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03/25/2026 H. David Gottlieb, DPM
The Best of Times, The Worst of Times (Allen M. Jacobs, DPM)
In all my years as a podiatrist, I do not recall
having, but imagine that I have met Dr. Jacobs,
but I have heard only good things about him. In
his latest post on the future and
standing/prestige of podiatry in today's medical
world, he eloquently stated what I have been
saying: "You are responsible for your own fate and
circumstances."
For my first 20 years, I performed hammertoe,
distal bunion, toenail surgeries. Nail
debridements and lots of the old C&C (corns,
calluses). My patients were thankful for the
relief from pain and the ability to continue their
chosen path. Several tracked me down years later
to express their gratitude. I could see that this
was a pathway to financial reward. Despite what
Dr. Jacobs states, a good living can be made
performing this vital service IF financial success
is all you are after.
When I realized that I was unhappy with my
practice as it was, I tried a few other settings
before making a big break. As Dr. Jacobs
opinioned, I realized that my destiny was only
mine to make. I was able to 'retool' and re-
engaged with the skills, knowledge, and abilities
equal to today's residents entering practice. To
my surprise, I found out that, though I could, I
wasn't interested in 6-axis lower extremity
deformity correction, hindfoot reconstruction, or
limb lengthening surgery. Rather, I enjoyed the
challenge and saved limbs of diabetic and severely
ischemic patients who didn't take care of
themselves.
Luck favors the prepared, as many wiser than I
have said. Today's graduates have the ability to
be prepared. Most podiatrists today have the
ability to be prepared. When you stop the 'woe is
me' and really look around, only then can you
change your situation. I know because I did and so
can you.
Know who is giving you advice. Stay away from
those who have been sanctioned by professional
organizations; as I wish I had checked back in the
day. Although it's much easier to check that today
than it was in 1997. As I have been told more than
once, with the Internet there is no longer any
excuse for being stupid.
H. David Gottlieb, DPM, Baltimore, MD
Other messages in this thread:
03/25/2026 Robert Kornfeld, DPM
The Best of Times, The Worst of Times (Allen M. Jacobs, DPM)
I graduated from NYCPM in 1980 and opened my own
private practice in 1982. And shockingly, there
was no such thing as managed care. We functioned
in an indemnity insurance model. You did your
work. You sent a claim form (handwritten, there
were no ICD 10 or CPT codes). You got paid 80%.
The patient or secondary plans paid 20%.
Bunionectomy with osteotomy back then through
commercial carriers, for example, could reimburse
in the $4-6,000 range.
On 20 patients per day, I ran a financially
successful practice. I was happy. Until I wasn't.
In the early 90s, if you weren't signed up with
managed care, insurance paid much higher out of
network fees. But little by little, they started
drastically reducing those fees and made
reimbursements more and more difficult to obtain.
And I was losing patients to in-network
podiatrists. So I signed up for a lot of plans.
Within 8 years, I was up to 50-60 patients a day.
I went from a staff of one to a staff of 6 and
then 8. Moved to much larger offices. My expenses
were astronomical. And so was the stress. I hated
going to work. By early 2000, I felt like I was
slipping into a second case of burnout. It was
definitely not a sustainable way to make a living.
I quit in 2000 and went to a direct-pay model.
They said it couldn't be done. But I did it and it
was very successful within 2 years.
So when we look at "fixing" podiatry, I believe we
need 2 plans - a long range plan and an immediate
plan.
Some of the challenges we face with the insurance-
dependency model:
1) The inflation gap – while Medicare pay has seen
nominal marginal increases, it has declined by
over 30% in inflation-adjusted dollars since 2001.
2) Staffing costs – MGMA reports that medical
groups are budgeting 4-6% increases in staff pay
for 2026 just to remain competitive far outpacing
the 3% reimbursement bump.
3) Site of service shifts – new 2026 rules
redistribute indirect costs, resulting in a 7%
drop for services performed in facility settings
(hospitals. ASCs), which critics say will drive
further consolidation and kill small practices.
4) Private payor lag – McKinsey (a global
management firm that plays a major role in the
health insurance industry, primarily by advising
payers) notes that private insurers are facing
their own enrollment declines and are likely to
squeeze provider reimbursements to maintain
margins.
Specific to podiatry, recent articles and the 2026
Medicare Physician Fee Schedule (MPFS) final rule
confirm that while there are nominal "wins," the
financial landscape for independent clinics is
becoming significantly more restrictive.
