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The Helping Ensure Life- and Limb-Saving Access to Podiatric Physicians (HELLPP) Act

H.R. 1221 / S. 626

Frequently Asked Questions

Sec. 1: Recognizing doctors of podiatric medicine (DPMs, or podiatrists) as “physicians” under Medicaid.

Q: Why is this provision necessary?

A: Recognizing doctors of podiatric medicine (also referred to as DPMs, or podiatrists) as “physicians” under Medicaid is necessary because Medicaid currently discriminates and arbitrarily precludes patient access to a licensed and credentialed specialized physician class, though the services provided — foot and ankle care — are covered benefits.

For more than 40 years, DPMs have been defined as physicians under Medicare, but not Medicaid. Medicaid only covers foot and ankle care if provided by a medical doctor (MD) or a Doctor of Osteopathy (DO). But Medicaid coverage for foot and ankle care provided by DPMs is optional for states, meaning “podiatry services” are teased out and classified as an “optional” benefit.

It’s a quirk in the law that is long overdue for correction, because in virtually all other health-care settings — Medicare, private employer coverage, Federal Employees Health Benefits (FEHBP), TRICARE, the Veterans Administration, and the Indian Health Service, to name several ― patient access to podiatric physicians and surgeons is ensured. Medicaid is the glaring exception.

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Maintaining a separate optional podiatry benefit has the effect of limiting access to care as the focus is on the type of provider rendering foot and ankle care, instead of ensuring the coverage of foot and ankle care. By recognizing DPMs as physicians under Medicaid, Medicaid patients will have another access point to obtain this medically necessary care.

DPMs Provide the Majority of Foot/Ankle Care in the U.S.

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Q: Isn’t this provision a government mandate or an expansion of the podiatric scope of practice?

A: No. This provision is not a government mandate, nor is it an expansion of the podiatric scope of practice. A mandate already exists under Medicaid in that medically necessary foot and ankle care is a covered benefit. However, patients only have access to MDs or DOs, not DPMs, under this mandate. This provision only creates access to DPMs. It does not mandate that Medicaid patients seek care from DPMs. Also, the podiatric scope of practice generally already includes the delivery of foot and ankle care. This provision has no effect on the podiatric scope of practice.

Recognizing DPMs as physicians under Medicaid will have the effect of enhancing patient choices and improving patient access. It will create a full range of medical and surgical options for Medicaid patients to address their individual needs.

This Medicaid patient access reform is a bipartisan effort. It was part of the Senate Finance Committee’s Chairman’s Mark of the Deficit Reduction Act (2005), and the House-passed Affordable Health Care for America Act (HR 3962) in the 111th Congress. It was also part of the US Senate’s Medicare SGR reform bills in the 113th Congress.

The provision neither mandates new Medicaid services or benefits, nor requires any Medicaid beneficiary to seek care from a podiatric physician. It would not expand the scope of practice for podiatric physicians.

Q: Does this provision seek to expand scope of practice for a specific type of health- care provider?

A: No. Doctors of podiatric medicine are physicians. They prescribe medication and perform surgeries. DPMs are licensed by their state boards to deliver independent medical and surgical care without any supervision or collaboration requirement.

DPMs have essentially identical education, training and practice allowances as medical doctors (MDs) and doctors of osteopathy (DOs), including:

• Four years of undergraduate education focusing on life sciences • Four years of graduate study at one of the nine podiatric medical colleges • At least three years of postgraduate, hospital–based residency training

The significant difference between the MD/DO and DPM educational models is that podiatric medical education focuses on the specialty area much earlier and in greater depth and breadth.

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Moreover, most of the health-care field does not differentiate care provided by podiatrists from care provided by other physician specialists in the coverage of medically necessary treatments and procedures. Neither Medicare nor commercial health insurance payers segregates payment based solely by degree.

Q: Isn’t this a state issue?

A: Would someone ask “Isn’t this a state issue?” if Medicaid’s patient access anomaly teased out cardiologists as “optional” providers, or ear-nose-throat specialists were classified as optional for states?

More likely there would be a public outcry that Medicaid patients were at an unfair disadvantage compared to most other Americans in seeking the specialty care that best fit their individual needs.

Currently, Medicaid fails the basic tests of free market competition and patient choice. Medicaid effectively discriminates and can arbitrarily preclude patient access to a licensed and credentialed specialized physician class, even though the services provided are covered benefits.

In a program like Medicaid ― where it is hoped that patient enrollment would be more temporary than permanent, and a patient transition to private insurance would keep him or her in relatively good health ― it seems incongruous that specialty physician access be subject to the political and budgetary winds of the day in each state. Patient access to specialty medical and surgical care may be denied for long periods depending on where someone happens to live; or access may be sporadic and constantly changing depending on where he/she happens to live.

