As I read Dr. Grapel’s story about 63 year old
internists retiring from private practice, the
question raised in my mind was did their
practice keep up with technology? Podiatrists,
as a whole, are early adapters when it comes to
technology, yet some continue to run their
practice much the same as they did 30 to 40
years ago.
A big part of the problem some offices have is
that they are staffed with the same people for
decades and these people either cannot or will
not learn new ways. One of our colleagues was
recently astounded that there are podiatrists
who still handwrite their notes and mail
typewritten claims to Medicare. Unfortunately,
in these situations the office gets overwhelmed.
Personally, I was amazed at the number of
practitioners who did not have a fax machine in
the late 1990s and today I am equally amazed at
how many offices do not have email or understand
how to securely transmit encrypted documents.
My other observation concerns what is happening
to health care in general. We are moving from a
disease treating system that was prevalent when
I was a child to a disease prevention system. We
are redefining some maladies from pathologies to
normal-abnormalities. We have a smarter
population and one that is more likely to learn
about disease prevention from the internet,
dieticians, personal-trainers, etc. than sitting
in doctors’ offices.
Physicians do not have all the answers and
patients want more information. Listen to your
patients and try to find the most efficient way
to get information to them, especially
information that also contains your name and
information about your practice. Imagine
returning home from your doctor’s office only to
find an email from your doctor with pertinent
health tips.
Richard A. Simmons, DPM Rockledge, FL
RASDPM32955@gmail.com
While I agree with 80% of Dr. Borriggine's
extensive post, allow me some remarks. I think
that the comparison with dentistry is not
proper. While many aspects of our profession can
be performed by orthopedists, dermatologists or
physical therapists, dentistry can ONLY be
practiced by dentists. Nobody else! In addition,
while about 60-70% of all people ever visit a
dentist, how many visit a podiatrist? I doubt if
more than 10%. This is a huge difference.
Dentistry never had to prove the value to the
public since poor dental health can have
immediate deleterious affects. With podiatry, it
is not so clear (with few exceptions).The
ongoing monumental healthcare changes are very
clear. As a result, in the last five years, the
percentage of solo practitioners in all medical
fields has decreased from 70% to 40%! And the
pace is accelerating. Many internists retire
earlier than ever before.
On a personal note, in the last 7 years, two of
my own internists retired at age 63. Both are
excellent clinicians with great reputations in
great hospitals. Both were sick and tired of the
constant struggle even though they did NOT
accept ANY insurance. One of them is teaching
residents at New York Hospital. At the same
time, North Shore University have admitted the
second group of medical students at their
Hofstra University campus. The numbers are
astounding ! They had 5034 applicants and only
700 were interviewed and ONLY 60 were admitted
(a 1.1% acceptance rate).Of that group, 32 were
females and 28 males. Food for thought.
Daniel Grapel, DPM, Bayside, NY, danipod@aol.com
To move forward on this topic, I would like to
disclaim that I am not "expert" on this subject,
but rather one who is a "forward thinker." I
have not begun to change how I practice podiatry
or even implemented the suggestions that I have
made in the last two posts. But, we are and will
be progressing in the next few years to
modified “cash based practice” and become very
selective to whom we see and treat. Our
participation in Medicare, Medicaid and other
managed care entities will continue, but over
time these types of patients will be few and far
between.
We are looking for a more "select" patient
population that has a more healthy and
progressive outlook on foot care. The "entitled"
patient mentality and expectation for healthcare
delivery make us enslaved to an insurance
company. We cannot continue to partake in an
industry that does not pay us what we are worth
or deal with a population that does "value" us
enough to pay for the service themselves. This
is the mantra of most patients: "Does my
insurance cover it"? But, as long as a physician
chooses to participate in "the system", then the
end result will be the same. Remember, the
definition of insanity is the same thing over
and over and expecting a different result.
Most of a podiatrist’s patient demographic is
aged, impoverished, and general unhealthy. We
generally see the "worst of the worst". Patients
usually present as referrals from their primary
care providers or make an appointment themselves
after they have seen everyone possible and there
has been no answer to their problem. We become
their last resort. And, we are experts at what
we do and typically diagnose, treat, and provide
a follow-up regimen for their foot condition in
a minimal time frame and cost-effective manner.
This may be the case with some patients, but
most of the patient population we see is for
nail and callus care, heel pain and other
treatments for general foot/ankle maladies,
minor in-office surgery, and the occasional
outpatient foot surgery. That's pretty much our
day in a nutshell. We may have alternate revenue
streams like nursing homes, diabetic wound care,
circulation tests, and durable medical equipment
supplies like Rx orthotics, diabetic shoes,
AFO's, walker boots, and wound care supplies.