The "worsening" trend is driven by a shift in how
Medicare pays for supplies and a new "efficiency"
philosophy that effectively caps revenue for
established procedures.
Here are a few more issues:
1. The Skin Substitute "Cliff"
Perhaps the most dramatic change in 2026 is the
reclassification of skin substitutes. Previously,
these were often paid based on the Average Sales
Price (ASP), which could be as high as $2,000 per
square inch.
The Flat Rate: As of January 1, 2026, CMS moved to
a flat "incident-to" supply rate of approximately
$127.14 per square cm for most products.
The Impact: This is estimated to reduce total
Medicare spending on these products by nearly 90%.
The "Applied-Only" Rule: New rules state that
Medicare will only pay for the units actually
applied to the patient. Discarded units or
"wastage" are no longer billable, placing the
financial risk of package sizing entirely on the
doctor.
The Shift: Analysts predict this will make it
financially unviable for many office-based
podiatry clinics to offer advanced wound care,
likely driving that patient volume back into
hospital-based settings.
2. The "Efficiency Adjustment" Tax
CMS finalized a new 2.5% "Efficiency Adjustment"
for 2026. This is a conceptual cut based on the
agency's belief that as doctors do a procedure
more often, they become "faster" and therefore
should be paid less for it.
Scope: This applies to most non-time-based
services (including many common podiatric
injections and minor surgeries).
The Squeeze: Because the cost of staff, rent, and
supplies is rising (estimated at 2.7% growth by
the Medicare Economic Index), a 2.5% cut to the
"work" value of a procedure creates a widening gap
between overhead and income.
3. The Facility vs. Office Divide
Starting in 2026, CMS is redistributing "indirect"
practice expenses.
Office-Based "Gain": Podiatrists practicing in
their own offices may see a slight 4% increase in
the Practice Expense (PE) portion of their
reimbursement to account for higher overhead.
Facility-Based "Loss": Conversely, if you perform
procedures in a hospital or ASC, those payments
are expected to drop by roughly 7% because CMS
assumes the facility is now covering more of the
overhead.
A small win:
To provide a full picture, the American Podiatric
Medical Association (APMA) did secure some
targeted increases that prevent 2026 from being a
total net loss in the short term:
Arthrodesis RVUs: Work RVUs for great toe
arthrodesis (CPT 28750 and 28755) were actually
increased for 2026, representing a rare upward
adjustment for surgical work.
MIPS Stability: The performance threshold for MIPS
will remain at 75 points through 2028, avoiding
what could have been a much higher bar for
avoiding penalties.
These buffers won't stand the test of time.
Insurance is a for-profit business and Medicare is
a "for borrow" business as the government has
historically used Medicare taxes to fund other
debts. This won't stop. And with the burgeoning
era of AI, many jobs might disappear and less
Medicare tax will be paid.
The immediate plan should be to wrestle the
controls away from insurance companies. They need
us. We don't need them. We have valuable skills
and expertise. That is marketable. Imagine. Not
needing them to decide your financial fate. So how
do we wrestle the controls away from them? Simple.
Stop participating (cooperating) with them.
Current reporting and industry analysis from early
2026 suggest that the shift toward Direct-Pay
(Cash-Pay) models in podiatry is no longer just a
niche trend but a strategic response to the
"insurance treadmill."
As Medicare and private payers tighten
restrictions—particularly around regenerative
medicine and advanced wound care—more
practitioners are opting out of traditional
reimbursement structures to regain clinical and
financial autonomy.
The public is also fed up with the current model
and the dynamics it imposes. There is a growing
trend in the public toward more holistic
(functional medicine) services, more natural
therapies (regenerative medicine) and are looking
for accessibility and a lot more time from their
doctors. Patients have realized that their
premiums only entitle them to pay thousands more
in deductibles, co-pays and non-covered services
and instead are opting to pay directly for more
personalized care and easy access to their
doctors.
Changing a volume-based model to a value-based
model does wonders to uplevel your reputation as a
physician because with a relaxed environment and
time to spend, your patients feel more connected
and are more compliant resulting in better
outcomes.
The long range plan needs 2 parts, in my opinion.
The first part is for every podiatrist to be well-
versed in functional medicine, since it is the
collision of many epigenetic and genetic factors
that determine the biological terrain of the
patient. And that is what creates the internal
struggles pushing patients across the morbidity
threshold. Instead of suppressing the immune
system or drugging the CNS for relief, we can lift
immune burdens and support a return to immune
efficiency so repair pathways become more
efficient. This would cement our reputation as
physicians since this approach to patient care
uplevels the health of the patient as a side-
benefit of approaching podiatric pathology from a
root cause perspective.
