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05/15/2024    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Ivar Roth, DPM, MPH


 


After reading Dr. Kornfeld’s response, I can again add some context to why my income dropped for such a long time. As a rare third-year residency-trained podiatrist back when I went full direct pay, my practice was mostly surgical. When patients called, they were not ready to pay out-of-pocket for surgery, and so my income took a major hit. The good thing was I had saved up for this transition. I agree with Dr. Kornfeld that the transition, if properly planned, can be shorter but as the original direct pay podiatrist, I had no guidance on how to make the transition. 


 


I do remember calling Dr. Kornfeld and asking him how he was doing, and I remember that he was off private insurance companies but still taking Medicare, so that may be a way to transition; but I had decided to go for it and delisted/ opted out from Medicare completely. I still maintain that this type of practice is only cut out for those relatively few podiatrists who have the full spectrum of skills required to go direct pay and have the full love of our profession at heart. This type of practice requires diligence and hard work above and beyond the typical practice.


  


Ivar E. Roth DPM, MPH, Newport Beach, CA

Other messages in this thread:


05/17/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: Is the Limited License of Podiatric Physicians Costing the Healthcare System More Money?


From: Bret Ribotsky, DPM


 


I had an opportunity this week to attend a pharmaceutical-sponsored county podiatric meeting here in South Florida, and the speaker was from out of state, a well known expert, discussing wound care grafts to apply. The lecture showed multiple pictures of completely or almost completely granulated wound beds to which they were applying a placenta graft tissue weekly at $2,500 per application, up to a total of $25,000 per application. When I queried why not just put a split-thickness skin graft over this wound, I learned that it was not within the podiatric license in the state in which this person practiced.


 


This got me thinking, is our limited license actually costing the system more money because of the inability to apply all the best medical practices by limitations of licensing? I know that while I practiced, I often would apply a split-thickness skin graft on a fully granulated wound bed. I was quite happy with then using additional products as needed, if necessary, What do others think about using these expensive grafts where the company makes all the money and the doctors do not?


 


Bret Ribotsky, DPM, Fort Lauderdale, FL

05/17/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Robert Kornfeld, DPM


 


Since this thread is still going, I would like to bring up a really important point that Dr. Meisler glossed over. Patients coming from these concierge practices were willing to pay directly when they came and were "surprised that they did not have to pay at the time of their visit." That should tell you something about the value they are experiencing in a direct-pay practice. That's number one.


 


Number 2, I agree with Dr. Meisler that eliminating poor payors will always make room for more value in the practice. However, it is important to note that as long as you continue to accept insurance, you will always be fighting an uphill battle. You will need to see a high volume of patients which means a large office, large staff, and high expenses. You will still have to navigate the slippery slope of...


 


Editor's note: Dr. Kornfeld's extended-length letter can be read here.

05/16/2024    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Kenneth Meisler, DPM


 


I practice in Manhattan. It is very difficult to find an experienced internist/primary care doctor that has not gone "concierge". Most charge thousands of dollars a year to be a patient in their concierge practice. I am referred many patients by these concierge doctors and when their patients come in, I accept their insurance. They are surprised they do not have to pay at the time of their visit. Almost all of the doctors that have made the switch are doctors with established practices, not newer practitioners. However, I think there is a limited number of podiatrists that will be able to have a practice that does not accept insurance. I think it will be very difficult until you have developed a reputation as an excellent provider among many physicians and patients.


 


Rather than not participating in any insurance plans, our office has stopped taking many of the lower paying insurances such as Medicare Advantage plans and other low paying insurances. At first, I wondered whether we would still be able to fill all of the doctors’ days after reducing the number of insurances we participate with. However, in a very short time (less than a few months), all of our doctors are booked. It was a decision I wish I had done years ago. I realize now that these patients with lower paying plans were filling up a good portion of our days, and other patients that wanted to be seen were not always able to get in as quickly as they would have liked. Frequently new patients and existing patients who have insurances that we no longer accept are willing to pay us directly.


 


I suggest for those podiatrists not ready to commit to no longer accepting insurances that you slowly stop taking the lowest paying insurances one at a time.  


