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