07/13/2026    Sev Hrywnak, DPM, MD

Why have podiatrist’s surgical fees decreased over the past 10 years?

Doing surgery is not the financial answer

Payer pressure and cost containment

*Private insurers and government programs have
pushed for lower reimbursement rates for
procedures, often through fee schedule updates and
value-based contracts.
*Global budgeting and utilization controls in some
regions limit total spending, compressing per-
procedure fees.

Shift to value-based and bundled payments
*Bundled payments for episodes of care incentivize
cost efficiency, which can reduce the negotiated
amount paid per surgery as part of a total-care
package.
*Emphasis on outcomes and standardized pathways
tends to favor predictable, lower per-procedure
fees over high, variable charges.

Increased supply and competition
*More podiatrists, clinics, and ambulatory surgery
centers (ASCs) performing foot/ankle procedures
increase market competition.
*ASCs and outpatient settings often command lower
negotiated rates than hospital-based surgeries,
pulling overall fees downward.

Technological and procedural efficiency
*Advancements in minimally invasive techniques,
implants, and perioperative care can reduce
resource use, length of stay, and complication
rates, influencing reimbursement to reflect
efficiency gains.
*Standardized coding and streamlined workflows
reduce variability and can lead to uniform, often
lower, valuation of common procedures.

Coding, billing, and administrative factors
*Revisions to CPT codes and Relative Value Units
(RVUs) can compress reimbursement for certain
podiatry procedures.
*Higher administrative burden, denials, and prior-
authorization hurdles can erode net earnings per
case.

Shifts in payer mix and leverage
*A growing share of patients may be covered by
plans with historically lower reimbursement (e.g.,
high-deductible plans, certain public payers).
*Hospital-employed podiatrists or groups
negotiating within large health systems may accept
standardized rates aligned with system-wide
bargaining power.

Policy and regulatory changes
*Reforms aimed at reducing waste and fraud, price
transparency initiatives, and payer consolidation
can influence pricing dynamics and compress fee
growth.
*Medication, implant, and durable medical
equipment pricing reforms indirectly affect
overall procedure economics.

Economics of elective foot/ankle surgery
*Demand fluctuations, elective surgery wait times,
and regional cost differences can create a
downward pressure on average fees in some markets.
*Competition from non-surgical or non-traditional
care pathways for foot/ankle issues can influence
the perceived value of surgical interventions.

Alternative revenue and business model shift
*Some practitioners diversify with ancillary
services, telemedicine, quality incentives, or
hospital affiliations, which can dilute the
emphasis on per-procedure fee growth.

Sev Hrywnak, DPM, MD, Chicago, IL

Other messages in this thread:

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07/14/2026    Allen M. Jacobs, DPM

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

Thank you Dr. Hrywnak for your contributions to
our understanding of the evolving medical care
milieu. Your discussions are of course greatly
appreciated. The new issue of JFAS contains a
study concluding that over the last 25 years, real
dollar reimbursement for surgical procedures has
declined over 49%! This is hardly news to those
who have been in active practice over this period
of time. Alternatively, a recent ACFAS study
indicated that podiatrists doing 500 or more
procedures per year have an average annual income
greater than $1,000,000

With that said, there is additional value to
performing surgical procedures from a financial
viewpoint. That is, your value to the health care
system goes beyond your reimbursement for a
procedure completed. One of my close friend’s son
is a recent osteopathic college graduate. His
starting salary for primary care practice was over
$400,000. One of his close friends, a DO
completing a cardio-thoracic fellowship, received
a starting offer of $1,200,000. Another, a DO
finishing his general orthopedic residency, is
starting at $800,000.

Why is this the reality in a world of declining
surgical fees? The answer reminds of the line from
Mel Brooks parody Spaceballs in which Yogurt
states “ merchandizing, where the real money from
movies is made” Substitute ancillary income for
merchandizing. Surgeons generate facility fees,
lab fees, radiology fees, physical therapy fees,
DME fees, additional consultative fees, we can go
on and on. That is the value of doing surgery.
That should be considered when you negotiate your
RVUs. Your surgical ability increases you value.

The more difficult scenario is private practice.
Your surgery fee is a part of your reimbursement.
You also generate ancillary fees for products and
services associated with the surgical procedure.
But are these income streams sufficient for
practice survival?

