ISSUE BRIEF The Equity and Access for Podiatric Physicians Under Medicaid Act Request • Medicare-eligible patients with diabetes seen by a podiatrist had a 23-percent lower risk of amputation and a 9-percent lower The American Podiatric Medical Association (APMA) requests you co- risk of hospitalization compared with those not seen by a podia- sponsor “The Equity and Access for Podiatric Physicians Under Med- trist; icaid Act,” soon to be introduced by U.S. Reps. Lee Terry (R-NE) and • For the general population, each dollar invested in care by a Diana DeGette (D-CO), and U.S. Sens. Charles Schumer (D-NY) and podiatrist results in up to $51 of savings; Charles Grassley (R-IA). • For the Medicare-eligible population, each dollar invested in care by a podiatrist results in up to $13 of savings. Problem The Equity and Access for Podiatric Physicians Under Medicaid Act The current Medicaid (Title XIX) statute covers physician services, in- Treatment costs for diabetic foot ulcers range between $7,439 and cluding in most cases medical and surgical care of the foot and ankle. $20,622 per episode. Estimated costs for a limb amputation are However, the definition of a physician is limited to care provided by a $70,434, and can cost as much as $500,000 over a lifetime. The po- medical doctor (MD) or doctor of osteopathy (DO) as defined in 1861(r) tential and very significant cost savings of ensuring access to podiatric (1) of the Social Security Act (SSA). physicians in all sectors of the health care system—including Medic- aid—cannot be disregarded. “Podiatric Services,” which are not specifically defined in Medicaid (Title XIX) but are presumed to mean services provided by a Doctor of Po- diatric Medicine (DPM), are considered optional, despite the fact that Strong Bipartisan & Outside Support podiatric physicians are educated, trained, and licensed to perform the Removing barriers for patient access to podiatric physicians has en- same foot and ankle care services as MDs and DOs. Doctors of po- joyed strong bipartisan support in Congress, with bill language previ- diatric medicine have been defined in the Medicare statute [1861(r)(3), ously garnering 32 Senate cosponsors and 220 House cosponsors. SSA] as physicians for more than 40 years and are covered as provid- It was included in the Senate Finance Committee’s initial Chairman’s ers in nearly all other federal health programs, including TRICARE, the mark of the Deficit Reduction Act of 2005 and in one of the major Veterans Health Administration (VA), and the Indian Health Service. health reform proposals in 2009. It is also supported by a diverse group of health-care stakeholders including the American Osteopathic Asso- Background ciation and the American Public Health Association. Essential medical and surgical foot and ankle care is covered as a benefit by Medicaid programs in all 50 states and the District of Cost Columbia, but it is not always covered when provided by a Doctor of The Congressional Budget Office (CBO) provided an estimate of the bill Podiatric Medicine. Current law effectively limits Medicaid beneficiaries’ in 2009. However, the estimate must be revisited since the assump- access to the quality, cost-effective services provided by podiatrists tions used at the time have changed. The previous estimate was $200 and discriminates against the type of licensed medical professional million over ten years, but did not examine savings that would result Medicaid patients might see for foot and ankle care. from the avoidance of unnecessary hospitalization or prevention of low- er extremity amputations and assumed a greatly expanded Medicaid- The Equity and Access for Podiatric Physicians Under Medicaid Act eligible population. would save lives, limbs, and money for the Medicaid program—for both states and the federal government. A higher-than-average per- centage of Medicaid beneficiaries are at risk for diabetes and related lower limb complications. Thomson Reuters, which provides industry expertise and critical in- Current Medicaid may deny patient access to formation to decision makers in financial, legal, tax and accounting, the licensed and credentialed medical and surgical and health-care areas, conducted a three year study (accessible at: specialty care provided by podiatric physicians, www.tinyurl.com/trstudy) that arrived at, among others, the following conclusions: even though the care they provide – foot and • Patients with diabetes in the general population seen by a podia- ankle care – is a covered benefit. trist prior to a foot ulcer diagnosis had a 20-percent lower risk of amputation and a 26-percent lower risk of hospitalization than those not seen by a podiatrist; Prepared by the American Podiatric Medical Association, 9312 Old Georgetown Road, Bethesda, MD 20814, 301-581-9200, www.apma.org. Contact [email protected] with questions. ISSUE BRIEF The Majority of Foot/Ankle Care in the U.S. is The Majority of Foot/Ankle Care in the U.S. is Performed by Podiatric Physicians but Medicaid Patients May Not Have Access The Majority of Foot/Ankle Care Performed by Podiatric Physicians but Medicaid Patients May Not Have Access For foot and ankle issues, most Americans seek out Whenever public or private health insurance programs specialists for their care, typically a Doctor of Podiat- preclude patient access to podiatric physicians, there are ric Medicine, an orthopedist, or other physician. The adverse impacts on our health-care delivery system: majority of medical care of the foot and ankle is performed by podiatrists. 