Front Page of AZ Daily Star: Preventing Prevention in Foot Care

This superb article from Stephanie Innes in today’s AZ Daily Star

    Arizona’s poorest residents are about to lose coverage for foot care, which will put diabetics in greater danger of losing limbs, some health providers say.

    As part of a statewide budget reduction, the Arizona Health Care Cost Containment System (AHCCCS) come Oct. 1 is slashing several health benefits for enrollees over 21.

    Among benefits about to end: most dental care (see related story on Page A5), insulin pumps, cochlear implants, certain transplants and all services provided by a podiatrist.

    The benefit cuts represent an annual savings of just over $6 million out of the state budget. The podiatric services alone will save $1 million annually, AHCCCS spokeswoman Monica Coury said.

    About 1.4 million Arizonans are enrolled in AHCCCS, which is Arizona’s form of Medicaid and is reserved for people who are extremely low-income or indigent. The income cap is generally 100 percent or less of the federal poverty level – an annual income of $22,050 for a family of four.

    “Someone looking at a spreadsheet might see a few million dollars and their impression of podiatry is hammertoes and bunions … but most of us are a gateway for diabetic patients with foot problems,” said University Medical Center researcher and podiatric surgeon Dr. David G. Armstrong, co-director of the Tucson-based Southern Arizona Limb Salvage Alliance. The alliance works through clinical care and research to improve foot care among diabetics and to prevent amputations.

    “I can only begin to empathize with the folks on the AHCCCS panel deciding who gets what funding. But this cut shows an astonishing amount of myopia,” Armstrong said. “This is eliminating preventive-care visits for people with diabetes. It’s not like someone else is going to do this kind of care. The most common reason people with diabetes end up in the hospital is a foot problem.”

    Armstrong’s UMC clinic records about 13,000 patient visits per year, and slightly more than one-third of the patients are enrolled in AHCCCS.

    Most primary-care doctors aren’t going to give diabetic patients the kind of wound care and prevention treatment they’ll need to avoid amputation, said Armstrong, who was honored by the American Diabetes Association earlier this year for his work in amputation prevention and wound healing.

    “Internists don’t usually look at the feet,” Armstrong said. “The podiatrist in many ways is like an ob-gyn – he or she does a lot of primary care and surgery, too.”

    In the long run the cut in podiatric services will result in more surgeries, agreed Dr. Joseph Mills, a UMC vascular surgeon who co-directs the limb salvage alliance with Armstrong.

    “It seems like they should focus more on developing systems of care,” Mills said.

    Coury said cutting benefits from AHCCCS was difficult but necessary.

    “When we first conducted our review of benefits our conclusion was that there were no frivolous benefits within AHCCCS,” she said. “We recognize any reductions to existing benefits will have a consequence for our members in some form. … With the podiatrists, it’s not that we’re not covering treatment for the foot – that care can be provided by other types of physicians.”

    Glendale-based podiatrist Dr. Kathleen Stone, who is also president of the American Podiatric Medical Association, says that rationale is going to end up costing us all more money in the end.

    Stone estimates at least 50 percent of the patients at most podiatric offices in Arizona have diabetes.

    Most states’ Medicaid programs cover podiatric services, she said.

    Nine percent of Arizonans in a 2005 state survey reported they’d been diagnosed with diabetes.

    “Look at downtown Tucson and Phoenix at the homeless population, many of whom are probably diabetic,” Stone said. “We have to take care of these people. That is what the Medicaid system is all about – taking care of people who don’t have the wherewithal themselves.”

    Armstrong estimates the cost of treating a diabetic foot wound is $10,000 to $30,000. But if someone has an amputation, the costs rise to $60,000 to $100,000, he said.

    “It just seems to me that no one really cares. It’s our poorest patients in our poorest neighborhoods.”

    Once they lose the benefit, AHCCCS patients will not have the option of using St. Elizabeth’s Health Center’s mobile podiatric clinic, either.

    St. Elizabeth’s, which is operated by Catholic Community Services, serves mainly the uninsured – often people who are still low-income but don’t qualify for AHCCCS.

    St. Elizabeth’s halted its mobile podiatry clinic this month due to county and city funding cuts.

    “We’re concerned because if you don’t meet those needs, certainly complications from diabetes can continue to be a problem,” said Dana Pepper, executive director of St. Elizabeth’s. “We’re hoping to use a volunteer model or perhaps find more funding as a way of incorporating foot care into our clinic.”

    Medicare rates

    President Obama signed a last-minute fix Friday to spare doctors from a 21 percent cut in Medicare payments, but many local doctors say it’s not enough.

    Of particular concern is that the so-called “doc fix” lasts for only six months, meaning it’s a temporary patch for seniors, and for baby boomers about to enter the Medicare system.

    The cuts are part of a formula Congress created in the 1990s to curb Medicare spending, but have been deferred every year. Congress did not act in time this year and on June 18 the U.S. Centers for Medicare and Medicaid ordered that health providers be reimbursed at the lower rate.

    Without congressional intervention, Medicare physician payment cuts will be 23 percent in December, the American Medical Association says.

    “My message is that people need to tell Congress that this needs a permanent fix,” said Dr. Timothy Fagan, an internist in Tucson.

    About 900,000 Arizonans are enrolled in Medicare, nearly 160,000 of them in Pima County. Medicare is the federal health-care insurance program for people 65 and older and for the disabled.

    The government-run health-care system’s rates are considered a benchmark for the health insurance industry, Fagan noted.

    “The issue has not been satisfactorily corrected,” said Dr. Jeffrey Wolfrey, president of the Arizona Academy of Family Physicians. “There’s more frustration and concern now than in the past. It’s a particular problem in Arizona, which already has a shortage of physicians.”

    Reimbursement rates for Medicare need “systemic wholesale improvement,” as they have not kept pace with physician costs, he said.

    Some Arizona doctors have opted out of Medicare, and others have stopped taking new Medicare patients, Wolfrey said.



    AHCCCS about to cut foot care, putting poor diabetics at risk

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