STATE liCENSURE 
AND

DISCIPLINE OF 
PODIATRISTS

'aYlc'.r. 
"" S
""Ja 
OFFICE OF INSPECTOR GENERAL 
OFFICE OF ANALYSIS AND INSPECTIONS 
DECEMBER 1988  STATE LICENSURE AND

DISCIPLINE OF PODIATRISTS

Richard P. Kusserow 
INSPECTOR GENERAL 
OAI-01-8-00583  DECEMBER 1988  .-._--..-
EXECUTIVE SUMMARY 
PURPOSE AND OBJECTIVES 
The overal ai'ofthis inspection was to promote a better understJnding of St  licensure and 
discipline practices concerning dentists, chiropractors, optometrists, and podatrq 
sought
. It 
to identify the extent and type of changes occurrng, the major issues being adc: 
ed. and 
th-= 
kinds of improvements that might be made. This repon, which focuses on the 
-=nsure and 
discipline of podatrsts, is the third in a series ofrepons to be issued as pan of th  inspection. 
Pror repons focused on dentists and chirpractors, and a founh will focus on opt()memsts. 
BACKGROUND 
The insption follows up on a simlar inquir conducted by the Offce of Insre;: or Gener 
in 1985 and 1986 that addrssed medcal licensur and discipline. It is based J :mary on
the lines of inquir: 
(1) telephone discussions with board members or staff  !e li  ensu,::
01 
and discipline boies, (2) 
a review of pertnent literatur and data bases, and (3) discussions
with representatives of national professional associations. 
This repon s organization and presentation closely parlel that of the first ana second report
of the overall inspection. A number of the findings and recommendations also p:::allel those 
set fort in the previous repons. 
FINDINGS 
In both the licensure and discipline realms, State board offcials tend 
to feel that 
they are inadequately funded and staffed, and.that, as a result, the eff ctiveness of 
both licensure and discipline operations is undennned. 
Licensure 
State podiatr board policies concerning licensure by credentials--the practice of
grting a license on the basis of one alady held in another State--tend to be 
extremely restrctive. Twenty-the boars wil issue licenses in this manner, but
19 of them impose one or more 
restrctions on the 'applicant. 
The majority of practicing podiatrists are concerned about this 
situatjl\r  becau 
they feel it inhibits their economic opponunity and freedom of 
interstate: 
movement. Less obvious, but of greater 
concern to consumers, is th::: in a 
number of States this policy appears to constrain access to 
podiatrc services, It is
strking that among the 28 States that wil not grnt licensure by credentiak :(1 
have podiatrst-to-population ratios below the national average.  ;.

,.
:' .
:;''::'  :!-\;  ,_:::":"
L.:y board offi  jals , paricularly in larger States, feel an increasing sense of 
about the adequacy of the background infonTation they receive on 
CC'" , tm 
. f::  ure, This involves both the validity of the credentials being 
submitted and the completeness of the infonnation being provided. 
A r.  jor factor contrbuting to this concern is the widely perceived inadequacy of 
the two national clearinghouses that collect and disseminate infonnation on 
Most board offcials express serious 
iplinary actions taken against podiatrsts. 
er\'ations about the extent , quality, and timeliness of the data provided by these 
cle  :inghouses. 
Disciplin 
D,j  :;lg the p:lst 3 years, the annual number of State board disciplinar actions 
apinst podiatrsts has nearly doubled. Between 1984 and 1985, it rose from 
: 84 to 107. From 1985 to 1986, it jumped from 107 to. 159. 
Fifteen State boards took no disciplinar actions against podatrsts from 1984 to 
19\6. 
Tr. ' ::'0St serious types of disciplinar actions--revocations, suspensions, and 
"'ns--accounted for only 35 percent of all the  taen 
disciplinar actions 
)diatrists. This represents a drop from 1984, when they represented 44 
per, 
.f al! actions, 
r..  acti0n rates concerning podiatrsts are much higher than those
r:' 
cor.,;aning medical doctors, or both dentists and chiropractors, the subjects of the 
fi;,: two rep0rts in this inspection. In 1985, podiatry boards disciplined about 9. 
00 
podiatrsts per 1, active podatrsts; denta boards, about 5.4 dentists per 1, 
dentists; chiropractic boars, about 5.3 per 1,00; and medcal boards, 
about 4.2 per 1,000. 
Va;-iation in disciplinar perfonnance is also substantial when State podatr 
b..'  are compared among themselves. These facts stand out: 
her 
years, tWo boards were disciplining podiatrists at a rate thar 
lllL' past 
far exceeded chat of any other board. In 1985, one ofchese boards 
l/ disciplinary actions taken against 
accowlIed Inr ahnll  26  percent of 
podiarrists illlhe Uniced Slates. 
There i,\ lillie variacirl1 in the rate of disciplinary activity with respect to the 
si:e nf SImes, Tile mosc significant variation lies  ",.'ith the medium-sized  percent of active podiatrists, yet were
States. These States hold  24 
1986. 
1984  to 
esponsible for 30 percent of all disciplinary actions from 

The rate of disciplinary action has been disproportionately high in the Sowh 
and low in the Midwest. Although southern States have only 20 percent of 
percem of the reponed disciplinary
active podiatrists, th y accounted for  34 
whereas in the Midwest, the comparable
actions betWeen  1984  and  1986, 
percent.
rates were  26  percent and 
Compartively low license renewal fees appear to be closely associated with low 
disciplinar  boards with annual renewal fees of 
rates of  action. Of the 10 State 
frm 1984 to 1986, and another State 
$25 or less in 1987, 5 took no actions at al 
disciplined poatrsts at a rate well below the national median for that period. 
Consumer complaints ar by far the major source of disciplinary actions against 
referrls 
poatrsts. In contrst, relatively few such actions emerge as a result of 
boar 
frm State poiatr societies or investigations initiated by the  themselves. 
State podatr boar officials tend to be supportve of the national data ban to 
established under Public Law 99-660. However, they rase a number of concerns 
the accuracy, confidentiality, 
assocated with its implementation, among them 
timeliness, and accessibilty. of the bank' s data. 
RECOMMENDATIONS 
State ,governments should ensure that State poiatry boards have sufficient 
car 
resources to  out their responsibilties effectively. 
join together to establish and use a high-quality, 
S tate podiatr boars should 
national clinical licensure examination. 
State podiatr boards should s.hore-up their credential verification processes. 
The Federation of Podiatrc Medical Boards (FPMB) should develop guidelines 
podiatr practice acts. 
for State 
The FPMB, in consultation with the American Podiatrc Medical Association, 
should accumulate and disseminate, on a regular basis, changes in State practice 
acts and regulations.  The FPMB should identify and disseminate to State boards the most effective 
techniques of credential verification. 
encourge more 
The, American Podiatrc Medical Association (APMA) should 
podiatr 
extensive and effective inter-action between its State societies and State 
boards. 
The Public Health Service should assist the FPMB to extend and improve its 
technical assistance and information dissemination activities. 
COMMENTS 
with the recommendations diected to them, 
The APMA and FPMB were in general agrement 
The PHS 
and in some cas  s have initiatives underway that address the issues in the repon. 
and American Association of Colleges of Podatrc Medcine expressed some concerns that the 
al comments received, 
repon did not go far enough in some areas. These concerns, as well as 
addressed in appendix IV of the repon. 
are " ... .... ........ .... ...... ....... .... .......... ..... .. ......  .. .......... .............. .... ..................................... ...................................... .................... ......................... .. .....................
........ ....................................................................... . ................... .................. ........... .............. ....................... ................ ............... .. ................ ............. ....... ...................... . .............. ..
TABLE OF CONTENTS 
EXECUTIVE SUMMARY 
INTRODUCTION... ....... ....... ....... ..........  .................... 1
PRACTICE OF PODIATRIC MEDICI N E ................................................ 1
STATE BOARDS OF PODIATRY ..................................................................... 4
......... 6
LIC E NSU R E. 
LICENSURE BY CREDENTIALS ..................................................................... 7
ADEQUACY OF BACKGROUND INFORMATION ................................. 8
:1 0 
DISCI PLIN E... ..... .... ..... ..... ..... 
INCIDENCE AND TYPE OF DISCIPLINARY ACTIONS .......................

TYPE OF VIOLATION................................ ............ ...... ....... 

SOU RCE OF DISCIPLINARY ACTIONS ..............................................

THE ADMINISTRATIVE PROCESS ................................................................

NG.........................................................0.. .... ................

INFO RMA TI 0 N S HARI 
TlONS ...... ...e.... 
R ECO M M EN D A 
APPENDIX I
NOTES ...... ... e.. ......... ........ .... .
.................... .e... ....
APPENDIX II
BACK G ROU N D 
APPENDIX III
............... ......... .................. ......... ... 27
METHODO.LOGICAL NOTES 
APPENDIX IV
COMMENTS ON THE DRAFT REPORT AND 
.29
OIG RESPONSE TO THE COMMENTS............................................ INTRODUCTION

