost on a monthly basis.
Custom orthotics are non-refundable. Please check coverage before they are ordered. The patient is ultimately responsible.
January 12, 2015
The residency interviews are over for another year. I just got done going down to Texas to interview 4th year Podiatry students for the Genesys 3 year residency. Our team of 4 doctors and 2 residents interviewed about 40 prospective candidates to 2 spots. Podiatry has a match system and presently does not have enough residencies for all students. A few thoughts come toe mind.
1. The students know an awful lot. I am always impressed by the educational level coming out of the schools. Most of the candidates that we interviewed would make fine residents. Choosing the right candidate was splitting hairs.
2. The interviews could be done over an internet conference and gain the same information. It would save a great deal of time and money.
3. The location of the interviews is still ridiculous. Frisco is a beautiful, new area of Dallas. It is very upscale and even where the Cowboys are building their headquarters. The problems is that that it is 40 minutes from the airport and the special price for the hotel is over $200/night. Making 4th year students spend $200/night for several nights is almost criminal.
4. It is much easier being the interviewer. The students are under so much pressure to interview well that it is sad. There should be enough residencies for all candidates. The quality and location should be the goal. Without obtaining a residency, a student becomes in limbo. They have their DPM degree but cannot practice in almost the entire country. They have to obtain a preceptorship to be able to defer their student loans which are about 250,000. That is a lot of pressure.
5. I still enjoy doing the interviews. It gets me back to an academic mode that I really enjoy. I enjoy the interaction with the students and relish in their excitement.
December 8, 2014
The Diabetic Foot Center at MidMichigan Hospital- Midland is now closed. The Foot Center has been part of the Diabetic Center for a very long time. I have no idea why it was closed, but it leads to a gap in the treatment of diabetes in the Mid-Michigan area.
Foot care is a very important part of management of a diabetic patient. Diabetics are prone to poor circulation and neuropathy of the lower extremities. Diabetics respond more poorly to infections and have a much higher incidence of ulceration and amputation. Evaluating diabetics feet is extremely important just as an annual eye exam is a must.
We are seeing a great many patients that use to go to the Diabetic Foot Center. We will continue to evaluate feet for care and provide access to quality Diabetic shoes. Diabetics with risk factors and on Medicare are elgible for a pair of inlay depth shoes once a year.
Please let your Primary Care Physician know that you need Diabetic Foot Evaluation or if you have any problems. We will try to fill the void created by the the closure.
December 2, 2014
There is a new prescription antifungal on the market. Jublia (efinaconazole) is the first new topical antifungal for fungal nails on the US market in over a decade. It is getting a lot of publicity and a lot of advertising dollars.
Jublia is very similar to many products. Presently, almost all the topical antifungals are based on tolnaftate as the active ingredient. The mechanism of geeting the substance into the nail was the difference between products. We have been using Formula 3 for a number of years which is a type of tolnaftate product. Jublia uses a new active ingredient.
The real truth is that topical solutions are very ineffective in treating significant fungal toenails. Jublia reports a 15% success rate in its own trials. The tolnaftate products are in the 10% range of effectiveness. These products work well with the start of a fungal nail involving just the distal tip of the nail.
Lamisil (terbinifine) tablets is still the most effective means of treating fungal toenails. It is 75-80% effective and is inexpensive. There are side effects but it normally well tolerated in 95% of patients. All products require the nail to grow out completely which takes 4-6 months.
Let us know if you want to try Jublia. The website is jubliarx.com.
November 13, 2014
The late season rush is upon us. The holiday season for medicine always means that patients are trying to get things done before January 1. Many insurances start a new deductible year January 1st and patients have met their deductible for the year. The news is reporting most deductibles are being increased for the next year, so we fully understand the reasoning.
We have added surgical times for December. I will be performing all day surgery on 2 Fridays next month instead of just the mornings. Most surgeries are being scheduled for late January and February. There are a few spots still remaining for anyone who needs a procedure for 2014.
