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05/09/2024
RESPONSES COMMENTS (NON-CLINICAL)
From: Elliot Udell, DPM
My position in this discussion is that there is nothing unethical about charging patients directly for medical services. My position is that telling practitioners all over the country to convert their practices into pure direct pay practices is problematic.
Yesterday, I saw a patient who did not have any medical insurance. The patient paid us directly. We did not have hassles with insurance companies, did not have to wait months for payment, etc. I reflected on this current discussion/debate that we are having and said to myself, "I only wish that all of my patients paid me directly."
The rest of the patients I saw that day were insurance company patients and one even called to make sure that we accept her insurance before confirming the appointment. Would converting my practice to a pure direct pay entity work for me? I doubt it and would advise any of my colleagues thinking about such a transition to discuss it with their accountants and family members before taking on this risk.
Elliot Udell, DPM, Hicksville, NY
Other messages in this thread:
05/10/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1 A
From: Lawrence Rubin, DPM, Ivar E. Roth DPM, MPH
I agree with Dr. Udell's advice that any of our colleagues thinking about transitioning to "direct pay" discuss this with their accountants and family members before taking on the risk. I also suggest that if the main reason for transitioning to direct pay is eliminating the burden of dealing with insurance claims hassles, give careful consideration to outsourcing all coding, documentation, billing, and practice marketing functions to one of the many excellent, full-service revenue management companies that are expert in podiatric business management. This can eliminate the stress and usually results in maximal return on investment.
Lawrence Rubin, DPM, Las Vegas, NV
I just read Dr. Udell’s post and would like to add some context. From my perspective, only about 5 to 10 percent of podiatrists are cut out to be direct care practitioners. It requires tremendous effort and will to succeed. One must think long-term to be successful. When I started, I took an 80% income cut and it took years to catch up to the old insurance days, but day by day things progressed until I had a very successful direct care practice. I say that this type of practice is not for the faint at heart but in the end, it is well worth the investment if you have the will to succeed.
Ivar E. Roth DPM, MPH, Newport Beach, CA
05/08/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1B
RE: The Future of Podiatry (Rod Tomczak, DPM, MD, EdD)
From: Robert Kornfeld, DPM
After the thread on The Future of Podiatry, many DPMs emailed me who are disgusted and fed up with insurance-dependency and hate going to work. Yet, most of them said the same thing to me, "My patients will never pay me!" This is testimony to the fact that many of you do not believe your services have any value. And that is the crux of the reason why you all stay in the system and suffer.
The reality is simple. If you accept insurance and your patients have very little out-of-pocket expense when they see you, why would they pay you? You are all correct. Those patients may like you, but the only reason they come to you is because they can come on insurance.
Your current insurance-pay patients are NOT your patient...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
05/08/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1A
From: Allen M. Jacobs, DPM
Dr. Udell posits his belief that direct pay medical care may be, in his opinion, unethical. Furthermore, Dr. Kornfeld felt the need to offer a defensive posture to his endorsement of the direct pay model of healthcare. As to the latter, Dr. Kornfeld is the messenger, not the message. He suggests, with good reasons, that the direct pay model may be a preferable means by which to practice podiatry. There is no need for Dr. Kornfeld to assume a defensive posture personally.
The direct pay model has been increasingly adopted in many areas of medicine, such as primary care, plastic surgery, dentistry, and many specialties within medicine. Those who practice traditional insurance-based medicine already practice direct pay medicine to some extent. You charge patients for increasingly larger co-pays. You charge patients for their deductibles. You charge for uncovered services. You charge for uncovered dispensed products. Therefore, the concept of direct patient payment for services provided in the traditional insurance-based healthcare model is not foreign to your practice.
Dr. Udell questions the ethics and morality of direct pay...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
05/06/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1B
From: Robert Kornfeld, DPM
Here is another "defensive" post which completely misses the point of what I shared. So, Dr. Tomczak, since you dragged me back into this discussion, let me enlighten you as to where I come from. First of all, I did deviate from conventional medicine long ago as I found that functional medicine did a far more reliable job of getting my patients well, especially the chronic pain patients who had been failed by many other doctors. I was so happy with this paradigm that I put a seminar together for our profession to teach what I had already learned. This was back in 2002. I wasn't so upset that they did not go over well and few sought to learn it. What I was more disgusted by was the level of vindictiveness in this profession.
Podiatrists who never met me and had no idea what I was doing for my patients chose to slander me online. Local podiatrists told patients very negative things about me, again, with no clue as to what I was doing in my office. My own NYSPMA also put me in harm's way back then. So I decided to step away from podiatry and...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
05/06/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1A
From: Elliot Udell DPM
This debate over direct pay vs. insurance company pay is boiling down to two issues. 1) Is it ethical to not accept insurance for payment for medical services? 2) Can a professional whose practice is dependent on patients coming via insurance companies survive if he or she were to suddenly convert to a direct pay model?