The second part is to seek a plenary license for
podiatrists and combine our training and expertise
with a D.O. degree. Without this, podiatry will
surely hit the same trail as the great northern
white rhinos of Africa. What are we holding on
for? History? Pride? It's time to look at the big
picture and realize as a tiny little non-plenary
specialty in medicine, we won't survive.
I'm 71 now. I've had a stellar career outside the
insurance-dependency model. No one can tell me
that it can't be done or it doesn't work. And if
we continue to foster the belief that podiatry can
stand on its own two feet, without a plenary
license, all I can say is I have a bridge in
Brooklyn I'd like to sell to you.
Robert Kornfeld, DPM, New York, NY
03/25/2026 Robert Kornfeld, DPM
The Best of Times, The Worst of Times (Allen M. Jacobs, DPM)
I graduated from NYCPM in 1980 and opened my own
private practice in 1982. And shockingly, there
was no such thing as managed care. We functioned
in an indemnity insurance model. You did your
work. You sent a claim form (handwritten, there
were no ICD 10 or CPT codes). You got paid 80%.
The patient or secondary plans paid 20%.
Bunionectomy with osteotomy back then through
commercial carriers, for example, could reimburse
in the $4-6,000 range.
On 20 patients per day, I ran a financially
successful practice. I was happy. Until I wasn't.
In the early 90s, if you weren't signed up with
managed care, insurance paid much higher out of
network fees. But little by little, they started
drastically reducing those fees and made
reimbursements more and more difficult to obtain.
And I was losing patients to in-network
podiatrists. So I signed up for a lot of plans.
Within 8 years, I was up to 50-60 patients a day.
I went from a staff of one to a staff of 6 and
then 8. Moved to much larger offices. My expenses
were astronomical. And so was the stress. I hated
going to work. By early 2000, I felt like I was
slipping into a second case of burnout. It was
definitely not a sustainable way to make a living.
I quit in 2000 and went to a direct-pay model.
They said it couldn't be done. But I did it and it
was very successful within 2 years.
So when we look at "fixing" podiatry, I believe we
need 2 plans - a long range plan and an immediate
plan.
Some of the challenges we face with the insurance-
dependency model:
1) The inflation gap – while Medicare pay has seen
nominal marginal increases, it has declined by
over 30% in inflation-adjusted dollars since 2001.
2) Staffing costs – MGMA reports that medical
groups are budgeting 4-6% increases in staff pay
for 2026 just to remain competitive far outpacing
the 3% reimbursement bump.
3) Site of service shifts – new 2026 rules
redistribute indirect costs, resulting in a 7%
drop for services performed in facility settings
(hospitals. ASCs), which critics say will drive
further consolidation and kill small practices.
4) Private payor lag – McKinsey (a global
management firm that plays a major role in the
health insurance industry, primarily by advising
payers) notes that private insurers are facing
their own enrollment declines and are likely to
squeeze provider reimbursements to maintain
margins.
Specific to podiatry, recent articles and the 2026
Medicare Physician Fee Schedule (MPFS) final rule
confirm that while there are nominal "wins," the
financial landscape for independent clinics is
becoming significantly more restrictive.
The "worsening" trend is driven by a shift in how
Medicare pays for supplies and a new "efficiency"
philosophy that effectively caps revenue for
established procedures.
Here are a few more issues:
1. The Skin Substitute "Cliff"
Perhaps the most dramatic change in 2026 is the
reclassification of skin substitutes. Previously,
these were often paid based on the Average Sales
Price (ASP), which could be as high as $2,000 per
square inch.
The Flat Rate: As of January 1, 2026, CMS moved to
a flat "incident-to" supply rate of approximately
$127.14 per square cm for most products.
The Impact: This is estimated to reduce total
Medicare spending on these products by nearly 90%.
The "Applied-Only" Rule: New rules state that
Medicare will only pay for the units actually
applied to the patient. Discarded units or
"wastage" are no longer billable, placing the
financial risk of package sizing entirely on the
doctor.
The Shift: Analysts predict this will make it
financially unviable for many office-based
podiatry clinics to offer advanced wound care,
likely driving that patient volume back into
hospital-based settings.
2. The "Efficiency Adjustment" Tax
CMS finalized a new 2.5% "Efficiency Adjustment"
for 2026. This is a conceptual cut based on the
agency's belief that as doctors do a procedure
more often, they become "faster" and therefore
should be paid less for it.
