05/20/2024    Steven E Tager, DPM

The Future of Podiatry (Kenneth Meisler, DPM)

Reflecting on numerous comments in this thread, I
offer this as it may be of benefit to those in
need. Altruistic as it may be, at least for me, the
desire to help others along with a little prestige
(at the time) may have been the prime motivation
for entering medicine. That, along with my own foot
and back issues led me to a podiatrist who
absolutely motivated me to pursue a career in
podiatry. Podiatry, allopathic medicine, dentistry
or whatever, all have experienced the tyranny of
the insurance industry. Strength in numbers (and I
mean $$) by the carriers have manipulated us
(collectively all medicine and dentistry) as well
as our patients, into the current system using
everything and anyone possible to accomplish
increased profits. Their greed and unbridled
aggression for the almighty dollar has squeezed the
life out of our collective private practices.

Recently retired, I reflect on my 56-year journey
in podiatry. Successful? Yes, I certainly think so.
How and Why? Early in my career, I met two
physicians who had a profound effect on my life.
The first was Merton Root, DPM who educated me as
to the how and why of multiple foot problems.
Slowly, and I mean very slowly, I came to realize
that common conditions we treat, if caught in time,
can be markedly improved and often reversed if the
foot is held in anatomic neutral or as close to it
as possible. The body, with its own ability to
heal, now takes over with the optimum ability to
function as close to normal or near normal as
possible thereby reversing the prime etiology of
many presenting signs and symptoms. Perhaps this is
the explanation for some of the bunion deformities
returning post op and some not so much even after
considerable consideration was given to the
appropriate procedure.

The second physician I met was in a book entitled
Psycho-Cybernetics by Maxwell Maltz. MD. My take
home message from this book was “you are who you
think you are” and if you can project your ultimate
image, start acting and looking like that image
ASAP. Those two messages became a learned behavior
and made me what I am today….ie happy and
successful in my own mind.

Starting my private practice career in RI I found
it unimaginable that 90+ percent of the population
was covered by BCBS. Only two plans were available.
A & B and both paid very poorly compared to other
states based on visiting other pods in both New
England and others practicing in other parts of the
country. After 16 successful years in RI, we left
for Silicon Valley. Maybe a mid-life crisis? Who
knows, but in California the reimbursement for
services were commensurate with my skills, or so I
thought. Starting over was a bit unnerving but
nevertheless accomplished since failure was not an
option. It soon became apparent that reimbursement
for our services by a variety of carriers was going
the way of Medicare instituted a few years back.
Slowly the insurance industry took hold paying just
over, and in many cases, just under Medicare
allowances. Got Ya! The end in sight. And then came
the PPOs, HMOs, capitation and you know the rest.

Fed up with insurance companies determining my
worth, I sold my practice to a highly qualified
employee, capitalized on the real estate boom, and
moved to a seaside community on the Monterey Bay.
The absolute frustration of declining reimbursement
by insurance carriers for services rendered in the
face of inflation and the lack of appropriate cost
of living increases made absolutely no sense to me
and the private practice model currently in use.

Circumstances as they were, gave me an opportunity
to join a practice as a consultant. This ultimately
led to returning to private practice. BUT this
time, no longer would I accept payment from any
insurance company!! Given the success of my
biomechanical expertise (Thank you very much Dr.
Root) I no longer chose surgery as an option and
would refer out those cases in need. I was stunned
and amazed that limiting my practice to lower
extremity biomechanics, general podiatry and minor
office surgery as needed based on a fee for service
platform was an eye opening experience. Patients
were informed prior to their initial visit that
this was a fee-for-service practice and no longer
accepted any insurance. Sure, there were those that
went elsewhere because of insurance coverage and
that was fine. Patients with conditions clearly not
within the scope of my new practice were referred
to others prn.

