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04/24/2024 David Secord, DPM
The Future of Podiatry (Allen M. Jacobs, DPM)
In an arena of increasing knowledge base and technocracy, the expansion of the knowledge base expected by tomorrow’s patient also increases as does that patient’s expectation that you are not simply seeing a wallet to pick clean upon their visit. As Allopathic physicians and surgeons, I believe that our destiny is to either follow the Osteopathic school of medicine (adopt the Allopathic standards of education and testing for licensure) or fade into oblivion.
I’m unclear as to how you trim a year off medical school and keep the same level of education in the World of expanding knowledge and expectations. As such, I believe that our future is a four-year degree, followed by a year of internal medicine internship and five years of surgical exposure to hone skills and knowledge and a year of fellowship in lower extremity trauma and care. There are many, many more of them than us, and we should either join the established crowd on the boat or expect to be left at the wharf.
For those who have managed to divorce themselves from the slavery of insurance reimbursement via a concierge practice, the ship has docked. For the grand majority, this is not an option. I deeply respect Dr. Jacobs and his position within the profession, but don’t believe that the public will accept a “cut-rate” doctor as a solution to access to care, reimbursement issues or student debt. Although only hinted at by Dr. Cabbabe, the push in his monograph’s conclusions for obligatory and unavoidable socialized medicine is fairly clear. His tone seems to hint that this is the ultimate solution to our problems.
As one estimate on the cost of “Medicare For All” was $98 trillion dollars, I can’t see how a Country with a National Debt of $34 trillion—and counting—could possibly institute this. Following either the Canadian or UK National Health Service model for cost containment via denial of timely care and services would do very little to assuage the public’s doubt that the healthcare industry cares about them in any way. If you look at the burnout rate for physicians within the NHS over pay and frustration, it is voluminous and dwarfs the rates in the United States.
A study a few years back surveyed physicians within the NHS and six of eight said that if they had an option, they would do something else for a living. When I practiced in Saudi Arabia, the number of physicians from the UK, Canada and Australia was amazing. All of them had homes and families in their host Countries but practiced in Riyadh because of the advantages of exiting the NHS, despite being away from their families for months at a time. Their numbers were truly legion and impressive. They hated Socialized medicine and the low bar of care delivery it wrought so much that the cost of only seeing their families three or four times a year was worth it, both financially and professionally.
My experience while in Riyadh was very influential upon my disdain for Socialized Medicine and I fully admit to such. Aiming for the goals outlined by Dr. Cabbabe to deal with NP nursing care encroaching upon medicine and managed care seeing patients as wallets to be picked clean while delivering as little care as possible doesn’t seem to be a viable alternative to the current situation. His enthusiasm for EMR is puzzling as well. I don’t know anyone who is as effusive in their love of electronic medical records as Dr. Cabbabe, with most of the physicians I know and with whom I work seeing the process as cumbersome, time-consuming, counter-intuitive and a general waste of time.
The administration at the clinic system where I’m employed is constantly attempting to end the “cut and paste from the previous note” epidemic seen by providers to simply get through the day and complete records. That is a huge unintended consequence of the EMR anchor around our necks and no good can come of it. We are at a crossroads in our profession and serious discussions as to where we should steer the vessel to avoid the maelstrom are needed. Pax.
David Secord, DPM, McAllen, TX
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04/30/2024 Ivar E. Roth, DPM, MPH
The Future of Podiatry (Allen M. Jacobs, DPM)
I “think” based on knowing how Dr. Jacobs has articulated himself in prior posts that his statement “for profit first” means the “greedy” direct care docs out there like Dr. Kornfeld and myself. I have a very good perspective concerning direct care practices as I was the first podiatrist to adopt this philosophy in the current insurance driven practice environment.
To explain the direct care concept correctly one must understand that we accept no insurance coverage at all, no Medicare, medical or any private PPOs, etc. To me it is the purest form of medicine as you must do a great job or else the patient is not going to be coming back. Why would a patient pay for services out-of-pocket when they can get the same or similar by using their free insurance coverage. The answer is that you as a direct care provider must offer at least the following two services in an exemplary manner. That would be great service and great professional care. No one in their right mind is going to pay you to do something that every other doctor down the street can do. So you must be the best of the best or offer services that no one else offers with either new cutting edge technology and or like myself offer a cure for fungus toenails or my Paincur procedure for pain, etc.
Direct care forces you to be the best you can be and a patient advocate. To me there is no cleaner way to practice it is simple and straight forward you get paid for every service you provide. It really is not about the money it is about giving great care and service and feeling like you have made a difference in someone’s life.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
04/29/2024 Robert Kornfeld, DPM
The Future of Podiatry (Allen M. Jacobs, DPM)
My esteemed colleague, Dr. Jacobs states, "For- profit first" thinking is the reason we are burdened with pre-authorizations, insurance payment reductions for services rendered, and denials for services. Money-first thinking denies access to healthcare, treats healthcare as a commodity rather than a right, and creates a conflict between doctor and patient.” He is actually not talking about doctors here. He is referring to the middlemen (insurance companies and private equity corporations) who suck off the knowledge and expertise of doctors. It is they that have created the mess we are in. Doctors clamber for ways to augment their insurance payments with non-covered services. This is not selfish “for profit only” motivation. This is survival.
