The Proper Use Of Diabetic Shoes To Protect Diabetic Feet

The use of diabetic shoes has been steadily increasing since the Medicare Therapeutic Shoe Bill was passed. For some diabetics, these are of vital importance to reduce shoe related foot complications. Unfortunately, overuse of these prescription devices and fraudulent distribution threatens the long-term viability of this program. This article will discuss the appropriate use of these shoes and how patients and physicians can assure proper utilization and monitoring of these devices.
The Rationale Behind The Use of Diabetic Shoes:
Medicare began this benefit in order to limit the incidence of foot wounds and general injuries caused by the use of improperly fitting shoes. Shoes have been the source of many friction and pressure-related wounds, leading to infection, hospitalization, and possibly amputation. They also have allowed for irritation of foot deformities already present, including bunions and hammertoes. As many diabetics have some level of poor sensation (peripheral neuropathy), shoe irritation pain cannot be readily felt and wounds form easily after a relatively short period of time. Combined with foot deformity like bunions and hammertoes, as well as chronic swelling (edema), the potential for the shoe to rub against the skin is dangerously increased. A diabetic shoe is defined as an extra depth shoe (especially in the toe box) to reduce pressure from above on the toes, as well as sized appropriately for width to reduce pressure on the inside and outside of the foot. This immediately protects feet with toe deformities or bunions, and benefits normal feet as well. The shoe material generally should have a construction to limit seams within the shoe, and should be durable to last one year's worth of daily use. Of vital importance is the inclusion of an insert made mostly of a material called plastizote. This material reduces pressure and shear forces. It can be heat molded to the foot, or in some cases must be custom molded to a foot if severe foot deformity is present. These severe deformities may be from amputation voids or a fracture-causing disease called Charcot arthropathy. Medicare has defined the minimum thickness of this material, and the use of anything less is inappropriate. When the extra depth shoe and plastizote insert are combined, the likelihood of shoe-related diabetic complications is significantly reduced.
Diabetic Shoe Misuse:
Unfortunately, diabetic shoes are over-utilized outside the medical community. In order for a diabetic to need diabetic shoes, they need to have some combination of neuropathy, foot deformity, calluses or corns (hyperkeratosis), prior foot ulcer, amputation, or arterial disease. If none of these are present, a diabetic does not need the shoe as the risk for problems is low, and Medicare will not cover it. A proper medical exam is needed to determine if these components are present, as a diabetic with any of these conditions should be under medical and podiatric care anyway. This can be done by the physician managing the diabetes, but a foot specialist usually handles this. A proper prescription for the shoes and a determination as to whether heat molded or custom inserts are needed is made, as well as a determination for any other modifications needed. At times, some diabetics have such severe foot deformities that a standard diabetic shoe is in appropriate, and a custom molded shoe is needed. This requires a much different process. After the shoe prescription is determined, the physician managing the diabetes then certifies the treatment of diabetes and the need for the shoe. This documentation is required by Medicare.
The above process is often ignored when medical supply companies and non-medical entities are involved in the distribution of diabetic shoes. A common scenario takes place when patients are contacted by mail or phone by these companies (who are on a calling list due to their diabetes), and an offer is made for a "free" diabetic shoe. These patients are then fitted through the mail based on the shoe size they admit to, or they mail in a foam box impression of the foot sent to them. Events are also held in which patients go to a hotel or general conference center for a one-day opportunity to be fitted. Rarely is an exam performed by the dispensing company, who rely solely on the certification of the treating physician to be in-line with Medicare documentation requirements. Most of these physicians are too busy to scrutinize the source of the shoes, and simply want to provide protection to their diabetics, so they sign it. The patients are then sent the shoes, and no follow-up is performed to determine if the fit is appropriate. If problems do develop, no one is available locally to inspect or modify the shoes. At times, the shoe styles used barely fit the qualifications for a diabetic shoe, as commercially available shoes are often used in place of a dedicated diabetic shoe, and the inserts used are of poor quality. Some companies will automatically use custom inserts whether or not they are actually needed as the custom inserts reimburse higher. All of this is done without the input or expertise of a foot specialist, or even the primary physician.
As if all this was not enough, in many cases companies will write off the 20% Medicare does not cover in the event a secondary insurance is not present (or will not cover diabetic shoes), in order to keep the marketing of "free" shoes accurate. This is illegal, as providers and suppliers are obligated by federal law to collect this.
The Big Picture:
In short, not all diabetics need diabetic shoes. Those who do need shoes that fit properly based on their specific foot, and a specialist is needed to create the prescription and follow-through with the product. Medicare needs to be billed properly and accurately. The over-extensive and fraudulent use of diabetic shoes for profit is threatening the long-term viability of this program. The determination for the use of these devices needs to rest solely in the hands of the podiatrist or physician treating the diabetes. The shoes should be dispensed directly from the podiatrist or from a skilled pedorthist/orthotist to ensure quality and proper follow-up of fit and function.