Scope: This applies to most non-time-based
services (including many common podiatric
injections and minor surgeries).
The Squeeze: Because the cost of staff, rent, and
supplies is rising (estimated at 2.7% growth by
the Medicare Economic Index), a 2.5% cut to the
"work" value of a procedure creates a widening gap
between overhead and income.
3. The Facility vs. Office Divide
Starting in 2026, CMS is redistributing "indirect"
practice expenses.
Office-Based "Gain": Podiatrists practicing in
their own offices may see a slight 4% increase in
the Practice Expense (PE) portion of their
reimbursement to account for higher overhead.
Facility-Based "Loss": Conversely, if you perform
procedures in a hospital or ASC, those payments
are expected to drop by roughly 7% because CMS
assumes the facility is now covering more of the
overhead.
A small win:
To provide a full picture, the American Podiatric
Medical Association (APMA) did secure some
targeted increases that prevent 2026 from being a
total net loss in the short term:
Arthrodesis RVUs: Work RVUs for great toe
arthrodesis (CPT 28750 and 28755) were actually
increased for 2026, representing a rare upward
adjustment for surgical work.
MIPS Stability: The performance threshold for MIPS
will remain at 75 points through 2028, avoiding
what could have been a much higher bar for
avoiding penalties.
These buffers won't stand the test of time.
Insurance is a for-profit business and Medicare is
a "for borrow" business as the government has
historically used Medicare taxes to fund other
debts. This won't stop. And with the burgeoning
era of AI, many jobs might disappear and less
Medicare tax will be paid.
The immediate plan should be to wrestle the
controls away from insurance companies. They need
us. We don't need them. We have valuable skills
and expertise. That is marketable. Imagine. Not
needing them to decide your financial fate. So how
do we wrestle the controls away from them? Simple.
Stop participating (cooperating) with them.
Current reporting and industry analysis from early
2026 suggest that the shift toward Direct-Pay
(Cash-Pay) models in podiatry is no longer just a
niche trend but a strategic response to the
"insurance treadmill."
As Medicare and private payers tighten
restrictions—particularly around regenerative
medicine and advanced wound care—more
practitioners are opting out of traditional
reimbursement structures to regain clinical and
financial autonomy.
The public is also fed up with the current model
and the dynamics it imposes. There is a growing
trend in the public toward more holistic
(functional medicine) services, more natural
therapies (regenerative medicine) and are looking
for accessibility and a lot more time from their
doctors. Patients have realized that their
premiums only entitle them to pay thousands more
in deductibles, co-pays and non-covered services
and instead are opting to pay directly for more
personalized care and easy access to their
doctors.
Changing a volume-based model to a value-based
model does wonders to uplevel your reputation as a
physician because with a relaxed environment and
time to spend, your patients feel more connected
and are more compliant resulting in better
outcomes.
The long range plan needs 2 parts, in my opinion.
The first part is for every podiatrist to be well-
versed in functional medicine, since it is the
collision of many epigenetic and genetic factors
that determine the biological terrain of the
patient. And that is what creates the internal
struggles pushing patients across the morbidity
threshold. Instead of suppressing the immune
system or drugging the CNS for relief, we can lift
immune burdens and support a return to immune
efficiency so repair pathways become more
efficient. This would cement our reputation as
physicians since this approach to patient care
uplevels the health of the patient as a side-
benefit of approaching podiatric pathology from a
root cause perspective.
The second part is to seek a plenary license for
podiatrists and combine our training and expertise
with a D.O. degree. Without this, podiatry will
surely hit the same trail as the great northern
white rhinos of Africa. What are we holding on
for? History? Pride? It's time to look at the big
picture and realize as a tiny little non-plenary
specialty in medicine, we won't survive.
I'm 71 now. I've had a stellar career outside the
insurance-dependency model. No one can tell me
that it can't be done or it doesn't work. And if
we continue to foster the belief that podiatry can
stand on its own two feet, without a plenary
license, all I can say is I have a bridge in
Brooklyn I'd like to sell to you.
Robert Kornfeld, DPM, New York, NY
03/23/2026 Judd Davis, DPM
The Best of Times, The Worst of Times (Allen M. Jacobs, DPM)
Dr. Jacobs states that, "These are indeed the best
of times to be a podiatric physician. Utilizing
Medicare reported RVUs, the average podiatrist
should earn a minimum of $269,900 annually." That
may be the case for gross income, but certainly
not for net income take home pay. Chat GPT and
Gemini AI searches both state that the average net
pay is around $150K. This is the bottom of the pay
scale as far as medical specialties go. Maybe Dr.
