Diabetic Shoes are Worthless

[Pronation]

Which shoes are best for my patients that like to leave them on for days at a time and take showers approximately biannually?

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[619]

Which shoes are best for my patients that like to leave them on for days at a time and take showers approximately biannually?

Barefoot running and walking

 

[Adam Smasher]

I've had a pretty big week for diabetic shoes rx's and dispensing, here's some highlights:

4 patients specifically requested shoes just because. All were on some kind of medicaid.
-one with bunionettes (foot deformity)
-one with (preulcerative) calluses
-one with longstanding skin breakdown between 4th and 5th toes (hx of ulcer)
-one who actually did have loss of protective sensation. She had burning neuropathy and was convinced shoes would help with that. Because they're magic!

Anyway, easier for me to prescribe the shoes than to argue with pts about what shoes can and cannot do.

On the dispensing front:
-really tall guy who always ulcerates at 5th met head. 2nd pair of shoes for him. I've had luck gluing forefoot varus post to the insole to offload the 5th ray. I probably could just glue something to the insoles of his regular shoes but then he wouldn't get the diabetic shoe magic.
-lady who got screwed by another surgeon (dpm or vasc, I forget). He amped rays 2-5 so she teeters on her first ray over to the 5th met stump. Now with 5th met base ulcer. She refuses tcc, refuses any kind of revision surgery, has her hopes pinned on magic shoes.
-another guy referred to me by another dpm with exact same situation as the lady above. Should have had a TMA, chronic ulcer from prominent metatarsal stump. I told him I would rx shoes but he needs more than that and a lot more than what his current dpm is doing for him. I wrote a detailed treatment note and sent it to his dpm, but she convinced him otherwise. At time of dispensing she had him nwb on a rollabout.
-kind of a squirrely guy with hx of tma on one foot, Charcot on the other. Referred to me by some other DPM. Pt is wearing an AFO for his charcot, and the dpm wants custom molded shoes. I hate custom molded shoes more than podiatry itself. They're too much work, they're ugly as sin, and the upper is too stiff so a lot of people find them uncomfortable, or if they have neuropathy, they blister/ulcerate. Anyway, I have no idea why the guy is in an AFO, but I just want to get through my workday and not waste time on arguments I won't win. So I dispense his shoes. He then says he wants to take them to the cobbler to pad the heel counter and I'm thinking ok fine whatever just leave, go bother your regular doctor.
-reality tall obese guy, he's spiraling. TMA on one foot, 1st ray resection on the other. I had him contained pretty well in his custom molded shoes for about 3 years. Lately he's been getting huge blisters on the undersides of his feet just from walking around and working. At least he tries to work. I think it's a problem of too much man on not enough foot. Expecting a sad ending to this story.

Admittedly, I don't know how many patients do not get ulcers because of their diabetic shoes. But I have a pretty good idea how many of my patients are not helped at all by them.

 

[air bud]

I've had a pretty big week for diabetic shoes rx's and dispensing, here's some highlights:

4 patients specifically requested shoes just because. All were on some kind of medicaid.
-one with bunionettes (foot deformity)
-one with (preulcerative) calluses
-one with longstanding skin breakdown between 4th and 5th toes (hx of ulcer)
-one who actually did have loss of protective sensation. She had burning neuropathy and was convinced shoes would help with that. Because they're magic!

Anyway, easier for me to prescribe the shoes than to argue with pts about what shoes can and cannot do.

