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

Other messages in this thread:

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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

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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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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