 


Kenneth Meisler, DPM, NY, NY

05/13/2024    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Robert Kornfeld, DPM


 


While I am in full agreement with Dr. Roth about the joys of direct-pay, I completely disagree with his assessment that only 5-10% of podiatrists are cut out to be direct-pay practitioners. My experience was that I had only one year where my income dropped and that is because I dropped out of everything all at once. It rebounded in year 2, but that is NOT the way to create a successful direct-pay practice. I do agree you need to provide services that are unique so that you eliminate the competition from insurance-dependent practices. But any podiatrist who desires to can create a successful direct-pay practice by first getting expertise in a niche. Then, drop your lowest payors and start seeing your niche patients for direct-pay.


 


As you build your brand and are consistent with marketing, they will come. And you will be surprised at the number of phone calls you will get asking what you do... 


 


Editor's note: Dr. Kornfeld's extended-length letter can be read here.

05/10/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Richard M. Maleski, DPM, RPh


 


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 healthcare 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 have done everything possible to keep ourselves included. And by being included in this payment model, we have been able to expand our status within...


 


Editor's note: Dr. Maleski's extended-letter can be read here.

05/07/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From:  Kathleen Neuhoff, DPM


 



It is unfortunate that local providers turfed their patients to Dr. Tomczak. However, in our area, this kind of turfing is rampant among those who accept insurance. Most of our local Latino population does not have insurance and many providers will not see them at all. 


 


Ironically, when I accepted insurance, I was taken to task by the administration of our local hospital because I gave a significant discount to all religious leaders (rabbis, priests, ministers, nuns, etc.). I was advised that I was in violation of the contracts with my insurance carriers and had to “cease and desist”. Now that I have no contacts with insurance companies, I have restored these discounts. I also see large numbers of patients who have no insurance and am able to provide care for them at a cost they can afford. 


 


Some of these patients are very sad. For example, Wednesday I saw a gentleman who had had an ingrown nail for months. He had been unable to find anyone to treat him until the local” free” clinic sent him to me. He is an uncontrolled diabetic and had osteomyelitis of the entire distal and part of the proximal phalanx. I had him admitted to the hospital which will end up eating the cost, and I will probably need to amputate at least his hallux. We have failed this patient at a huge cost to him and to our healthcare system. I do not think this is an issue of self-pay vs. insurance providers. It is a loss of the patient care mentality which should guide all of us.


 


Kathleen Neuhoff, DPM, South Bend, IN


05/07/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Greg Amarantos, DPM


 


I find it interesting how a post can be interpreted from a different lens and diametrically opposing conclusions are reached. In reading Dr. Tomczak's response to Dr. Roth, I read Dr. Roth's post differently.


 


While we should believe we are providing the best possible care, we have to face the facts; in private practice, our treatment protocols are at least partially driven by the insurance company policies. I do not read any impugning of the profession. Dr. Roth should believe he is providing the best care, as should you and I. Cash frees the practitioner from the shackles of the insurance company policies. Think of the man hours used on "meaningless use/MIPS" and the like. Dr. Roth reminds me that medicine made a deal with the devil years ago and...


 


Editor's note: Dr. Amarantos' extended-length letter can be read here.

04/23/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: The Future of Podiatry - Part 2


From: Allen M. Jacobs, DPM


 


As we move forward (I should say you, as I'm on the 18th green and putting out), there must be a realistic examination of the future of medicine. As corporations and healthcare institutions continue to take over medical care, and insurers evaluate our care, the bottom line is cost-effectiveness. This is a major reason why NPs and PAs are replacing MDs and DOs as independent healthcare providers. This is a driving force for pharmacists beginning to provide healthcare. It is a driving force for urgent care centers replacing emergency departments, surgical centers providing services; we can site example after example.


 


Ultimately, insurance carriers want the least expensive medicine provided, whether it be testing, office fees, drug choice, or procedure selection. Industry, such as corporate-driven medicine, to the contrary, wants you for profit. You are evaluated by industry first and foremost by the profit you generate. The conflict between industry and...


 


Editor's note: Dr. Jacobs' extended-length letter can be read here. 

