07/05/2016 Michael M. Rosenblatt, DPM
MACRA is the Death Knell of Podiatry (James R. Christina, DPM)
I agree with Dr. James Christina, Executive
Director of APMA who said that MACRA does not mean
the "end" of podiatry. Dr. Christina correctly
points out that many previous "attacks" against
private practice have fallen aside. "Managed care
and capitation" were high on that list, as well as
various Medicare pay cuts. None had any effect on
me. And I was not alone. We have seen these fads
come and go like wind-blown clouds. One humorous
example comes to mind many years ago when BCBS
decided to "require" any treatment over 100
dollars obtain a second opinion. Apparently their
bean-counters believed that most medical care was
"unnecessary."
You can guess the outcome: Second opinion
practices bloomed like flowers in the desert and
BCBS ended up paying for both the necessary
surgery/treatment AND a very expensive, detailed
second-opinion. Within a year that particular
nonsense was quietly phased out. There lots more
dumb ideas where THOSE came from.
But it does make sense to plan for changes you see
coming. This would certainly include requiring
patients to pay up-front for non-Government
covered trimming of corns, nails and calluses.
When patients asked for this service for "free" or
asked me why I charged for it, (when "other"
podiatrists did not), I simply stated: "It is
illegal for me to bill Medicare for non-covered
services." Instead, I invited them to come to a
local senior center where I did this for free,
once/month. Many did. Some DPM's offer one
afternoon/month for free RFC in their office. You
must explain that the service is free and CANNOT
be billed to Medicare or any other insurance.
Every private practice doctor needs a personal
financial plan. Marital stability is a key feature
of personal financial planning. Another is
widening your investments into rental real estate.
During the 2008 financial crisis, many
opportunities were available for very low cost
rental-RE investing. Even now, such opportunities
still exist, but require more investigative
efforts to unearth. Retail sales of over-counter
products in your office is yet another. Kaiser
Healthcare makes enormous profits from their OC
sales! They do not consider those profits to be
"unprofessional."
In 2006, I published an article in Podiatry
Management Magazine on "Podiatrists investing in
Rental Real Estate." It is interesting that this
article remains relevant even now. All that is
necessary for successful rental RE investing is a
"steady" dependable income from non-RE sources.
You could correctly counter that in 2006 it was
much easier to borrow money. But that has not
stopped entrepreneurs who make far less than DPMs
from still doing it.
Rather than looking at podiatry as a "fragile"
profession, you might consider its advantages: In
many occupations (like engineering) age
discrimination very frequently forces out well-
paid engineers in their mid-fifties. They rarely
get rehired. Some DPMs, on the other hand have the
option to practice well into their 70s out of
choice. That said, I would have to say that I have
never considered myself a "victim" for investing
my life in podiatry, MACRA notwithstanding...
Michael M. Rosenblatt, DPM, San Jose, CA
07/04/2016 James R. Christina, DPM
MACRA is the Death Knell of Podiatry (Joseph Borreggine, DPM)
Please allow me to provide some background, as
well as some information about what APMA
members can expect with regard to MACRA and its
potential effect on podiatrists. Members can
also visit www.apma.org/macra to access all our
resources on this topic.
MACRA is legislation that was passed by
Congress and signed by the president. The
Medicare Access and CHIP Reauthorization Act of
2015 (MACRA) repealed the sustainable growth
rate (SGR) and replaced it with the Merit-based
Incentive Payment Systems (MIPS) and
Alternative Payment Models (APMs), among many
other programs the legislation addressed. Once
Congress passes a law, the implementation of
the law falls to regulatory agencies, and in
this case implementation of MIPS and APMs falls
to CMS. CMS released a proposed rule related to
MACRA and the implementation of MIPS and APMs
with a comment period that ended on June 27.
APMA and many other medical associations and
others responded with comments. CMS will review
the comments and then publish the final rule
for these programs. Until the final rule is
published, the only information that can be
provided is tentative and should carry the
caveat that it is based on the proposed rule.
However, based on the proposed rule some
important points to consider:
MIPS and APMs will begin in 2017 with their
effects on payment to start in 2019.
The maximum negative payment adjustment for
those who participate in MIPS starts in 2019 at
4 percent and increases to a maximum of 9
percent by 2022. There are no details to
indicate beyond 2022 if the payment adjustment
will increase past the 9-percent threshold, and
information from CMS at this time shows the
adjustment remaining at 9 percent past 2022.
There are also opportunities for positive
payment adjustments—so there will be winners
and losers in the MIPS program.
