Preventing diabetic foot disease: Lessons from the medicare therapeutic shoe demonstration

Objectives. Every year about 38 000 elderly people with diabetes have a lower extremity amputation. Therapeutic shoes are prescribed by clinicians specializing in foot care to prevent foot ulcerations and amputations among at-risk patients with diabetes. Medicare ran a 3-year demonstration of a therapeutic-shoe benefit for beneficiaries with diabetes. Medicare added the benefit nationwide in May 1993. Methods. This paper describes the benefit and its implementation in the demonstration based on demonstration records, a patient survey, and discussions with clinicians and shoe suppliers before and during the demonstration. Results. During the demonstration, far fewer beneficiaries applied for the therapeutic shoes than were eligible for them. The paper discusses reasons for the low beneficiary application rate and the associated low participation rate among physicians treating patients with diabetes. Conclusions. The benefit is unlikely to be used any more in the national program than in the demonstration unless physicians are educated in the role therapeutic shoes can play in diabetic foot disease, they prescribe the shoes for their patients, and they increase their patients' awareness of the shoes' value.