All these things are the business of podiatry.
Through the years, we have seen revenue
opportunities come and go like endoscopic
plantar fasciiotomy (EPF), ESWT, Anodyne,
PADnet, wound care in the office (Apligraft and
Dermagraft), subtalar joint arthrodesis and
other procedures have all gone by the wayside
because of regulation, no CPT code, or decrease
or minimal reimbursement. "Riding the wave" to
the next greatest thing has hounded this
profession for years all in the name of making a
living. Unfortunately, with more and more
restrictive insurance guidelines, healthcare
reform, a decreasing fee schedules the ability
to make money in podiatry is getting harder and
harder every year. With the loss of the
potential to make money and the inability to
replace the loss of revenue, retirement or
quitting all together may be the best option for
some. But, for others deeply entrenched in their
practice and still having monetary liabilities,
the only option is to figure out the "next step".
There still many options for a podiatrist to
make a living in spite of the changes to
healthcare. The fact is we all able to change
our destiny as long as we choose a different to
get there. We have enough podiatric services to
provide that will allow us to still make a
decent wage and keep the doors open. For
example, with the advent of FDA approved LASER
technology for fungal nail treatment, a
podiatrist can use this as an excellent revenue
stream to replace lost income to deflated fee
schedules. This can be excellent supplement your
income and continue to provide traditional
treatment regimens for these types of foot
conditions. You may also consider hiring an
aesthetologist and/or certified medical nail
technician. There are other examples of
podiatric care which are considered "non-
covered" services, but if marketed properly and
create "value" in the mind of the potential
customer, then the sky is the limit.
The annual podiatric conventions we attend have
vendors who for so long have concentrated on
demonstrating their products and services as
things we could provide and hence bill insurance
and get paid. But, when you attend look for
vendors who are specializing in wares that can
be sold in your practice. Yes, I said "sell"!
You have to be a salesman to be successful when
you are providing a product or service to the
public. You are the "expert" and you must "sell"
yourself to the patient and build a trust and
confidence in them so that your services can be
rendered, hence "value" is created and you get
paid. No matter what you provide in your
practice, this motto must be followed to be
successful. Stop thinking because a podiatric
service is not covered you will not even
consider offering it the patient.
I would also entertain a “concierge type
practice” (if the demographic allows) which
would eliminate acceptance of any insurance.
This type of business model allows one to take
a "retainer" for annual medical services. This
could really let a practitioner hone in on
a "select" population of patients related to
their interests. Whether it is general foot
care, sports medicine, in-office procedures and
outpatient foot surgery an annual fee could be
collected to cover those expenses. Let's just
say for example you have 250 patients who are
will to pay you a $2000 a year as a retainer for
podiatric care. You do the math.
I hope these posts have helped some, if not
most of my colleagues, understand that the sky
is not falling, but rather it is the perception
that it actually is. Changing your mindset and
convincing yourself that you are the best at
providing foot care to population at-large. Your
training, knowledge and experience have allowed
you to the best at what you do. Now, just go out
there and convince everyone else what you
already know.
Joseph Borreggine, DPM, Charleston, IL,
footfixr@consolidated.net
I do not want to leave people hanging with words
of discouragement and wondering what to do from
here on out. My last post left no possible
solution for the time being, but rather was
doing nothing more than "stir the pot" so to
speak. I am not in any way disenchanted with the
profession choice that I made. It is what it is,
and I am going to fulfill my obligation to it
until I retire or until I am no longer able to
be productive in the profession.
Regarding the changes to healthcare with all the
inordinate policy changes and regulation that I
spoke of previously, I would like to offer some
suggestions for practicing podiatrists. These
suggestions may be applicable to most, but some
may not be able to participate due to
contractual obligations regarding employment in
a group practice clinic or hospital. This is may
be unfortunate for those podiatrists in that
realm, but for other this may be an opportunity
to at least make something of your practice and
eventually retire with some money in the bank.
Since a the podiatric practice environment
traditionally is a solo venture or a small group
practice with partners or associate, these
suggestions may be feasible to implement only in
that practice setting. I must first say that
the paradigm for traditional fee-for-service in
our profession needs to be changed in the
mindset of podiatric physicians. For years, we
have tried to create parity equal to our
allopathic colleagues in the way we are
reimbursed. But, that still has flaws and
prejudice.
