10/21/2022    Vince Marino, DPM

The High Cost of Being a Foot and Ankle Surgeon

I am glad my post in response to Dr. Block’s
original post about the “High Cost of Being a Foot
& Ankle Surgeon” has provoked some very good
responses and initiated some thought and
discussion. But I feel I must issue a
clarification- I am not against performing surgery
and still do a fair amount of surgery when the
clinical circumstances require it. Yes I do minor
office surgery which certainly reimburses at a
higher rate than outpatient hospital and
surgicenter.

Yes, we need to be able to teach our residents who
wish to perform surgery and Yes, most of my
surgeries are done at a surgicenter which at least
in my area, is infinitely more streamlined and
efficient than going to the hospital. In fact there
are probably only 4 reasons I use the hospital for
outpatient surgery: Patient BMI too high for
surgicenter; patient’s medical history or condition
is too complex to safely perform surgery at a
surgicenter in case something happens; insurance
contracts dictate that I need to use the hospital;
or I need to use an implant for which the
surgicenter will not be reimbursed for hence
causing them to lose money on the case.

The point of my post was to dispel the myth that
every podiatrist needs to be a “super surgeon” able
to do complex reconstructive foot and ankle
surgery- especially with the advances and
increasing number of fellowship trained Orthopedic
foot & ankle surgeons. As Dr. Block pointed out in
his editorial, a recent article in Foot & Ankle
Orthopedics concluded, “Over the past two decades,
physician reimbursement for foot and ankle
procedures has dramatically decreased by up to
48.3%.

Continued downward trend in orthopedic foot and
ankle physician reimbursement may lead to decreased
access to quality foot and ankle care.” I think
unless you are in a large HMO type organization or
employed at a teaching hospital or institution, the
number of patients visiting our offices for
reconstructive foot, rearfoot and ankle surgery is
nothing compared to those patients coming to us for
the more common problems of heel and arch pain,
fungal nails, ingrown toenails, warts, diabetic
foot care and ulcers, not to mention the good old
palliative care elderly patients, who in my
experience are usually the most appreciative
patients I have.

So let’s as a profession be honest with the younger
generation of podiatrists, future podiatrists,
podiatric medical students, and residents. Let’s
teach them the BUSINESS SIDE OF PODIATRY- not just
how to be a good surgeon. Perhaps with that
knowledge they can succeed and pay down those
ridiculously exorbitant debts they have incurred.
As Dr. Bret Ribotsky famously said, “Surgery is
fun, but fungus pays the bills.”

Vince Marino, DPM, Novato, CA

Other messages in this thread:

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10/24/2022    Robert Kornfeld, DPM

The High Cost of Being a Foot and Ankle Surgeon

I have been reading the posts about the high cost
of being a podiatric surgeon and would like to
chime in for those of you who are sick and tired of
fighting with insurance companies and being forced
into high volume, high expense practices. I am a
1980 graduate of NYCPM. When I went into my own
private practice in 1982, there were only cash
patients, Medicare and indemnity plans that paid
80% of everything you billed (there were no fee
schedules back then). Some insurance companies paid
based on location and estimated expense levels, but
most paid 80%.

That golden goose died when podiatric surgeons
started billing for multiple procedures with no
bundling. This led insurance companies to look for
more cost effective (profitable) models. Hence,
managed care hit the scene. Now, you were at the
mercy of the insurance company. Most offices must
hire full time staff just to fight for money that
is rightfully theirs. The entire system sucks!
Please don't answer this post with the nonsensical
"altruism" defense. You are in business to make a
living. With the responsibilities we shoulder, we
should be paid a lot of money. Otherwise, why
bother?

In 2000, I had had enough of the insurance game. I
decided that I would drop out of every plan and go
direct pay. The first year was scary. My gross
income dropped 50%. Until I realized I had better
get busy marketing my services to the public. I had
a weekly radio show. I did public lectures. I wrote
articles for local magazines. And it was a no-
brainer. I developed a low volume, low stress, high
income practice. It is not only possible, you will
prosper if you do the right kind of marketing with
a strong niche.

The only warning! Since Covid, less people have
been willing to pay out of pocket. I am sure other
direct pay docs will admit that their volume is
down. But of course, this won't last forever. What
I can guarantee, if you stay with the current
insurance model, you will eventually be making so
little profit that you'll have to look for a second
job.

Robert Kornfeld, DPM, NY, NY

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10/19/2022    Kathleen Toepp Neuhoff, DPM

The High Cost of Being a Foot and Ankle Surgeon (Vincent Marino, DPM)

I have appreciated the discussion on the costs of
hospital surgery vs clinical outpatient care and
certainly agree that income per hour is much
higher in the office vs the OR. As was pointed
out, some of this is because of the fees. Some of
it is also because of the inefficiencies of OR
surgeries. This can be improved by using
surgericenters and scheduling back to back
procedures. However, the hourly reimbursement rate
is also improved by performing many procedures
such as exostectomies or hammer digit correction
in your office.