04/23/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: The Future of Podiatry


From: Allen M. Jacobs, DPM


 


A recent article published in KevinMD.com, written by a St. Louis plastic surgeon, Dr. Samer Cabbabe, caught my attention. I suggest that his discussion on the corporatization of medicine is thought-provoking. Many of his conclusions are, in my opinion, applicable to podiatry. Dr. Cabbabe concludes his article with certain recommendations for the future of quality medical care. I will paraphrase some of these with podiatry relevance and additionally share my personal opinions.


 


1. Curriculum changes are needed to focus on non-clinical aspects of medicine, including insurance, leadership, business, and other political aspects of medical care delivery. Medicine is a business, and practice survival as well as decision-making regarding employment require knowledge and good information. The business of medicine must be taken seriously by the...


 


Editor's note: Dr. Jacobs' extended-length letter can be read here. 

04/18/2024    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Frank Louis Lepore, DPM, MBA


 


I am excited to announce that the American Board of Multiple Specialties in Podiatry (ABMSP) has taken a significant step towards promoting unification within the profession. Earlier this month, ABMSP proudly submitted its "Roadmap for Board Unification" to the American Podiatric Medical Association (APMA). This roadmap outlines a strategic framework aimed at fostering cohesion and collaboration within the podiatric community. ABMSP recognizes the importance of unity in advancing the profession and ensuring the highest standards of care for patients.


 


Through this submission, ABMSP reaffirms its commitment to working closely with APMA and other stakeholders to streamline board processes, enhance professional development opportunities, and, ultimately, elevate the field of podiatry.


 


Frank Louis Lepore, DPM, MBA, President, American Board of Multiple Specialties in Podiatry

04/16/2024    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Paul Kesselman, DPM


 


This posting needs a significant amount of clarification. First off, Salus University took over the operation of the Pennsylvania College of Optometry, and it now operates under a much larger organization which provides degrees in multiple healthcare affiliated fields. This is no different than most if not all podiatric colleges and even many medical and osteopathic schools, which are also part of large university stems.


 


Second, the orthotics and prosthetics field represented by the American Orthotics and Prosthetic Association (AOPA) has been a super ally to APMA. As the de facto liaison between these organizations, I am happy to report our leaderships have developed mutual respect for one another and we have much to learn from each other. We have supported each other's initiatives with Medicare and in the halls of....


 


Editor's note: Dr. Kesselman's extended-length letter can be read here.

04/12/2024    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Greg Caringi, DPM


 


Salus University, the former Pennsylvania College of Optometry, now has a certified Orthotics & Prosthetics program. Has our profession completely abandoned a science and a skill that distinguished us from other health providers?


 


Greg Caringi, DPM, North Wales, PA

04/11/2024    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Sarah B Clark, MS


 


I have been using Freshbooks for nearly 5 years and have been very pleased with it. They have an extension for check writing that integrates seamlessly, as well as payroll options. There are a variety of plan levels depending on needs and budget. It is web-based and there is an app for your phone as well, and all updates are done without extra fees.


 


Sarah B Clark, MS, Charlotte, NC

04/09/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1C



From: Edward S. Orman, DPM


 



I have also used Quick Books for about 30 years. Initially, it was 3-5 years before I had to get a new version. Over the years, the price more than doubled. In 2023, I looked into QB online and ended up purchasing that. I thought I was saving money but was lied to multiple times about the cost. It ended up being more expensive. It's a completely different program, which I didn’t like, with a steep learning curve. I eventually went back to QB desktop. These companies are pigs and don’t care about their clients.


 


Edward S. Orman, DPM, Perry Hall, MD


04/09/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Richard Rettig, DPM, Kim Antol


Quicken is a great product, and the most expensive version is $5.50 per month first year, then about $120 per year. Since you are outsourcing payroll (good idea), you never needed Quickbooks in the first place. Unfortunately, you cannot convert your Quickbook files to Quicken. 



Richard Rettig, DPM, Philadelphia, PA 


 


If all you need is a simple program to print checks....Quicken should do the trick for under $100. Not subscribing to online versions and options will save you from annual fees.