In June 1987, the Offce ofInspector General undenook an inspection of State 
licensure and 
discipline practices concerning dentists, chiropractors, optometrsts, and 
podiatrsts. The over
riding purose of the inspection was to provide the Federa and State governments and the 
respective professional communities with a better 
understading of these practices. More
specifically, it sought to identify the extent and type of changes 
takng place, the major issues 
that are suracing, and the kinds of improvements that might be 
made. (For more background 
on why the study was undenaken, see appendi II. 
This repon focuses on podatrc mecine and is the third of four repons to be issued as par of
the above-noted inspection. It is based on 
thee avenues of inquir: (1) telephone discussions
with board members or sta associated with poiatrc licensure and discipline boes in 
states; (2) a review of pertnent literature and data bases, includig joural arcles, studies, 
prepar speeches, and statistical compilations of public and private organizations; and (3) dis
cussions with rep  sentatives of varous professional associations. These include the 
American Podatrc Medical Assoiation (APMA), American Association of Colleges of 
Podatrc Medicine (AACPM), Federation of Podatrc Medcal Boards (FMB), and the 
Council on Podatrc Medical Education (CPME). (For more methodological background, see 
appendix III. 
Podatrc medcine has 
fewer practitioners than any other health profession 1; nonetheless, it
has an imp,onant and grwing role in health car. In 1987 there were about 12,40 practicing
pod trsts2 in the United  tates. Podatrsts ar 
classified as "physicians" under Medicar 
law, but only with respect to the functions they ar legally authorize to perform in 
the State 
in which they practice. Thus the services they 
provide within the scope of their State license
ar "physician s services" and ar reimbursable on a reasonable charge basis under Pan B of 
the Federa Medicar Prgram In Fiscal Year (FY) 1985. these 
expenditurs totaled $211.8
millon. 
In the case of Medcaid, the role of 
poatrsts and the level of expenditur for which they ac
count are less clear. Statistics ar dificult to come by because 
podatrsts are included in the 
general category of "Other Physician Services.  It is estimated, however, that less than 5 per
cent of poatrsts ' practice income comes from Medicaid. 
This repon stas with brief overviews of the practice of podiatrc medicine and State boards 
of podiatr. It also examines the major changes and issues affecting licensure and 
discipline and suggests areas of action directed primarily to State boards of 
podiatr. 
PRACTICE OF PODIATRIC MEDICINE 
Much like dentists and chiropractors, podiatrsts practice in relative isolation. While increas
ing numbers of podiatrsts have staff privileges at 
one or more hospitals, offce tratment still
predominates. By 1983, 73 percent of podiatrists had some type of professional privilege in  . :.
.' :":'
hospitas and 58.5 percent had surgical privileges, but less than 15 percent ofpodia::-..
S The \':
physicians treated more than 5 percent of their patients in hospital settings, 
::.iority 
of patientS continue to be trated in the podiatrsts ' offces, 
Even in the office setting, most podiatrsts work alone. According to a report prep:i:-" 
: for the: 
1985-- --about 72 perctnt of 
APMA by ELM Services, Inc., in 
 The Economics of Foot Care 
podatrc physicians were in a solo practice, 13 percent were involved in a parership, 5 per
cent were in a group practice amgement, and the remaining 10 percent were eithe :Q' 
employed by the government or a podiatrc medical college, or not in active practk\;, 
A 1983 surey of  by the APMA found that increasing number 
poatrsts conducted 
podiatrsts are looking to the American Boar of Podatrc Surgery (ABPS) and the American 
Boar of Podatrc Onopecs (ABPO) for certfication in these two specialties. According 
to the surey, in November of 1983. 14.8 percent of active  ABPS cenified, 
poatrsts were 
with 16.5 percent eligible, and 1.9 percent were ABPO certfied, with 0.1 percent elIgible for 
board certfication. 
tie 
The grater pan of a podatrst  is spent on activities that ar considered genemJ practice, 
Although, in recent year an emphasis has ben placed on poatrsts' developing skills in 
surgery and foot ortopedcs. this specialty is most often incorporated into their regu!  :- prac
tice. Specialzation, in the everyday medical sense, is rae. 
Podatr is largely a white male profession, although the numbers of minority and femJ.::: stu
dents enrlled in colleges of poiatrc medicine have been incrasing, as shown in fi;:. -
FIGURE I 
NUMBERS OF WOMEN AND MINORITIES ENROLLED IN 
COLLGES OF PODIATRIC MEDICINE. 1976-1986 
700 
650  !Q  INORITIES 
600 
550 
500 
450 
400 
350 
300 
250 
200 
150 
100 
JAil 
1976  1977  1978  1979  1980  1962  1963  1984  1985  1986 
1981 
Source: AMERICAN ASSOCIATION OF COLLEGES 
PODIATRIC MEDICINE  It should be noted, also, that the attrtion rate for women and minorities is greater than the 
7 percent. According to data from the American Association of Col
overall attrtion rate of 12.
leges of Podiatrc Medicine (AACPM  minorities in 1985 experienced an atttion rate of 
20. 8 percent and women 17.2 percent. 
The number of all students enrolled in the colleges of podatrc medicine has leveled off after 
a period of expansion in the late sixties to mid-seventies. The growth at that time was due to 
incrased Federa aid to both schools and st  dents and to the schools' effons to increase class 
size. Another general upward trend in enrollment occUIed in the 1980's when tWo new 
schools opened, the College of Podatrc Medicine and Surgery in Des Moines, Iowa (1982), 
Bar 
and the  University School of Podiatrc Medcine in Miam Shores, Florida (1985). 
FIGURE II 
PODIATRIST:POPULATION RATIOS SHOWING GEOGRAPHIC

DISTRIBUTION OF PODIATRISTS,

1974, 1983, AND 1987 
NORTHEAST 
t.AIDWEST 
&1 SOUTH 
o WEST

raTOTAL UNiTED STATES

1974 1983 
1987 
Sources: 1974 Data on Active Podiatrists From 
National Center for Health Statistics; 1983 Data 
From APMA; 1987 From State Boards/Census Bureau 
Although the number of practicing podatrsts has increased over the past 10 to 15 year, there 
has been no significant improvement in their geogrphic distrbution when concomitat in
creases in population ar also considered. For example, the data show that from 1974 to 1987, 
the Nonheast had the highest ratio of podiatrst to population as well as the 
largest per-ratio in
crease over those year (figure II). 
In 1984 the American Podiatrc Medical Associ::tion(APMA) fonned a panel of prominent 
podiatrsts and others to take a look at the profession of podatrc medicine and char a path for 
its future. Called the "Project 200 Commission," its final repon was presented to the APMA 
House of Delegates in 1986. The report cited several major aras of concern identified by the 
Commission. One of these was the education of podiatrsts. "The goal of podatrc medical 
education, " stated the report, "must be to produce a ' comprehensive footcar physician, ' a 
tOtal specialist who is well versed in all areas of his or her field, with a redirection and em  . ..
, "
phasis on non-invasive and biomechanical procedures in patient care. 
II " The repon, according
to former APMA president Dr. 
Jerr D. Brant  did nOt say that 
podiatrc surgery should be
abrogated. On the contrar, 
excellence must be the standard here
, because competirion among
physicians wil be most intense in this area. It is crtical for the 
profession to prouce all-
aroun loot car p 
l" 
YSlClans. 
The repon also recommended adoption 
ofa uniform podiatrc practice act It is widely felt
that differing State laws
' confuse not only the 
public but Other practitioners as well. The base
of this uniform act would be the scope of practice recommended by the 
Prject 200 
Commis
sion. Ths cals for an anatomical scope that includes the foot
, ankle and soft tissue of the
lower leg, dista to the tuberosity 
(protUberance) of the tibia. 
STATE BOARDS OF PODIATRY 
Two deades ago, State podiatr boards, like Other State licensing boards, were little-nOticed
entities of State Government. In many cases, because the regulation of 
podatr was assigned
to the medcal boards, it was dominated by medical 
doctors. Only where independent
podatrc licensing boards existed did the profession itself dominate. Most 
of the boards,
whether podatrc or composite, had linle operational interaction .
with o  er professional
boards or even with sister boards in other States. Although their 
responsibilties typically
covered both licensure and discipline, they focused primarly on the former
, and in panicular
on the development and administration of their own licensing examinations. The 
boars
would discipline a podiatrst occasionally, but their 
authority and n;adiness to do so were quite
limi ted. 
Now the pictue has changed 
somewhat. With the growth in the number of podatrstS, the 
development of the consumer movement, the widespread use of practice-
building techniques
(including advenising), the heightened concerns about infectious disease, and the 
incrased at
tention to the cost and quality of health care, State boards of 
podiatrc medicine function in
more visible environment with a 
grater degree of accountabilty to the public. Although the
scope and intensity of the changes have not been as great for State medical 
boars, they never-
theless have been significant 
About 63 percent of State podia 
' boards repon that they 
ar now pan of a centralized State
agency, and at least 80 percent have one or more non-
I2 Nearly all the boards (94 percent) have repspoodniastirbsitl imtye fmorb beorst ho nli ctehnesiru rbeo aarndd  odfis
directors. 
cipline. 
The staff and financial resources available to the boards are not as e
asily detennned. Only
three of them report that they have two or more staff members
, but in many cases this does not
include staff reporting to an umbrella agency that may provide some assistance to a board, 
Similarly, the budget of a board is often obscured within the budget of a larger agency.  im
It is clear, however, that in nearly all States the board revenues derive entirely from fee 
posed on podiatrsts and any other occupational groups covered by the board. These inciuj

revenue is the license 
application , examination, and varous other fees. The major source of 
nual
renewal fee imposed on practicing podiatrsts, which in 1987 ranged from $10 to $65() 
ly; the medan was $50. Half the boards with whom we spoke imposed fee increases during 
f~e. 
the last 2 years or are planning to do so, although one State reported lowering its renewal 
the State budget process and subject to the same 
But, because boards tyically ar pan of 
budgeting and personnel controls as othe! State agencies, fee increases do not necessarly 
mean an incrase in their resources. Thus, even though the licensure and discipline of 
may 
board rep
podatrsts has grown to become an estimated $2 millon-a-year enterprise, 14 
resentatives feel they ar seriously underfunded in caring out their extensive responsibilities,  LlCENSU RE 
Over time, State 
podatr boars have come to judge applicants on the basis of four major re
quirments: (1) 
graduation from an accredited or approved college of 
passage of the Wrtten exam given by the National Board of  podatrc medcine; (2)
Podiatrc Medical Examners; (3)
passage of a State clinical exam; and (4) in increasing numbers, completion of an approved 
residency or preceptorship. 
Of these four requirements; 
grduation is the most consistently and formally applied by the
States. Almost all have specific wrtten regulations that 
school approved by the national accrediting body, the Coruenucirile o ann  applicant be a graduate of a
Podiatrc Medcal Education