As to ethicality of direct pay, on one hand we took an oath to help and not harm patients. On the other hand, overhead expenses in medical offices is extremely high and rising. In our practice, if patients don't have insurance and cannot afford our services, we have opted to either not charge anything or reduce our fees so as to make it affordable for the patient. As to whether our practice or any other podiatric practice could survive a sudden complete change to "direct pay" is questionable. Advising people to take that risk is problematic and might even border on being unethical.
Lastly, debates on this forum are important and often highly educational. We should keep debates on the topic, respect different points of view, and prevent debates from devolving into ad hominem attacks on any practitioner.
Elliot Udell, DPM, Hicksville, NY
05/03/2024
RESPONSES COMMENTS (NON-CLINICAL)
From: Rod Tomczak, DPM, MD, EdD
In the current debate concerning direct pay for services rendered versus acceptance of insurance and being a provider, two thoughts trouble me greatly from a meta-ethical point of view. I have tried to find a redeeming tone in each of them and have delayed responding to ensure I am not just shooting from the hip. The implications of these two statements are, to say the least, profound especially for our podiatric students and younger more impressionable readers.
Dr. Roth, who was among the the first podiatrists to switch to a fee-for-service medical reimbursement system claims that it works for him because he provides the best care possible to his pay for service patients. In order to be successful, he must provide...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
05/01/2024
RESPONSES COMMENTS (NON-CLINICAL)
From: Allen M. Jacobs, DPM
"Profit first decision making" in medicine has nothing to do with direct pay medical practice. Many plastic surgeons, dentists, veterinarians, and concierge practices are but a few examples of those who engage in direct pay medical practice. Dr. Kornfeld has presented reasonable and cogent arguments to endorse the direct pay model of practice. There is no more greed inherent to the direct pay model than exists in the traditional billing of third parties for medical care rendered. Your misinterpretation of the commentary which I made on this subject is the suggestion of a need for you to re-examine your own motivation for the practice of podiatry. The concept of avarice appeared in your mind, not mine. Dr. Kornfeld's thoughts and philosophy on direct pay are well taken and acknowledged as such.
Regardless of the payment model, ethical behavior and unethical behavior are what they are. Unnecessary surgery, the irrational use of...
Editor's note: Dr. Jacobs' extended-length letter can be read here
04/30/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1C
From: Ivar E. Roth, DPM, MPH
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 refers to 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....
Editor's note: Dr. Roth's extended-length letter can be read here.
04/30/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1B
From: Robert Kornfeld, DPM
I wholeheartedly disagree with Dr. Udell's damning assessment of direct-pay practice. It is very easy to sit in a defensive posture when you have absolutely no experience with this kind of practice. But take a look around, Dr. Udell. Doctors are already drowning in quicksand. And that is not going to get better. You cannot come from a place of fear when you know damn well that change is needed.
The reality is that continuing to participate (cooperate) with insurance is economic suicide. Right now there are hundreds of MDs and DOs converting to direct-pay. There are also more DPMs than just me who have converted to direct-pay and are happy and thriving. How do they do it? They give patients a compelling reason to pay them directly. There are many ways this can be accomplished. And there are doctors offering courses to assist in this endeavor to free yourself from the rigors of insurance-dependency or PE employment.
The "too late" mentality is akin to failure mentality. If fear of failure is your main motivation, then you will stay stuck and at the mercy of insurance companies. I see life very differently. When I see something I want, I do what I have to do to get it. To be at the mercy of a third-party or corporate employer whose vested interest is in exploiting your knowledge and expertise for their gain is professional suicide. You have it backward, Dr. Udell. Direct-pay is salvation from a place of fear when you know damn well that change is needed.
Robert Kornfeld, DPM, NY, NY
04/30/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1A
From: Jack Sasiene, DPM
I agree in concept with Dr. Jacobs and respect Dr. Kornfeld’s choices, but you have to look no further than the 4-26 PM News post via Dr. Kesselman to support Dr. Kornfeld’s response as to who is to blame for the average decent doctor trying to make a living. $741 million net income in 3 months! And they are pulling back in 2025 to protect profits! And others will cut benefits (i.e., care of patients or reimbursement to us).
In response to Dr. Udell. It’s never too late to jump off the Titanic…you just need a life raft (a plan). I practiced prior to us becoming contract labor for insurance companies. It was genius in foresight by them ... like giving out free crack, and now we are hooked as well as our patients. I agree that it would take a high percentage of doctors to exit contract labor to turn this around.