On the dispensing front:
-really tall guy who always ulcerates at 5th met head. 2nd pair of shoes for him. I've had luck gluing forefoot varus post to the insole to offload the 5th ray. I probably could just glue something to the insoles of his regular shoes but then he wouldn't get the diabetic shoe magic.
-lady who got screwed by another surgeon (dpm or vasc, I forget). He amped rays 2-5 so she teeters on her first ray over to the 5th met stump. Now with 5th met base ulcer. She refuses tcc, refuses any kind of revision surgery, has her hopes pinned on magic shoes.
-another guy referred to me by another dpm with exact same situation as the lady above. Should have had a TMA, chronic ulcer from prominent metatarsal stump. I told him I would rx shoes but he needs more than that and a lot more than what his current dpm is doing for him. I wrote a detailed treatment note and sent it to his dpm, but she convinced him otherwise. At time of dispensing she had him nwb on a rollabout.
-kind of a squirrely guy with hx of tma on one foot, Charcot on the other. Referred to me by some other DPM. Pt is wearing an AFO for his charcot, and the dpm wants custom molded shoes. I hate custom molded shoes more than podiatry itself. They're too much work, they're ugly as sin, and the upper is too stiff so a lot of people find them uncomfortable, or if they have neuropathy, they blister/ulcerate. Anyway, I have no idea why the guy is in an AFO, but I just want to get through my workday and not waste time on arguments I won't win. So I dispense his shoes. He then says he wants to take them to the cobbler to pad the heel counter and I'm thinking ok fine whatever just leave, go bother your regular doctor.
-reality tall obese guy, he's spiraling. TMA on one foot, 1st ray resection on the other. I had him contained pretty well in his custom molded shoes for about 3 years. Lately he's been getting huge blisters on the undersides of his feet just from walking around and working. At least he tries to work. I think it's a problem of too much man on not enough foot. Expecting a sad ending to this story.

Admittedly, I don't know how many patients do not get ulcers because of their diabetic shoes. But I have a pretty good idea how many of my patients are not helped at all by them.

Sounds like you need to get out of the diabetic shoe business. Please share some of the billing reimbursement associated with that so we can decide if it's worth it

 

[Adam Smasher]

Sounds like you need to get out of the diabetic shoe business. Please share some of the billing reimbursement associated with that so we can decide if it's worth it

Once you hammer out the kinks in the system, it's quite profitable. Like sex work, you can make a lot of money but it eats away at your soul.

 

[Adam Smasher]

Some hard numbers:
In my state, Medicare reimburses me about $70/shoe (so $140/pair) and $40/insert (comes with 6 inserts). Custom molded shoes reimburse about $430. Amputation fillers (L5000) reimburse an extra $500. My cost to acquire is about $160/pair from the vendors. Devil's in the detail though. You need all your i's dotted and t's crossed to make this work because you WILL get audited. For example: you need a PCP note that says each of the diagnosis that you're using, which often times means requesting addenda. You need to document that you observed them walking and that they fit ok. If it's a custom molded shoe, you have to have the patient stand on a piece of paper and draw a tracing of the foot--my partner had to pay back medicare a hefty sum because he didn't do tracings and they withdrew payment on a bunch of shoes.

If you can get the bureaucracy down, it's quite a good cash flow. But telling some of these entitled time-waster patients to F off is absolutely priceless

 

[Pronation]

Oh wow tracing shoes, cool

 

[heybrother]

Some hard numbers:
In my state, Medicare reimburses me about $70/shoe (so $140/pair) and $40/insert (comes with 6 inserts). Custom molded shoes reimburse about $430. Amputation fillers (L5000) reimburse an extra $500. My cost to acquire is about $160/pair from the vendors. Devil's in the detail though. You need all your i's dotted and t's crossed to make this work because you WILL get audited. For example: you need a PCP note that says each of the diagnosis that you're using, which often times means requesting addenda. You need to document that you observed them walking and that they fit ok. If it's a custom molded shoe, you have to have the patient stand on a piece of paper and draw a tracing of the foot--my partner had to pay back medicare a hefty sum because he didn't do tracings and they withdrew payment on a bunch of shoes.

If you can get the bureaucracy down, it's quite a good cash flow. But telling some of these entitled time-waster patients to F off is absolutely priceless

Thank you. In one concise and excellent post you have reinforced for me that I do not need to add diabetic shoes to my practice.

 

[DYK343]

Some hard numbers:
In my state, Medicare reimburses me about $70/shoe (so $140/pair) and $40/insert (comes with 6 inserts). Custom molded shoes reimburse about $430. Amputation fillers (L5000) reimburse an extra $500. My cost to acquire is about $160/pair from the vendors. Devil's in the detail though. You need all your i's dotted and t's crossed to make this work because you WILL get audited. For example: you need a PCP note that says each of the diagnosis that you're using, which often times means requesting addenda. You need to document that you observed them walking and that they fit ok. If it's a custom molded shoe, you have to have the patient stand on a piece of paper and draw a tracing of the foot--my partner had to pay back medicare a hefty sum because he didn't do tracings and they withdrew payment on a bunch of shoes.