Interestingly, I noted that patients who paid for
services at the time they were incurred were far
more appreciative than many of those in my prior
insurance-based model. Because of my biomechanical
education, I found my NICHE. Helping to keep the
foot function around what I believed to be anatomic
neutral appeared to not only help the foot but
helped a variety of other concomitant LE
complaints. Successful conservative management of
the foot soon led to helping those with knee, hip
and back problems. The word spread and I soon began
to enjoy success in podiatry without insurance
constraints.

In summary, having experienced the transition from
both the insurance based private practice model and
the non-acceptance of all insurance, I can say for
certain that finding one’s niche and excelling at
it has value to both the practitioner as well as
the patient. Sure, it’s not for all. Lifestyles
differ, and we all accept that just like our
individual practice styles differ along with our
own subspecialties within podiatry. Criticizing the
manner in which others practice (as noted in this
format) does no good at all. If the shoe fits, wear
it. If not, go elsewhere.

Keep in mind, we ALL offer “foot care” which is
exactly what every insurance dependent practice
offers. For me, that translated into offering
something special and different that set me apart
from others in my area. My style of practice now
achieved after all these years (thank you Dr.
Maltz) in combination with my post-doctoral
biomechanics education (thank you Dr. Root) I had
the tools to continue practicing podiatry my way.
My objective was simply to educate my patients to
the best of my ability as to cause and effect and
then provide treatment options and alternatives
when appropriate. With positive realistic outcomes,
success in private practice was again soon
realized.

An Afterthought: Salmon swimming upstream don’t
make it. Fighting amongst ourselves is
counterproductive. We continue the salmon approach
and fight the upstream establishment. It’s time for
podiatry to merge with medicine and its individual
specialties. Fight back and take control of our
future. No longer should we allow insurance
carriers to dictate medical care of our patients.
Do we not know what’s in the best interest of our
patients? Should we not rely on our years of
training? Have we totally allowed the abdication of
decision making to corporate America? Look where we
are today.

Are we better off? Private practice and personal
one on one care has all but gone. Personally, I
believe the APMA has failed us. Their job, from my
perspective, is to educate the public, inform and
educate. In my tenure, It has never happened.
Therefore, the merger of podiatry into mainstream
medicine is essential. Podiatry will NOT be lost.
Has Ob/Gyn, dermatology, proctology, urology
orthopedics, psychiatry neurosurgery been lost with
an MD degree? Oddly, they all have MD after their
names followed by their unique specialties. WHY NOT
AN MD degree followed by whatever podiatric
specialty of choice?

I now rest my case with the hope that my journey
characterized in this thread will be of some
positive value to others.

Steven E Tager, DPM (retired), Scottsdale, AZ

Other messages in this thread:

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05/16/2024    Robert Kornfeld, DPM

The Future of Podiatry (Kenneth Meisler, 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
fee reduction and claim denials. You will still
receive chart requests, periodic audits and in many
cases, demands for refunds from insurance
companies. You will still have your services
devalued by the system. You will continue to deal
with prior authorizations and high accounts
receivable. None of that changes.

However, I strongly disagree with Dr. Meisler that
a limited number of podiatrists can succeed in this
payment model. That is a statement that comes from
a lack of information and knowledge about the way
this works. If all you offer in your practice is
exactly what every insurance-dependent practice
offers, you will have a very hard time succeeding.
It is not about a reputation as an excellent
"provider". You are not "providers'.

That's what insurance companies call you so they
can eventually replace you with non-doctor health
professionals who will work for less than you do.
You are doctors. It is about establishing a
reputation as a doctor who can offer everything
that insurance-dependent doctors offer, but also
possesses expertise in a niche that can make a
difference in the lives of those who have not been
helped by conventional approaches. I find it
disturbing that so many podiatrists dismiss direct-
pay and effectively close down a potent way to get
out of the horrors of insurance or corporate
employment.

I have spent many years seeing 8-10 patients daily
and made much more than I did seeing 50-60
insurance patients and burning out in the process.
If you allow fear to rule your decisions, you will
forever be a slave to the system. It's a choice.

Robert Kornfeld, DPM, NY, NY