 


Kim Antol, President, Sigma Digital X-Ray

04/09/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Jeff Root


 


You might want to consider using Quicken Classic Business and Personal if your accounting needs are fairly basic as you suggest. I believe the annual subscription fee is around $120 and costs about half that for the first year. You can set up custom income and expense categories and run income and expense reports that should satisfy your basic accounting needs. You might even be able to import some of your historical data from Quickbooks but you should check with Quicken or Quickbooks support about that first. I have been using Quicken for my personal accounting needs since the 1980s and used Quickbooks for business purposes for many years. I have been very satisfied with Quicken and they have excellent customer support.


 


Jeff Root, President, KevinRoot Medical

04/02/2024    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Kathleen Neuhoff, DPM


 


I accepted Dr. Tomczak’s challenge and answered all of the questions in Part Two correctly. I think I answered all in Part One correctly also but did not see the answer for one so I am not sure…all others were correct. It does not seem that these questions would be too difficult, especially if students received a board passing course which is pretty standard for most professions requiring passage of an exam for licensure.


 


I am one who is not in favor of an MD degree as I was not in favor of lengthening the podiatry curriculum or requiring everyone to do a surgical residency. I believe these things are eliminating the skills which made us unique and channeling our potential students into PA schools. However, I think it is a disservice to our students and schools to say that the inability to pass the test is the reason not to proceed.


 


Kathleen Neuhoff, DPM, South Bend, IN

03/29/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Podiatrists and the USMLE


From: Rod Tomczak, DPM, MD, EdD


 


I have recently heard from several DPMs that because we teach essentially the same curriculum as the MDs, “I’d bring Steps 1 and 2 USMLE to their knees.” It’s not what is taught in the podiatry schools that concerns me, it’s what is not taught that scares me.


 


In case anyone would like to explore what is not taught in the podiatry schools, I invite any podiatrist who figures we are just a month’s rotation in obstetrics/gynecology and a month’s rotation in psychiatry from an MD degree to explore the samples of USMLE Steps 1 and 2 which are posted at: Here and Here


 


I think anyone who passes the two sample exams, can take a black Sharpie and cross out the word "Podiatric" in Doctor of Podiatric Medicine and become Doctor of Medicine.


 


Rod Tomczak, DPM, MD, EdD, Columbus, OH

03/29/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1B



From: Ivar E. Roth, DPM, MPH


 



As I have mentioned before, I agonized for quite a while if I should charge a credit card fee. I have been doing so for the last 6 months with very little opposition.


 


For the few patients who complain, I usually just waive the fee to make them happy. In the end, I am saving tens of thousands of dollars per year which is a nice bonus.


  


Ivar E. Roth, DPM, MPH, Newport Beach, CA


03/29/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1A



From: Connie Lee Bills, DPM


 


We started this about a month ago. Patients are more likely to pay cash or check when faced with a 3.5% fee. My optometrist started it about two months ago and spurred me to follow suit. 


 


I checked with the local credit union and they said HSA cards can be used for the fees as long as they are from a healthcare registered facility. Everyone should be doing this.


 


Connie Lee Bills, DPM, Mount Pleasant, MI

03/28/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 1


RE: The Value of Podiatric Biomechanics


From: Jeffrey Trantalis, DPM


 


As podiatrists, we appreciate the skills involved in providing non-surgical options. For example, a large majority of my patients were Boeing workers who stood hours on their feet.  A majority were treated with conservative care using biomechanics, an area which most podiatrists understand and appreciate. We are able to treat symptoms from the foot to the lower back. I worked for a back surgeon, and after a year he fired me because I was helping his patients that he wanted to do surgery on. This said a lot about the benefits of biomechanics. The sad and unfortunate consequence is these patients will not likely walk into your office.  


 


While a student at ICPM, I personally benefited after being diagnosed with a pelvic rotation and a relative limb-length difference. This allowed me (with lift and orthotic therapy) to successfully be able to run 4-5 miles a day to improve my health. As podiatrists, we are more than just surgeons. We provide a lower extremity alternative. Another area is young women with femoral anteversion. Many women would otherwise have to undergo surgery, but with orthotics can lead a very athletic and productive life. The difficulty for podiatrists is that a lower back patient is less likely to walk into your office. That is the proverbial $64,000 question. I feel that as podiatrists we can offer much more to our patients. 