We have an ageing population, increasing incidence
of diabetes and other chronic disorders, athletic
related pathology in our active society. The need
and demand for foot and ankle surgery has
exploded. Conversely, it appears to me that it is
increasingly difficult if not impossible to
generate a reasonable office sustaining and
profitable income providing primary care podiatric
services. The increased cost of private practice
is largely responsible for this.

What has become most offensive are the fees
associated with care of patients with diabetes or
PAD. These patients are not an MIS bunion
correction in a healthy 35-year-old. These are
patients we see on rounds in the hospital, who
require careful chart review and complex
evaluation and decision-making. They are generally
older, take more time and thought, require more
ancillary testing. They require nights in the OR,
consideration of co-morbid conditions, evaluation
for drug and procedure complications and sequela.
They require non-reimbursed dressing changes,
phone calls, concern, more documentation. They are
a greater medical legal risk. The reimbursement
for the care of these patients is obscene.

The solution for these issue lies in the fact that
increasingly, podiatrists are employed by
hospitals, medical groups, orthopedic groups,
government health care providers, in which the
true value of our services is appreciated. The bad
news? The days of honest and legitimate individual
private practice other than “direct pay” will be
increasingly if not impossible to maintain.

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

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07/13/2026    Sev Hrywnak, DPM, MD

Why have podiatrist’s surgical fees decreased over the past 10 years?

Doing surgery is not the financial answer

Payer pressure and cost containment

*Private insurers and government programs have
pushed for lower reimbursement rates for
procedures, often through fee schedule updates and
value-based contracts.
*Global budgeting and utilization controls in some
regions limit total spending, compressing per-
procedure fees.

Shift to value-based and bundled payments
*Bundled payments for episodes of care incentivize
cost efficiency, which can reduce the negotiated
amount paid per surgery as part of a total-care
package.
*Emphasis on outcomes and standardized pathways
tends to favor predictable, lower per-procedure
fees over high, variable charges.

Increased supply and competition
*More podiatrists, clinics, and ambulatory surgery
centers (ASCs) performing foot/ankle procedures
increase market competition.
*ASCs and outpatient settings often command lower
negotiated rates than hospital-based surgeries,
pulling overall fees downward.

Technological and procedural efficiency
*Advancements in minimally invasive techniques,
implants, and perioperative care can reduce
resource use, length of stay, and complication
rates, influencing reimbursement to reflect
efficiency gains.
*Standardized coding and streamlined workflows
reduce variability and can lead to uniform, often
lower, valuation of common procedures.

Coding, billing, and administrative factors
*Revisions to CPT codes and Relative Value Units
(RVUs) can compress reimbursement for certain
podiatry procedures.
*Higher administrative burden, denials, and prior-
authorization hurdles can erode net earnings per
case.

Shifts in payer mix and leverage
*A growing share of patients may be covered by
plans with historically lower reimbursement (e.g.,
high-deductible plans, certain public payers).
*Hospital-employed podiatrists or groups
negotiating within large health systems may accept
standardized rates aligned with system-wide
bargaining power.

Policy and regulatory changes
*Reforms aimed at reducing waste and fraud, price
transparency initiatives, and payer consolidation
can influence pricing dynamics and compress fee
growth.
*Medication, implant, and durable medical
equipment pricing reforms indirectly affect
overall procedure economics.

Economics of elective foot/ankle surgery
*Demand fluctuations, elective surgery wait times,
and regional cost differences can create a
downward pressure on average fees in some markets.
*Competition from non-surgical or non-traditional
care pathways for foot/ankle issues can influence
the perceived value of surgical interventions.

Alternative revenue and business model shift
*Some practitioners diversify with ancillary
services, telemedicine, quality incentives, or
hospital affiliations, which can dilute the
emphasis on per-procedure fee growth.

Sev Hrywnak, DPM, MD, Chicago, IL

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07/13/2026    Sev Hrywnak, DPM, MD

Why have podiatrist’s surgical fees decreased over the past 10 years?

Doing surgery is not the financial answer

Payer pressure and cost containment

*Private insurers and government programs have
pushed for lower reimbursement rates for
procedures, often through fee schedule updates and
value-based contracts.
*Global budgeting and utilization controls in some
regions limit total spending, compressing per-
procedure fees.

Shift to value-based and bundled payments
*Bundled payments for episodes of care incentivize
cost efficiency, which can reduce the negotiated
amount paid per surgery as part of a total-care
package.
*Emphasis on outcomes and standardized pathways
tends to favor predictable, lower per-procedure
fees over high, variable charges.