Consequently, doctors of podiatric medicine are fighting battles each and every year in all 50 states and the District of Columbia in order to deliver their highly specialized medical and surgical care to one of the most vulnerable populations in the country.

Moreover, unnecessarily higher Medicaid spending by states also translates to unnecessarily higher spending by the federal government, because Medicaid is financed jointly by the federal government and the states. The federal government matches state Medicaid spending. (See Arizona Medicaid study on p. 6)

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Q: How would ensuring patient access to doctors of podiatric medicine improve Medicaid?

A: Scientific evidence shows that when DPMs are members of the health-care team, outcomes are better, hospitalizations are fewer and shorter in duration, and the health-care system saves billions of dollars annually.

Adult Medicaid patients have consistently worse health problems than individuals enrolled in union or employer insurance. Medicaid patients are more than twice as likely to have diabetes or asthma, and have higher rates of obesity and high blood pressure.

Preventable chronic conditions will become an even greater cost burden for the Medicaid program unless policymakers make the commitment to ensure patient access to preventative or otherwise timely specialty medical and surgical care.

Two prominent studies have found that care by podiatrists for individuals with diabetes alone could save our health-care system as much as $3.5 billion per year.

Thomson Reuters concluded in a 2011 study (accessible at: www.tinyurl.com/trstudy) that among patients with commercial insurance, a savings of $19,686 per patient with diabetes can be realized over a three-year period if each patient visits a podiatrist at least once in the year preceding a diabetic ulceration. Among patients with 6

commercial insurance, each $1 invested in care by a podiatrist results in $27 to $51 of savings for the health-care delivery system.

Among Medicare-eligible patients, a savings of $4,271 per patient with diabetes can be realized over a three-year period if there is at least one visit to a podiatrist in the year preceding ulceration. Among Medicare eligible patients, each $1 invested in care by a podiatrist results in $9 to $13 of savings.

Conservatively projected, these per-patient numbers support an estimated $10.5 billion in savings over three years if every at-risk patient with diabetes visits a podiatrist at least one time in the year preceding the onset of a foot ulcer.

In a different study, Duke University researchers found that Medicare-eligible patients with diabetes were less likely to experience lower extremity amputations if a podiatrist was a member of their patient-care team.

These researchers explained that patients with severe lower extremity complications who only saw a podiatrist had a lower risk of amputation compared with patients who did not see a podiatrist. They concluded that a multidisciplinary team approach that includes podiatrists most effectively prevents complications from diabetes and reduces the risk of amputations.

Additionally, Arizona’s decision to jettison Medicaid patient access podiatrists has led to a “marked worsening of outcomes and cost for patients with diabetic foot infections,” according to a new peer-reviewed study released at the 73rd Scientific Sessions of the American Diabetes Association (June, 2013).

The study Foot in Wallet Disease: Tripped up by "Cost Saving" Reductions concludes that each $1 of Medicaid program “savings” the state anticipated from the elimination of podiatric medical and surgical services actually increased costs of care by $44.

Q: Do Medicaid patients receive foot and ankle care without this Medicaid DPM access provision in federal law?

A: Theoretically, yes. Medicaid patients might receive medically necessary foot and ankle care from another type of health-care professional. However, the US already has a growing physician shortage and Medicaid enrollment will soon be increasing, which means they will likely find it difficult to find a timely appointment with any physician, let alone find a physician who specializes in foot/ankle care.

According to a study by Healthpocket, in early 2015 only 34 percent of physicians are listed as taking Medicaid in a government database, compared to 43 percent in 2013. And according to a US Department of Health and Human Services Office of Inspector General report from December, 2014 more than half of doctors who are listed as serving Medicaid patients are not available to treat them. Among doctors who offered appointments, over a quarter had wait times of more than one month, and 10 percent had wait times longer than two months, the report said.

The current scheme fails to utilize appropriately the full range physician specialists.

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On a related note, non-DPM providers may not be the best equipped to deliver the most appropriate foot and ankle care to patients.

For example, in April 2013 comedian Jerry Seinfeld visited the New York College of Podiatric Medicine (NYCPM) to express his gratitude to podiatrist Joseph D'Amico, DPM, for ending his 30-year struggle with heel pain. Dr. D'Amico, a former chair of the orthopedics department at the school and a long time instructor, succeeded where numerous other medical professionals failed by identifying the biomechanical basis of Mr. Seinfeld's problem.

Mr. Seinfeld shared his experience with a small group of NYCPM administrators. When speaking about his eponymous award-winning sitcom, Mr. Seinfeld said, “I have a hard time watching the reruns because I see the shoes on my feet and remember how painful that experience was.”

Similarly, NBA star Shaquille O’Neal publically recounted his own story where he initially sought care from a non-DPM provider for his unique, vexing foot health problem, but was grateful that he finally saw a podiatrist who was able to solve, permanently, his health issue.

Q: Is there a federal budget cost to recognizing DPMs as physicians under Medicaid?

