San Francisco Medicare Patients Need to Brace for Worsening Customer Service at Doctor Appointments

Medicare Cuts of 21.2% can only spell longer waits and less time with the doctor.

On 2/26/2010 is was reported that nothing short of a political miracle in Congress can prevent a scheduled 21.2% pay cut to doctors across the San Francisco Bay Area and the rest of of the U.S. The fact is that the extraordinary cost of living, rent and office space in the San Francisco area can only have one reasonable effect... poor customer service in doctor's offices.

For the past several months, Democrats in Congress have attempted to get legislation to pass and avoid the massive pay cut, which was written into law by the old "sustainable growth rate" formula Medicare uses to determine how much physicians get paid for treating patients. However, this week Sen. Jim Bunning (R-KY) effectively blocked the bill that would have extended the deadline by 30 days.

The big problem with this situation is that many doctors cannot make a living by seeing Medicare patients for less money. Others find a way to survev, but are forced to ration care and perform "assembly line medicine." If physicians are true to their warnings and quit seeing these people, Medicare beneficiaries might experience difficulty making an appointment with any doctor or podiatrist who takes Medicare. One poll among neurosurgeons showed that about 40% would cut back on seeing new Medicare patients if reimbursement continues to decline, while 18% would quit accepting new Medicare patients into their medical practices altogether. Another 27% said they would treat fewer Medicare patients who were already in their practices.

The fact is that all doctors in San Francisco went to medical school so they could spend their careers helping people. But when it comes to continual decreases in pay with continual escalating costs of seeing patients, something has to give.

There are really only a couple of ways doctors can deal with the 21% cuts in Medicare reimbursement that will take effect Monday morning. One option is for doctors to stop taking Medicare. That means they just don't schedule your appointment. Or you have to pay for the visit yourself. Very few doctors have had the courage to do this. However those that do, find they can provide more time, attention, and personalized care with each patient.

The other option is to just see more patients. Its just math. A doctor that was seeing 50 patients a day, will now need to seen something like 70 per day. With all of the rules and regulations about what has to be documented in the medical record for each visit, that can only translate to very short visits.

Don't be surprised if you go to the doctor on Monday and are told "we'll have to tall about that problem at your netx visit, we just don't have time for more than two problems during your visit today." But don't take it personally of you can't get in to the San Francisco podiatry office to treat that diabetic foot infection or remove that ingrown toenail... it's just math.

Dr. Christopher Segler is a San Francisco Podiatrist and Foot Doctor who stopped accepting Medicare so he could practice Direct Medicine. He provides housecalls and is a podiatrist who will go to your home so you don't have to wait in some dingy waiting room all day. He practices podaitry in the San Francisco Bay Area and treats urgent foot problems 24/7 in the Bay Area. You can use the “foot pain finder” to learn more about foot problems at www.AnkleCenter.com and www.DocOnTheRun.com.

New Research Confirms Diabetics at High Risk of Surgical Infection

I'll never forget the day that Mrs. Williamson looked me in the eye, waving her finger and said, "I want you to promise me that you won't cut off any of Warren's toes."

Warren Williamson was the father of my sister's best friend when I was growing up. And he was a diabetic who had developed neuropathy (numbness in the feet from diabetes). He had a "spot" on his foot he was concerned about and wanted me to make a housecall to check his feet. But Mrs. Warren was fearful. An uncle of hers had died after a toe infection led to an amputation. All she new about that episode was that her uncle was diabetic, he got a minor toe infection, then he needed a toe amputation and now he is dead.

As a longtime friend, and a diabetic foot surgeon, I was taken aback by her fear. So I looked her in the I and said, "I promise I will do everything in power to make sure you husband leaves this world with all of his toes." I could see the relief, as her expression changed.

As it turns out I kept my promise. But unfortunately Warren did ultimately die of a post-operative infection. Only it was after back surgery. The growing population of diabetic patients is leading to more and more surgical infections.

This month a new study was published in the Journal of Bone and Joint Surgery which shows that diabetic patients are significantly more at risk for surgical infections than non-diabetic patients. The article is entitled "Postoperative Infection Rates in Foot and Ankle Surgery: A Comparison of Patients with and without Diabetes Mellitus."

The researches set out to determine whether or not patients with diabetes are really at increased risk for infection following foot and ankle surgery, or not. To find out they reviewed the charts of 1000 patients who had orthopaedic foot and ankle surgery. The recorded whether or not any of those foot surgery patients had a diagnosis of diabetes mellitus, if they had a postoperative foot infection and information about the severity of infection. They also recorded whether the surgery was inpatient surgery or outpatient surgery, whether or not they used of internal fixation (like screws or plates to hold the bones together) or external fixation (like rods attached on the outside of the foot or ankle), history of tobacco use, history of organ transplantation, history of rheumatoid arthritis, the total length of surgery, follow-up time in weeks, and other medical conditions that might contribute to the foot surgery infection.

What they discovered was that 52% of all foot and ankle infections occurred in diabetics. But diabetics accounted for only 19% of all patients who had foot surgery or ankle surgery. They found that of those patients having foot and ankle surgery, those that had diabetes were about 4 times more likely to develop a post-operative infection following foot or ankle surgery.

Even worse, we know that diabetics get more severe infections. The study confirmed this and showed that diabetic patients were 5 times more likely to develop the sort of severe infection that might lead to prolonged hospitalization, a foot amputation or death from the infection.

Interestingly, there was no real difference in foot infection rates between those without diabetes and someone with uncomplicated diabetes (a mild case of diabetes). However, those with complicated diabetes (a bad case of diabetes) did have much higher rates of surgical foot infections than those with uncomplicated diabetes (a mild case of diabetes).

So, if you or someone you love has diabetes and is going to have foot surgery, make sure the surgeon understands all of the implications is taking precautions to prevent the infection. Ask questions. Ask whether or not the patient will get antibiotics at the beginning of the surgery. Ask in the surgeon covers the toes with ioban. Ask the surgeon for a scrub brush with surgical soap to scrub the foot the night before surgery. Ask the surgeon how often his diabetic foot surgery cases go bad.

It is your foot and you have the right to know. If your diabetic foot surgeon thinks he or she doesn't need to take the time to answer all of your questions, find another surgeon.

Dr. Christopher Segler is a podiatrist and award-winning podiatrist who practice in the San Francisco Bay Area. He provides House Calls for diabetic foot exams, diabetic foot emergencies, and diabetic foot wound treatment. Serving San Francisco, Marin, Palo Alto, and Walnut Creek. You can learn more about house calls in San Francisco as a solution to foot problems at www.DocOnTheRun.com and www.AnkleCenter.com.