All right you sickos, here is the rest of the report, and its long.

Immediate Futures for US Healthcare with Relevance to Podiatry

National concerns about healthcare quality and rising healthcare costs have contributed to a broad shift in the American healthcare landscape. The healthcare paradigm has shifted from volume based to value-based payments, from fee-for-service to managed care, from individual providers to team-based centralized care, from individual to population-based metrics and from episodic to person-centered care. Even the pharmaceutical industry sees healthcare changing “from reactive and retrospective to proactive and predictive”⁴.

In this new environment, providers are responsible for patient outcomes, not just services supplied. Providers are also expected to keep and report the data needed to demonstrate newly critical outcomes: value for payment disbursed, contribution to managed care, individual and population level outcomes. Effective health care provision now utilizes collaborative care models which prioritize prevention, positive outcomes, reduction of costs and fewer hospitalizations. These collaborative teams span the breadth of primary care and hospital-based interventions as well as a full range of relevant social and mental health services.

These shifts require all health professions to adjust education, training and maintenance of competence efforts. The degree and impact of these changes present an opportunity for podiatry as a profession to provide leadership at local, state and national levels in meeting these new performance metrics. APMA would be the logical organization to unify podiatry and provide a strategic engine for innovation, needed reforms and adjustments. Failure to act or ineffective action will allow other professions to set performance expectations for podiatry practice, usurp podiatric practice areas and therefore podiatric professional identity. This erosion will occur first at local then state and finally national levels. Along that continuum the APMA will become irrelevant to members and membership numbers will continue to drop.

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Directions toward an Improved Future for Podiatry

Podiatric advocacy focused on providing demonstrable value in primary care will create economic value for podiatrists, more supportive collegial work environments and result in a more just and healthier society. To operationalize the achievement of a redefined advocacy goal requires transformative, system-wide change across the APMA. Four initial changes are suggested below.

Collect and disseminate evidence demonstrating podiatric contribution to public health

There are a range of common public health challenges where podiatry plays an important role in producing positive results. Minimally these include diabetes, fall prevention, obesity, chronic pain and opioid reduction. The contribution of competent podiatry to personal and public health metrics in these and other areas are not well understood by the public nor by local, state and national authorities.

The APMA could organize and facilitate the creation and maintenance of relevant databases at national, state and local levels. Combined with organized, facilitated and funded research teams, analytic teams, writers and publicists these results would bring and maintain focus on podiatry as a critical part of healthcare evolution. These efforts should include a variety of efficacy metrics including improved health status (e.g., fewer amputations); money saved (e.g., fewer hospitalizations) and better integrated care (e.g., no patient drops).

This data and the personal stories behind the data should be widely disseminated. All manner of publications should be pursued on a routine basis. Direct public-facing outlets (e.g., newspapers, podcasts, TV) should be included in addition to healthcare professional journals. Wide message diffusion will support broader appreciation of podiatric contribution to improving healthcare metrics locally, at state and national levels.

Along with detailed local situational analysis, results information distribution should be strategically targeted to locations where podiatry is experiencing difficulty acting on the full scope of their practice capabilities. Data should be collected on the information penetration and trigger conditions should be specified for targeted follow up with legislators, payers, managers and other providers at local levels utilizing the publicity to achieve local gains for podiatry.

This is a not a one time effort but must be structured to operate as a continuous virtuous circle: identify areas needing attention; define, identify and analyze relevant data; disseminate information to target audiences; follow up with specific change requests; define outcome data indicative of change results; repeat cycle.

Commit to constant improvement in podiatric education, training and performance

Routinely study the range of KSAs (knowledge, skills, attitudes) required in the content of podiatric practice. This information is required to validate and refresh curricula and to develop supports for practitioners’ efforts to maintain minimal competence as the practice changes

These KSAs must be examined critically, not merely observed in practice. Which specific KSAs are requirements in high frequency situations and how are the KSAs related to and indicative of each other?

Identify, compile, assess and improve effectiveness of defined critical KSAs across schools, residencies and programs to assure continuing competence.