(CPME); if this requirement is not offcially spelled out in the statutes or regulations, it is 
usually the policy of the 
boar nevenheless. Few applicants for poatrc licensur
graduates of foreign schools. Only seven State board 
representatives reponed that they had
frm 
received inquires. grduates of foreign schools over the past 3 to 4 
only four had received fonnal applications. Seven States told us that it  year, and of these,
is possible to be
licensed without a degre from a U. S. podatrc medical college, most often because of a lack
of specific language in State laws and regulations. Most States said they had never had to deal 
with such a situation. 
The NBPME testing requirement is the second most consistently applied by States, with near
ly all specifying that an applicant for licensure must pass the two-pan test. 
focuses on the basic biomedical sciences, is usually taken  Pan I, which 
II, taen durng the  afer 2 year of poatr school; par
final year of school, addsses varous 
cliical subjects 
Accordig to a 
Council of State Governments repon published in 1986, 
20 of the 50 States
and the Distrct of Columpia require 
passage of a practical clinical exam for 
licensur and 16
requir passage of an ora clinical exam. Most States have 
ing numbers (eight as of August 1987)  developed their own, but increas
ar using a clinical exam developed for VIrginia by the
Local Government Researh Corporation of 
State College, Pennsylvania. It was first used in
VIrginia in 1982 and is presently under consideration by severa States. 
Each of the practical exams seeks to assess the clinical readiness of candidates, and in so 
doing 
reuirs them to conduct procedures on patients. Yet the contents of the 
the detennnations of acceptable  tests var as
perfonnance. 
The founh major requirement--completion of an approved residency or preceptorship--
ing prominence among the States. Ten of the 17  is gain-
States that reponed major legislative or
regulatory changes in licensure requirements over the past 3 to 4 
year named 
of a residency/internship/ preceptorship requirement. While this was the mostthe instituting 
sure change, two other issues were also mentioned: licensure by credentials-- COmmon licen
suing a license to a podiatrst on the basis of a  the practice of is
license held in another State--and the adequacy
of background information provided on applicants for licensure.  LICENSURE BY CREDENTIALS 
restrctive and 
The policies of State boards in granting licensure by credentials ar extremely 
severely limit the ability of podiatrsts to move freely from one State to another. States usual
ly have adopted three approaches to the question of recognizing a license frm another State. 
curnt 
The fIrst of these is simple non-recognition of such a license--the  practice in 10 States. 
All applicants must meet the same criteria as a new grduate of poatrc mecal school seek
ing licensure for the first time. This usually means they must pass the curnt licensing exam, 
which can pose a problem for those who are not recent graduates. Moreover, increasingly 
trning. 
they must fulfll a reuirement for some kind of post-graduate 
The second approach is the grting of a license by reiproty. That is, the State recognizes 
the licenses of practitioners only from States with which they have fonnal reciprocal agree
grt 
States  licenses in this manner, but only 3 do so without imposing 
ments. CUIently, 18 
funer restrctions. The most common of these restrctions ar the stipulations that the prac
titioner must have taken a clinical practical exam and, increasingly, that they must have com
pleted a residency program in order to have been licensed initialy. 
The third approach adopted by some States is endorsement or crentialing. Ths shifts the 
focus to the individual qualifications of the applicant. Endorsement is a unilatera decision by 
a- State to adt licensed individuals frm another State to practice without examnation. 16 Al
though 23 States grnt licenses by endorsement, 19 of them impose one or more restrctions 
on the applicant, in effect limiting the tre meaning of endorsment. 17 There is a need to 
simplify and broaden the whole process. It is believed by some in the licensing community 
that a national clinical examination is one key to the achievement of universal licensing by en
dorsement 
FIGURE II 
PODIATRIC RESIDENCIES AVAILABLE TO GRADUATES OF

COLLEGES OF PODIATRIC MEDICINE, 
ACADEMIC YEAR 1984-85

600 
NUMBER OF' PROGRA 
500  :.MaER OF APPROVED 
,IRST - YEAR POSITIONS 
R: 
TOTAL NIJM9  R OF' 
350  GRADUATES 
300  F'RST - YEAR POSITIO 
PER lOa GR  UAiES 
200 
150 
1 C/' 
Sourc e:  F'ifth Report to the President and 
Congress on  the  Status of Health 
Personnel in the U.  , March 1986  But owig to an increasing number of States requirng that an applicant complete a residency
for licensure (and residencies are limited
, as shown in figure III) and that they pass whatever
exam the State recognizes, the mobilty 
of podiatrsts remains restrcted. 
ADEQUACY QF BACKGROUND INFORMATION 
Durig the early 1980s, State medcaJ boards were severely shaken by scandas involving 
frudulent crentials from two Carbbean medical schools and by breaches of security on
some medical licensure examnations. State podatr boards have not had to face comparble
developments. Yet among may of them, panicularly those in the larger States and in States
where podatr is handled by the medical boar, there seems to be a growing uneasiness about
the quality of the background information provided to 
boars on applicants for licensur,
whether these applicants 
ar aleady licensed in another State or seeking their initial license.
The validity of any crentials cited in an application is not seen as a problem
, as much as the
completeness of the information bearg on an applicant s professional conduct. The follow
ing comment frm a State boar 
representative ilustrtes this concern vividly: 
States sometimes lie when it comes to 
inquirg about applicants. I think some-
ties a State may really want to get rid of a bad practitioner wi 
, so they  probab
ly not give the whole picture about the applicant. 
Boards usually now 
reuir more extensive documentation with an application for licensure. 
Yet the proessing ties for applications have incred 
signifcantly in only 20 percent of the
States. Two States, in fact, repon that the processing time 
has decrased mainly beause of ad
ministrtive improvements. Seventy percent of 
those States reponing incrases cite more in-
depth background checks as the cause for the delay. The remaining 30 percent cite an 
incrase
in the number of applicants as the reason for the longer processing time. 
About 10 percent of the State boar 
repon that in the past 3 to 4 years they have implemented
changes that call for more detailed 
informtion on application forms and/or more vigorous ef
fons to veriy the crentials of applicants. Other boars ar also planning changes of this
son. Most of the changes involve the revision of applications to provide a fuller accounting of 
the applicants ' past and to reuir disclosure of any disciplinar problems they may have had.
To limit opponunities for submitting 
altere records, a number of States now reuir that col
leges send 
trscripts and other States send any licensing and 
disciplinar history diectl
the board. A few boards underte more diligent verification through telephone inquiresy, to
fingerprinting, and even Federal Bureau of Investigation checks. 
Overall, however, the scope of these changes is limited and, many board 
offcials suggest, in
adequate. The major reason cited by the boards for their 
failure to take more 
substatial ac
tion is the lack of suffcient resources. Their staffs 
are simply inadequate to do a job properly.
The result, a significant number of boards repon, is that the 
backgrunds of many individuals
are checked superfcially, if at all
, and the boards are compelled to rely too heavily on the as
sumption that applicants are tellng the 
trth. They add that this situation seems to present a
parcular vulnerability in the case of applicants who are already licensed in other States.  A second factor that inhibits more effective board action in reviewing applicant backgrounds 
is the widely perceived inadequacy of the national disciplinar action clearnghouses main
taned by the Federation of Podatrc Medical Boards (FPMB) and the National Clearnghouse 
on Licensure, Enforcement and Regulation (CLEAR). Although 60 percent of the boards 
18 the majority 
repon that they use one or both of these clearnghouses,  of them feel that their 
Prarly, 
usefulness is limited.  this is due to the fact that neither of them comes close to 
having a complete listing of all the disciplinar actions taen by the 51 States. Other reasons 
bear on the insuffcient data held by the clearnghouses on podatrsts who have ben dis
ciplined and the time involved in sending data to the boars. Severa States note, however 
that the regular report sent to the boards by FPMB are helpful. 
Neverteless, the unease generated by the limitations of clearnghouses is especialy sig
nificant in States that endorse previously held licenses and thus are more liely to be review
ing applications from podatrsts licensed in other States. But it is felt to a considerable degree 
in most other States as well. Expressing much frstration over the deficiencies of the current 
system, one board representative told us, "We need all the help we can .get  DISCIPLINE 
Over the years, the authority of State boards to discipline podiatrsts has 
ben increasing
grdualy, with respect to bOth the grounds upon which they can 
.take disciplinar action and
the typ of action they can take. During the past 3 to 4 years, about 35 percent of the boards 
have experienced some legislative or regulatory change concerning their 
disciplinar
authority, the-founhs of it increasing that authority and none of it serving to decrease it. 
Most often, the changes have involved an expansion of their range of 
disciplinar actions. 
As of 1984, the latest year for which aggregate data ar 
available, all the boards had the power
to discipline podatrsts by suspendig 
or revoking their license upon proof of a punishable 
violation. Other types of disciplinar actions that could be imposed were limited, however:
19 had the authority to assess probations, 17 to issue reprimands, 13 to 
restrct poatrc prac
tice, 9 to impose censure, and 5 to impose fines of up to $1 
00. Two States had the authority
to requir a coure of 
education or training, and one could 
reuir a licensee to perform up to
100 hours of public service. 
Since 1984, these numbers have 
incrased, with more States gaining a 
nar options. Yet may still lack a full complement of options as well agsr aottehre rr abnagseic o afu tdhioscriip li
ties, such as the power to issue subpoenas or to summarly suspend the license of a 
podatrst 
who poses a clear and present 
dager to the public. 
INCIDENCE AND TYPE OF DISCIPLINARY ACTIONS 
How may and what tye of disciplinar actions ar being taen against podatrstS in the
United States? Although this question is 
basic, it is one we 
leared could not be answered.
The existing information bases were too lited 
to provide even reasonable estiates. 
Accordigly, in our 
discussions with representatives of the State boards, we asked them to in
dicate the number and type of 
disciplinar actions imposed on podiatrsts during each of the
past 3 calendar year. We received the data from all 48 States with whom we were able to 
speak. The result is an essentially complete picture of the extent and 
nature of 
tions taken in 1984, 1985, and 1986. The data provided by the State boards  disciplinar ac
figu  ar summarzed
in  IV. 
During a period when the numbers of 
poatrsts steadily increasd and national concern about
the quality of health care grew
, it is not surprising that the total number of 
disciplinar actions
taken against podiatrsts by State boards also 
incrased, by nearly 100 percent from 1984 to
1986. The figure rose from 84 actions in 1984 to 
107 in 1985, an increase of almost 30 per
cent, and reached 159 actions in 1986, a funher increase of about 50 percent. 
Over this 3-year period, in stak contrast to 
dentists and chiropractors (subjects of the fIrst two
repons in this inspection), tier 
1 actions--the more serious ones involving license revocation 
suspension, or probation--regularly accounted for less than half of the 
disciplinar actions
 taken by State boars, and as little as a third (figure V). For dentists and chiropractors such ac
tions composed roughly tWo-thirds of al disciplinar actions. Tier 2 actions, such as 
reprimands and fines (designated in figure V as "Other ) represent no more than 44 percent of 
total actions in anyone year. The tier 2 actions identified by board representatives can be 
broken down as-follows: 81 letters of reprimand, 73 consent agreements (which can include a 
varety of stipulations agreed to and signed by the licensee), 5 decrees of censur, 2 restraining 
63 unspecifed "other" actions. 
orders or restrctions on practice, and 
FIGURE IV 
NUMBER AND TYPE OF DISCIPUNARY ACTIONS TAKEN BY 
STATE BOARDS OF PODIATRIC MEDICINE AGAINST 
PODIATRISTS. 1984-1986 
110 
100  I3 SUSPENSIONS

