People with diabetes are 50 times more likely to develop a foot ulcer than those without, and diabetes-related foot problems are a leading cause of hospital admissions among people with diabetes. It’s the number one cause of medical amputations, which run a total cost of $80,000, including the surgery itself, wound care, prosthetic fitting and follow up treatment, according to the Centers for Disease Control and Prevention.
Routine foot care to inspect and prevent foot ulcers, the usual cause of diabetes-related amputations, has long been touted by the CDC and the World Health Organization as one of the cheapest and easiest ways to prevent amputations and ensure quality of life.
But insurance coverage for preventive care is another matter. Registered nurses in Oregon can provide basic foot care services, such as toenail trimming, debridement for overgrown toenails and wound care for ulcers, which is done at Kaiser and the Veterans Administration working under a doctor's order. But, self-employed foot care nurses, who make up the majority of the specialization, cannot bill an insurance company for any services, including basic foot exams.
Sara Genta, a self-employed foot care nurse in Portland, charges $30-35 for exams in a clinic setting, and $45 for a home visit, or more if she is referred by an agency. Each visit includes a basic exam, a nail trim, reduction of skin lesions and nails, plus washing, exfoliation and a lotion massage.
She provides services at Loaves and Fishes centers, senior centers and for people transitioning out of homelessness. Medicare's fee schedule, according to a menu of services listed on the Center for Medicare and Medicaid Services' website, reimburses physicians between $47 and $66 to trim just one corn or callous. In addition, Medicare only covers two visits by physicians for preventive foot care each year.
The American Diabetes Association recommends diabetics examine their feet daily and get them checked by a professional once a year (or more if they have severe problems). But many of Genta’s patients are unable to care for their own feet due to limited mobility or cognitive disabilities, so she typically sees them every six to eight weeks. She also encounters people who tell her they need foot care, but simply can't afford it.
She'd like to see both Medicare and Medicaid to begin investing in preventive foot treatment to save money in the long run. “All the state would have to do would be to piggyback on what Kaiser's doing.”
It's always been hard to difficult to get insurers to pay for prevention, said Dr. Julia Overstreet, a podiatrist in Bellevue, Wash., and founding member of the American Foot Care Nurses Association. Overstreet started practicing in the 1980s, and at the time Medicare didn't pay for shoes or inserts for diabetic patients. Now it does, but that wasn’t always the case. “One guy told me, it's actually cheaper to cut off a few legs than to give everybody shoes,” she said.
Medicaid is a different story, and Oregon is paying particular attention to diabetes in its transformation efforts. Diabetes-related hospitalizations cost the state $1.1 billion, according to a 2008 Department of Human Services report, and the cost of amputations alone is steep. Numbers released by the Oregon Health Authority show there were 334 total diabetes-related lower extremity amputations in 2012, at a cost of about $30,000 per patient – adding up to $10 million in diabetes-related amputation altogether, including those paid for by Medicaid and those covered by other payors.
The Oregon Health Plan does cover preventive foot care for diabetics as long as they’re seen under a doctor's order, including home health nurses, said spokesperson Christine Stone.
“Diabetic care and treatments are ranked very highly on the prioritized list, with the Health Evidence Review Commission very aware of the need for preventive care for diabetics to avoid complications from the disease such as diabetic foot ulcers that can lead to amputation,” Stone said.
Stone said some coordinated care organizations could pay a case management fee or other alternative payment – not tied to a specific visit – it would allow registered nurses to perform some billable foot care services. Historically, that hasn’t been the case under the Oregon Health Plan.
Meanwhile, Genta received certification as a foot care nurse after she deciding to work in community settings rather than in a hospital. “Foot care is one of the few areas where an RN can practice and have their own business,” she said, noting that many foot care nurses are semi-retired.
Not only are amputations expensive, most diabetic patients see a dramatic increase in mortality, with 65 percent surviving the first year after surgery, and just 5 percent still five years later. Studies on the morbidity of post-amputation diabetics show that this population is often elderly and in poor health at the time of surgery. The research community has recommended that efforts increase to prevent amputations to give patients a longer life span and higher quality of life.
“Routine foot care isn't all there is to it, but if we could find problems sooner, at least we wouldn't have to pay for amputations,” said Overstreet. “The amount of energy it takes to get around on one leg instead of two is so much more. It's a much higher energy task to get on one leg instead of two. It just wears out their heart to do normal daily activities, and if you're overweight at all, it's just impossible.”
Christen can be reached at [email protected].
This story has been edited to clarify the scope of the Oregon Health Authority data on lower-limb amputations, and to reflect the scope of prevetive services reimbursed by OHP.