 


Jeffrey Trantalis, DPM, Delray Beach, FL

03/19/2024    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Elliot Udell, DPM


 


Dr. Gurnick's concerns about cases of poor foot care patients receive when they go to urgent care centers, and often at emergency rooms, is unfortunately correct. My own internist once lamented to me about the poor level of care patients with general medical conditions get at urgent care centers. We do, however, need to separate hospital emergency rooms from "street-corner" urgent care centers. If the hospital is large, one would expect access to numerous doctors in different fields including podiatry. The problem with hospital ERs is that there is often a long wait before being seen by a physician or even a triage nurse.  


 


My personal experience with taking my ailing parents to emergency medical facilities is that urgent care clinics tend to be run by PAs and nurse practitioners. These medical professionals while good at triage and some treatments, cannot be expected to be experts in all facets of medicine and surgery. Hence they sometimes make mistakes or ideally will tell the patient to go to the local hospital if the condition looks serious. This is a problem that Dr. Gurnick cites from the perspective of being a doctor. Unfortunately, we will all have to deal with this problem at some stage when we or our family members become the patients. 


 


Elliot Udell, DPM, Hicksville, NY 

03/18/2024    

RESPONSES/COMMENTS (NON-CLINICAL) -PART 3



From: Rod Tomczak, DPM, MD, EdD


 


I had trigger finger surgery almost thirty years ago on the 5th finger of my non-dominant (left) hand. It was so bad I could no longer get that finger into a glove. The orthopedic hand surgeon performed a tendon lengthening and a V->Y skinplasty that extended into the palm of my hand. I wore a cumbersome plaster splint for a week but I could remove it when I wanted, like showering, but had to be careful I did nothing that would jeopardize the repair. 


 


The surgeon told me to be careful I didn't put the finger in a situation where I could hyperextend it. That was the major warning. So I wore the splint all day except for showering and wore it even while sleeping on the couch, at my wife's insistence. I'm sure there is a lighter splint today. I operated about 2 weeks after the repair. I was surprised how much I used the non-dominant little finger in the OR. The contracture never recurred.


 


Rod Tomczak, DPM, MD, EdD,  Columbus, OH

03/15/2024    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Paul Kesselman DPM


 


While there are not many 80+ year olds in leadership positions in podiatry, there is one here in NY for whom if I did not comment I would simply be ashamed. Dr. Arthur Gudeon has been a shining light in this profession here in NY for more than 60 years. He is 89 and shows no signs of slowing down. There are many podiatric bambinos who Arthur has mentored and yet he still finds time to practice and play tennis a few days a week. If not for Arthur, podiatry would certainly not be where it is today in NYS.


 


Paul Kesselman, DPM, Oceanside, NY

03/15/2024    

RESPONSES/COMMENTS (NON-CLINICAL)



From: Joseph Grillo, DPM, Eric Trattnor, DPM


 


I too had had trigger fingers. These are very painful and annoying. I had injections also to no avail. I was offered PRP injections and surgery. I chose to go for broke. I have my own radial pulse therapy machine in my office that I use for plantar fasciitis. I gave it a shot on my trigger fingers. Don't ask me how-but it worked. 


 


I gave myself repeated pulses every 5 days. It took five or ten treatments but it got rid of them. Do yourself a favor-skip the surgery-find someone in your community who has an Enpuls RPT device and give it a go. It can't hurt to try and can save a lot of headaches and disability for surgery that may or may not work.


 


Joseph Grillo, DPM, Ft. Myers, FL


 


I also had a trigger finger of the 4th finger on my dominant hand. It was easily released by a hand surgeon in the office with a needle, no incision, glue or sutures. The post-op course was virtually painless. It was suggested that I take a week-10 days off, but I returned to a full schedule in about 3-4 days. It’s true, self-employed people heal much faster than others.


 


Eric Trattnor, DPM, Twinsburg, OH
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