Block can post the most recent annual survey
results for net and gross pay to help confirm
these numbers?
I have personally watched my income being eroded
away by ever increasing overhead and stagnant
unchanging reimbursement from Medicare and most
commercial insurances, even witnessing some
podiatrists being pushed right out of business for
this reason. In 1987, I had b/l matrixectomies
done and my parents paid $800 cash, and thought
wow, I can help people and make that kind of
money. Sign me up. Today, almost 40 years later
Medicare pays $245 dollars for those same two
procedures. That's some serious deflation.
No one told me about the 50% reduction for the
second procedure, and wait there's something
called a global period where the follow-up visit
is free? Of course those rules probably didn't
exist then until some brilliant insurance analysts
came up with those concepts and the medical
community was dumb enough to go along with it.
Those analysts are sitting on their own private
islands in the Bahamas right now.
The golden years, from what I read on PM News,
were apparently the 1980s when bunionectomies paid
$2,000, now its around $500, and 90 days of free
follow up visits afterwards. That doesn't pay the
bills very well. Any industry such as ours that is
completely controlled by insurance reimbursement
is in an uphill struggle and the general public is
hearing about this. I believe this is one of the
many reasons people in general don't want to go
into podiatry or medicine as a whole.
Is the DPM degree going down in flames? Probably
not. There will be a huge need for us as the
population ages more. Would an MD behind our name
elicit more respect and responsibility in the
medical community? Absolutely. How that gets
accomplished nobody knows. I must believe we are
somewhere between the best of times and worst of
times.
Judd Davis, DPM, Colorado Springs, CO
03/19/2026 Joseph Borreggine, DPM,
The Best of Times, The Worst of Times (Allen M. Jacobs, DPM)
Two esteemed podiatrists, Drs. Amarantos and
Jacobs have dedicated their careers to advancing
the field of podiatry. Both recently have
addressed crucial topics that are essential to our
profession.
Dr. Amarantos has expressed his concerns about how
the podiatric profession has historically
overlooked a vital aspect of our practice,
biomechanics, and relegating it to a secondary
position.
As a graduate of Scholl College in 1988, after
transferring from CCPM during my freshman year, I
was fortunate to have access to Scholl’s renowned
in-house orthotic laboratory and the expertise of
Professor Oleg Petrov DPM, a former CCPM graduate
who joined the faculty in 1979. This collaboration
between podiatric expertise in sports medicine and
biomechanics became an integral part of the
educational curriculum.
Throughout my career as a podiatrist, I have
consistently utilized this knowledge to provide my
patients with numerous pairs of prescription
orthotics that effectively alleviated a wide range
of foot-related issues.
Interestingly, I never permitted my assistant to
take mold impressions of the feet, whether using
plaster or fiberglass socks. I assumed full
responsibility for the entire process of
prescribing orthotics. If any errors were made, it
was my fault, and the orthotic laboratory promptly
corrected them when necessary.
As a podiatrist well-versed in biomechanics and
skilled in taking mold impressions, during my
years at Scholl, I accepted the significant number
of castings that were destroyed in the hands of
Dr. Petrov due to incorrect impressions on my
part. However, I believe that this was an
essential part of the learning process.
Regrettably, many podiatrists today minimize this
training and education, delegating it to
assistants and dismissing it altogether. This
practice extends to various aspects of foot care,
but that is a topic for another day.
I recognize that Dr. Petrov is currently serving
as the President of the National Board of
Podiatric Medical Examiners. I hope that he will
continue to prioritize the inclusion of our
profession’s expertise in biomechanics in the exam
curriculum.
Dr. Jacobs presents a compelling and often
contentious perspective on the podiatric
profession, drawing upon historical context and
its current state. His quote from Charles Dickens’
“A Tale of Two Cities” resonates deeply with our
profession’s identity.
Regrettably, the future of medicine appears
uncertain. Several factors contribute to this
bleak outlook, including the ongoing decline in
insurance reimbursement, the displacement of
private practice by corporate entities in
hospitals, healthcare facilities, and supergroups,
and the escalating cost of medical school tuition,
which takes years to recoup.
The future trajectory of podiatry remains
uncertain. We may transition to a dual degree
program, establish foot and ankle surgery as our
primary focus (parallel to our current three-year
residency and fellowship training), or fully
embrace artificial intelligence and its potential.
These are indeed “the best of times and the worst
of times.”
Joseph Borreggine, DPM, Ft. Myers, FL
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