1. Costs increase by driving patients to a more expen- sive point of service (e.g., hospital emergency rooms) Even though foot and ankle care is generally a covered for the same services. benefit under Medicaid, the program currently teases out 2. It exacerbates America’s growing physician shortage a separate podiatry benefit as being “optional” for pa- by not appropriately utilizing the full range of physi- tients, focusing on the provider of services, rather than cian specialists. ensuring coverage of medically necessary care regard- less of the qualified professional furnishing such care. 3. It denies patients the option of seeing the physicians Thus, Medicaid effectively discriminates and can arbitrari- who are best trained for the foot and ankle care ly preclude patient access to a licensed and credentialed they seek. specialized physician class even though the services they provide—foot and ankle care—are a covered benefit. COMMON FOOT & ANKLE PROBLEMS TREATED BY PHYSICIANS Amputation of Toe Ankle Fractur e Open Fi x PODIATRI C Bunion Surger y PHYSICIAN Hammertoe Repai r ORTHOPEDI S T ALL OTHER Metatarsal Fractur e Open Fi x Remove Ingr own Nail Repair Achilles T endon Ulcer Debridement 0 10 20 30 40 50 60 70 80 90 100% Source: Thomson Reuters Market Scan survey data for 2010 commercial health insurance claims Prepared by the American Podiatric Medical Association, 9312 Old Georgetown Road, Bethesda, MD 20814, 301-581-9200, www.apma.org. Contact [email protected] with questions. ISSUE BRIEF Estimate of (CBO) Should Revisit pre-PPACA Budget Office The Congressional The Congressional Budget Office (CBO) Should Revisit pre-PPACA Estimate of The Equity and Access for Podiatric Physicians Under Medicaid Act In 2009, the Congressional Budget Office (CBO) scored ling 2011 study conducted by Thomson Reuters Health- HR 3962, the Affordable Health Care for America Act, care (published in the Journal of the American Podiatric as introduced. The estimate included a budgetary impact Medical Association1), which compared outcomes of care analysis of The Equity and Access for Podiatric Physi- for patients with diabetes treated by podiatrists versus cians Under Medicaid Act—which would define podia- care by other health care professionals and physicians: trists as “physicians” under Medicaid—indicating as part of a larger budgetary table that the legislation related to • Among patients with commercial insurance, a sav- podiatrists would increase federal spending by $200 ings of $19,686 per patient with diabetes can be re- million over 10 years. alized over a three-year period if there is at least one visit to a podiatrist in the year preceding a diabetic APMA believes the federal budgetary impact of defin- ulceration. Among patients with commercial insur- ing podiatrists as physicians under Medicaid would ance, each $1 invested in care by a podiatrist re- be significantly lower under a new CBO analysis due sults in $27 to $51 of savings for the health-care to recent changes to Medicaid coverage which would af- delivery system. fect scoring assumptions. • Among Medicare-eligible patients, a savings of • Expansion population is smaller—The House leg- $4,271 per patient with diabetes can be realized islation upon which the 2009 CBO estimate was over a three-year period if there is at least one based called for the expansion of Medicaid to all in- visit to a podiatrist in the year preceding ulcer- dividuals under age 65 (children, pregnant women, ation. Among Medicare eligible patients, each $1 parents, and adults without dependent children) with invested in care by a podiatrist results in $9 incomes up to 150 percent of the Federal Poverty to $13 of savings. The Equity and Access for Podiatric Physicians Under Medicaid Act Level (FPL). The Affordable Care Act (ACA) as enact- ed into law stipulates a reduced Medicaid expansion Conservatively projected, these per-patient numbers only to 133 percent of FPL. support an estimated $10.5 billion in savings over three years if every at-risk patient with diabetes sees a • Expansion is optional—Additionally, based on the podiatrist at least one time in the year preceding the on- Supreme Court’s ACA ruling that the statute’s Med- set of a foot ulcer. icaid program expansion must be optional for states, CBO projects that about 6 million fewer people will be enrolled in Medicaid.