AHCCCS to AHCCCS: How Tough Fiscal Choices Can Hamper Patient Care Under US Medicaid

I was asked by the editorial staff of Podiatry Today to summarize our thoughts regarding recent fiscal rulings to reduce the weight of the Arizona Health Care Cost Containment System (AHCCCS) on the state of Arizona’s budget. One of those rulings eliminated all foot care provided by podiatrists. This figure, which amounts to approximately one million dollars (out of the several billion dollar AHCCCS budget) makes sense philosophically. It is a line item on a budget– and it is a conceptually superfluous item. After all, people don’t die from hammertoes or bunions or ingrown nails or heel pain. However, what gets missed in this discussion is that many of these patients– a disproportionate amount– are at high risk for severe complications of diabetes, including ulceration and amputation. Now, that bunion or hammertoe– or tight fitting shoe– becomes something slightly less superfluous. About half of people with diabetes at any given time may have reductions in sensation that put them at risk for skin ulcers, infections, and amputations.

This discussion is happening seems remarkably prescient. Two robust, large-scale nationwide studies (linked here and here) have just been published describing the very convincing role of podiatric footcare in preventing amputations. These have confirmed many other regional and local studies reporting the same trend toward prevention. This preventative effect is particularly potent when podiatrists team up with other generalists and specialists. This team approach, which we have coined the “toe and flow” is featured in a historic and first of its kind dual issue of the Journal of Vascular Surgery (JVS) and Journal of the American Podiatric Medical Association (JAPMA).
Judging by the amount of mail that we receive and that has been posted to stories on the issue, we know that many patients and clinicians are angry about this budgetary deletion. I would urge people to consider tempering this approach. I am convinced that this cut isn’t any sort of nefarious scheme to limit access. This is something done by well-intentioned folks who want to make sure that a state-funded agency remains fiscally viable. That being said, this is a real opportunity not to scream and yell, but to educate. This is one of those few areas encountered where all data point in one direction– that podiatric care helps people with diabetes.
In the state of Arizona, for instance, the one million dollars discussed above that can be saved by simply deleting podiatric care in AHCCCS may seem like a real and immediate savings– and it is. However, if preventative podiatric care prevents just ten or twenty people from undergoing amputation over the course of the year for the entire state (not to mention loss of productivity, additional emergency department visits, readmission to hospital, or any other softer figures), then that million dollars vanishes fairly quickly. I think it can be safely and very conservatively estimated that most podiatrists have easily that many high-risk patients showing up in their clinic next week– and just as many with open wounds teetering on the brink of limb loss. This is the beginning of a logical discussion that can be had not only up and down the state, but around the country or worldwide. This is especially true since, in the time it takes you to read this brief missive (even if you’re a speed reader), six or eight people will have lost their legs due to diabetes around the world.
Let’s make a difference– but let’s do it together– as patients, as doctors, and as federal healthcare agencies.

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