Please call the office and let us know if the surgery is needed for 2014. It will be difficult, but we may be able to acommodate a few more people. The deadline will be Thanksgiving unless it is emergent.
October 31, 2014
The NBA season is just starting and already there are two Podiatric problems that have had a dramatic effect. Kevin Durrant, the reigning MVP, and John Randle, a first round draft pick of the LA Lakers are sidelined with lower extremity injuries.
Durrant suffered a Jones fracture of the 5th metatarsal in the exhibition season. A Jones fracture is a fracture of the 5th metatarsal shaft past the base of the bone. This is significant as these fractures have a high incidence of not healing. A 5th metatarsal base fracture has a much higher recovery rate. Surgery was performed on Durrant and will be reevaluated in 6 weeks. Normally, a plate and compression screw is used to fixate the fracture. An older method is to put a larger screw down the shaft of the bone.
Original reports called for 6-8 week recovery. This is very optimistic. Even an NBA athlete will require 10-12 weeks to be back on the court. The impact of a 6 foot 11 inch professional athlete requires the bone healing and strengthening the tendon.
John Randle suffered a tibial fracture in his first NBA regular season game.This is breaking the main bone of the lower leg. He is out for the season although his long term prognosis is very good.
From a biomechanical standpoint, the impact that the NBA athletes absorb is remarkable. These players are jumping over 30 inches off the ground at all different angle and landing points. No wonder that the bones cannot always absorb this stress.
Good luck to Kevin Durrant and John Randle in their recovery.
October 8, 2014
I am considering increasing my staff by 1 person in the near future. Obamacare plus the EMR system has led to an increase of patients and time to see each patient. I am just not sure of where to place the additional person.
Presently, we have a receptionist, back assistant, and a part time business person. My part time business person, Penny, also can fill in for the other two employees. This has worked well for many years. Now, things of changed.
I can add another front person to help with the many referrals and preauthorizations that are required in a given day. Another possibility is to add a back person whose responsibility would be to help document into the EMR system and work up new patients. This could be a medical assistant or better yet a Nurse Practitioner(CNP). A CNP could also treat patients with me supervising the treatment.
I need the help of the medical community. What makes sense? The modern system of medicine is always chang. Midland Family Footcare must change also. Email me any suggestions.
October 2, 2014
I have been in private practice for 23 years and I still cannot fiqure out something. How do I make the public know all the things that I do as a Podiatrist? I am asking your help for the answer.
I deal with this fact of life every day. A patient has an ingrown nail and comes to see me. The same patient sprains their ankle and they go to Urgent Care. I have gotten use to this fact and have tried to educate the public. In fact, this website is one of my attempts to do this very act. My frustration grows when friends even don't know.
My daughter's friend recently fractured her foot. I do not have a close office, so they go to their family doctor for xrays and treatment. The Primary Care Physician (PCP) diagnoses 4 fractures by xray and schedules an appointment with an orthopedic surgeon. While I am picking up my daughter at her friend's house, I ask about her foot and explained that it seemed to be a Lis Franc's injury and that the orthopedic consult is to determine whether surgery is needed.
The parents were somewhat shocked. No one had explained the injury or possible treatment plan. No one had even mentioned surgery. Of course, they had no idea that I knew anything about this problem. IT IS ONLY A FOOT!! The orthopedic surgeon, of course, did surgery. The fault in this situation lies with me and my Podiatric collegues. People just do not know what we do.
Please contact me with any ideas or suggestions to educate the world on the scope of Podiatry. I have failed miserably for 23 years.
September 24, 2014
I am finally perfroming my first cases at Riecker Surgery Center. It has taken a very long time and a ton of paperwork to allow this to happen. I am going to try to devote one Friday morning and one Tuesday morning to Riecker per month. This will allow about 6 surgeries per month to performed at this facility.
Riecker Surgery Center is on the grounds of Mid Michigan Midland Hospital and is a free standing building. The advantage of the Surgery Center is to allow easy in and out procedures that avoid the problems encountered at the main hospital Most of the Podiatric procedures can be performed in a surgery center environment as most are short and outpatient. I will not be using Riecker for ankle or rearfoot cases as well as diabetic infections that require admission to a hospital.
