§ 01
What is the House of Delegates? — The Basics
The Legislative Body
The HOD is APMA's lawmaking branch — elected representatives of every state podiatric society. It determines official APMA policy, elects officers, and votes on propositions that reshape governance, training standards, and the certification landscape.
Who Has the Power?
The HOD, the Board of Trustees (BOT), and CPME exist in a complex web of authority. CPME accredits schools, approves residencies, and recognizes specialty boards — but its relationship to the HOD is the central governance conflict of this era.
Why Residents Must Care
HOD decisions shape what your residency looks like, whether you need ABFAS or ABPM certification to get a job, how much political power podiatry has on Capitol Hill, and what you can bill — and get paid — for. This is not remote politics.
§ 02
Deep Dive — What Each Outcome Really Means
01
Resident & Fellows' Section
Governance Reform · Inclusion · Next-Generation Voice
✓ Passed
What it is: A new formal section of the APMA House of Delegates for residents and fellows — giving trainees organized, recognized standing in professional governance. Not as observers, but as participants with institutional authority to develop positions, bring propositions, and advocate collectively at future HODs.
📋 Why This Was Needed
- The HOD has historically been the domain of established practitioners. Residents had no formal mechanism to collectively influence policy — only occasional ad hoc representation with limited standing.
- Decisions on training, board certification, scope of practice, and reimbursement directly shape the careers of people currently in residency — who had no vote on those decisions.
- Other professions (medicine, dentistry) have robust trainee governance bodies. Podiatry's structural gap was a professional development liability and a succession planning failure.
✓ What Changes Now
- Residents and fellows have a formal organizational home within APMA — with the ability to develop policy positions, bring propositions, and advocate collectively at future HODs.
- The section creates a leadership pipeline — trainees will understand governance before they're suddenly expected to lead it.
- For you specifically: If you're in residency now, you are part of the inaugural cohort this section represents. Get involved early — early engagement in governance structures compounds over a career.
02
Framework for Issues of Magnitude
Policy Architecture · Data-Driven Decisions · Stakeholder Inclusion
✓ Passed
What it is: A formalized decision-making framework that applies whenever APMA or the HOD considers major changes to education, training, testing, scope of practice, or licensure. Decisions must be prospective (forward-thinking), evidence-based (grounded in data), and inclusive (built with meaningful stakeholder input before votes are taken).
📋 The Problem It Solves
- The 2023–2025 CPME conflict exposed how consequential standards decisions — like draft CPME 220/230 — could advance far before stakeholders (students, residents, program directors) even knew they existed.
- The One Board effort (Prop 2-24, 2024) passed on sentiment without structured analysis of antitrust risk or implementation pathway — then stalled for exactly those reasons.
- Large professional decisions have been made reactively and politically rather than proactively and analytically, creating whipsaw effects on training programs and diplomates.
✓ What Changes Now
- Future decisions — on residency structure, board certification, scope expansions, licensing reform — must go through a structured process with data and stakeholder engagement before the HOD floor vote.
- This is the institutional answer to the CPME/HOD governance wars: a procedural guardrail that requires deliberation, not just political momentum.
- For you specifically: Major changes to residency requirements or board certification won't happen without your input. This framework brings residents into conversations before decisions are locked in.
03
Opposing Harmful Payer Practices + HOD Position on Surgical Certification
Policy · Insurance Reform · Board Certification Position
✓ Passed
What it is: The HOD formally went on record opposing three specific payer practices that harm podiatric practices — and separately, adopted its official position on surgical certification (the ongoing ABFAS vs. ABPM debate). These position-setting measures direct APMA advocacy and establish the profession's official stance.
The Three Payer Issues — What They Mean in Practice
Downcoding of E/M Services
Payers systematically reduce reimbursement levels for Evaluation & Management services billed by DPMs — often to codes that don't reflect actual complexity of care provided during a visit.
→ DPMs lose revenue for time spent on documentation-intensive, medically complex patients
Limits on Non-Surgical & Non-Opioid Treatments
Some payers restrict coverage for evidence-based conservative care — physical therapy, orthotics, wound biologics — that reduce the need for surgery and avoid opioid exposure.
→ Forces patients into more costly interventions; contradicts value-based care principles
Automatic Modifier 25 Denials
Modifier 25 bills a separate significant E/M service on the same day as a procedure. Automatic denials without clinical review are improper — and effectively unpay you for legitimate evaluation work.
