1 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. 2 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. 3 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. 4 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) 5 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