Increased supply and competition
*More podiatrists, clinics, and ambulatory surgery
centers (ASCs) performing foot/ankle procedures
increase market competition.
*ASCs and outpatient settings often command lower
negotiated rates than hospital-based surgeries,
pulling overall fees downward.

Technological and procedural efficiency
*Advancements in minimally invasive techniques,
implants, and perioperative care can reduce
resource use, length of stay, and complication
rates, influencing reimbursement to reflect
efficiency gains.
*Standardized coding and streamlined workflows
reduce variability and can lead to uniform, often
lower, valuation of common procedures.

Coding, billing, and administrative factors
*Revisions to CPT codes and Relative Value Units
(RVUs) can compress reimbursement for certain
podiatry procedures.
*Higher administrative burden, denials, and prior-
authorization hurdles can erode net earnings per
case.

Shifts in payer mix and leverage
*A growing share of patients may be covered by
plans with historically lower reimbursement (e.g.,
high-deductible plans, certain public payers).
*Hospital-employed podiatrists or groups
negotiating within large health systems may accept
standardized rates aligned with system-wide
bargaining power.

Policy and regulatory changes
*Reforms aimed at reducing waste and fraud, price
transparency initiatives, and payer consolidation
can influence pricing dynamics and compress fee
growth.
*Medication, implant, and durable medical
equipment pricing reforms indirectly affect
overall procedure economics.

Economics of elective foot/ankle surgery
*Demand fluctuations, elective surgery wait times,
and regional cost differences can create a
downward pressure on average fees in some markets.
*Competition from non-surgical or non-traditional
care pathways for foot/ankle issues can influence
the perceived value of surgical interventions.

Alternative revenue and business model shift
*Some practitioners diversify with ancillary
services, telemedicine, quality incentives, or
hospital affiliations, which can dilute the
emphasis on per-procedure fee growth.

Sev Hrywnak, DPM, MD, Chicago, IL

---

03/11/2026    Sev Hrywnak, DPM, MD

Why have podiatrist’s surgical fees decreased over the past 10 years?

Doing surgery is not the financial answer!

* Payer pressure and cost containment
Private insurers and government programs
have pushed for lower reimbursement rates for
procedures, often through fee schedule updates and
value-based contracts. Global budgeting and
utilization controls in some regions limit total
spending, compressing per-procedure fees.

* Shift to value-based and bundled payments
Bundled payments for episodes of care
incentivize cost efficiency, which can reduce the
negotiated amount paid per surgery as part of a
total-care package. Emphasis on outcomes and
standardized pathways tends to favor predictable,
lower per-procedure fees over high, variable
charges.

* Increased supply and competition
Ambulatory surgery centers (ASCs) performing
foot/ankle procedures increase market competition.
ASCs and outpatient settings often command lower
negotiated rates than hospital-based surgeries,
pulling overall fees downward.

* Technological and procedural efficiency
Advancements in minimally invasive
techniques, implants, and perioperative care can
reduce resource use, length of stay, and
complication rates, influencing reimbursement to
reflect efficiency gains. Standardized coding and
streamlined workflows reduce variability and can
lead to uniform, often lower, valuation of common
procedures.

* Coding, billing, and administrative factors
Revisions to CPT codes and Relative Value
Units (RVUs) can compress reimbursement for
certain podiatry procedures. Higher administrative
burden, denials, and prior-authorization hurdles
can erode net earnings per case.

* Shifts in payer mix and leverage
A growing share of patients may be covered
by plans with historically lower reimbursement
(e.g., high-deductible plans, certain public
payers). Hospital-employed podiatrists or groups
negotiating within large health systems may accept
standardized rates aligned with system-wide
bargaining power.

* Policy and regulatory changes
Reforms aimed at reducing waste and fraud,
price transparency initiatives, and payer
consolidation can influence pricing dynamics and
compress fee growth. Medication, implant, and
durable medical equipment. Pricing reforms
indirectly affect overall procedure economics.

* Economics of elective foot/ankle surgery
Demand fluctuations, elective surgery wait
times, and regional cost differences can create a
downward pressure on average fees in some markets.
Competition from non-surgical or non-traditional
care pathways for foot/ankle issues can influence
the perceived value of surgical interventions.

* Alternative revenue and business model shift
Some practitioners diversify with ancillary
services, telemedicine, quality incentives, or
hospital affiliations, which can dilute the
emphasis on per-procedure fee growth.

Sev Hrywnak, DPM, MD, Chicago, IL, Linkedin