→ DPMs go unreimbursed for medically necessary evaluation paired with a same-day procedure
📋 On the Surgical Certification Position
- The HOD's adopted position on surgical certification is significant — it represents organized podiatry formally clarifying which certification pathways are recognized and legitimate.
- The ABPM CAQ in podiatric surgery (launched without CPME approval) was the immediate flashpoint. The HOD position navigates the antitrust constraints that halted the One Board Task Force.
✓ What This Means for Your Practice
- APMA now has a formal policy mandate for CMS comment letters, Congressional outreach, and payer negotiation against all three payer practices.
- For you specifically: Modifier 25 denials and E/M downcoding will be among the first revenue challenges you face. Knowing APMA is formally fighting these — and how — is direct business literacy you need.
04
New HOD Sections for Stakeholder Organizations
Governance Reform · Expertise · Institutional Representation
✓ Passed
What it is: A governance mechanism allowing organizations beyond state components — specialty societies, academic institutions, affiliated groups — to participate formally in the HOD through new purpose-built sections. These bring subject-matter expertise to governance that geographically-organized state delegates may not possess.
📋 The Structural Logic
- The HOD has traditionally been organized geographically. But debates on CPME standards, board certification, and residency structure require clinical and academic expertise that doesn't map to state lines.
- ACFAS, ABFAS, podiatric colleges, and residency programs have historically entered governance indirectly — through lobbying and back-channels rather than formal participation.
✓ What Changes Now
- Specialty societies and stakeholder groups now have a formal pathway into HOD participation — bringing deeper expertise into deliberations and votes.
- For you specifically: As you develop subspecialty interests, the organizations you join may eventually have formal HOD representation. Your professional network becomes part of governance infrastructure.
05
Preventive Foot Care Access Taskforce
Access · Scope · Public Health · DPM-Centered Care
✓ Passed
What it is: A taskforce charged with exploring how to expand patient access to preventive foot care — addressing coverage gaps, care deserts, and access barriers — while ensuring DPMs and their clinical expertise remain central to care delivery, rather than being displaced by allied health providers or non-physicians.
📋 The Tension This Addresses
- A significant portion of the US population — elderly, diabetic, and rural patients in particular — lacks adequate access to preventive foot care. DPM practices are not uniformly distributed geographically or economically.
- If podiatry doesn't proactively solve the access problem, policymakers will solve it for us — often by expanding scope for lesser-trained providers or bypassing DPMs in coverage frameworks entirely.
- The diabetic foot care reimbursement landscape (routine foot care exclusions, Class Finding requirements) already creates barriers that harm patients and undercut DPMs simultaneously.
✓ What This Could Produce
- Potential recommendations on supervised care models, telehealth integration, and community health worker collaboration — designed to expand access without substituting DPMs with less-qualified providers.
- CMS advocacy to revise routine foot care exclusions — one of podiatry's most persistent reimbursement inequities.
- For you specifically: "DPM-centered care" is a political choice that must be actively defended. The scope-of-practice landscape you practice in will be shaped by this taskforce's output.
06
Flexible Governance Structure Update
Organizational Reform · Adaptability · Future-Readiness
✓ Passed
What it is: Structural updates to HOD and APMA governance mechanisms designed to make the organization more adaptable and responsive — reducing procedural bottlenecks that have prevented the profession from responding quickly to fast-moving challenges: CMS rulemaking cycles, AI adoption, scope-of-practice legislative windows, emerging payer policy.
📋 Why This Matters Now
- The CPME/HOD governance conflict of 2023–2025 exposed how slow and adversarial the existing structure was — with agencies and elected bodies in open conflict for years without a resolution mechanism.
- AI, new biologics, emerging surgical technologies, and rapid changes in payer policy require an association that can move faster than annual HOD meetings and months-long committee cycles.
✓ What Changes Now
- A governance structure that can convene, deliberate, and act faster — reducing the gap between an emerging crisis and an organized professional response.
- Alongside the Framework for Issues of Magnitude, this creates a dual mechanism: deliberation guardrails for major decisions AND agility for fast-moving issues.
- For you specifically: The APMA you'll lead in 15–20 years must be capable of responding to challenges that don't yet exist. This lays the structural foundation for that.