I personally am not an advocate of putting money before patients. They are and have always been my priority. But to be honest, there is no way I would still be practicing podiatry if I did not move to a direct-pay model. To do what we do, we deserve to be paid very well. I quit insurance way back in 2000. I was seeing 50-60 patients daily and at the end of the month, there was not much to show for my hard work. Sorry Dr. Jacobs, but insurance companies have ruined everything that medicine should stand for.
One thing I will say is that when all of the tenets of medicine were laid down, there were no insurance companies. Perhaps it is easy to defend this mentality when an entire career was built on accepting insurance and it is too late to move into another practice model. But I have no interest in serving the greed of insurance companies. I would rather take care of my patients, my family and myself. And that was the point of my post.
Additionally, these middlemen force doctors into high volume - high expense practices that lead to high levels of stress, dissatisfaction and burnout. Do you not think it is a huge waste of money to employ 2 or 3 people just to chase after money that insurance companies withhold? This is a broken system. Enough with the calls for altruism!
Robert Kornfeld, DPM, NY, NY
04/24/2024 Robert Kornfeld, DPM
The Future of Podiatry (Allen M. Jacobs, DPM)
While I agree with almost everything Dr. Jacobs stated in his post regarding the future of podiatry, there are some issues that I think need to be re-visited. No doubt, the APMA and affiliated State Societies have done a very poor job getting the public to understand what it is we do and how well trained we are to do what we do. I also believe they completely missed the boat in advocating for podiatrists. In a HUGE way. And I say this after 42 years in my own private practice (the past few decades as a non-member).
The “business” of medicine should not rely on insurance issues. Those issues have been created by insurance companies in order to exploit and abuse doctors for their gain. Likewise, private equity corporations employ doctors and still, like insurance companies, have a profit motive, not a health care motive. They, too, will exploit and abuse their employees for profit. Therefore, the only way that you will ever see logical, fair and appropriate insurance reimbursements is for doctors to stop cooperating, stop participating and let medicine go back to a free market. In this way, insurance companies are out of business. If they want back in, they’ll have to come up with a fair reimbursement model but at the same time, leave the standard of care up to the doctors. Not this nonsensical standard created for nothing other than to maximize their profits. Free market, as you know, has its fees controlled by competition.
It would be best if patients paid their way, had a catastrophic plan in place for major medical events and we never went back to insurance- dependency. Indigent patients will still have Medicaid coverage and seniors will still have Medicare coverage.
As for “cost-effective” medicine, this is a misnomer. What we need is for there to be high value in the services we provide, independent of cost. What a patient spends is up to them. There are literally billions of dollars wasted every year on services that are limiting cost, and that leads to limitations in value realized by patients. Let’s help our patients in the most effective way possible. That means we need to learn patient optimization and not focus on “better modalities, surgeries and therapies”. The answer lies in an efficient immune system. Not in a better laser, etc.
So residencies should allow for the comprehensive assessment of each patient’s unique epigenetics and genetics. Every podiatrist should be well versed in why the patient crossed the morbidity threshold, not just the pedal diagnosis. And they should learn how to manage the underlying mechanisms of pathology outside of simply looking at biomechanics. We have really missed the boat as medical experts in our field.
And I must say this OUT LOUD. Profit in a podiatry practice should not be secondary. It needs to be primary. This is a business. ALTRUISM DOES NOT PAY THE BILLS. There is no reason for anyone to put in the time it takes to be educated and trained to practice podiatric medicine and surgery just to realize that all of your non-doctor friends and relatives are making a lot more money that you are. Sorry, but this does not cut it. For what we do , the value we offer the public as to their health and lifestyle, we should be paid very well. I honestly believe this push for altruism has been used as an excuse for staying stuck in a fear mode and not exercising the power that we truly have as doctors. It’s an excuse we have invented so we can rationalize doing what we do for peanuts.
As I see it, the future of podiatry looks bleak. Little by little, fees or salaries won’t sustain us. Other allied professions will usurp a lot of our current expertise and limit our market share. The surgery-only mentality has done much to destroy our foot and ankle medical expertise and has created a new generation of podiatrists sorely lacking in fundamental medical diagnostic skills.
If you want to secure your future as a podiatrist, you had better look outside the box that you have been stuffed into. Become your own advocate. Get yourself free from reliance on employment or insurance reimbursement. There’s a whole new world out there that is waiting for you and will welcome you once you make the choice to step into it. But the current direction we are in is guaranteed to crash and burn and leave you stranded without sustenance. And that is an absolute shame.
Robert Kornfeld, DPM, NY, NY
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