Prevention with Profit

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.