This addition in privileges give the patient more options. Choices are now:
Mid-Michigan Hospital Clare- Friday mornings
Genesys Health Park
The Surgery Center of Health Park
Great Lakes Bay Surgery and Endoscopy- Wednesday afternoon, once a month
Riecker Surgery Center
I have the option of using the main hospital OR in Midland but am unsure of how to fit that into the schedule. Let us know of any particular concerns or needs.
September 18, 2014
Another ankle injury has hit the news. Robert Griffin III, the quarterback of the Washington Redskins, dislocated his ankle this Sunday. This injury will put him out of the game for at least 12 weeks. The amazing thing is that this was a non contact injury.
An ankle dislocation basically means that the ankle joint came apart. The talus needs to completely come out from beneath the tibia without fracturing bones. This is extremely difficult to do. Normally the fibula will break before the talus can come out of the joint. A great deal of force is needed at the correct ankle to cause this to happen. Falling off a height, or having the body torqued while the foot is planted would be typical times. Robert Griffin jumped.
The injury to Griffin came as he threw the ball while running to right. I have no idea how this could cause the ankle to dislocate. His foot did not get caught. He just threw the ball off of one foot. Possibly, Griffin has a very flexible ankle that already had stretched ligaments or it is a freak occurrence.
The ankle had no fractures in this case. The problem is that all the soft tissue must be torn to pieces. Treatment would be to put the joint back in place and then immobilize for at least 4-6 weeks in a nonweightbearing cast. Rehab to strengthen the ankle will be at least a 2 month proposition.
Good luck to RGIII in his recovery. NFL players are only 1 hit away from the injury list. RGIII did not even get hit.
September 11, 2014
School is back in session which means that kids are back into their variety of sports. Every year, we see a host of injuries in young people starting with their team. This includes soccer, football, hockey, gymnastics, etcc. Each sport presents its' own risk factors. How do you prevent them and when should they go to the doctor?
Some injuries cannot be prevented. It is the nature of physical activities for the body to give out. My best advice is to start slowly. Many children are sedentary during the summer and try to do the full activity right away. Slowly build up endurance and strength for the sport. The muscles take time to handle the stress.
Proper equipment and bracing can prevent injuries. Make sure shoes and pads fit correctly. Kids grow. The same cleats might not fit since last year.
Allow rest. We all want to play through the injury, but sometimes rest is the best medicine. Do not let coaches play your child if the injury in dramatically effecting the athlete. This is especially true of ankle sprains. The ankle will not get better if continually stressed.
A visit to the doctor is indicated if it preventing the athlete from playing or the condition has lasted for more than a week or two. Young people usually heal quickly. When they do not heal, take it very seriously. There are many ways to treat young athletes that will lead to quicker recovery and increased stability.
August 19, 2014
It has finally happened. I am finally on staff at Mid-Michigan Hospital-Midland and Riecker Surgery Center. After years of problems, and a credentialing process that took over 6 months, my staff privileges were granted at both facilities.
How is this going to effect patients?
1. Patients will have one more option as to facilities to perform surgery. I will still be doing surgeries at the other facilities as scheduled. Complicated procedures will still be done on Friday mornings at Mid Michigan-Clare and Genesys Regional Hospital.
2. Patients can now be admitted to Mid Michigan-Midland and have me continue care in the hospital setting.
3. I am not sure how consultations will work in the hospital. Primary Care Physicians will need to contact me for consultations. I am presently informing family physicians of this option.
4. Scheduling will be the biggest problem. I am not sure which days are available for outpatient surgery at Riecker Surgery Center. I am also not sure how this will effect my schedule.
There will be a learning curve with the new facility. Please let us know if you prefer surgery at Mid Michigan-Midland and Riecker Surgery Center.