REVOCATIONS 
IS PROBATIONS

.JTHER 
1985 .  1986 
FIGURE V

PERCENT DISTRIBUTION OF DISCIPUNARY ACTIONS 
TAKEN AGAINST PODIATRISTS BY STATE BOARDS, 
BY TYPE OF ACTION. 1984-1986 
REV, =-6% 
SUS, = 19% 
OTH.=56% 
1984 
PROS, = 16%  PROB, = 13% 
REV. = 12% 
REV. =9% 
SUS"0' 
_7? 
SUS. 
OTH. =68%  OiH = 65 
1985  1986 
Sources:  State Boards as Reported to the 
Offic e of Inspec tor General, 1987  ::.
When the perfoffance of State boards of podiatr is compared to that of State medical 
, dental
and chiropractic boards, some notable differences emerge concerning both the incidence and 
type otf hdis ciplinar actions. First, the podiatr boards have been fa, more active than the 
other  in disciplining members of the profession. In 1985, for example, poiatr boards 
disciplined 9.7 podi  trsts per 1,00 licensees, dentists 5.4 per 1 00, chirpractors 5,  , and
medical doctors 4.
2. 0 
A second noticeable difference among the four tys of boars involves contrsting trends in 
the proportonate emphasis given to the more severe, tier 1 disciplinar actions. Although
such actions have been increasing as a share of all 
disciplinar actions taen by denta boards 
against dentists, they have essentially remained constat for chiropractors (65 percent 
average), and they 
ar declining for both medical doctors and podatrstS. For the latter, tier 
actions composed 44 percent of all actions taen in 1984; by 1986 the 
figur had dropped to 
35 percent after reaching a low of 32 percent the year before. Similarly, for 
medcal doctors, 
tier 1 actions dropped from 63 percent of total actions in 1982 to 53 percent in 1985. 
From 1984 to 1986 there was a steady decrease in probations as a percentage of 
al actions 
taken by the State podatr boards, and the percentage of suspensions dropped by almost 50 
percent from 1984 to 1986 after reaching a low of 7 percent of all actions in 1985. Overall, 
tier 1 actions accounted for only 36 percent, or 126 of the 350 total actions over the 3-
year
period. It is imponant to note, however, that from 1984 to 1986 the percentage of revocations-
the most serious action possible--
imposed Qn podiatrsts by State boards doubled. They rose
frm 6 
percent of total actions in 1984 to 12 percent in 1986. 
The varations in disciplinar performance ar no less atphpar nt when State poatr boards 
compard among themselves rather than with the other 
boars. Over a. 3-year period, for
instance, two State boars, Arizona and Florida, disciplined poatrsts at a rate that far ex
cees that of any other board. In fact, Florida's alone accounted for about 26 percent of all dis
ciplinar actions taen by State podatr boars in the United States in 1986, and 17 percent in 
1984 and 1985.

FIGURE VI 
PERCENT DISTRIBUTION 
OF ACTIVE PODIATRISTS 
(1987) 
AND OF REPORTED 
DISCIPLINARY ACTIONS 
(1984-1986). BY SIZE RANKING OF STATES

lRG-3..  X-SM_" 
LRG. =32'7  X-SM. = 1 70 
X-LRG, = 3570  X-LRG, =33'7 
Ac tive POdiatrists  Reported Disciplinary Actions 
Sources: Fifth Report to the President and 
Congress on the Status of 
He:Jlth Personnel in 
the U. S. and State BoardS as Reported to OIG
 Slight varations among the boars ar also apparent when their rate of disciplinary activity is 
corrlated with the varable of size of poiatrst population in a State. Since year-to-year fluc
tuations in this regard may be misleading, we have aggregated and analyzed the data over the 
year period from 1984 to 1986 (see figure VI above). 
Out of this comparative examiation, it can be seen that the most significant varation existed 
in States classifed as medium-sized. While those States had 24 percent of active podiatrsts, 
from 1984 to 1986. Thee of 
they were responsible for 30 percent of all disciplinar actions 
the other four categories--small, large, and extra large-prouced only slightly fewer actions in 
relation to the number of podatrsts in those aras. When compared with respect to regional 
divisions, however, the results ar quite different (figue VII. 
FIGURE VII 
PERCENT DISTRIBUTION OF ACTIVE PODIATRISTS 
(1987) AND OF REPORTED DISCIPLINARY ACTIONS 
(1984-1986). BY CENSUS REGION 
NORTHEAST=36  MIDWEST=9% 
MIDWEST.. 26% 
SOUTH=34% 
SOUTH.. 20 
Active Podiatrists  Reported Disciplinary Actions 
Fifth Report to the President and 
Sourc es: 
Congress on the Status of Health Personnel and 
State Boards of Podiatry as reported to OIG

The rate of disciplinar action was highest in the South and lowest in the Midwest. Although 
the Southern States had about 20 percent of the active poatrsts licensed in the United States, 
the 
they were responsible for 34 percent of the reponed disciplinar actions. Likewise, for 
Midwestern States, the figures were 26 percent and 9 percent. 
Why was the rate of disciplinar action higher in some States than in others? Was it because 
practicing podiatrsts in some States were more incompetent, dishonest, or unprofessional than 
in Others? . Or because levels of board commitment to take action vared? Or because boards 
were constrained by inadequate authority or insuffcient resources? Each of these factors may 
be explanatory to some extent, but, in the case of one--insufficient resoures--we have some 
data to suggest an association.  We found that of the 10 State boards with annual renewal fees of $25 or less in 1987 
, 5 had no
actions at al and another fell well 
below the median rate of 
21 Additionally, if the comparson is extended to Stadteiss ciplinar actions of the State
boards.
with renewal fees of $50 or 
less, we find 11 States with no actions ard 5 more below the median rate; 3 of the 5 had less 
than half the medan rate for disciplinar actions. At the other end, the association, although
not as strong, was nevenheless significant. 
Of the 18 States with annual renewal fees of $75 
or more, 7 had a 3-year rate below the median, with 3 that took no 
disciplinar actions at all;
and of the 11 States that fell above the median rate of diciplinar actions, 3 were within one 
And so we found that although a comparatively high renewal fee is no 
percentage point of it 
guartee in itself of a higher level of disciplinar activity, it seems to have helped increase
the activity of poatr boards in a number of States. 
Finaly, it is imponat to recognize that State boards are not the only forum for disciplining 
podatrsts. Another, as note in appendi I, is the Office of Inspector General (OIG), which
can impose sanctions on professionals who have commtte fraud or abuse. Durg 
the past 5
years, OYG sanctions against 
podatrsts have averaged about 3 percent of al the OIG sanc
tions imposed, ragig frm 1 percent in FY 1985 to 5.4 percent in FY 1982. 
TYPE OF VIOLATION 
Unlike our previous studies of medcal doctors and of dentists and chiropractors, this study 
ty 
found there is no one  of violation that stoo out among the bases for 
disciplinar actions
taen by State podiatr boards. Of the 33 States that reponed having taen at least one dis
frm 
ciplinar action  1984 to 1986, relatively equal numbers said that clinical misjudgment, 
unprofessional conduct, self-abuse of alcohol or drgs, 
inappropriate prescrption wrting, and
violations of advertsing laws were their primar causes for disciplining 
poatrsts. Six of the
33 States said they could not identify any primar cause for discipline because they took too
few actions. One large State did repon that for the 
period from 1984 to 1986, "
The majority
of our disciplinar actions (total 80 actions) have ben for por clinical performce or inade
quate clinical judgment." Of these 80 disciplinar actions, 69 
were only the less severe tier 2
actions, and of the 11 tier 
1 actions, 4 were revocations, and the other 7 were probations. 
Only one-third of the States said that they had 
disciplied at 
least one podatrst because of
poor clinical performance over the past 3 to 4 
year. Of the two-thirds that had not, the
reasons most often given were much the same as those cited by medical doctors in our earlier 
study: (1) the complexity, length, and cost of such cases, (2) the substantial 
buren of prof
required, and (3) the considerable varation in what constitutes 
acceptable practice. A sig
nificant number of board offcials expressed the belief that one 
reason that helps account for
the small !'umber of actions based on poor clinical performance is that the 
oJrJ boy network
within the State podiatrc societies "
takes care of their own" before a State board ever hears of
the problem. Indeed, some board offcials said they prefer it 
this way because it lessens the
burden on their shoulders. Given their limited stafs and 
resources, the bows felt that it does
not hun the profession if such issues ar 
left up to the State societies to resolve. 
If the
societies fail, then the board wil hear about it and 
disciplinary proceedings can tae 
place.  Some of the States to whom we spoke also identified continuing education effons as a factor 
in keeping cases of poor clinical perfomlance to a minimum. According to a Council of State 
22 33 States in 1986 
Governments report, requird some continuing education for license 
renewal, with an average reuirement of 19.4 hour annually. 
Thus far, the most visible and consequential of the early intervention efforts intended to cor
rect problems before they lead to violations ar the rehabilitation progras dited to im
paid podatrsts. In our review, two-thirds of the boards indicated that such progrs were 
available. They were most often admistered by the State medcal societies, but podatrsts
had access to them. In a smal number of States, the programs were' available under the 
auspices of the board itself. In a few other States, Massachusetts, for instace, the programs 
were run by a peer review commttee within the State 
podatrc medical society. 
SOURCE OF DISCIPLINARY ACTIONS 
Complaints frm consumers were the major soure of disciplinar actions against podatrsts
in almost tWo-thirds of the States. This pattern held regardless of a State s size or region. In 
contrst, few disciplinar actions appear to have been based on referrls from State podatr
societies. No State cited the societies as the most common soure of complaints, and only tWo 
cited them as even the second most common source. Again, the opinion that State societies 
take car of their own " unless there is a serious problem was widely expressed by the board 
representatives with whom we spoke. 
Individual practicing poatrsts have been among the least frequent sources of refeITal. 
Recently, though, their tendency to refer cases of possible violations to the State boar 
seems 
to be on the rise. Two factors ar seen as providing the impetus for this increase: mandatory 
reponing laws. which exist in a number of States, and the increasingly competitive environ
ment characterizig the practice of podatrc medicine. A third factor may well become more 
prominent in the near future. The language in the Health Car Quality Improvement Act of 
1986 that extends immunity to practitioners who make refeITs for goo cause may increase 
dict 
the number of  refeITals by poatrsts. 
More than hal of the States have laws or regulations calling for other agencies to repon cases 
involvig  poatr 
possible violations to the  boards. Most often these laws reuire hospitals 
and insurace companies to repon malpractice cases, but some States have extended these 
laws to require practitioners as well as State podiatr associations to repon possible violations 
to the board. Even when these types of provisions exist, however, many cases stil go un-
reponed. As one board offcial put it, "  ll never be able to catch all the ones that fall 
through the cracks. It' s impossible. 
THE ADMINISTRATIVE PROCESS 
Over the past 3 to 4 years there seem to have been measurable improvements in the backlog of 
cases awaiting investigation. Although five States cited an increase in their backlogs during  this..period (most often attbutable to a  mor 
lack of staf),  States said there has been a
decrease and several others stated they have no backlog of cases that need to be investigated, 
Board representatives from 19 States reponed they had made changes in the 
the intent of expediting their boards  reent past with

