07/04/2022 John Keenan, DPM
Why Does Podiatry Continue to be Its Own Worst Enemy?
I've read with interest the viewpoints from the
“Who wants to be a podiatrist?” and podiatrists vs.
Orthopod letters. Some of those viewpoints come
from doctors with names I readily recognize, and
some from Doctors I've never heard of. All have at
least some objective facts and some subjective
opinions. Below are some of my opinions, and
hopefully I'll be able to throw in some subjective
facts to back them up.
Podiatrists are their own worst enemies. A
podiatrist that's been practicing for years more
than myself corrected me once: we don't do 'routine
foot care' (RFC). We do 'at-risk foot care'.
Medicare doesn't pay for RFC unless that patient
needs the care of a professional due to risk
factors (or pain). Why do we refer to it as
'routine'? If it's that routine, could (apologies
to GEICO) a caveman do it? Yet we continue to
minimize the services we provide in our own minds.
Don't. We save limbs. We save a lot of healthcare
dollars by catching problems early and addressing
them before they can become very, very expensive to
treat.
Despite our limited scope of practice, we are the
premier comprehensive specialists in foot problems.
We are the specialists that focus on all aspects of
the Foot (and in some states ankles and lower
legs). We do dermatology, orthopedics,
biomechanics, sports medicine, infectious disease,
wound care, etc. every day we go into the office,
surgery or hospital. Don't minimize your
contributions so casually. Don't disparage your
colleagues. Don't feel like a second-class doctor
because you can't take the USMLE or do Ob/Gyn
rotations or Psych rotations.
We, as podiatrists have enough problems already
with insurance companies minimizing our
contributions. We contacted a regional insurance
carrier to inquire about dropping our contract with
them. Their reimbursement is very, very poor. They
offered us a 10% increase in their rates because
'we're such a valuable part of their plan'. I asked
for the fee schedule. They're paying us 35 to 55%
of Medicare allowed rates for our most common CPT
codes. The fee schedule was titled: “Podiatrists
Fee Schedule”. Why not 'Provider Fee Schedule'?
I showed it to a primary care doc who is involved
in administration for a local hospital system. He
couldn't believe they could pay that little (his
hospital system gets more than 100% of Medicare
allowed from the same carrier for the same codes).
Why can insurance companies determine that we are
lesser providers? Why do we tolerate that? We
provide the same services as an MD/DO, billing the
same CPT codes for the same ICD-10 diagnoses, yet
we get far, far less for the work we do?
On to "Who wants to be a podiatrist?": There's
discussion on whether podiatry students should be
able to take the USMLE (US Medical Licensing Exam).
The NBME (National Board of Medical Examiners) has
said Podiatry Students aren't eligible due to the
way we are trained. For arguments sake, let's say
the 10 or 11 Schools of Podiatric Medicine make
sufficient changes to their curricula and gain some
rotations to make the students qualified to take
the exam, then gain the approval to take the USMLE
from its governing body. How long will that take?
10 years is a minimal estimate from some people
I've talked to. What will the failure rate be for
the students in the 'new model' Podiatry Schools?
Will the students get a dual MD/DPM (or DO/DPM)
degree? Be able to do residencies outside Podiatry?
How many years to work that out for internships and
residencies? 5 more years? 10 more years? If
that's the case, we're seeing changes 15 or 20
years in the future.
My own opinion is that many of us are missing the
elephant in the room. There are not going to be
Podiatry schools in 10 or 15 or 20 years. Simple
economics is going to kill us. medical, osteopathic
and podiatry schools all have similar tuition.
About $200,000 to get through the four-year
programs. Then a 3-year residency (low paid, I may
add!) at a minimum depending on the MD/DO
specialty. You're now 7 years of making no or very
little money after your undergraduate degree (more
for specialists). Then podiatrists make an average
of $150,000, but MD/DOs in primary care fields make
$200,000+ at the low end of the average salaries,
and far, far more at the better paid specialty end
(Orthopods at $500k, cardiology at $450k). Why go
into podiatry if MD/DOs can make much better money
for the 'same' (time wise, not content wise)
training? If you can't get into Allopathic or
Osteopathic schools, then why not become a nurse
practitioner ($50 to 80k tuition, 2-to-3-year
Masters level program after working as an RN for a
few years), nurse anesthetist (similar pathway as
an NP), or a Physician Assistant (again, as similar
pathway). So, for 3 years of post-graduate
training, you make $115,000 as a nurse practitioner
or physician assistant, or over $175,000 as a nurse
anesthetist.