July 29, 2014
Vacation time is upon Midland Family Footcare. The office will be closed from July 30-August 12. We will be back in the office on Wednesday, August 13th. I will be in town until August1st as I am at my Grand Blanc office on July 31st.
Appointment can still be made during the vacation by leaving a message on the answering machine. My staff will be checking messages regularly. I will still be answering emergency phone calls a 734-516-8267.
If you have a foot problem during the vacation, options include:
1. Mark Young DPM- He is right next door to our office. Phone #:989-832-5114.
2. Urgent Care- They can address problems that cannot wait until we are back.
3. Emergency Room
"All work and no play makes Johnny a dull boy"- The Shining
We will come back from vacation refreshed and ready to take care of foot problems for many years to come.
July 23, 2014
We are seeing more new patients than ever before. 2014 has seen an increase in new patient volume. Referrals are coming from more different sources as well as direct patient contacts. We try to acommodate our patient's needs, but it becomming difficult to schedule these new people.
Several things will help us.
1. Get to the appointment 15 minutes early to fill out paperwork.
2. Have your medical history, allergies, and medications already printed out for us to copy.
3. Bring any lab reports and xrays with you so we do not have to redo the testing. We have access to Mid Michigan Hospital reports via the computer.
4. Plan on a one hour experience for a new patient in the office.
5. Call the office if you cannot keep the appointment. We are usually able to fill the empty spot with a patient needing care.
Thanks again for helping the practice row since 1996.
June 24, 2014
The arthroscopy part of the practice has increased a great deal recently. I perform two arthroscopic procedures:
1. Ankle arthroscopy
2. Endoscopic plantar fasciotomy and gastroc. release
These are somewhat specialized surgery and not being performed by all podiatrists or orthopedic foot specialists. Both procedures are long standing in their efficacy and I having been performing both for more than 10 years.
The ankle arthroscopy is puting a camera in the ankle joint to diagnose and treat a variety of problems. It is the same idea as a knee athroscope except in the ankle. Many problems such as locking of the ankle and chronic joint pain can be treated with 2 small incisions and a recovery time of about 3-4 weeks.
The endoscopic plantar fasciotomy (EPF) and endoscopic gastrocnemius release (EGR) use the same camera and are used for plantar fasciitis (heel spurs) and achilles tendonits respectively. The EPF allows part of the plantar fascia on the bottom of the foot to be released allow the fascia to be stretched. The EGR involves release of the membrane behind the calf muscle so the muscle is not as tight. Both involve 2 small incisions and a recfovery time of a few weeks.
Check out the "Surgery for Heel Spurs" and :Special Surgery" sections on the website.
May 27, 2014
Serge Ibaka made a miraculous recovery of a calf sprain to lead the Oklahoma Thunder to victory in game 3 of the NBA Western Conference Championship. There are some very interesting items in this injury from a podiatric standpoint.
Ibaka tore his gastrocnemius muscle during the last game of the Conference Semi-finals. He was barely able to walk and put weight on the area according to reports. Muscles are made up of fibers within the muscle. Usually a small amount of fibers rupture in an injury (like torn ropes). This leads to a hematoma which is just blood in the tissues. It also causes swelling and pain. Why was Ibaka's diagnosis so poor that he was ruled out for the rest of the playoffs? The MRI.
An MRI is considered to be the gold standard for almost all athletic injuries. The real trurh is that the MRI is not always correct. The blood and swelling in the calf probably made the rupture and strain in the gastrocnemius more pronounced that it really was. I see this on tendon ruptures all the time. The MRI is read as a rupture but is actually fluid in the tendon when surgically exposed.
Once the swelling went down in Ibaka's calf, the MRI showed a more manageable injury. The moral is to treat the patient and not the MRI. Ibaka comes from the Congo and is one of 18 children. He is an NBA warrior but let's not consider this a miracle. It is a very motivated, worldclass athlete whose injury was not well diagnosed.
May 6, 2014
The Affordable HealthCare Act is now further in effect and the world has not come to an end. Millions of people have signed up for insurance on healthcare.gov or through the phone number. This is a little deceiving as many were Medicaid recipients having to alter their coverage. With all the problems with the website at first( A Barack Obama embarassment), things are going OK.
