It costs $1,400 to cover the oozing sore on the diabetic's foot with a piece of artificial skin, helping it heal if patients keep pressure off that spot. So when Medicare paid for the treatment but not the extra $100 for a simple walking cast to protect it, an artificial skin maker last year started giving free casts to some needy patients.
Without the right cushioning, "the person will walk to the bus stop and destroy it," fumes Dr. David G. Armstrong of the Southern Arizona Limb Salvage Alliance.
Limb-salvage experts say many of the 80,000-plus amputations of toes, feet and lower legs that diabetics undergo each year are preventable if only patients got the right care for their feet. Yet they're frustrated that so few do until they're already on what's called the stairway to amputation, suffering escalating foot problems because of a combination of ignorance — among patients and doctors — and payment hassles.
"There's no magic medicine right now for the diabetic foot," says specialist Dr. Lawrence Lavery of Texas A&M University, who bemoans that simple-but-effective preventive care just isn't attention-getting.
"People come in (saying), 'Hey, my wife noticed a bloody trail today as I was walking across the linoleum in the kitchen. What should I do?'"
President Barack Obama got a drubbing from surgeons this month after a confusing comment about how they're paid for foot amputations that cost $30,000 or more. That tab is the total cost, including hospitalization; surgeon fees range from about $750 to $1,000.
Obama's larger argument: Better payment for early-stage diabetes treatment, or even care to prevent diabetes, could save the nation money.
The money part's hard to prove but it's a lot of misery saved if it's your foot, and the spat highlights a huge problem. Some 24 million Americans have diabetes, meaning their bodies can't properly regulate blood sugar, or glucose. Over years, high glucose levels gradually damage blood vessels and nerves.
One vicious result: About 600,000 diabetics get foot ulcers every year. Poor blood flow in the lower legs makes those ulcers slow to heal. And loss of sensation in the feet, called neuropathy, makes patients slow to notice even small wounds that rapidly can turn gangrenous.
A mere nick while clipping nails, or a blister from an ill-fitting shoe, can begin the march toward amputation — and about half of patients who do lose a foot die within five years.
Saving those feet isn't cheap. Treating a slow-to-heal diabetic foot ulcer can cost up to $8,000. If it gets infected, $17,000. Worse, a fraction of patients gets multiple slow-to-heal ulcers each year.
— Routine foot checkups. There's great variability in how insurers pay for foot screenings before someone's deemed at high risk, says Dr. Harry Goldsmith, a consultant on podiatric reimbursement. Yet some simple tests, like one that measures blood pressure at the ankle to predict circulation clogs, can signal later risk of ulcers. Medicare patients who do develop certain risk factors qualify for the next step, regular clinic visits to have a technician trim nails or smooth calluses, time that should include a quick check for any wounds, Goldsmith says.
— Gadgets like $20 telescoping mirrors let diabetics who can't move well check their numb soles for wounds between doctor visits, and infrared foot thermometers that cost up to $100 can detect changes in temperature that mean an ulcer's brewing before the skin breaks. Again, insurance payment varies.
— Taking pressure off the foot is key, starting with supportive shoes or insoles that target weak spots before an ulcer strikes. Medicare will help pay for certain therapeutic shoes although paperwork limits the diabetics who try them, says Lavery. He finds that an athletic shoe checked by a foot specialist for proper fit can help many patients.
When an ulcer demands more advanced care like grafting that artificial skin, Armstrong says removable walking casts — to-the-calf Velcro boots that injured athletes often wear — ease pressure best but seldom are covered. Worried that doctors wouldn't prescribe its wound healer Dermagraft if patients crushed it before it could work, Tennessee-based Advanced BioHealing has provided nearly 1,900 of the boots through a patient-assistance program since last year, said vice president Dean Tozer.
— The "toe and flow" approach, diabetic limb-salvage teams that pair specialists who otherwise seldom work side-by-side, like podiatrists and vascular surgeons. Wound care won't work well until clogged leg arteries are cleared to improve blood flow, notes Armstrong, whose team at the University of Arizona, Tucson, documented a drop in amputations in its first nine months. Such teams can eliminate some of the time diabetics wait for appointments to treat a festering foot, plus stress prevention.