MIPS is based on a fee-for-service model. The
payment adjustments are adjustments to the
reimbursement you will receive from CMS based
on your billing of CPT codes. In other words,
if you receive the maximum payment adjustment
for MIPS in 2019 based on your 2017
performance, you would receive a 4-percent
payment reduction on all Medicare Part B
services you bill in 2019.
According to APMA consultants (assuming no
significant changes to the proposed rule in
relation to the APMs), almost no providers
(including podiatrists) will be in a qualifying
ACO to be a part of the APMs initially. This is
due to the risk-sharing requirements in the
current proposal.
It has been pointed out that certain practice
situations may be optimal in the future. APMA
continues to work to improve the prospects for
podiatrists in these settings. The VA Provider
Equity Act, when passed, will improve the
employment situation for VA podiatrists, and we
hope that with that obstacle overcome, we can
then successfully address the military pay
issue for podiatrists. Our work and presence at
the RUC help protect the value of the services
podiatrists provide and directly affect those
members whose reimbursement depends on the use
of RVUs.
Historically, you will find that changes in
payment systems have always been predicted to
be the end of medicine (including podiatry).
However, we have seen the demise of HMOs,
third-party administrators, capitated payment
systems, and even a very slow development of
ACOs to this point in time.
APMA members can rest assured that just as we
did in preparation for ICD-10 and incentive
payment programs related to e-prescribing,
PQRS, and meaningful use, we will continue to
provide resources for MACRA to educate and
prepare them to make the decisions that best
suit their practice situations. The education
we provide is a benefit of APMA membership. We
are proud of the value we provide through these
educational and advocacy efforts on behalf of
our members and to the benefit of their
patients.
James R. Christina, DPM, APMA Executive
Director and CEO, Bethesda, MD
07/04/2016 Joseph Borreggine, DPM
MACRA is the Death Knell of Podiatry (Allen Jacobs, DPM)
I have to agree very little with Dr. Jacobs on
his recent posting with respect to the
"prosper" list and for the future of podiatric
medicine. However, I cannot agree at all with
the response from "Name Withheld".
First, Dr. Jacobs' list is quite complete and
makes total sense, but what are the current
percentages of podiatrists who hold these
positions. I do not know if we have exact
statistics from any of our profession
organizations on this subject matter. It would
be interesting to see the actual number of
podiatrists who are employed and the actual
numbers. Still the numbers of private practice
podiatrists still outnumber the ones that are
employed.
Secondly, Dr. Jacobs might be right if the
practitioner is 50 years old and has no student
loans and can work on a set salary. The problem
is that he does not address the remaining 97%
of the Podiatrists out there. Obviously, Dr.
Jacobs must not be in private practice or is
involved in a residency directorship and/or
must have other revenue streams to supplement
his income.
Additionally, PAs and NPs are fully licensed
DPMs are not. So, an NP can debride that
diabetic ulcer, maybe a sacral ulcer, and then
write a script for insulin and also an anti-
hypertensive. And yes, they are 100% proven
more cost effective than a DPM. The government
would not be clambering for more PA schools and
NP schools if that was not the case.
For example, if a PA or NP can do epidurals
they can handle a toenail avulsion, a heel spur
injection, a tenotomy and so on. So, who do
you think the government will choose when it
comes to cost-effectiveness?
Have we proven that we are more cost effective
than other providers who can do what we do? And
another fact is that podiatry is a technical
field 90% of the time and diagnostic the other
10%. Here is something to ponder: can I get a
non-medically trained person to do the
following: make an arch pad, cast for
orthotics, cut nails, trim calluses etc.??
Conversely, now can I get that same person to
interpret labs, make a diagnosis and prescribe
the right medications? Therefore, how important
are we really if other ancillary field of
medicine can do what we do cheaper? It has
already been shown that 78% of DPMs are not
cost effective.
And finally, Dr. Jacobs states that it is for a
podiatrist to become and stay "prosperous" by
understanding and properly implementing the new
MACRA rules in the next few years. He certainly
knows that Medicare rates are followed by
private insurers lowering their rates to be in
line with Medicare. This is a fact at the
present time. Following the new MACRA makes you
lose money not "prosper".
Now, "Name Withheld" may be gainfully employed
at a hospital and be a top-earner and be quite
secure in his position as a successful
podiatrist, but I would consider him in the
minority. Yes, I have heard and seen hospital
employed podiatrist make $400K or higher in
their practice. But, that, again, is not
reality. I need to ask this podiatrist if they
have ever been in private practice. If they
were, then why did they become employed instead
of staying as an independent practitioner? I
bet the main reason was trying to obtain
financial stability in the waning business of
medicine. I say, "Good for them".