Our practice has seen a new influx of newly insured people. Most of these patients are Medicaid recipients that previously did not qualify for insurance. All the previous patients that were covered through Midland Health Plan are are also now covered by a Medicaid type plan. The item that is still unknown is the level of reimbursement for these patients. Originally, the federal government was going to fund Medicaid a a much higher level to make the reimbursements on par with Medicare levels. Whether this is the case is still up for debate.
I welcome Medicaid patients as a committment to the MidMichigan Community. My practice has never been about the bottom line. I feel a certain civic responsibility to provide quality care for all patients. In reality, this hurts the practice in certain ways. Presently, Medicaid patients take up appointment times that do not generate an appropriate revenue. In a weird irony, seeing less Medicaid patients would actually generate more revenue as I would have more appointment times for higher paying patients.
Presently, I am not going to change our policy. The government changing the reimbursement rates would make this decision easier.
April 17, 2014
The Medicare reimbursement data from 2012 is now available online. The Wall Street Journal provides a link to the data. The link is projects.wsj.com/medicarebilling.
It provides information on all 880,000 doctors in the U.S. that billed to Medicare in 2012. It breaks down the reimbursement by procedure codes. It is interesting for the practitioner. The general public would have very little interest except for the outliers who billed an abnormally high amount to Medicare.
These numbers would be more interesting if they had a percentage attached to them of where this places the practioner in the region and the country. This information is available and used to flag overused billing codes by doctors. The other take home point are that our reimbursement rates are pretty poor. Podiatrists get paid around $30 for mycotic nail care. This includes evaluating their feet for medicare coverage, billing the procedure, the debridement, charting, and friendly reminders of the risks that they face.
The next time that someone asks me "Do I get paid too much for cutting toenails?", the answer will be an emphatic NO. How a Podiatrist can bill over 1 million dollars to Medicare as 1 practitioner is still a mystery.
Physician data will now be available to the general public. In the next few weeks, billing data from Medicare will be available to the public concerning the 880,000 doctors in the United States. What does this mean?
Medicare is able to keep track of the reimbursement rates to each doctor over several years. The idea is to point out the outliers to the system. The American Medical Association has fought this release of information for many years. I personally have no problem with releasing the information. There may particular reasons that some practitioners lie either high or low compared with the national average. It will also give more incentive to re-examine billing practices.
We live in an information age. Almost every piece of data about everything is available at a click of a mouse. Medical reimbursement is no exception. I will follow up with the link to access the data as soon as I locate it. I also have no idea as to how I will compare to the rest of Podiatry. I may be regretting this blog.
We are asked "Where do your patients come from?". There is no easy answer.
Patients come from many different sources. First, physician referrals are a very valuable patient source. Many family physicians and specialists refer people to us for their foot needs. From diabetics patients to fractures, we provide a service for the Midland Medical community.
Second, patient referrals are a continual source of patients. This is a happy source since our present patients' are testimony to good physician care. It means that a present patient is confident enough to refer a friend or family member. The patient is already comfortable with the office.
This website provides an increasing large patient base. Our goal was to educate and raise awareness of the practice. It is becomming increasingly valuable as a larger percentage of people search for everything electronically. It has also brought a younger demographic into the office.
Patients come from seeing the sign, health insurance lists, yellow pages, and a bunch of other sources that even I do not know. The area we draw from continues to increase. We draw from as far away as Flint and West Branch. Thank you to the Mid-Michigan community for almost 18 years in Midland.
March 5, 2014
The cold keeps coming. All Michiganders have experienced a very cold, snowy winter. The winter has taken it's toll on the office as well.
The continuous salt has worn the carpets. The thermostats needed to be replaced and are now electronic. The driveway has been cleared well but are slippery at times. Please be very careful outside the office. we are doing our best to keep it safe. The carpets will be cleaned as soon as the weather breaks. Please let us know if the temperature of the office is acceptible. We have 2 furnaces and it is hard to get the temperature even throughout the office.
