12/18/2025    Allen M. Jacobs, DPM

-25 Modifier and RFC (Ivar Roth, DPM, MPH)

The "direct pay" or "concierge" practice models
are certainly an option for a select number of
podiatric healthcare providers whose patients have
the capability of paying for health care directly.
Unfortunately, the majority of Americans cannot
afford the "direct pay" model of healthcare..

I would remind Dr. Roth and others who advocate
the direct pay model that many of our patients
struggle just to pay for their cardiac or diabetic
or cancer or other needed medications or
therapies. We have an increasingly large
geriatric population (that is correct before you
say it people such as myself) who are on a fixed
income and struggles to maintain a date to the
existence for basic food and housing. Yes there
is a subpopulation of well-heeled individuals who
can afford to pay directly for medical care, and
there is certainly nothing on ethical or illegal
to care for such patients and received direct pay.
However, what do we do for the majority of
individuals in this country? The direct payment
philosophy exhibits a prejudicial judicial
exclusion of those are underinsured, uninsured, or
simply cannot afford the direct a model. In some
respects, the direct pay practice is self-centered
and selfish benefiting the doctor and ignoring the
needs of the majority of patients who cannot
afford podiatric services which are frequently
neither urgent nor required for survival, as are
for example, oncologic or cardiac or internal
medicine services.

Sir William Ostler stated over 100 years ago "you
have entered this profession to make a living, but
at all times this must be secondary concern". The
question one musk ask is for what reason did you
enter medicine? PM readers understand the
economic realities of practice survival. However,
as noted by Sir William Osler, once money and the
acquisition of well become a priority we have lost
the true spitrit for which you entered medicine.
Personally, I was always a science bug, and spent
much of my youth at the Franklin Institute in
Philadelphia in the study of science. I wanted to
be the Doc in Gunsmoke, a regular guy respected
for scientific knowledge and service. And hanging
at the Miss Kitty's tavern for the occasional
beer.

The direct pay model is simply not practical for
the majority of podiatric health care providers.
The "simple answer" Dr. Roth is to change the
ridiculous regulatory burden associated with the
provision of medical care. The answer is to stop
treating health care providers like convicted
criminal being supervised on probation. The simple
answer is to practice in an ethical and efficient
manner to make medical care less expensive. The
simple answer is a patient first profit second
philosophy of practice.

The overwhelming majority of our patients employ
third party carriers for medical service payment.
That is and will be a continued reality. If every
podiatrist were direct pay, that would likely be
financially advantageous for the individual
practitioners. However, it is certain that such a
world would restrict the number of patients
receiving podiatric foot and ankle care,
compelling the overwhelming number of patients
needing or wanting such care to go to other health
care providers.

You proposed not too long ago that podiatrists be
allowed to implant spinal cord stimulators. Would
you charge cash for that service? I suppose you
deserve cash payment for the 100% proprietary
onychomycosis cure you suggest to have available
for your patients. I suppose I would as you
consider demanding direct payment for this toenail
miracle. You have claimed to have a proprietary
cure for arthritis and musculoskeletal pain, a
series of injections I believe called PainCur.
Again, if I were the holder and provider of such
benefits for my patients I might consider a pay
for service model. However, I do not have the
advanced capabilities that you maintain, and
therefore neither my patients nor myself can
benefit from these and other advanced modalities,
and as a result I am mired in the traditional
model of healthcare provision.

The majority of podiatrists cannot and do not have
the capability of the direct pay model. It is like
a Porche, nice if you can drive one. The majority
of podiatrists are honest and ethical and well-
meaning health care providers, driven by a spirit
of providing services to those in need of such
services. There is nothing "wrong" with direct
pay. It is an option for a few, but disregards the
needs on "the many".

Regulatory burden is the problem. The demand for
excessive documentation and pre-certifications is
the problem. Decreased payment for provided
services is the problem. The everything is fraud
and abuse philosophy Medicare follows is the
problem.

Excluding the majority of patients from health
care access with a direct pay model is, is my
opinion, not the answer for the public, although
it is an answer for the doctors wallet. Most of us
must deal with the reality of serving an
increasing population in need of our services. You
and others are to be congratulated for a
successful direst pay practice. However, I do not
believe this will serve the majority of those in
practice and would result in decreased
availability of podiatric care to a large swath of
our population, particularly those with
socioeconomic issues limiting their ability to pay
directly for healthcare.

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

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