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