If you can get the bureaucracy down, it's quite a good cash flow. But telling some of these entitled time-waster patients to F off is absolutely priceless

That is pretty profitable. Pays way more than a bunion.

Easy to make a house payment or loan payment just dispensing a few patients shoes. Easily could (legally) dispense 3-5 patients a day in most DPM practices with new shoes

I have zero knowledge outside of a lab or two when a student on how to make them (cant be hard... foam box and send off) and especially the documentation required behind them to get them covered. Its crazy the documentation thats needed for some things. Its just words on paper and means nothing.

Edit: I guess it pays about 1/2 a bunion unless you do partial foot prosthesis when factoring in cost of the shoes. But still could easily prescribe quite a few pairs in a day and collect a nice profit.

But hanger is so easy...

 

[Adam Smasher]

Its crazy the documentation thats needed for some things. Its just words on paper and means nothing.

This is what's bizarre about DME in general. You have items that are marked up 400-600% but in order to withstand an audit you need to make sure your notes contain the "phrase that pays."

 

[halluxander.the.great]

This is true for many MD/DO residencies, but only in podiatry does it get significantly worse as an associate.

I have heard the poorly-compensated and abusive associate positions also exist similarly in dentistry.

 

[Hybrocure]

Those numbers looking nice wonder if I can do a cobbler fellowship

 

[Boba Foot]

Wow, decent money from shoes. Only two or three pair dispensed will buy me a revolver so I can put myself out of my misery when these abuelitas come back and complain about every little thing with the shoes.

 

[DYK343]

One of my attendings in residency told me "you can make some serious cash with diabetic shoes but dont do it. You will burn out and kill yourself"

So... yeah theres that.

 

[dtrack22]

I have heard the poorly-compensated and abusive associate positions also exist similarly in dentistry.

It probably occur more frequently now with the increase in large, corporate practices. Unless companies like Mint are allowing you to profit share/become partner somehow. Everything I know about private equity in medicine makes that seem unlikely…but maybe a dentist will chime in

 

[Hybrocure]

It probably occur more frequently now with the increase in large, corporate practices. Unless companies like Mint are allowing you to profit share/become partner somehow. Everything I know about private equity in medicine makes that seem unlikely…but maybe a dentist will chime in

If you’ve ever been to a corporate chain dental offices that nickle and dimes you for every little thing, pushes the $300 toothbrushes on you, tells every patient they need deep cleaning w antibiotic implants etc when they have normal teeth….it’s pretty bad out there.

 

[shadesofgrey]

That is pretty profitable. Pays way more than a bunion.

Easy to make a house payment or loan payment just dispensing a few patients shoes. Easily could (legally) dispense 3-5 patients a day in most DPM practices with new shoes

I have zero knowledge outside of a lab or two when a student on how to make them (cant be hard... foam box and send off) and especially the documentation required behind them to get them covered. Its crazy the documentation thats needed for some things. Its just words on paper and means nothing.

Edit: I guess it pays about 1/2 a bunion unless you do partial foot prosthesis when factoring in cost of the shoes. But still could easily prescribe quite a few pairs in a day and collect a nice profit.

But hanger is so easy...

This is so true. I hate DME. My partners see overall less patients than me but kill me on revenue collected because of DME.

They push custom orthotics at the drop of a hat. "Your insurance covers these custom orthotics!" (conveniently failing to mention that it pays after their 5k deductible is met). "Oh you have diabetes, no hx of ulcer or callus but have a hammertoe. Let's get you some DM shoes." Last year, one of my partners got a limited ambulator custom orthotics and DM shoes .

 

[Adam Smasher]

Last year, one of my partners got a limited ambulator custom orthotics and DM shoes

I've done this before. But here's how it plays out.

At their PCP appt:
pt's adult daughter: is there anything else I should be doing for my dad?
PCP: uh I think that sums things up (I need to get out of here I've got 40 more patients to see today)
pt's adult daughter: well I heard about diabetic shoes, should he be wearing them?
PCP: um that would be ok, check with his podiatrist (gtfo my clinic)

At their DPM appt:
pt's adult daughter: should my dad be wearing diabetic shoes?
DPM: your father doesn't walk outside of his home. diabetic shoes would be of no real benefit to him.
pt's adult daughter: but his PCP says he should have diabetic shoes
DPM: ok fine (gtfo my clinic)