Smart students...the ones we want to go to Podiatry
School...will look at the numbers and disregard
Podiatry as a viable career in a lot of cases.
Applications are steady or declining to Podiatry
Schools (with more schools fighting for students
and 900 to 1000 applicants for half that number of
openings), yet increasing to MD/DO schools (85%
increase over the last 20 years). PA Schools got
27,000 applicants for 8,000 positions.
Does that mean podiatry as a career is non-viable?
No. Not if you're willing to fight for it now.
First and foremost, you need to ask yourself how
active you are in helping make Podiatry a well-
recognized and viable career. How many of the
readers of this letter have gone to a local
Podiatry Association meeting? Our local chapter has
70+ members. We have regular meetings and only the
same 7 or 8 members show up at all of them. Our
state Association has 800+ members (out of more
than 1000 practicing Podiatrists in the state), yet
when the local association Delegates go to the
annual House of Delegates meeting, it's the same
people year after year. When you see a list of
donations to our state Political Action Committee
and the APMA PAC it's the same people time after
time. Why aren't YOU more active? It's not time
intensive.
Here's what YOU can do:
Get more active in your local and state
Associations. Go to meetings. Become informed about
the current concerns effecting podiatry at the
State and National levels.
Donate (even a few dollars) to your state and
national PACs. Don't like the APMA or your state
association? The Political Action Committees are
the ones helping to lobby to make changes that
benefit our profession, and stop changes that hurt
our profession, and they are not the same thing
(The PACs are separate corporate entities, so even
if you're not happy with your state or national
association, realize that the PACs function
independently).
Push for legislation that helps podiatry. Do you
know what Title XIX is? (Medicaid grants from the
US Government). Podiatry is pushing for us to be
included as a necessary service, so we cannot be
excluded from Medicaid programs. That takes
lobbying.
Do you know any local or state or even national
level politicians? Go to one of their fundraisers.
Ask your local/state Association (or PAC) for a
donation for them. Politely make the donation and
ask to talk to their staff about the concerns about
podiatry. Your being there at a fundraiser and
being a polite and concerned constituent makes more
of a difference for the future of podiatry than all
the editorials and fighting over how to get parity.
Talk to local colleges/universities about podiatry
as a career and offer to have students come to your
office or meet with prospective students. Even
local high schools for seniors looking for what to
do in the future. If students don't hear about
podiatry, they can't consider it as a career.
I knew in the abstract (but not the specifics that
have been mentioned in other letters) that the
scope of practice for podiatrists varies
considerably among states, but that is something
that should get a national and state level push to
get a uniform scope throughout the U.S. That's done
through our PACs and political activities.
Insurances and other providers will fight it, so it
will be difficult, but it can be done. Again, that
takes lobbying.
At the same time as the above, we (all podiatrists)
need to push for the same reimbursement for the
same codes as MD/DO providers get. That has to be
done at the state or national level via
legislation. Until we get podiatry recognized, as
it should be, as the premier providers of
comprehensive foot (and ankle and lower leg)
medicine and surgery, we're never going to get
incomes commensurate with our training and
experience, we're never going to get more
applicants to podiatry schools, and not wither away
as a profession.
Insurance companies should not be the ones to
determine parity with other providers. We're all
in the same boat. Maybe I'm wrong and it's not
slowly sinking, but until we determine if it is
sinking, maybe it's better to bail the water out of
the boat instead of arguing about how to arrange
the deck chairs.
Lest this letter be taken the wrong way, I like my
profession. I've saved limbs and lives in some
cases. I think it's a rewarding career. It may have
its ups and downs, and among those downs is
definitely fighting with insurance companies and
dealing with regulations. Do I wish I was paid more
('parity' if you will) like an MD? Hell yes. Who
wouldn't want to make more money...but even then,
it's not 'more' money, it's 'the same money as
someone else is paid for the same service, provided
by someone with similar training'.
John Keenan, DPM, Lehighton, PA