A: In 2009 the Congressional Budget Office (CBO) estimated a federal budgetary cost for the Medicaid portion of the bill of $200 million over 10 years ($20 million per year).

However, the assumptions used at the time have changed significantly. The previous estimate did not examine savings that would result from the avoidance of unnecessary hospitalization or prevention of lower extremity amputations, and it assumed a greatly expanded Medicaid-eligible population.

CBO’s 2009 score of the DPM physician recognition provision was based on the House- passed health reform bill — which expanded Medicaid to 150% of the federal poverty level (FPL). But the final Affordable Care Act (ACA) legislation signed into law by the president provided Medicaid only to those up to 133% of FPL.

Additionally, the Supreme Court ruled the ACA’s Medicaid expansion must be optional for states, which further reduced the expanded population. CBO estimates that about 6 million fewer people will be enrolled in Medicaid as a consequence of the Supreme Court ruling, reducing overall Medicaid spending by $289 billion over 10 years.

In 2014 CBO assigned a score for the Medicaid and Medicare portions of the HELLPP Act (without the budget offset) of $1.3 billion over 10 years when the HELLPP provisions were included in the Senate’s permanent SGR overhaul bills (S 2110, S 2122, and S 2157). APMA is working with bill sponsors address a misunderstanding by CBO, in that the agency interpreted the Medicare diabetic shoe section as a program expansion. It is not; it is merely a paper-work clarification (See Sec. 2: Clarifying and Strengthening the Medicare Therapeutic Shoe Program).

Regardless of the federal budget cost, the HELLPP Act contains a budget offset provision that would more than cover any additional federal budgetary costs, would 8

strengthen Medicaid program integrity, and would reduce the federal budget deficit (see Sec. 3: Budget Offset / Savings — Strengthening Medicaid Program Integrity).

Sec. 2: Clarifying and Strengthening Coordination of Care in the Medicare Therapeutic Shoe Program for diabetic patients.

Q: What is the current policy issue/problem with Medicare Therapeutic shoes for diabetic patients?

A: CMS auditors are discounting or completely ignoring comprehensive medical examination records submitted by podiatrists and orthopedists to qualify their patients for therapeutic shoes. Consequently, refunds are being asked from the commercial and podiatrist-suppliers.

CMS and its auditors have said they are sympathetic to these problems, but that they must act according to their interpretation of current statute and Medicare program regulations.

Q: What would the Medicare clarifying language do to remedy this problem?

A: The proposed clarifications would maintain Medicare’s system of checks and balances and preserve the role of the MD/DO as the certifying physician, who would still hold ultimate decision-making authority over the patient’s medical care in determining appropriateness of treatment for the underlying condition, diabetes.

The Medicare Therapeutic Shoes section of the HELLPP Act would remove confusion and regulatory inconsistencies in the provision of this medically necessary benefit. It would clarify the role of the prescribing doctor in terms of medical necessity, specifically — shared responsibility with the certifying MD/DO. It would also allow the prescribing physician (DPM /orthopedist) to document physical finding details of risk through identification of one or more of the six lower extremity conditions, which are stipulated under current Medicare statutory and program requirements.

These clarifications would provide several tangible improvements for the Medicare program and diabetic patients by: • allowing each member of the collaborative team—MD/DO, DPM, and supplier— to work together more effectively and seamlessly on behalf of diabetic patients; • significantly reducing frustrations of physicians and suppliers over the current administrative policies involving this benefit; • helping ensure Medicare patients most at risk and eligible for shoe benefit receive it; and • decreasing the need for additional office visits, which would save money for the Medicare program and beneficiaries.

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Q: Is this an expansion of Medicare’s therapeutic shoe program?

A: No. There is a specific rule of construction in the legislation stating that “Nothing in this section shall be construed as expanding Medicare coverage for therapeutic shoes for individuals with diabetes.”

Sec. 3: Budget Offset / Savings — Strengthening Medicaid Program Integrity

Q: What is the budget offset section of the HELLPP Act?

A: The HELLPP Act contains a budget savings / offset section that would close a loophole that allows tax-delinquent Medicaid providers to receive full Medicaid reimbursements. This provision would save the Medicaid system money and more than offset any additional federal budget costs associated with the recognition of DPMs as physicians under Medicaid. Such a mechanism already exists in Medicare and has saved billions of dollars for the public health-care system.

Under current tax law, Medicaid providers who owe significant federal back taxes are still getting paid in full by Medicaid because of this loophole. The Government Accountability Office (GAO) conducted a study highlighting this anomaly, released July, 2012 (GAO-12-857): “Providers in Three States with Unpaid Federal Taxes Received over $6 Billion in Medicaid Reimbursements.”

This loophole has existed for a number of years. GAO estimates that the government could have recouped up to $330 million in uncollected taxes due in 2009 in three states alone if this loophole related to Medicaid were closed in the same manner as Medicare.