We have established and tried to convey this
mantra that we are "physicians" with the
education, training, and knowledge which is
equal to our allopathic colleagues. This may be
true to some degree, but with the continual
battles with issues like Title XIX, this may not
be as true as we think.
The dental profession has never used the health
insurance industry the way we have as a vehicle
for financial success. Hence, they are not
fiscally deterred from being profitable in their
practices. Why is that so? You may ask? It is
because they have created "value" in what they
do in their patient population. We have not.
Think about it. How many patients would actually
come and see you for treatment and participate
in care if they did not have insurance? I do not
think many would come. Why? Because people truly
do not find "value" in the care we provide and
they have so many other options to have the same
services provided to them by other healthcare
providers like orthopedists, allopathic and
osteopathic physicians, wound care nurses,
pedorthotists, physical therapists, and
chiropractors.
This is unfortunate. What do we do that is
truly "proprietary"? Foot surgery, wound care,
and orthotics are services that can be
optionally provided by other health care
providers. This creates a problem. The type of
medical care that we provide like foot care,
biomechanics, and in-office procedures we do
(like ingrown nails) is the best anywhere in
medicine. These examples of care should be
considered our "property" and our field of
expertise. As students we were trained to do
this type of care through the clinics, external
programs and post-graduate training. In most
practices, it still makes up over 80-90% of our
business. We must therefore, concentrate on
providing things that continually create "value"
for the public-at-large.
This line of thinking laughs in the face of what
we have done and fought for years through our
professional representative organizations. Even
though we had made many gains throughout the
years on matters of parity, licensure, hospital
privileging, and insurance reimbursement it is
still not enough. In certain circles, we still
are not considered or defined as "physicians"
and therefore, we may be left out of certain
healthcare reforms. With all the regulations in
place and those pending in the upcoming years we
need to re-think what we are doing and how we do
it.
If you are unable to believe that you can and
must create "value" in what you do in daily
practice along with understanding that financial
success will happen over time. Because as a
podiatrist disconnects from the grip
of ”insurance monster" and starts to actually
collect money for the services rendered the day
they were provided, then freedom will ensue. The
electronic health record and meaningful use are
going to be the vice grip that will allow
the "insurance monster" to keep hold of
physicians. The federal government and other
insurance companies will eventually have access
to our computer systems regarding our patient
health records. Why? It is because they paid us
the liberty to do so to the tune of $44,000.
With all the stages of meaningful use being
implemented and our annual attestation we are
paid incentive dollars to entice us to
participate.
And as we get deeper into each stage of
meaningful use, then the freedom of health
record information exchange and evaluation by
third parties will become more and more
transparent. As that happens, the metrics that
are in place are there to control healthcare
delivery and spending and therefore, will
dictate who gets to keep or not keep those
previously paid incentive dollars. So, if you
have not gotten a meaningful EHR, then you may
consider not getting one because it will save
you money in the long run. Then if you do not
get a required EHR, then you will have to take
the penalty if you decide to stay as insurance
provider. Or you can name your own price to your
patients without worry and keep your money by
choosing not to participate.
The Accountable Care Organization (ACO) is the
federal government's answer to saving money in
healthcare delivery, but it truly is nothing
more than a new-fangled HMO program. ACO's are
nothing more than organizations where doctors
will be policing themselves and allowing
there "selected" panel members to eliminate
those providers who do not follow the mandated
metrics in place required to save money. Once
the metrics are met by the ACO, then every panel
member will receive a "bonus" for playing by the
rules and providing federally mandated cost-
effective care. If you are not chosen to be on
the on the "select" panel of providers or chose
not to be in an ACO, then what happens? Well,
then you may have just consider closing your
doors our going back to my premise of
creating "value" and do what you do best. Make a
living the old fashioned way collecting actual
money for what you do without restriction.
ICD-10 is another nightmare which will slowly
rob you of your income either by slowed or
delayed payment because of its integration not
being implemented properly by software vendors
or insurance companies. The way around that is
just choose to not bill or participate with
insurance companies. The convoluted coding in
ICD-10 is another way to "see" what physicians
are doing on their patients and make sure that
they are doing in the most cost effective manner
possible. There is a reason the United States is
one of the last bastions that are still using
the ICD-9. We will see what happens on Oct. 1,
2014. I believe it will be delayed, but that's
not to say it will not be implemented. ICD-11 is
currently be used in some countries, so we have
to convert. You may want to eliminate this cost
by not billing insurance or even using these
codes. Get paid cash for what you do without the
scrutiny and laborious task of figuring out the
right code to use. Consider even dropping off
managed care panels?
