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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