Jack Sasiene, DPM, Texas City, TX
04/29/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1C
From: Kenneth Jacoby, DPM
I have read the recent posts by Dr. Jacobs regarding the future of podiatry and agree with him 100%. His conclusions were very well thought out, insightful, and well communicated. As a retired podiatrist who practiced for 37 years, I loved what I did for a living and would not have changed anything. I am also proud to have had the opportunity to practice with my son Cory for 6 years and pleased he took over my practice.
Incidentally, I took over the practice from Roger Hess, DPM who practiced for 50 years who took it over from a DPM who practiced for 12 years, making the practice over 100 years old. What a wonderful profession.
Kenneth Jacoby, DPM (retired)
04/29/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1B
From: Elliot Udell, DPM
Dr. Kornfeld has been a long-time critic of how medicine, including podiatry, dug its graves by getting involved with insurance companies. He is correct. If podiatrists could free themselves from dependence on insurance companies, doctors would be making more money with less hassles. The problem is that telling our entire profession to separate itself from the insurance industry is akin to telling someone drowning in quicksand that he should not have hiked in the woods. It's too late!
Dr. Kornfeld has a special niche practice and may be able to get away with running a cash-only practice because he does not have competition. For most doctors who practice in an increasingly competitive environment, telling patients that they can only be seen if they present "greenbacks" as full payment is akin to telling those doctors to commit economic suicide. Dr. Kornfeld is correct but the medical profession is too late.
Elliot Udell, DPM, Hicksville, NY
04/29/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1A
From: Robert Kornfeld, 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 who 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...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
04/26/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 2
From: Joe Agostinelli, DPM
I have read with interest on the topic “Future of Podiatry“ and have to say I totally agree with Dr. Jacobs. Today, I read Dr. Saxena’s comment on this subject and have to say I am also impressed with what he has to say. His thesis for his post-graduate work and his podcast bring new concepts that I haven’t thought about before, especially on the length of time in obtaining medical degrees and subsequent residency training time. The lack of enough primary care doctors has resulted in many non-physician providers of care such as PAs and nurse practitioners, who by the way, provide comprehensive primary care and offer many services that doctors with more training time do.
In my military career, I can say I had some of the most complete and thorough annual physical examinations by PAs and flight medicine primary care providers. For military retirees, PAs, and nurse practitioners are vital in providing primary care services due to the military readiness and high operational tempos with the various world situations. Readers of this thread need to investigate Dr. Saxena’s podcast/thesis. You may change your present thinking on this subject. We have to be thinking “out of the box” on the subject of the future of podiatry, and this would be a good place to start thinking that way. I applaud Drs. Jacobs and Saxena for addressing this subject so thoughtfully and proactively!
Joe Agostinelli, DPM, Niceville, FL
04/25/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1B
From: Amol Saxena, DPM, MPH
Dr. Jacobs points out a great website Kevin MD and changes needed in U.S. medical education in general. My MPH thesis was on redesign of U.S. medical education which I have posted on my website, and I was asked to do a podcast on Kevin MD on "Bias in Medicine". The cost of U.S. medical school contrasted with primary care salaries is a good reason to consider incentives to take on primary care which only 20% of U.S. MD/DOs choose compared to 50% of foreign doctors. More access to primary care improves many economic metrics including GDP.
Currently, almost 1/3 of U.S. medical schools are "accelerated", either three years of medical school or 6-7 years of both undergrad and medical school. With NPs and PTs now receiving doctorates in seven years, I fear the motivation to shortening MD/DO education may be threatened. The AMA holds the length of their training as one of the reasons for them to be called physicians and surgeons but not others. The book The Social Transformation of American Medicineby Paul Starr gave me huge insight...podiatry was not mentioned once in the 500+ page book.
Amol Saxena, DPM, MPH, Palo Alto, CA
04/25/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1A
From: Allen M. Jacobs, DPM
The commentary of Dr. Kornfeld with regard to the need for profitability in maintaining practice survival is appreciated. He has long represented a particular view on non-insurance based patient care which has been successful for himself and others. Medicine, including podiatry, differs from other "ordinary businesses". The practice of medicine is a calling, with a duty to care for patients as the foundation upon which all other business concerns emanate.
The practice of medicine is based upon the four cornerstones of medical ethics: beneficence, non-maleficence, autonomy, and justice. "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...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
04/24/2024
RESPONSES COMMENTS (NON-CLINICAL) - PART 1C
From: Robert Kornfeld, 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 healthcare motive. They, too, will exploit and abuse their...
Editor's note: Dr. Kornfeld's extended-length letter can be read here.
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