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The changing nature of practice.......

Posted by Ed Davis, DPM on 4/30/03 at 21:39 (117490)

Tommorrow, Thursday, is my surgery day but I have no surgical cases scheduled until next week.

I will start at 7 am with six Dornier EPOS patients which I will treat at a local center, then come back to the office in the early afternoon to treat four patients with the Siemen's Sonocur.

I was at our state meeting last weekend and had a pleasant conversation with a urologist who is one of the principles in United Shockwave of Chicago. He recalls the parallel development of renal lithotripsy. It was ridiculed at first but soon became the gold standard of care. Surgical treatment of kidney stones has a high complication rate. Once a number of patients who had suffered complications with surgery realized they could have been treated more successfully via lithotripsy, they filed suit. We feel that doctors will, at the very least, need to inform prospective surgery candidates for plantar fascial release surgery that there is a non-surgical alternative with a higher success rate and lower complication rate despite the coverage issues. It is disturbing that insurers can insulate themselves from liability when using coverage issues to influence treatment choices that are not in the best interest of the patient.
Ed

Re: The changing nature of practice.......

BGCPed on 4/30/03 at 23:30 (117505)

I feel eswt is a much better option than pf release. While I am not sold on the success level due to differing studies it is MUCH better than cutting fascia. It provides an alternative that is much more conservative with greatly reduced complications if it fails.

Unfortunatly I see too many pt that have the same story about pf release. They are STILL wearing improper footwear, have a crappy fo they dont wear or it doesnt function. They say I had about 5 injections over a year then they did pf release, I am worse off or no better, I wish i never did it.

I know that is not the case in all pfr procedures but given the alternative I would much rather see eswt tried after more conservative measures. I dont like Lawyers but I think the guys that do pfr after just injecting cortisone 5 times and giving poor to no footwear/othotic options should be called on it.

Re: The changing nature of practice.......

Ed Davis, DPM on 5/01/03 at 18:47 (117590)

BG:
Keep in mind that the only study that failed to support effectiveness was the Australian study published in the AMA Journal. The study was so badly flawed that a lot of readers were dismayed that a reputable journal would allow it to be published. Most of the docs I have talked to agree that that study was designed intentionally to fail.

There, sometimes, is a mindset that conservative modalities are a stepping stone to surgery so they not taken seriously by some providers. Many patients have that same mindset, somehow assuming that surgery is more definitive. It is incredible to see how many will opt for surgery while still wearing their Nike Air Fluff specials.

Surgery is also the path of least resistance when it comes to insurance companies. I have never seen an an insuracne company that said no to plantar fascial release surgery but many who will balk at ESWT, orthotics and other non-surgical approaches.
Ed

Re: The changing nature of practice.......

Max K on 5/02/03 at 02:42 (117639)

Dr Ed,
so the insurance companies generally prefer surgery over ESWT, even though that preference is neither medically nor financially justified? Well, that sounds like something is very wrong. I understand that insurance companies work with numbers, statistics and probabilities; but if I understand correctly, the numbers and statistics favor ESWT over surgery, as far as both cost and success rates. Maybe the insurance companies with their sluggish bureaucracy simply lag behind 10 years, behind whatever new treatments are shown to be safe and effective? Does that sound right, or is it more complicated than that?
Max

Re: The changing nature of practice.......

Ed Davis, DPM on 5/02/03 at 13:15 (117675)

Max:
You have delved into one of the great mysteries of our time. I think that there are multiple factors involved with the one's you mentioned being very valid. Many insurance companies have medical directors who are retired doctors or doctors who have, for a variety of reasons, left clinical practice.

The original Blue Cross/Shield plans written in the late 1940's were primarily surgical plans. One can find many paragraphs from the original plans still in insurance contracts.

Yet another factor to consider is that health insurers are paying doctor and hospital bills only. They are not paying for time loss or disability so they do not have a financial stake in that aspect.

Finally, there is a question of future utilization. ESWT, because it is safe, non-invasive is a modality that few patients will refuse, especially if covered. Most patients who are well informed prefer to avoid surgery so those numbers will never be high. The insurance companies may envision a near future scenario where they have a very large number of ESWT claims -- plantar fasciitis, elbow, shoulder and so on as those indications come around.
Ed