Remember, the Tigers are playing Spring Training in Lakeland. Spring is coming.
February 25, 2014
I have been asked to lecture at the American College of Lower Extremity Surgery (ACLES) meeting in Livonia, MI at the end of April. I have attended this meeting for the last 15 years and will be the second year in a row that I lecture. I lectured last year on the use of the Graft Jacket type product in ankle surgery. Ths year, I will lecturing on the use of implants for arthritis in the great toe. It is an honor to lecture and really enjoy the process.
The ACLES meeting is one of hundreds of conferences that can be attended to gain CME credits towards our podiatry license. Michigan requires 150 credits every 3 years to renew your license. The advantage of the ACLES meeting is that it is varied. There are surgical lectures, practice management seminars, international podiatry news, and anything that relates to the foot world. It also allows all ideas and a myriad of lecturers to have a voice.
I am trying to encourage practitioners to support the ACLES. They provide alternative board certification and encourage a free exchange of ideas. It is also somewhat of a bargain for about 35 credit hours. E-mail me with any questions.
February 11, 2014
It is my turn to complain. I have been having a nightmare trying to connect my biller's software with my new amazing charts EMR system. I know that the average patient could not care less, but this is a forum where I can vent.
Amazing Charts is an EMR system that is quite affordable to the average practitioner. I use an outside billing office that uses a system called E-Thomas from Genus Solutions which is based in Southfield, Michigan. Amazing charts advertises that they easily connect to many software packages including E-Thomas. The idea is that they can share data so we do not have to enter the patient information twice. We can also use our existing patient database. Sounds great. Not so much.
First, the interface costs $500 on each end just for the right of transferring data. Second, neither party has any interest in making it happen. They activate the interface but will not help set up the rest of it. They tell me to hire an IT person. OK!!!!
I hire the IT person who has to start from scratch and contact the parties in both companies. Only 1 person at Genus Solutions can help at all and he tends to be on vacation a lot. The IT person thinks that I am small time and thinks that his prices are too rich for my blood. I assure him that I am willing to spend the $1000-$1500 that it will take to get it done. I am still waiting for this to actually happen.
The real truth is that neither company wants to transfer data. Genus Solutions wants me to use their EMR software. The problem is that it is very expensive. Amazing Charts really wants me to use the billing software built into their system. The problem is that my biller has E-Thomas and it is not up to me. It is a tangled web.
Both companies should have a general instruction sheet to be handed to an IT specialist. They should not have to start from scratch and contact everyone. IT specialists always act like they are inventing the wheel. Networking is really not that hard with the new systems.
Here I wait waiting for the wheel to be invented. Thanks for letting me blow off some steam.
February 1, 2014
The Winter Olympics start this Thursday. The opening ceremonies are Friday in Sochi, Russia. I love the Olymic Games.
The time change in Sochi means that many events can be seen live during the morning and afternoon. NBC will be showing live coverage on NBC Sports Channel and MSNBC. We be keeping the games on in the waiting room. Please let us know if you need to change the channel to catch a different event.
We will have the same policy for the FIFA World Cup this summer. My staff is already dreading having a boss who loves sports. The Weather Channel will take a brief hiatus.
January 29, 2014
I have decided to swollow my pride. I have applied for outpatient surgical privileges at Riecker Surgery Center at the hospital. I have always maintained that I would not get on staff at a hospital that has never welcomed me since 1996. I guess never is a short time.
I have tried over the years to get in staff on Mid Michigan Hospital here in Midland. Even though I have been on staff at Genesys Health Park since 1997 and Mid Michigan Hospital-Clare since 2003, Midland has always found a reason to say no. The fact that it would aid my patients' well being and I use the hospital for many testing and consultations, there has always been an administration reason for not allowing me to have staff privileges.