Once familiar with the requisite KSAs, competence-based models (CBE) should be investigated to optimize efficiency in learner time and focus. CBE allows learners to test out of standard program sections by meeting performance challenges much as they do now in residencies. This approach allows sufficiently skilled performers to move along to new areas and teachers to focus on those needing more time. This individualized approach demonstrates more professional respect than does forcing all learners through identical learning and testing situations and timeframes.

The APMA should become a reliable source of innovation to help all schools, residencies and working podiatrists exceed standards for excellence in primary and specialty foot and ankle care. That would put the APMA ahead of peer organizations in making a significant contribution to public health and providing leadership in the ongoing improvement of healthcare structure, delivery and outcomes.

The APMA should track and publicize results at all stages of these educational reforms taking every opportunity to improve public awareness, payer and legislative support and cooperation with other healthcare professions in the workplace and in the political arenas.

Reconsider, redefine and reformulate direct work on parity

Drop use of the word “parity” until the word can be more carefully defined based on local and state conditions and evidence. Stating parity as a goal admits inequality and reflects insecurity. A more inclusive word, such as advocacy, would be more useful.

Develop a cooperative/ collaborative approach within/ across podiatry to define areas needing attention and to recognize the various contributions/ responsibilities in achieving and maintaining those changes.

Compile detailed information on podiatric practice at local and state levels. Look for what works and what does not. Identify specific barriers and design locally supported solutions.

Work with local and state podiatric leaders to identify and address common barriers and opportunities

Identify barriers and opportunities shared across localities and states. Organize to pool and coordinate approaches, provide support.

Design, support, analyze and disseminate relevant data to publicize advocacy efficacy at local, state, regional and national levels.

Commit to strategic and operational renewal for APMA

The APMA has the opportunity to be the catalyst, the innovator and the source of continuing energy needed to reposition podiatric practice in the evolution of healthcare. The professional healthcare environment within which podiatry functions has changed significantly since the last APMA strategic review in 2005. Podiatry needs to define its role and contribution more clearly in service of public health and to the future of healthcare which requires that a renewed APMA develop internal capacity for monitoring healthcare evolution at national, state and local levels. A futures-focused redefinition of the role and function of organized podiatry must be collaboratively approached and conducted with the commitment of all leadership organizations within the profession. The results of these efforts must be widely publicized in order to recruit students, attract and preserve APMA membership and focus public attention on podiatric efficacy in achieving public health goals.

The actual content of podiatric practice, mostly medicine and to a lesser degree, surgery, must be accurately presented to the public, to legislators, to other health care professionals and to prospective students and colleagues. APMA must structure ongoing collection, compilation, analysis and dissemination of podiatric efficacy evidence and any other outcomes useful to make change arguments at local, state or national levels. Becoming effective at local political change will require the APMA to identify, develop and utilize proven personal connections and success stories, opinion leaders and access points.

The APMA should reconsider its internal organization, governance structures and operations. The current structure did not prevent or mitigate the very public and very high risks undertaken in the Joint Task Force and White Paper processes and the APMA suffered negative consequences as a result.

1. The pattern of roles and responsibility across the organization, including both administrative and governance sides, should be examined for the efficacy of their structure, content and function.

2. The internal feedback and performance appraisal mechanisms across the organization should be improved.

3. As part of this internal improvement program the APMA should commit to ongoing training for all board and staff members. Training needs to be individualized by position, role and responsibilities and be appropriately goal oriented.

4. The APMA must reorganize to foster and support more continuous and effective two way communication with front line members, state, local and other national podiatric leaders.

5. APMA management should cultivate soft leadership skills. Ideas should be explored like a “Strategic Leadership Cabinet” to make more available routine access to a wider range of experience and contacts.

6. Commitments must be made to require credible, validated evidence to support policy and implementation plans. Most of this evidence will come from state and local levels. Governance bodies like the Board Advocacy Committee, the Parity Committee and the Board itself must insist on this evidence as part of their own legitimacy.