I also wonder if this person has any difficulty
getting patients referred to their hospital-
based practice. I am sure they do not. The fact
is that employed physicians refer to one
another and not the independent practitioner;
that is just how it is. This is so that the
revenues generated do not "out-migrate". This
is good business sense. I would also like to
ask "Name Withheld" if they are doing more
surgery than they have ever done before now
since they are a hospital employed physician. I
would like for them to see if they explain why
this might be?
Is it because the RVU system and the year-end
incentive bonuses drive the doctor to do more
because they must meet the required RVUs to get
a base salary and then the more RVUs generated
after that the more they get paid at year's
end? Again, this is good for the individual
physician who wants to make money more than the
minimum salary.
But, the problem is that patient population
that generates the RVU total may not be the
same demographic as in private practice. What I
mean is that the socioeconomic status of a
hospital-based practice patient population is
much lower than in a private practice setting.
These patients are in the hospital-based
healthcare delivery system because they have
been driven to the hospital based on their
insurance plan and not their desire to seek out
a physician of their choice.
These hospital-based patients receiving medical
care are usually on Medicare and/or Medicaid.
These patients normally are not the "select
population" of patients that physicians in
private practice would seek years ago, but now
with managed care plans having fee schedules
equal or less than Medicare, it makes more
sense to be a hospital employed physician where
fee-for-service is replaced by the RVU and the
type of health insurance the patients has or
their ability to pay does not matter.
The RVU system works quite well in large
hospital and corporate healthcare systems to
compensate all their employed physicians and
hence, attracts all "comers" that are seeking
healthcare who otherwise would not be seen in a
private practice. So, of course "Name Withheld"
is a "top producer" at their hospital because
they are seeing more patients and doing more
procedures which in turn, generates high RVUs
and hence produces a high annual salary.
These employed physicians do more and get paid
more regardless of the patient, the health care
plans, and whether the procedures performed are
"necessary". But with that said, would this be
the same thing if this doctor was in private
practice and actually knew what the insurance
actually paid for all that was done on the same
patient population? I do not believe the answer
would be the same.
Private practice is a money loser. It is dead
in the next five years. With MACRA and all it
trimmings I can hear "For Whom the Bell Tolls";
and it just might be this profession. We need
to change are strategy sooner than later if we
are going to survive in the future.
Joseph Borreggine, DPM, Charleston, IL
07/01/2016 Allen Jacobs, DPM
MACRA is the Death Knell of Podiatry (Joseph Borreggine, DPM)
The impending MACRA implementation may be the
canary in the coal mine for private practices
of all types. MACRA is certainly a cause for
concern. However, the Death Star scenario
proposed by some may not prove to be entirely
accurate.
1. Institutionally-based podiatrists will
continue to prosper;
2. VA based podiatrists will continue to
prosper;
3. Military podiatrists will continue to
prosper;
4. Orthopedic group podiatrists will continue
to prosper;
5. Medical group podiatrists will continue to
prosper;
6. MACRA competent podiatrists and podiatry
groups will continue to prosper.
7. Those whose income is not primarily Medicare
dependent will continue to prosper;
8. A worst case scenario is that of a 22%
decrease in Medicare based income, not total
income.
Alternative providers (eg- PA, NP, MD, RN) may
attempt to provide services commonly provided
by a DPM. They will neither provide these
services as well nor as cost effectively. It is
my personal belief that if anything, the value
of a good podiatrist will be elucidated by
those attempting to fill that role. And
importantly, the patient will demand better
care.
Perhaps " practice enhancement" philosophies
endorsed by organizations such as AAPPM, FABI,
IPED, and the like, require reconsideration.
Maximizing profits on every patient may indeed
prove to be the cause for the issuance of a
MACRA pink slip to your practice.
The intellectualization and rationalization to
justify unnecessary services will prove costly
to those who continue to follow a maximize
profit first approach to foot and ankle care.
One might also be concerned if a practice is
onychopathy based. The day of the million
dollar non-cash based nail bed and distal
practice is over.
The real answer? Start practicing cost
effective medicine today. Any good football
coach knows that punting to gain field position
is frequently preferable to going for it on
fourth and three. Hold the opposition with a
good defensive stand. Get the ball back with
better field position.
Allen Jacobs, DPM, St. Louis, MO