A few years ago, I was invited to perform outpatient surgery at the outpatient center. The basic reason is need. Riecker is not performing enough surgery so economically the hospital needs more practitioners to bring cases to the center. Great Lakes Surgery & Endoscopy Center has taken a lot of business away from the hospital. My gut check reaction was to be stubborn.
Getting on staff at Riecker would be beneficial to patients. Now, I bring patients to Mid Michigan-Clare on Fridays or to Great Lakes on Wednesdays. Opening up surgery time at Riecker would offer another option. I have some patients that have difficulty driving to Clare and lose people. This is more important than my pride
I will people up to date on this new option for surgery..
January 19, 2014
The practice continues to evolve every year. Ankle disorders and ankle surgery continues to become a larger part of the practice. Many problems that used to go to orthopedic surgeons now come through our door. In fact, orthopedists are referring patients to us.
Many ankle problems are ignored by family physicians and internists. Normally, ankle pain is less severe than knee or hip pain. People can function in a limited capacity with an ankle ailment. However, many problems can be addressed.
Problems with the ankle include arthritis, chronic ankle sprains, bone chips, and chronic tendonitis. Injections, bracing, and complete evaluations can be done at an ordinary visit. Outpatient surgery includes arthroscopy, ankle stabilization, and tendons repairs. These surgeries require a 4-6 weeks recovery time and are very successful.
Call for an appointment for your ankle problems.
January 8, 2014
Happy new year Tri-Cities. The weather so far has been awful except for skiers and snowmobilers. We have survived another year and have been in Midland since 1996. Dr. Hughes actually started the practice in 1993.
2014 will see the implementation of a Electronic Medical Record (EMR). I am presently setting up a system called Amazing Charts. The old paper charts will be a thing of the past. Patients will see a laptop being used during treatment to record information. Patients will need to bring in an updated list of medications and allergies.
The Affordable Health Care Act (Obamacare) has made the EMR a priority. We are have been slow to adapt. Lazy would be the correct term. I am sure the transition will be problematic, but will work out in the end. Please be patient during the transition. It will allow us to send prescriptions directly to the pharmacy, communicate with your primary doctor, and many other nice things.
Thanks for your patience in the next few months. Keep warm.
December 30, 2013
Midland Health Plan is shutting down it's operations as of April 1, 2014. This is a direct response to the new health care act. I have had patients complaining about losing their coverage and that they are without insurance. This is absolutely wrong.
Midland Health Plan was a county ran program for the uninsured who did not qualify for the Medicaid program. The coverage was poor but it was better than having no health insurance at all. Now, the people who qualified for Midland Health Plan can get better coverage through Healthcare.gov at a subsidized price. This is the reason for the health plan shutting down. It is actually a good thing.
There are things not to like about the Affordable Healthcare Act. This is a thing to rejoice. The government has done a poor job in informing people of the changes in healthcare. The media sometimes spends so much time judging the system rather than to inform. Go on Healthcare.gov and check out available plans and their cost. All Midland Health Plan customers should be able to get a plan at an affordable cost. People without access to the internet can call a toll free number or go to te library to use the internet.
December 17, 2013
We are in the process of trying to expand the in office capabilities of performing surgery. Presently, procedures such as hammertoes, soft corn removal, and soft tissue masses are being performed in the in office surgical room. We would like to perform simple bunions and other minor bony work in the office.
In office surgery has the advantage of being cost effective. Hospitals and surgical centers can charge for room costs and have sedation available. Office based surgery is done under local anesthetic without sedation. This saves thousands of dollars.
Convenience is also a reason for in office surgery. It is easier to schedule and does not require a physical for a healthy patient. We are able to schedule in office surgery on any day except Thursday. Oral anti-anxiety medication can be prescribed before the procedure.
Ask about in office surgery the next time that you are in the office.
December 3, 2013
The recruiting of new residents at the hospital has begun again. Genesys Health Park continues to run a 3 year Podiatric residency. There are 2 positions each year and is considered an excellent residency nationwide. The residents rotate through many departments at the hospital as well as perform surgery at all the hospitals and surgical centers in the Flint area.