' investigatory and review activities. 
More than half of
these involved increases in investigative 
stafng, appointment of a hearng officer to help with
complaits, and creation of new investigative offces. In one State, where there is no backlog
and there have been no recent changes, a board offcial told us, "
We don t nee to make any
changes. There hasn t been anything to expedite. 
Another comment-- It taes alost an act of God to get a restraining order to protect con
sumers from bad practitioners 
--came from a board offcial in one 
of the States with the 
largest number of practicing podiatrsts. It typified the 
frstrtion expressed by many offcials
with whom we spoke. In about half the 
States, board represen  tives told us that there are
weakesses in the disciplinar 
process and that there 
ar constrints that hinder improvements
in it. The most 
often cited weakesses were underfundig and lack of appropriate 
quately address discipline matters.  staf to ade
Much of the frustration expressed also resides in the delays associated with due 
proess protec
tions. A representative in one State noted that such delays were largely responsible for the fact
that it taes a little over two 
and a hal years to proess a 
case, with the podatrst tyically
continuing to practice durng that time. 
But a board official in another State viewed the 
tion from a broader perspective, commenting as follows:  sitUa-
Some might see weaknesses, but I view the discipline process as one that is fully 
endowed with protections for the licensee; this sometimes slows things down, but 
it is palatable to other authorities such as the couns, attorneys, civil 
libertans,
etc. 
INFORMATION SHARING 
Over 85 percent (41) of the States regularly send notice of 
disciplinar actions to a national
clearnghouse. Thirt indicated that they send the infonntion to the clearghouse operated
by the Federation of Podiatrc Medical 
Boars (FPMB) only; 9 send notice of actions to the
Clearnghouse on Licensure, Enforcement and Regulation (CLEAR); and 4 
to both FPMB and CLEAR. In addition, a  States send nOtice
small number of States that have composite boards
also send nOtice of actions to the Federation of State Medical 
Boars. The comments we

heard in our review indicate that confidence in the FPMB and CLEAR clearnghouses is lack
ing, mainly because of the incompleteness of their data bases. Most States, although they 
send notice of acrirj ls to the clearnghouses, prefer to rely on communication among themsel
ves to obtain accurate and timely information. 
Many factors severely limit the effectiveness of the two clearnghouses. 
State boards typically
do nOt report on licensure denials or on informal actions. 
Many do not report in a timely man
ner, sometimes waiting for months before sending the data to a clearinghouse. When they do  repon, the data provided on disciplined podiatrsts ar limited, often not including the name of
their podatrc college, their social securty number, or even their date of bir. And, while
their report do specify the type of disciplinar action taen , they reflect widespread inconsis
tencies in how the underlying violations ar 
described. and, indeed, on the type of disciplinar
action imposed for a paricular type of violation. Within their individual 
States, only 11
boards told us they have a clearly defined set of guidelines for 
detenning 
the appropriate
level of disciplinar action. 
The executive dirctor of a State 
podiatr board commented as follows about the new national 
disciplinary action data bank to be established under P.L. 99-660, the Health Cae Quality Im
provement Act of 1986: 
This clearnghouse must be the best kept secrt anywhere. We ar sitting on the edge
of our chairs waiting to see 
what the regulations will require us to do. And the
clearnghouse wil be of limited use if past actions 
ar not included in the data bank. 
Many other board offcials in other States voiced 
simiar concerns. 
During our discussions, held in the Fall of 1987, many State 
boar offcials were unawar that 
included in this data bank as a result of P.
podiatrsts' would  be  L. 100-93, the Medcar and
Medicaid Patient and Progrm s Prtection Act of 1987. When told that the reportng require
ments would apply to podiatrsts, most were generally 
enthusiastic. 
Among the specifically noted concerns 
rased about the prospetive national clearghouse,
those expressing the need for a common language for violations and 
disciplinar actions were 
prominent. Among the other 
questions rased were the followig: 
How accurate wil the data be? What 
steps wil be taen to ensure its accurcy? 
Wil the confidentiality of the data be maintaned? 
Might State laws assurng
confidentiality be compromised? 
How quickly wil the data be accessible? What wil be done to 
ensure that the system
does not bog down because of administrative overload? 
How extensive wil the reponing demands 
placed on State podiatr boars be? Wil all
the boards be able to meet these demands? Wil there be any Federal financial help? 
Wil the national data banks produce aggregate data summares that wil facilitate an
understanding of trends and help shape risk management effons? 
\Vil podiatry be associated with medicine in a way that might be to the disadvantage of 
the profession? Will the uniqueness of its practice setting be recognized?  the information sharng that occurs within a State is 
Finally, it is imponant to reognize that 
, some
also of signifcance. In this sphere, pod atr boards ar becoming somewhat more open
times because of legislative mandate, in disseminating information within the State on discipli
nar actions  n against podiatrsts. The vehicle for this dissemination is most often a 
podatr society, State Medicaid Fraud Control Units, State in
newsletter sent to the State-
surance agencies, and other State or local entities. In only a relatively few States is an active 
effon made to shar the information with the genera public through general cirulation 
newspapers or other popular media outlets.  RECOMMENDATIONS

