03/17/2026    Ed Davis, DPM

Why have podiatrists’ surgical fees decreased over the past 10 years? (Sev Hrywnak, DPM)

Drs. Hwrynak and Graziano discuss the decrease in
third-party fees paid to podiatrists. It is
important to consider that we engage in contracts
of adhesion when contracting with big insurance
companies that leave little room for negotiations
and even less room for negotiations.

“An adhesion contract exists if the parties are of
such disproportionate bargaining power that the
party of weaker bargaining strength could not have
negotiated for variations in the terms of the
adhesion contract. Adhesion contracts are
generally in the form of a standardized contract
form that is entirely prepared and offered by the
party of superior bargaining strength to consumers
of goods and services. Adhesion contracts are
commonly used for matters involving insurance,
leases, deeds, mortgages, automobile purchases,
and other forms of consumer credit.

Because adhesion contracts do not afford consumers
a realistic opportunity to bargain, the consumers
are often faced with adhesion contracts on a take-
it-or-leave-it basis. Under such conditions, the
consumer has little to no ability to negotiate
more favorable terms. Instead, consumers cannot
obtain the desired product or service except by
acquiescing in the form contract. “ (Cornell Law
School, Legal Information Institute)

”Current antitrust enforcement policy unduly
restricts physician collaboration, especially
among small physician practices. Among other
matters, current enforcement policy has hindered
the ability of physicians to implement efficient
healthcare delivery innovations, such as the
acquisition and implementation of health
information technology (HIT). Furthermore, the
Federal Trade Commission and Department of Justice
have unevenly enforced the antitrust laws, thereby
fostering an increasingly severe imbalance in the
healthcare market in which dominant health
insurers enjoy the benefit of largely unfettered
consolidation at the cost of both consumers and
providers.”

Clin Orthop Relat Res . 2009 Sep 12;467(11):3017–
3028. doi: 10.1007/s11999-009-1006-4
Physician Collective Bargaining Anthony Hunter
Schiff 1,2,3, PMCID: PMC2758953 PMID: 19756908
https://pmc.ncbi.nlm.nih.gov/articles/PMC2758953/

Physician insurance contracting involves providers
being offered contracts in which they cannot
negotiate the terms nor the fees to any reasonable
extent. So this is not an example of our fees
being due to market forces. There is no free
market in effect in this situation. It is not a
matter of us “agreeing” to work for lower fees.

Large health insurance companies control the
healthcare market in that they set fees, set
policies, direct patients to certain practitioners
or practitioner groups, determine which services
they are going to cover without regard to the
standard of care. Medicare also acts in a similar
fashion with respect to fee control and
restrictions placed on practitioners to act within
the standards of care. Medicare Advantage plans
go further with respect to such restrictions.

Hospitals may require healthcare providers to be
on certain insurance plans at times and generally
require Medicare participation.

While third-parties have the upper hand with
respect to fees, it is incumbent on healthcare
providers to set the standard of care. No
antitrust policies exist to restrict our ability
to do so! There has been a complete failure of
healthcare professional organizations to step up
to the plate and set such standards. If we had
such standards published then we create a
reference and standard with which to fight
insurance company denials.

If every doctor in America would withdraw from all
third-party contracts tomorrow, the power of the
big health insurance companies would disappear.
Loss of autonomy occurred gradually over decades
due to us signing bad insurance contracts. Of
course, the chance of a mass doctor walk away from
third-party insurance contracts is unlikely to
happen and may be viewed as collusion depending on
how such an action is coordinated. Something to
think about though.

Ed Davis, DPM, San Antonio, TX

There are no more messages in this thread.