7. The APMA should also commit to routine independent audit of critical features of organizational output including at least the following:

• Relevance and currency of strategic direction

• Process and relevance of annual goal definition

• Process of annual budget development and relation to goals

• Communications planning, delivery, execution and results.

• Process of assessing organizational efficacy by achievements against goals

• Membership recruitment by targeted sector: student, resident, early career, mid-career, mature career, involved retirees.

Committee Response:

Again, APMA’s strategic plan has been updated multiple times since 2005 and is regularly reviewed.

APMA is not responsible for podiatric education and training. To suggest that APMA study and “improve” knowledge, skills, and attitudes at individual schools or across the profession is to suggest that APMA violate the important separation between the specialty’s professional association and its credentialing body. The Council on Podiatric Medical Education, the American Association of Colleges of Podiatric Medicine and its Council of Teaching Hospitals, and the individual colleges are responsible for oversight of podiatric education and training.  

Dr. Curry’s advice in this section includes many directions APMA has long since been pursuing with significant success, as demonstrated in regular reports to our House of Delegates and member communications, including:

• Ongoing collection of evidence of the value of podiatry to the public health
• Widespread publicity of such evidence and the personal impacts for patients (media relations and public education campaigns)
• Creation of national evidence databases (APMA Registry)
• Constant improvement in education, training, and performance (CPME)
• Student recruitment
• State and federal advocacy efforts

APMA and its Board of Trustees and staff commit to evaluating the definition of parity and accompanying strategic goals through the collection of significant stakeholder input. We further commit to transparent communication around these activities.

Dr. Curry’s recommendation that APMA should reconsider its internal organization, governance structures, and operations demonstrates a lack of research on her part, as Substitute Resolution 14-15 called for a management firm to conduct an independent governance and management review of APMA. This multi-phase review, conducted over the course of three years, included a consultant’s report from Strategic Performance Group and Barnes Association Consultants that was submitted to the 2016 House of Delegates. A governance task force was created to review the results of that study and submitted a consensus report to the 2017 House of Delegates. This was done at considerable cost to APMA and resulted in the extensive bylaws and operational changes that were approved by the House of Delegates in 2018.  

Conclusion and Next Steps

The committee again appreciates the effort and time of those involved in these stakeholder interviews. The committee recognizes that the AMA resolution and white paper caused concern for some members, and we appreciate hearing their thoughts and recommendations. The committee will continue to work with these stakeholders and others to develop a pathway that provides flexibility for local and state leaders to define parity and accountability for each other and members. 

APMA considers this report to be a distraction from our mutual goals of moving forward collegially and achieving parity with allopathic and osteopathic physicians. This process requires the collaborative effort of all concerned stakeholders, and the committee and APMA Board of Trustees are eager to start the next phase of pursuing parity.

We are also genuinely concerned by comments in the report that reflect a poor understanding of the education, training, and experience of our physician and surgeon members. Widespread dissemination of this report and its commentary on podiatric medicine and surgery could significantly damage the profession’s reputation with its allopathic and osteopathic colleagues and in the eyes of the public.

APMA is eager to move ahead in the spirit of the original request from our stakeholders:

• To collect and assess a wide cross-section of stakeholder perspectives on parity.
• To engage stakeholders with diverse opinions and backgrounds in the process of defining and implementing ongoing efforts to achieve parity.
• To communicate transparently to our stakeholders about ongoing tactics implemented in support of goals for parity.

There will be dedicated time for discussion of parity at the 2022 House of Delegates meeting. Additionally, the APMA Board of Trustees has proposed that the delegates consider a Policy Proposition (see Appendix 3) on pursuing parity through shared principles and a Budgetary Action Item Resolution (see Appendix 4) that establishes workgroups to develop an action plan on achieving physician parity recognition through various pathways.

We believe the policy proposition and budgetary action item will help us to accomplish our mutual goals, and we look forward to working collaboratively with you as we continue to advance foot and ankle medicine and surgery.