Given the situation descrbed in the previous pages, our centr recommendation is the folIow
109: 
State governments should ensure that State podatr boards have sufficient resources to 
car 
out their responsibilties effectively. 
In most States, this is not now the case. In both the licensur and discipline realms, resource 
limitations (mainly staf limitations) ar undennning the capacity of the boards to do their 
jobs. With the fonhcoming implementation of the national data ban and the additional 
responsibilities it wil place on the State boards, the strns generated by the curnt resource 
shortall are likely to become even grater. 
Since most of the revenue of the State boars derives from renewal fees charged to practicing 
podatrsts. they are probably the best source for generatig additional revenue. As noted ear
lier, the medan annual renewal fee in 1987 was only $40. 
In addition to our centr recommendation concerning resources, we have a number of more 
specific ones diected to the State podatt boards, the Federation of Podiatrc Medcal 
Boards, the American Podiatrc Medical Association, and the U.S. Public Health Service. 
Boards 
Stal Podiatry 
In many States, the boards must have a fuller rage of disciplinar options available to them 
and a greater degree of enforcement authority; it is pancularly imponant that they be able to 
issue subpoenas and be able to suspend immediately the license of a podatrst who poses 
clear and present dager to the public. But even more importt is that they car out existing 
enforcement authorities more rigorously. This means that they must not only react swiftly and 
effectively to complaints and referrs but also assume a more active investigatory role of their 
own. 
Such a strngthening is imponant primarly because it wil help boards protect the public from 
those few podiatrsts who perform in an unprofessional, incompetent, or fraudulent manner. 
Not to be overlooked, however, is that it wil also suppon the case for lic nsur by credentials, 
If State boards have more confidence in one another s enforcement and discipline effons, they 
wil have all the more reason to enact policies that allow for licensure by credentials. 
State podiatr boards should join together to establish and use a high-quality national 
c1inicallicensure examination. 
Among State podiatr board offcials, this is a very sensitive topic because it involves States 
rights and prerogatives. Yet, from a 51-State perspective, the current situation--with the 
presence of several separate State clinical examinations, a small number of States using one  . (j  :.,., 
:\:,  '.: ,!' -;- ':~ 
exam--an ! q\me State:- without any clinical examination at all--has become increasingly 
counter-pwductive. It restrcts mobility of practicing podatrsts. It suggestS that the profes
sional C0  i1unity cannOt agree on the miimum level of knowledge and skills necessar to 
practice pr,di  results in a duplication of resources devoted ,to testing. And it divens 
a try. It 
State board attention and resources that might otherwise be devoted to enforcement and dis
cipline a.:ti\"itie  i1i:i professional boards have successfully established a national clinical 
licemu ;: examination; it would appear to be constrctive for State podatr boards to do the 
same. 
State podatrc licensing boards should shore-up their creentials verication 
pT(x:  duTes. 
A num  :,r  boars have aleady moved in this diretion. But, as many State boar offcials 
indicate, r;, ;; must be done in terms of the extent and type of (1) information requested of 
licemu  ;,licant  and (2) verification undenaken by board offcials. Without such addition
al safeguards, many boarc' wil reman too vulnerable to irgularties that could result in 
some undeserving indi\'  s receiving a poiatr license and in an undermining of public 
confidence in the entire licensure process. 
Federatiun of Podiatric Medical Boards 
For more than a half-centur, the Federation of Podatrc Medcal Boards (FMB) has 
provided :  forum for State podatr board officials to addrss common concerns and chan 
directions that ar in their mutual interest. In the last 2 year, these officials have used the 
FPMB to help develop a national clearnghouse of disciplinar actions and to work on many 
other pre'  that have benefited podiatrc medicine. It is important, we feel, for the FPMB 
to supplement these actions by taing initiatives that will help individual Suite boards move in 
the directions recommended above. Given that the FPMB recently reeived a grt frm the 
S. p,. ?n'ice to more fully develop its clearnghouse on disciplinar actions and 
that many State boards must clearly improve their enforcement and 
djsciplinar effons, 
feel it i  ::Jly imponat for FPMB to exert leadership that wil encourge and support 
f' _. 
such effoI1s, Our specific recommendations follow: 
The FPMB, in consultation with the American Podiatrc Medical Association, should 
".. g\::d~lines for State podiatr practice acts. 
As nOk  ;Iier the Project 200 Commission formed by the APMA called for the estab
lishment 0: a uniform podiatrc practice act. Such an act or set of guidelines could promore 
State uniformity not only in the definition of podiatrc practice but also in the 
greater S tate-to-
ground  l::' ' ,., which disciplinary action might be taen and the proedures for enforcement. 
In this re  :trd, it could serve as a useful reference point for State reforms, much as A  Guide to 
the ES5Cn:iuls of a Modem Medical Practice Act,  issued by the Federation of State Medical 
Boards, d0  " for Stat  medical boards.  The FPMB should accumulate and disseminate, on a regular basis, changes in State 
practice acts and regulations. 
Infonntion dissemination of this kind would be extremely useful to the State boars. It 
would enable them to stay more fully abreast of developments in other States and to assess 
what if any signifca,nce such developments have for their own States. It would serve as a 
valuable, more comprehensive supplement to the interaction that now occurs by word of 
mouth. 
The FPMB should identify and disseminate to State boards the most effective 
techniques of crdential verification. 
Because this is not now a crsis area, it is an easy one to 
overlook. Yet it does involve a poten
tial dager that should be addrssed. The FPMB can help individual boards in this 
regar by 
identiying and distrbuting infonnation about some of the best practices 
underten by mem
ber boards. 
The American Podiatric Medical Association 
The American Podatrc Medical Association (APMA) should encourge more 
extensive and effective interaction between its State societies and State podatr 
boards. 
Such action is imponant because most State societies make few 
podatr
referrls to State 
boards and because the societies ' own peer review effons are often quite limited. 
There is a
need to strngten the per review system, to identify practice that is substadad, and to tae
steps to help these practitioners improve their technical 
skils or behavior. 
The Public Health Service

The Public Health Service (PHS) should assist the FPMB to extend and improve its 
technical assistance and infonnation dissemination activities. 
The PHS has long provided such assistance to professional  grt 
boies, and its reent 
to the
Federation is a.very important and .positive step in providing much ne 
ded assistace to the na
tional body that is most closely associated with the individual State licensing boards. Now is 
an opponune time to extend whatever suppon is possible to FPMB to help it play an even 
more effective leadership role vis a vis its member 
boars. This is parcularly important with
respect to the enforcement and discipline 
aras, where the need for such leadership is
compellng.  APPENDIX I

NOTES 
S. Deparent of 
Health and Human Services, Public Health Service,  Fifh Report to
the President and Congress on the StatU of Health Personnel in the United States 
March 
1986, p. 71. 
Here, and elsewhere in the repon, unless otherwise noted, the data are derived from our 
surey of 48 of the 50 States. See appendix III. 
Data obtaed by phone from the Health Car Financing Admnistrtion. 
Fifh Report to 
p. 7
the President, 
Data frm the American Podatrc Medical 
Association as presented in the  Fifh Report to, 
the President,  p. 18.

ELM Servces, Inc., for the 
American Podiatrc Medical Association,  Economics of Foot 
Care,  p. 18. 
Fifh Report to 
p. 7
the President, 
Data from the Council on Podiatrc Medical Education as presented 
in the  Fifh Report to 
p. 7-
the President, 

Data from the American Association of Colleges of 
Podatrc Medicine. 
10. Fifh Reporr to the President p. 7
11. Prepard remarkes before the House of Dele gates of the American Podatrc Medcal 
Association, 1986. 
12. The Council of State Governments, State Credentialng of the Health Occupations and 
Professions, pp. 174-196. 
13. Ibid.
14. We developed the $2 milion estimate as follows. 
For each State we' multiplied the 
tOtal
number of licensed podiatrsts in 1987 by the renewal fee for that year. That resulted in 
a tota of 1.35 mi11on. We then assumed that renewal fees accounted for two-thirds of 
overall fee income from podiatrsts, and, accordingly, added one-third to the above needed 
tOtal. This resulted in a new total of $2 
mi11on.  196. 
15.  State Credentialing of the Health Occupations and Professions, pp. 174-
1982, p. 66. 
16.  Benjamin Shim berg,  Occupational Licensing: A Public Perspective, 
17.  Data ar a combinations of information obtained in our survey of State licensing boards 
Slate Credentialing of the Health Occupations and
and data contained in the CSG repon, 

pp. 174-196. 
Professions, 
18.  Of the 29 boards that indicated they regularly check with a clearnghouse when a person 
nOted that 
applies for licensure, 18 said they use FPMB only, 7 use CLEAR only, and 4 
they use bOth.

19.  The national data bank now being established under title IV of the Health Care Quality 
Improvement Act of 1986 wil provide a basis for answering this question in the years 
ahead. 
20.  Medical Licensure and Discipline: An Ovenliew 
See our previous inspection report, 
State licensure and Discipline of
State Licensure and Discipline of Denrists, 
 and 
for more detaled information. 
Chiropractors, 
21.  Using 1985 as the stadard, we found that the medan rate at which podatrsts were 
00 
disciplined by State boards was 13. 36 per 1, licensees. 
22.  pp. 174-196. 
State Credentialing of the Health Occupations and Professions,  APPENDIX II

BACKGROUND 
The licensure and discipline of health care professionals is a traditional function of State 
Government. It dates back to the 
pioneering effons of the American colonies in the 1600'
But it did not gain permanence until the late 1800' 
s, when Texas passed the fIrst modern medi
cal practice act (1873) and the U.
S. Supreme Coun upheld West Virginia 
s act as a valid exer
cise of State police powers (1889). 
In recognition of this traditional State role, Congrss, when it 
Medicaid progrs in 1965, left it to the States to  established the Medicar and
determne whether physicians and 
health car  Other
professionals were legaly authorize to panicipate in these progrs. 
sequently, Congrss has empowered HHS and its preecessor (HW) to  Sub
those professionals (and other provider groups) who have abused or defraimudpeods eth seasnec tions on
progrs. However, the Federal Government has continued to depend on the States to serve 
as the disciplining agent for 
Medicaid progrs.  transgrssions that do not dirctly relate to the Medcare or
Thus, States have been providing an imponant front line of 
these two federaly funded programs. This protection  prOtection for beneficiares

has been at no cost to the Federa
Government and at only minimal cost to State Government. Nearly all the costs have been 
covere by licensure fees imposed on the health car 
professionals. 
As Medcar and 
Medicaid expenditures have 
grwn to a point where they now account for
more than one-
fourt of U.S. health care expenditures, Federal interest in the effectiveness of
State licensure and discipline practices has increased. For the most pan, this 
est has focused on those practices concerning medical doctors. In essence thish eisig bhetceanuinsge  tinhteeyr 
are the most prominent of the health care professionals and because they account for a larger 
share of Medicare and Medicaid 
expenditurs than any of 
the other groups. More specifically,
serious concerns about the adequacy of State medical licensure and discipline practices were 
raised by General Accounting 
Offce repons, meda 
investigations, and scandas involving
fraudulent medical credentials 
frm two Cabbean medical schools. 
Accordingly, in 1985 and 1986, the 
Offce of Inspector 
General (OIG) conducted an inspec
tion examining the activities of State medical boards. Based 
primarly on visits to 14 
boards and telephone discussions with the executive directors of  State
anOther 10, the inspections
sought to provide an overview of the major developments and issues facing 
final repon, issued in June 1986, received widespread publicity and helped gtehnee rbaotae rrdesf.o Trmhes 
r,) improve the effectiveness of State medical boards, panicularly with respect to. 
nar pracrices.  their discipli-
Given the positive response and effects of that inspection 
decided that a similar one
directed to other health care professionals eligible for Med, ithcea rDeIG o  r Medicaid reimbursement  would also be warnted: For 
these Other professionals no less than for medical doctors 
licensur and discipline boards offer a vital front line of protection for the  , State 
beneficiar. 
We chose dentists, podatrsts, chiropractors, and optometrsts as 
doctors, they  1i focus because, like medical
ar dirct care professionals who have diagnosing and prescribing respon
sibilties, who can receive 
presence on the health cardei sccte nMee.d Diceanrteis trse, ipmobduartsrsetmsent, and who, overal, represent a major
, chiropractors, and optometrsts
together with doctors of medicine and osteopathy are the six groups of health care profes
sionals defined as "physicians " under Medicare law. 
Recognizing the value of obtaining a better national picture of the 
licensur 
and other health care professions, HHS (through the Public Health Service) aawctaivrditeieds a o 3f these
contrt 
in July 1984 to the Council of State Governments (CSG) and the National  year 
ghouse on Licensure Enforcement and Regulation (CLEAR) to develop a compositeC Sletaatren-
State infonntion system on the crentialng of  by-
health professions. The project generates
informational repons on the varous professions, drawing primarly on State practice 
State boar regulations. The  acts and
as the organizational pattern orfe pthoret S ptartees ebnota rddast,a  thine  s parte tables that address such matters
of the boards, the types of ex  administrtive and enforcement functions
inations required, and the fees imposed. Overal
tive information provided focuses more on licensing than on  , the descrip
and CLAR have published repons on each of the four groupdsi stoc ibpel inar activity. The CSG
addrssed in this inspec-
tion--chiropractors (1986), poatrsts 
(1986), dentists (1987), and optometrsts (1987). 
The CLEAR, whiCh is composed of State 
offcials involved with occupational licensing and

