05/10/2024    Richard M. Maleski, DPM, RPh

RE: The Future of Podiatry (Elliot Udell, DPM)

The recent thread in this forum on the future of
podiatry has been extremely interesting and
thought-provoking, with the most recent emphasis on
the pros and cons of direct pay versus the more
typical insurance dominated practice model. Let's
not lose our historical perspective on this. Back
in the 1960s, with the advent of Medicare,
everything in health care changed. Prior to that
virtually all practices were direct pay, and the
only insurance coverage was Major Medical,
sometimes referred to simply as "hospitalization."
When Medicare came around, our profession clamored
to be included.

There are colorful stories of the behind closed
doors antics that went on inside politicians'
offices to assure that podiatric services would be
covered. Since then, any time there has been a
change, such as the emergence of managed care, we,
along with every other medical group has done
everything possible to keep ourselves included.
And by being included in this payment model, we
have been able to expand our status within the
medical community at large.

At this point in time, we are arguably, the pre-
eminent provider of diabetic foot care, including
major surgical interventions and wound care of the
lower extremity. My own practice followed that
trajectory, and I dare say that I would not have
had the opportunity to treat those patients if I
was not on their insurance plan. I believe our
entire profession has followed that same path. By
treating these patients effectively, we have shown
to the medical community that we are truly a
necessary cog in the healthcare machinery.

As with everything, there are changes in medicine,
some good and some bad, and we must constantly re-
evaluate our own personal positions as well as the
position of our profession. Maybe that includes
more emphasis on a direct pay model or maybe it
doesn't, but regardless we need to keep a long-term
perspective of the past to properly evaluate where
we go in the future.

Richard M. Maleski, DPM, RPh, Pittsburgh, PA

Other messages in this thread:

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05/08/2024    Allen M. Jacobs, DPM

RE: The Future of Podiatry (Elliot Udell, 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 increasing 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 large copays. 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 health care model is not foreign to
your practice.

Dr. Udell questions the ethics and morality of
direct pay (and by implication I would assume
concierge medicine or boutique style medicine). The
AMA, the American Academy of Family Physicians, the
Institute of Clinical Bioethics, and many others
have carefully examined the provision of direct pay
and concierge medicine. All have issued policy
statements on this matter. They have all concluded
that direct pay models are NOT inherently
unethical. The principle of patient autonomy is not
violated by direct pay, so long as the patient
understands that services which are covered by
traditional insurance are also available to that
patient, and that the patient understands this and
willingly without undue coercion elects the direct
pay model.

As for beneficence and non-maleficience, the direct
pay model to not relieve the provider of the
obligation to provide standard of care diagnostic
and theraputic services. If anything, the relevant
studies demonstrate that patients receiving direct
pay care do indeed obtaining better care, as treat
patient receives more time with the health care
provider, and are likley to have greater counseling
and preventive care. In the traditional insurance
based model, you may now bill for time and medical
complexity and decision, making, which may help you
to provide some of the benefits of direct pay care.
With direct medicine you are providing better care,
not necessarily better medicine.

Dr. Udell to his great credit provides free or
reduced fee services to under-insured patients. The
direct pay model does not prohibit a practitioner
from doing the same. In fact, in some circumstances
this may be to the advantage of patient and
provider. For example, there is regulatory fiat
which prohibits you from waiving co-payments or
deductibles or lowering fees in Medicare patients.
You can do so with direct pay without violation of
any law.

The most challenging arguments against direct pay
lie in the ethical principle of justice. Does this
create a two-tiered medical care system, i.e.-those
who can and cannot afford to pay. What do you
already do now with patients who cannot pay for
uncovered services such as laser or orthotic
management? What do you do now with uninsured or
underinsured patients in need of your care? What do
you do now when the patient cannot afford to pay
for a product you which to dispense?

With regard to the healthcare provider, every
available study demonstrates the high rate of burn-
out and frustration among doctors. Doctors and
patients both are not satisfied with rushed
appointments. How often to you regret not having
the ability to spend more time with a patient? How
often do you desire to provide additional services
which are uncovered but which you believe would
benefit a patient? How many diagnostic errors occur
because of rushing through a schedule of patients
on any given day?

In summary, the suggestions by Dr. Kornfeld that a
direct pay model provides benefits to both
podiatrist and patient are well supported in
studies examining this question. That is a fact.

Allen M. Jacobs, DPM, St. Louis, MO