Prevention with Profit

The right shoe can help prevent diabetic foot ulcerations and boost qualified providers' bottom line.

It's been 16 years since Congress passed the Medicare
Therapeutic Shoe Bill. In that time, home care providers have
helped a lot of seniors and made a profit, a win-win in today's
battered HME market.

According to Michael Barr, vice president and co-owner of
OrthoFeet, Northvale, N.J., although there is a tough and
time-consuming service component involved, the margin on diabetic
patients can add up.

With the demand for diabetic footwear showing no signs of
slowing, it is not too late to get involved. To recap the basics,
Medicare covers the yearly cost of one pair of therapeutic shoes
(also called diabetic shoes) and three inserts. As long as
documentation of medical necessity is there, CMS pays the full fee
in hopes that patients will avoid even more costly complications or
amputations. CMS does not consider therapeutic shoes for diabetics
to be DME or orthotics, but instead the footwear falls under a
separate category of coverage under Medicare Part B.

While shoes must be prescribed by primary care physicians,
podiatrists or other qualified doctors, they must be provided by an
orthotist, prosthetist, pedorthist, certified fitter or other
qualified individual (check with your Medicare DME MAC for specific
definitions). Providers looking to expand their business and
capitalize on this opportunity must ultimately get certified, or
hire someone who is.

Despite all those years on the books, many diabetic patients
still don't know about the Medicare shoe program, which started as
a Medicare-only proposition before expanding to include some
insurance companies and HMOs that are providing similar deals for
younger patients. With the help of the media, and better
communication from clinicians, awareness will likely increase.

From a demographic perspective, the market for diabetic shoes
will grow based on pure need. The American Diabetes Association
reports that there are 23.6 million diabetics in the United States,
or roughly 8 percent of the population. Total cases went up 13.5
percent from 2005 to 2007, and Americans still receive
approximately 80,000 diabetes-related amputations per year.

Despite the undeniable demographics and reasonable profit, some
providers are still hesitant to dive in. After all, the clinical
stakes are high. The American Podiatric Medical Association
estimates that poorly fitted shoes account for as many as half of
the problems that lead to amputations.

“In the shoe business, we have to admit that there is a
big responsibility, especially if you compare it to a cane or so
many other things,” says Barr. “You have to put
something on the foot that will make a difference. It is not for
nothing that Medicare is asking for some certification, education,
knowledge and training before they allow you to implement this
treatment … This is real treatment, and it takes

For providers looking to profit in the long term, Barr is
adamant that shoe quality must be considered first above all.
“For the short term, you can look for the least expensive
shoe that will give you the best profit, because the reimbursement
does not look at what your cost is,” says Barr.

“Looking at the long-term health of your business, you
must look at the quality of the shoe. For example, the lining of
the shoe must be as seamless as possible. It's like you are putting
your hand in a glove, with no irritation or pressure

Gladys Fournet, owner of Fournet's Pharmacy & Professional
Home Medical in Franklin, La., carries several different brands of
diabetic shoes. After taking the classes and putting in the hours,
Fournet became a certified fitter and certified orthotist,
distinctions that Medicare has deemed necessary to be in the shoe

In addition to operating a full-service pharmacy, Fournet also
carries oxygen, hospital beds, power chairs, scooters and a full
selection of DME.

“If the shoe business was stand-alone, it would make
money,” says Fournet. “But we service the whole
patient, and the shoe business is only a fraction of what we do. A
pharmacy without HME is on its way out, and an HME without a
pharmacy is on its way out.”

Cultivating referrals from a variety of clinicians yields
reimbursement mostly from Medicare but also Louisiana Medicaid and
private insurance. All these payers require certification, and
Fournet believes this is often the main barrier for HME providers
who wish to enter the market.

“Some HME providers want the fast buck, and they are not
thinking of service and caring for people,” laments Fournet.
“This is not an easy product to distribute. It takes a
certified person. It takes patience, inventory, and you have to be
trained to fit the shoe.”

With real clinical consequences for poor fitting, the service
component is sizable. When a shoe customer comes in, Fournet
immediately stops what she is doing to fit the patient. If
follow-up is necessary two or even more days later, she is there
for the customer.

“If you are trained and you are certified, this business
is very profitable, but it is not a fast buck thing,” says
Fournet, whose company includes three locations serving a 40-mile
radius of Louisiana's Cajun Coast. “It is a great
patient-builder. It ensures patient loyalty to your pharmacy and to
your business.”

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