regulation issues, also runs the National Disc 
plinar Infonnation System (NDIS). This is an
interstate service that provides 
parcipating State agencies with bimonthly repons on discipli
nar 
actions taken against licensed professionals in a number of professional disciplines. Den
tists, podatrsts, 
chirpractors, and optometrsts 
ar among the occupation groups included in
the system. The disciplinar actions 
taken 
agaist these and other groups 
a voluntar basis and at this point involve only 32 States. The Federation oarf  Ssteantte  Mto eNdDicIaSl  on
Boards operates a similar but more detailed and complete system that focuses on 
actions taen against medical doctors.  disciplinar
Two reent congressional actions provide an imponant stimulus 
towar 
the funer sharng of
data on disciplinar actions. First of all
, the Health Care Quality Improvement Act, 
99-660), passed in 1986, calls for the establishment of a national data bank to be run by 
(PL. 
the HHS Secretar (or a 
designee thereof). It stipulates that entities making malpractice
ments associated with the work of physicians and  pay
Other licensed health care professionals
must repon peninent infonnation concerning those payments to 
the data bank. Similarly,
mandates the reportng of disciplinary and peer 
review actions taken against medcal doctors,
osteopaths, and dentists. The infonnation maintained in the data bank is to be 
request, to State licensure and discipline boards, health care entities, attorneys wavhaoi lfaibleled,  au pon
malpractice complaint with a coun against a specific practitioner
, and individuals interested in
records on themsel ves.
 The second peninent congressional action (P.L. 100-93) is the Medicare and Medicaid Patient 
and Program Protection Act Passed in 1987, this legislation includes a provision that would 
extend the national reponing responsibility of State licensure and
, discipline boards to encom
pass disciplinar actions taen against podiatrsts, chiropractors, optometrsts, and other 
licensed health care practitioners. 
Thus, on the basis of the authority provided by these two acts, State boards wil be 
able to 
draw upon a national data ban to detennine if any 
disciplinar actions have been taken 
against an applicant for licensure. It is expected that this data bank wil be operating in 
1988. 
Finaly, with respect to podatrsts, on whom this repon focuses, it is importt to add that 
since 1985, the Federation of Podatrc Medical Boars (FMB) has operated a national
clearnghouse on disciplinar actions taen by State podatr boars. Fony State boards 
members of the clearnghouse, but with widespread anticipation of the establishment of the na
tional data ban, parcipation in the FPMB clearnghouse has dropped in 1987. The infonna
tion in the FPMB clearnghouse is available to members upon wrtten request and over the 
telephone. Those States that issue licenses on the basis of credentials have tended to be the 
most active users.  APPENDIX II 
METHODOLOGICAL NOTES 
We held discussions with representatives from 48 State boards. (We were unable to speak 
with a representative from DC, WY, or 

TD. ) Usualy we talked with the executive director of
the board or with a chairman or Other member of the board. 
Our aim was to 
tion and discuss issues with a board representative who was well informed aboobutta bi oianrfdo arcma
tiviities both at present and over the past 3 to 4 years. 
The major ara in which we sought quantitative information from these officials concerned the 
disciplinar actions taen by the boars against 
podatrsts in 1984, 1985, and 1986. Here, we
asked for the number of fonnal actions 
taen and a breakdown of the types of actions--
nated as revocation, suspension, probation desig-
, or other. 
All 48 of the boards with whom we spoke were able to provide us with the numbers of dis
ciplinar actions taen in each of the 3 years. We cannot confmn that the 
information is all-
clusive or completely accurate. However in-
, we did strss that we sought all board disciplinar
actions against 
poatrsts and often checked back when we suspected there might be errors.
The board officials, typically, were quite responsive in checking their 
the data in a timely fashion.  reords and providing

In analyzing the differential perfonnance of the States in disciplining podiatrsts, we decided 
to aggregate the 
disciplinar data over the 3-year period. We felt that comparsons over only a
1- or 2-year period would be of questionable value because of the 
sociated with year-to-year fluctuations.  distortons that might be as

In this context, we treated performance as a dependent 
varable and considered two major 
dependent varables: size and region. With respect to size, first of all in
, we identified the num
ber of active poatrsts in each State and, then, using varance analysis, identifed five 
of States differentiated on the basis of the number of active podiatrsts  clusters
The clusters and as-
sociated States are as follows: 
(1)  extr small (AK, HI, ID, MS, MT, SD, and VT;
(2)  small (AL, AR, DE, KY, ME, NE, !\Tf, NM, NV
, OK, RI, SC, UT, and WV);
(3)  medium (AZ, CO, CT
, GA, lA , IN , KS, LA, MA, MD
, MN, MO, NC, OR, TN, VA, WA
and WI);

(4)  large (FL, n., MI
, NJ, OH, and TX); and extra large (CA 
, N  and PA).

With respect to region 
, we used U. S. Bureau of the Census categorizations to identify four
regions of the 
countr. The categorizations and associated States are as follows: 
(1)  Northeast (CT ME, MA, NJ , NH, NY, PA, RI, and VT);  (2)  South (AL, AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA , and 
WV); 
(3)  Midwest (lA , n., IN. KS, MI  TE, ND, OH , SD , and WI); and 
, MN, MO, 
(4)  West (AK, AZ, CA, CO, HI, il, MT, NV, NM, OR, UT, WA , and 'NY).  ). 

APPENDIX IV 
COMMENTS ON THE DRAFT REPORT AND OIG RESPONSE 
Within the Deparent of Health and Human Services, we received comments on the draft 
repon from the Public Health Service and the Health Car Financing Administration. In addi
tion, we received comments from a number of organizations outside the deparment: 
the
Federation of Podiatrc Medical Boards (FPMB), the American Podiatrc Medical Association 
(APMA), the American Association of Colleges of 
Podatrc Medicine (AACPM), 
and the Na
tional Commssion for Health Cenifying Agencies (NCHCA). Their comments are contained 
below, in their entity. The 010 response to all comments foIIows. 
FPMB COM UENTS 
A few comments on the recommendations of the repon 
are in order; comments on disciplinar 
data reponing follow.

Recommendations: 
Page iI', National Clinical Licensure Examination 
The Federation, the National Board of 
Podatrc Medical Examiers, and LOR Examnations 
(State College, Pennsylvania) have formed a consortum 
to respond to a reuest for proposals
issued by the State of VIrginia relating to their licensing examination. Already, 15 States have 
contrcted to deploy the "VlTginia Examination.  the podiatrlLGR consortum wins 
If the
competition, States wil have a direct role in the funher development of a licensing examina
tion which is alrady a proven success. 
Approximately 60% of the 1988 
grduating class took the "VIrginia Examnation " durng the
last administrtion cycle. The 
podatrlLOR consonium wil be able to promote the examina
tion funher. 
i".  Guidelines for State Practice Acts 
Page 
At the Federation Board of Directors ' meeting in August, the Board approved a motion to es
tablish a subcommittee of the board to develop a model for State podiatrc medical practice 
legislation. The committee has begun its work; h wil reference the recommendations of the 
APMA "Project 2000" .repon as they pertain to the definition of practice and appropriate 
education. It wil drw from the recommendations of existing State law models for other 
professions (i.e., medicine, etc.  We expect to present recommendations to our membership 
in August, 1989, at our Annual Meeting in Boston 
, on the 18th and 19th.  Infonnation on Changes in State Practice Acts 
FPMB aleady has a librar of State laws and regulations relating to podatrc medical prac
tice, and we have an index for the compilation. We communicate regularly with State 
podiatrc medical  Federation News. 
associations though our newsletter, 
APMA/State Association Interaction with FPMB 
At the August, 1988 meeting of the American Podiatrc Medical Association House of 
Delegates, a resolution was adopted (1) designating the Federation as the centr disciplinar
repository for State licensing board actions, and (2) 
encourging APMA and its affiliates to 
suppon the Federation s effons in data collection and handling. 
Last Paragraph 
Report Findings  Page  9 -
Since mid-1987, the Federation has made 
drmatic improvements in its data collection and 
reportng system. A new repon form, engineered in mid-1988, enables States to summarze 
their report while they meet all of the content reuirments set by law through PL 99-
660 and 
PL 100-93 in regard to data reportng. 
In Januar, 1988, State boards .received copies of the " 
1987 FPMB Year-end Repon, " with an 
accompanying alphabetical index. The names of twenty-three persons whose 
licenses were 
subjected to revocation, suspension, probation, (or other miscellaneous action) were listed; the 
alphabetical index listed the names and dates of al 
of the more than two hundred actions 
reponed to FPMB since 1982. 
The repon generated so much comment that those boards that had not already sent in repon
ing sheets and copies of findings of fact and wrtten orders, did so in 
Februar and Marh. 
Consequently, a revised repon was issued in April, 1988; that repon listed 48 separate license 
actions. 
The Federation of State Medical Boards reponed 2,302 disciplinar actions in 1986 (FSMB
Federation Bulletin , Februar, 1988, p. 46). The 48 actions reponed by FPMB amount to 
just less than one-half of one percent of the total number of podiatrsts nationwide (ap
proximately 11,
(0); the 2, so amount to just less than one
302 actions reponed by FSMB 
half of one percent of the total number of MD' 
s and DO' s nationwide (approximately 
500,00). 
Since Januar, 1988, 25 case actions have been reponed to the FPMB data bank. We are 
operating under a rule of thumb wherein if the number of new cases reponed exceed twenty 
we wil produce a repon and circulate it to the State boards. We wil prod  ce another year end 
repon in Januar, 1989; we wil include alphabetical and date indices for al names 
reponed to
the FPMB data bank at the same time. With the active fall months to come, 
we expect more
than fony case actions wiH appear on the 1988 year end repon.  , "