Even if you cannot meet the criteria for a
surgericenter, it is not difficult to dedicate a
room to sterile surgery. Infection rates are
generally lower in this environment than in
hospital ORs. Many patients are willing to have
procedures done with local anesthesia and COVID-19
fears made many patients prefer an office surgery
to a hospital surgery.

With a good staff, the patient is roomed, consent
and initial prep done while you continue to see
patients. You pop in to meet with the patient,
and give the local anesthesia, then see another
outpatient, then scrub in, perform the surgery,
have your scribe chart the surgery note while you
do the surgery, and return to your outpatients
while your staff discharges the patient, reviews
the post-op instructions, takes post-op
radiographs and schedules the next appointment.
Although the patient is probably in your office
for over an hour, your total time in the OR may be
10 to 20 minutes which makes the fee paid much
more acceptable.

One of the concerns I have with our surgical
residency programs is that residents rarely have
the opportunity to perform surgeries in offices
and will not be comfortable doing so. The cost of
their education is so high that they need every
advantage possible. Finally, it is important that
we remember the main stakeholders in our care are
our patients.

Clearly for certain procedures such as tarsal
tunnel and rearfoot reconstructive surgeries
hospital or surgericenters are the only reasonable
option. Also, a patient who prefers that
environment or who prefers MAC or general
anesthesia should have their preference honored
even for a minor procedure. Fortunately, the
variety of work we can do in podiatry not only
make it fun, it also protects us a little bit from
the "fee adjustments" made to surgery fees by
Medicare and insurance carriers.

Kathleen Toepp Neuhoff, DPM, South Bend, IN

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10/17/2022    Vince Marino, DPM

The High Cost of Being a Foot and Ankle Surgeon

Kudos to Dr. Block for hitting the nail on the
head. To emphasize the point-my old associate and
friend Fred Youngswick, DPM used to say we make at
least 2x the income with ½ the liability by being
in the office. Let’s take a look at an example.
Let’s say you have a patient who needs a
bunionectomy with metatarsal head osteotomy, repair
of a second hammertoe deformity and a Weil
osteotomy with a plantar plate repair for a
subluxing and painful 2nd MPJ all on the same foot.
These are reimbursements for Marin County in CA
(Expensive county)

Procedures-
CPT Code Reimbursement (Medicare Fee)
Private Insurance (Roughly 25% more if you are
lucky)
Bunionectomy with osteotomy 28296
$597.78
$747.23
Weil Osteotomy
28308-51 $227.60 (50% -Multiple
surgery rule) $284.50
“Plantar Plate Repair”
28200-51 $96.63 (25%- Multiple surgery
rule) $120.79
Hammertoe Repair
28285-51 $113.16 (25%- Multiple
surgery rule) $141.45

Total reimbursement:
$1035.17
$1293.97

Time Out of Office= Approximately 3.25 hours ( 30
min travel + pre-op- 2.25 hours for procedure- 30
min post-op and travel back to office)

Hourly rate comes to $1035.17 / 3.25= $318.51
(Medicare) $398.14 (Private Insurance)

Now let’s say you can see 4 patients per hour in
the office (3.25 x 4=13 patients)- of which 2 of
the 13 are New Patients one of whom requires an X-
ray.
NP reimbursement (99203) = [$132.51 (Medicare)
$165.64 (Private Ins)] x 2 patients= $265.02 or
331.28.
X-ray Foot (73630)= $45.32 (Medicare)
$56.65 (Private)

11 Established patients-
Of this 5 (Medicare) are routine care with PVD –
nails and corns (11721-Q8 and 11056-Q8)
11056-Q8= $108.10 11721-XS-Q8 =
$53.94 = $162.04 x 5 =$810.20

6 private patients (CPT 99213) on of whom requires
an x-ray (73630) and one of whom requires PF
injection(20550) and strapping (29540). One also
needs orthotics (Covered- $550.00)
99213 = $108.15 x 6 = $648.90
73630 = $56.65
20550 = $68.79
29540 = $33.17
Orthotics = $550

Total for all 13 Patients = $2478.05
Revenue per hour in office= $619.51

Considering you will probably see at least half
those “in office” patients at least 1 more time
within the next 90 days, you can add roughly
another $1000.00 whereas the surgical patient is
seen “for free” for 90 days ( unless you take x-
rays ($56.00) or provide a cam boot ($185) for
instance)

SO for the 13 patients over the 3 month period,
CONSERVATIVELY you are grossing roughly $3,500 vs.
about $1100-$1200 for the surgical patient and a
whole lot less liability. So what would you prefer
to be doing?

Vince Marino, DPM, Novato, CA