Medicare participation is another venture of
insanity. The longer you participate the harder
it will be collect reimbursement for what you
do. Along with the failure of fixing the
Sustainable Growth Rate (SGR or "Doc Fix")
regarding the fee schedule and the continued
increased regulations including meaningful use
EHR's, eRx, and PQRS, the participating provider
is in a "no win" scenario when it comes to being
a participating provider. Most think the easy
way out is just choosing not being
a "participating" provider. Not so, if you have
collected incentives through EHR, eRx, and PQRS,
then I believe you are "locked in" to be
a "participating" provider. Good luck trying to
convert, but that is just me.
Completely dropping out of Medicare may be your
best option. Your patients who find "value" in
what you do will pay for the services you
provide. Why? Because you are the "best" person
to do so and they have to and will eventually
see that. Feet are just as important as teeth!
So, let’s act like they are and start asking our
patients if they would pay for the care you
provide if insurance did not pay? We just have
to keep proving that we are the best medical
provider when it comes to foot care. We must
stop thinking the government and our allopathic
colleagues are our friends, because really they
are not. Let’s stop trying to prove who we are
to them. Then if no them, then who are our true
advocates? It is our patients as it has always
been and not the aforementioned.
DME suppliers we able to be and some of us are,
but as you have seen with diabetic shoes, wound
care and now AFO braces. The policies and
restrictions are becoming insurmountable. What
is the point of even trying to provide a service
that requires a thousand hoops to jump through
before you get reimbursement? And then you are a
target for an audit if the "T's" are not crossed
or the "I's" are not dotted just so. Rx
orthotics has faced the same demise. Again, in
these matters cash is king! If there is "value"
then a person will pay for the service, if not,
then they won't. It really is their choice.
Again ask if a patient would pay for a Rx brace
or pair of orthotics? See what they say? If they
would pay for dentures, then why would they pay
for orthotics? Because insurance companies
traditionally do not!
Podiatry schools also need to wake up and see
the writing on the wall. Podiatrists are
fighting an uphill battle and have been for
years. I have to believe that podiatry schools
had to merge with established medical schools
because of either the waning attendance and
hence, the lower enrollments causing a fiscal
crisis. The merging of podiatry schools with
medical schools inevitably saved the profession
from its own demise, but for how long?
The podiatric medical student must have other
options available to them to obtain a DPM degree
by allowing them the opportunity to obtain
possibly a physician assistant degree (as was
suggested by a podiatric colleague to me in a
recent phone conversation). With the PA degree
with DPM degree allows the podiatrist to have
the ability to make a living and prepare for the
possible elimination of podiatry from the
healthcare delivery system. If I see the writing
on the wall, then I opine podiatry may be slated
to be eliminated from healthcare as way to save
money. It's just a thought. Poll the current
student population and see what they think? I
hear this has been done already in a podiatry
school. I was told the results were surprisingly
predictable. The MD/DPM may be the best option
at the end of the day. We need to protect the
future of our young rather than eat them.
The residency shortage, I believe has not been
solved in podiatry. There may be a stop gap
measure in place for now, but over the next few
years I believe residency slots may be
eliminated without prejudice in efforts to save
money. I currently understand that the federal
government provides subsidies to hospitals to
fund podiatric residency slots. If this dries up
or is cut, then what? I do not know the answer,
but I bet someone other does. This is not being
said to scare anyone, especially our newly
graduating podiatrists, but it’s re-affirming
the fact that the government will and may cut
funding for podiatry residencies to save money.
The only way it can be stopped is by "proving"
that we are of value. Can anyone say Title XIX?
So, with these things said and put out there for
all to read, one may became mad and say I have
no idea what I am talking about or insane! I beg
to differ. I think we need to re-think where we
are going as a profession and stop this business
of dividing this profession into the "have" and
have not’s". We have to really know that we are
headed for uncharted territory and we need to
band together and figure this thing so we can
head into the future and be necessary part of
healthcare. And if that requires a certain
population of "not participating" in all the
federal policy changes and "go out on our own".
Then so be it. Other may choose to stay as they
are and still other may modify how they practice
and get reimbursed. But, whatever the case we
are still podiatrists and the best medical
providers of foot care and you can always take
that to the bank. We are of "value", but does
the public really know?
Joseph Borreggine, DPM, Charleston, IL,
footfixr@consolidated.net
