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Medicare Widens Foot Exam Coverage

Acts to decrease amputations, especially among diabetics

FRIDAY, Nov. 9, 2001 (HealthDayNews) -- Alarmingly high rates of toe and foot amputations linked to diabetes have prompted the Bush administration to widen coverage of foot exams for some Medicare beneficiaries.

The Department of Health and Human Services (HHS), which administers the government health insurance program, says participants soon will be entitled to two foot exams a year to monitor the loss of sensation that can lead to limb-threatening foot ulcers.

Nerve damage, known as peripheral neuropathy and stemming from diabetes, leads to more than 85,000 amputations a year, half of which are preventable, experts say.

The policy change, prompted by the American Diabetes Association, was announced in mid-October but went largely unnoticed amid the reports of anthrax.

"A minor injury or infection that could be treated routinely for most patients can cause severe problems, even leading to amputation, for people with diabetes," says HHS Secretary Tommy G. Thompson in a statement announcing the move. "By covering regular foot care for those of high risk of foot ulcers, Medicare will help many beneficiaries avoid potentially dangerous complications."

An estimated 16 million Americans have diabetes, which results from problems with the production or response to the sugar-processing hormone insulin. The vast majority have Type II, or the adult-onset form of the disease, in which their cells become resistant to insulin. However, people with both Type I and Type II diabetes are vulnerable to nerve problems that can lead to irreversible foot trouble and amputation.

Medicare generally does not cover routine foot care, except for certain localized illnesses. The new initiative will pay for up to two foot exams a year to check on diabetic peripheral neuropathy "provided they have not seen a foot-care professional for some other reason," the government directive says.

Dr. Lee Sanders, immediate past president for health care and education at the American Diabetes Association, calls the expanded coverage "a major important change in health policy" that will not only improve patient care but should cut Medicare's bottom line by reducing expensive amputations.

"There are reports in the literature that point to the effectiveness of these types of programs in reducing lower extremity amputations and therefore costs," says Sanders, chief of podiatry at the Department of Veterans Affairs Medical Center in Lebanon, Pa.

Medicare says about 5 percent of its spending goes to diabetes, but Sanders says the figure is closer to 27 percent. The agency was not immediately able to say how many beneficiaries would be entitled to the new coverage.

In a survey released earlier this month, the Centers for Disease Control and Prevention (CDC) reported that diabetes accounted for 44 percent to 85 percent of all preventable leg, foot and toe amputations in this country in 1997. People with the blood sugar syndrome were nearly 30 times more likely than normal to undergo amputations of their lower extremities not related to trauma, with men, blacks and the elderly bearing the biggest burden.

The rate of amputations among people 65 and older, the population eligible for Medicare benefits, was about three to five times greater than that among Americans under age 45, says the CDC.

An estimated 54 percent of diabetic amputations occur at the foot or below, Sanders says. About a quarter occur below the knee and 21 percent above the joint.

"There is evidence to show that with programs offering a multi-disciplinary approach, including comprehensive foot care, there is a decrease in the number of amputations, and the amputations performed are performed more distally," meaning they involve toes and feet and not more of the legs, he says.

Dr. Joseph Chin, a Medicare official who helped prepare the new policy, says the foot coverage should take effect in about six months.

The agency is putting the most stock in a sensory test that uses a piece of monofilament line to gauge the sensitivity of people's feet, and will reimburse only those doctors trained to use the device. While podiatrists may have the most experience with the monofilament test, Sanders says the average primary care physician should have no trouble doing it properly.

"This is a test that is so simple and is so inexpensive and is so reproducible that everyone should be able to do it, and every physician should be encouraged to have a monofilament in their pocket," he says.

A CDC study last year showed that diabetics are sorely under-served in preventive care, from routine blood sugar monitoring to foot checks and eye exams.

The percentages of diabetics who reported receiving these tests were far below the 80 percent goals set for the year 2010 for all patients, the study says.

Sugar monitoring rates ranged from about 30 percent of people surveyed in Hawaii to 65.5 percent in Montana, the only state to meet the 2010 goal of 60 percent. The percentage of people receiving yearly eye exams ranged from 47 percent in Arkansas to 81 percent in Massachusetts, one of just three states to meet the 2010 guideline of 75 percent for this test.

No state met the 2010 yardstick for annual foot exams.

What To Do: To learn more about diabetes, visit the American Diabetes Association, the CDC or the National Institute of Diabetes and Digestive and Kidney Diseases online.

SOURCES: Interviews with Lee Sanders, D.P.M., chief of podiatry, Department of Veterans Affairs Medical Center, Lebanon, Pa.; Joseph Chin, M.D., medical officer, Division of Medical and Surgical Services, HHS, Washington, D.C.; Nov. 2, 2001, CDC Morbidity and Mortality Weekly Report
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