The recruiting process starts with externships at the hospital. Fourth year students rotate through the program on a regular basis. This is the best way make a great impression on the program. Many applicants visit the program just to get a feel for the program. The final step are the interviews.
Just like last year, I will be one of the interviewers this January in Frisco Texas. The interview team evaluates the applicant"s transcripts, credentials, and then conduct a 20 minute interview. It is very difficult to separate applicants in 20 minutes. Much of the process is getting a general impression that the person will be trainable and good to work with. The personality is much more important than the answers.
Good luck to the applicants. It is an honor to be part of the interview team.
November 18, 2013
Compound pharmacies are becoming larger in the area. These are pharmacies that mix their own compunds to use for various problems. Many of the creams use standard medications in different proportions to achieve relief of pain and neuropathy.
We are trying two different medications at the present time. One is for skeletal pain and the other is for diabetic neuropathy. They are used 2-3 time daily on the painful area and certainly cannot hurt. It is like using a super Bengay product. Some of the qualities are from lidocaine cream that numbs the area. The other ingredients treat inflammation and irritibility of the tissues and nerve.
Studies show some evidence of these compounds working. It is not a substitute for oral medications but should be used in conjuction with oral medication. The best part is that there are very few side effects.
Ask about these products next time that you are in the office.
November 11, 2013
We have seen a rash of foot fractures in the last few weeks. Most are injuries from sports or falling. The interesting thing is that they originally presented to urgent care facilities around the area.
There are a great deal of advantages of coming directly to our office with an injury. Luckily, the urgent care facilities refer them to us very quickly. The advantages are:
1. Expertise- This is all that we do. The entire practice is devoted lower extremity problems.
2. Speed- We strive to see emergencies such as fractures the very next day. We keep appointments open for this very reason.
3. Cost Effective- We can do xrays and treatment of injuries under the same roof. We do not charge emergency costs and compare favorably with all other providers.
4. No Need for Surgical Referral- If the injury requires surgery, you are in the right place. We perform foot surgery for sprains and fractures on a regular basis.
The bottom line is to think about coming directly to Midland Family Footcare for injuries of the foot and leg. It saves time and money.
November 4, 2013
The Affordable Health Care Act (Obamacare) is just starting to effect a greater number of people. Since it is a politically volatile subject (SHUT THE GOVERNMENT DOWN), there are a lot of misconceptions. I am going to try to give some basic parameters to help.
1. Medicare patients are not affected. Things may change but not because of Obamacare.
2. If you get your health insurance through your employer, there is little effect. Your employer may choose to change policies including a policy on the exchanges, but your employer always has shopped for health insurance.
3. The main people effected are those without health insurance or who pay for their own policy. People may shop for insurance on healthcare.gov (if it ever works). The policies are subsidized based on income and have to meet certain criteria of health care. There are also different levels of coverage available.
4. All citizens must have health insurance. Adults can be covered up to 26 years old under their parents policy no matter on living arrangements or income. Those without insurance will be fined on their taxes up to $95/year.
5. Employers with over 50 employees must provide health coverage. Employee contributions to the coverage is still allowed just like it is now. Small businesses can choose an exchange insurance as well.
This is a very simple overview. The cost of your insurance is the unknown. No one really knows what premiums will do under the new law. Please consult with more complete sites such as healthcare.gov for specific information. Human resource departments at your place of business will also help.
October 15, 2013
New medical devices are available every day. There have been great advances in equipment and fixation devices over the last few years. The newest thing that I have been using is compressive staples.
Staples have been used to fixate bone for decades. The advantage is that are strong and easy to use. It takes a fraction of the time that is used to install screws. The disadvantage is that it does not compress. The new staples actually compresses when it reaches body temperature. The takes away the major disadvantage.
I have been using these new devices for rearfoot fusions and some aggressive bunionectomies. Speeding up the procedure leads to less infections and complications. The chance of a bone staple failing or needing to be removed is much lower than a plate or screws.
Ask about these new staples. It is an exciting advancement.