The FPMB 
disciplinar repons are issued to the State government staff assigned to the eleven
combined medical/podiatrc licensing boards, and to the staff of 
the 41 free standing boards as
well. Copies ar also provided to the presidentslchairs of these boards, the vice-chais, 
member  the
(podatrst) secretaes, State legal staf, and the podatrst 
members seated on the
boards of mediCine in eight of the eleven States mentioned above. We 
the conditions and terms for sharng this information with third pany  ar just now exploring 
OIG as well. By the  carers, and with the
tie you receive this, we will have initiated communication with Mr.
James Patton in that regard. This information is ready now even as we 
boards for full panicipation in the Federal data bank programs mandatedp rbeyp PaLr  o9u9r- State 
100-63.  660 and 
On page 18 of your report, you mention that only eleven States are using a clearly defined set 
of "guidelines for determining the appropriate level of 
figue relates to the eleven combined medical/podiatrcd bisocairpdlsi,n warh iaccht iaorne. " Presumably, that
alady 
with the "Guidebook on Medical Discipline familar
" developed by the Federation of State Medical
Boards. 
This May, FPMB was awarded a purchase order to develop and implement (1) a nationwide 
standard disciplinar action classification system, (2) guidelines for 
determing 
ing board disciplinar actions, and  State licens
(3) a program to educate the 
sification and guidelines. The first meeting of the FPMB Commbiottaeers o inn  Cthlaes suisfec aotfi othne a cnlda s
Disciplinar Guidelines took place in Washington, DC, September 9 and 10, and the project is
well under way. A draft classification and guidelines 
end of 1988, and final version guidelines wil be availawiblle b ien  amvaidil able to State boars by the
1989. 
You and your staff 
ar to. be commended for the excellent draft repon. 
have far-reaching impact on the profession and the public we all serve. TIht ew idllo cpurommenott ew milean
ingful qualty assurance in a 
most constrctive way. 
APMA COMMENTS 
With regar to 
your letter of July 22, when you transmitted to the Association a 
the report  State Licensure and Discipline of PodiatrstS, drt copy

" I take this means to applaud that ef
fon. Our compliments go to Dr. Mark Yessian, who directed a thorougr. and 
repon.  constrctive
For your added information and fies 
, I am enclosing a copy of APMA' 
Peer Review 
Guidelines and Procedures Manual. 
 We hope you wil find this helpful in understanding the
function we perform in this critically imponant area. 
You should also be aware that APMA has been 
workig 
closely and wil continue to do so
with the Federation of Podiatrc Medical Boards 
as it seeks to extend and improve its technical
assistance and information dissemination activities. We have extended both time and resou rces in suppon of the Federation to assure that it may play an effective role in helping to 
launch the national data ban established by Public Law 99-660. 
We look forward to receiving your final repon. 
AACP  f COMMENTS 
I requested the Deans of the Colleges of Podiatrc Medicine to review and comment on the 
draft copy of the "State Licensur and Discipline of Podiatrsts. 
The Deans think it is a useful document which comprehensively examnes a very sensitive 
subject. However, they have some concerns. They 
ar the 
(1)  potential misuse of aggregate 
disciplinar data on podatrsts by other
professions, although there is suppon for the development of a data base. 
This issue could be resolved during the design phase of the clearnghouse. 
(2)  constraints which are imposed upon podatrc physicians in moving from State 
to State, parcularly as they relate to assuring adequate car to podatrc
patients in states where demand for foot 
car has increased. 
The seriousness of these 
ing the finalc onrsetrnptso murstt  be more fully explore before complet
(3)  absence of suffcient resources to enable State licensure 
boards to effectively
perform even their basic legaJ responsibilities as a licensing authority. 
The Depament of Health and Human Services, in collaboration with the State 
licensur boards, must identify sources of revenues to enable these 
boars to 
e?Cer-
cise this authority. 
Podatrc Medicine is seriously exploring the introduction of a Pan III Clinical Examination 
under the auspices of the National Board of 
Podatrc Medical Examiners 
that wil be avail
able nationally for all podiatrc physicians. 
This Association is pleased to note that the podiatrc licensing boards have been in the 
forefront in adheri '1g to a code that insures quality health car to all U. S. populations. FlJf this
reason , the AssOt iation believes that every effon should be made to continue this 
exemplar
service to the ndtion s public. 
Thank you for the opponunity to review and comment on the repon.  NCHCA COMMENTS 
Thank you for providing the National Commission for Health Certifying Agencies (NCHCA) 
with an opportunity to comment on the drt 
report entitled " State Licensure and Discipline of
Podiatrsts. " This drft report was well prepared and provides a goo summar of critical
licensing issues affecting podatrsts. 
The National Commission for Health Cenifying Agencies is in 
agrement with the recommen
dations made to improve the licensing of podatrsts. We ar panicularly concerned with the
fmding that State podatr boards have insufficient resources to carry out their responsibilities 
effectively. The increasing costs and personnel 
demads involved in operating effective
progrs ar 
licensing  becoming a problem in many professions and consumers may 
ultiate
ly suffer from this trnd. It is parcularly unfonunate since the public expects that State licen
sure effons wil "weed out incompetent practitioners
" and conduct thorough and
comprehensive disciplinar actions when' 
appropriate. Unfortunately, this expectation 
appears
to be the exception rather than the norm in many areas of professional licensing. 
The National Commssion for Health Cenifying Agencies suppons effons to improve public 
awareness of the appropriate means of dealing with incompetence in licensed professionals. 
Perhaps licensure fees could be incrasd to suppon incrased public information program
about licensure and additional funds could also be used to improve the verification 
proess 
and provide incrased suppon for poatr 
boards. 
We alo strngly support the concept of State 
podiatr boards joining together to establish and
use a high qualty, national c1inicallicensur 
examnation. 
Our certfication progrms use 
national cenification examnations and this eliminates the 
problem of practitioners having to deal with different requirements from one pan of the 
countr to another. We appreciate the opponunity to comment on this draft repon and we 
would like to receive a copy of the final repon. 
PHS CO IMENTS 
Licensure of Podiatrists 
We agre that the National Practitioner Data Bank established under Public Law 99
660 and

amended by Public Law 100-93, when implemented, wil be useful to State boards in 
learing
of adverse action experiences of podiatrsts seeking licensure by credentials. 
Federation of Podiatric Medical Boards (Federation) 
The three recommendations to the Federation 
ar goo, but may be unrealistic, because the
Federation has a very limited staff and, therefore, would be unable to comply adequately. 
These recommendations caB for the Federation to develop guidelines for State 
podiatr 
prac tice acts, accumulate and disseminate changes in State practice acts and regulations, and iden
tify and disseminate to State boards the most effective techniques of credential verification. 
Role of the American Association of Colleges of Podiatric Medicine (Association) 
We believe that there should be some reference in the report to the Association and the role of 
podatr 
schools in p  parng licensure applicants, The Association should be consulted about
the 
tyes of trning needed to meet State or national standards, and how best to meet existing
standards. Accordngly, we suggest 
the following recommendation be considered for in
clusion in the OIG repon. 
The American Association of Colleges of 
Podiatrc Medicine should encourage 
more 
extensive and effective interaction between 
the podiatr 
schools and State podiatr 
boards. 
Public Health Service Assistance

With regar to the OIG recommendation that PHS should assist the Federation to extend and 
improve its technical assistace and information and 
dissemination activities, the Health
Resoures and Services Admnistrtion, PHS, awared a contrct to 
The contrct is to (1)  the Federation last May.
develop a classification of 
miing the actions to be taen disciplinar actions and guidelines for deter
, and (2) implement a progrm to 
educate the State boards in the
use of the classification and guidelines. This project is intended to improve the 
unifonnty of.
licensur disciplinar actions against podiatrsts and wil 
nar  contrbute to the value of discipli
action data when it is submitted to the National Practitioner Data 
Ban. 
PHS recognizes that there 
ar other aras in which the Federation needs assistace and 
continue to provide such technical assistance. In addition, PHS  wil
podiatrc profession to  wil continue to work with the

enhance the education and practice of its professionals. 
HCFA COMMENTS 
We have reviewed the draft repon which focuses on State licensure and discipline practices 
concerning podiatrsts. The major finding in 
the repon is that in 
realms, State board offcials tend to feel that  bOth licensure and discipline
ar 
they  seriously understaffed and, as a result
the effectiveness of both licensure and discipline operations is compromised. Since 
mendations in the report require action by HCFA  no recom
, we have no specific comments to offer. 
We concur with the repon 
s findings and recommendations, and we support the effons of the 
to improve the current State practices. Thank you for the opponunity to comment on this 
DIG 
repon.  OIG RESPONSE TO ALL COMMENTS 
progrss in address
We ar pleased with the positive responses to the repon and indications of 
ing issues raised in it. 
At the -same time, we must note that continued progrss could be jeopardcizaerd  if State govern
out their respon
ments do not act to assure that State boards have suffcient resources to 
has 
sibilities effectively. The same applies with respect to FPMB. We applaud the actions it 
car 
taken, yet, we agree with PHS that additional staf capacity is needed to  out the more 
substatial role we have defined. 
With respect to AACPM' s concerns about the constraits imposed upon podatrc physicians 
in moving from State to State, we must note that these constraints were not often mentioned 
discussions with the State bo:uds. On page 8 of the repon, however, we do address 
durig our 
that the mobilty of podiatrsts remains limited. 
Finally, in regard to PHS' s suggestion that we consider an additional recommendation urging 
the American Association of Colleges of Podatrc Medicine to encourage "more extensive and 
effective interaction between the podiatr schools and State podatr boars," we share its con
addrssed 
cern about the importnce of such interaction. However, because this issue was not 
or rased in our study, 'we feel that it is beyond the scope of our recommendations.