§ 03
Understanding the Political Context That Shaped These Votes
The Governance War Behind the Framework & Flexibility Votes
CPME autonomy vs. HOD oversight — the defining conflict of the 2024–2026 cycle
🛡️ CPME's Position
- CPME holds USDE recognition as an independent accreditor — political override of standards would jeopardize that recognition and, by extension, the legitimacy of podiatric education
- The firewall between CPME and APMA is required by federal accreditation rules; this is not secrecy but structural necessity
- Draft CPME 220/230 revisions were standard updates; the criticism was politically motivated rather than substantively grounded
- CPME's transparency is comparable to other recognized accrediting bodies — the "opacity" narrative is a political framing
vs
🏛️ HOD Reform Bloc's Position
- CPME is an APMA agency — the HOD created CPME and delegates authority to it. That delegation does not make CPME sovereign or unaccountable
- CPME repeatedly resisted HOD directives; without accountability mechanisms, governance breaks down entirely — which is what happened 2023–2025
- Draft 220/230 standards attempted to transfer authority over subspecialty recognition away from the HOD — discovered only late in the comment period
- Conflict-of-interest disclosure is standard in comparable bodies; CPME's refusal is an anomaly that undermines trust in board recognition decisions
The Board Certification War — Context for the HOD's Certification Position
ABFAS vs. ABPM: decades of professional identity, market power, and antitrust risk
🦶 ABFAS / Consolidation-Cautious Bloc
- 10,000+ board-certified diplomates; the de facto standard for surgical hospital privileges since 1975
- ABPM's CAQ in surgery was launched without CPME recognition — must be withdrawn before good-faith consolidation talks can proceed
- Any HOD-forced merger risks Sherman Antitrust liability via group boycott theory — confirmed by legal counsel
- A certification position that disadvantages existing ABFAS diplomates would provoke significant resistance and litigation
vs
📋 One-Board / ABPM Advocates
- Two boards — plus an unauthorized CAQ — confuse employers, credentialers, and patients. Podiatry is the only medical specialty with this fragmentation
- Proposition 2-24 passed the 2024 HOD with ~62% — the profession already voted for consolidation; implementation should not be blocked indefinitely by antitrust concerns
- Modern PMSR/RRA training is fully surgical; ABPM's CAQ reflects clinical reality whether ABFAS recognizes it or not
- A unified credential would strengthen podiatry vs. orthopedic surgery and allied health for surgical market share
§ 04
How We Got Here — The Arc from 2019 to 2026
2019
Blue-Ribbon Panel & CPME Autonomy Granted
Panel reaffirms one-board-per-specialty; grants CPME broad independence. JCRSB replaced by SBRC with reduced HOD accountability. Seeds of the governance crisis planted.
2023
ABPM Launches Unauthorized CAQ in Surgery
ABPM creates a Certificate of Added Qualification in podiatric surgery without CPME recognition. ABFAS, ACFAS, and CPME respond with formal opposition. Board certification war escalates sharply.
2024
Proposition 2-24 Passes (~62%) — One Board Mandate
HOD directs APMA to form a One Board Task Force. ABFAS raises Sherman Antitrust concerns, halting implementation. CPME draft 220/230 standards face hundreds of critical public comments.
2025
Governance Reform Push — G-25 through K-25
HOD debates CPME transparency, BOT veto authority, surgical case logging reform, fellowship standardization. CPME publishes critical impact statements opposing key propositions. Governance conflict peaks.
March 2026
The 100th Presidency — Six Actions Pass
Patrick DeHeer, DPM inaugurated as the 100th APMA President. The HOD passes all six actions described in this brief: the Resident & Fellows' Section, Framework for Issues of Magnitude, payer policy positions, HOD position on surgical certification, stakeholder sections, and governance modernization.
✓ All six outcomes confirmed
Board Certification: What You Need to Know Right Now
§ 05
What Comes Next — The Work That Begins Now
Your Profession is Being Built Around You — Be a Builder, Not a Spectator
The 2026 HOD passed structures specifically designed to include you: a Resident & Fellows' Section, a Framework that requires your input before major training decisions are made, and policy positions that will directly affect your first practice revenue cycle. These are not abstract actions — they need people to inhabit them. The residents who engage in the next 12–18 months will set the precedent for how much influence the next generation has. Understanding these issues is your competitive advantage. Most of your peers don't.
Join the Resident & Fellows' Section
Read HOD Proposition Texts Directly
Know Your Board Certification Options
Track Modifier 25 Denials in Your Program
Follow APMA Advocacy Outcomes
Attend Your State Component HOD
APMA Emerging Leaders Program
Understand AI in Your Practice