Areas oversaturated with pods...

[HenryH]

Several e-mails published in recent editions of PM News questioning the latest APMA supply/demand trends for podiatrists have made me a bit nervous. According to several of the letter writers, a sure-fire sign that an area is oversaturated with practitioners is obvious if a podiatrist is able to schedule appointments within 48-72 hours; when I saw a podiatrist in March for a sprained ankle, I called the doctor on Friday and secured an appointment for Tuesday. My mom also visited a podiatrist recently and was able to be seen with similarly brief delay. She went for a purely dermatological problem, and after the appointment, she expressed confusion to me over the podiatrist's decision to take x-rays of both of her feet -- despite going for a purely superficial, on-the-skin issue that had only presented itself on one foot. The reason I mention this is because eagerness of practitioners to take x-rays for simple dermatological consults was cited (in a PM News letter) as another "red-flag" of oversaturation.

So my question is, does it sound like my area is currently satisfied (perhaps too extensively) with its crop of podiatrists? My city currently has a population of ~190,000 people, and a brief Yellow Pages search suggests that there are 10 podiatrists practicing here.

This means that there is one podiatrists for every 19,000 people; would this ratio be considered favorable from a podiatrist's perspective? I'm not "bashing" podiatry...I simply want to gauge, albeit crudely, a possible supply/demand trend since I would like to practice here when I graduate. I'm investigating similar statistics for dentistry if it matters...

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[jonwill]

Several e-mails published in recent editions of PM News questioning the latest APMA supply/demand trends for podiatrists have made me a bit nervous. According to several of the letter writers, a sure-fire sign that an area is oversaturated with practitioners is obvious if a podiatrist is able to schedule appointments within 48-72 hours; when I saw a podiatrist in March for a sprained ankle, I called the doctor on Friday and secured an appointment for Tuesday. My mom also visited a podiatrist recently and was able to be seen with similarly brief delay. She went for a purely dermatological problem, and after the appointment, she expressed confusion to me over the podiatrist's decision to take x-rays of both of her feet -- despite going for a purely superficial, on-the-skin issue that had only presented itself on one foot. The reason I mention this is because eagerness of practitioners to take x-rays for simple dermatological consults was cited (in a PM News letter) as another "red-flag" of oversaturation.

So my question is, does it sound like my area is currently satisfied (perhaps too extensively) with its crop of podiatrists? My city currently has a population of ~190,000 people, and a brief Yellow Pages search suggests that there are 10 podiatrists practicing here.

This means that there is one podiatrists for every 19,000 people; would this ratio be considered favorable from a podiatrist's perspective? I'm not "bashing" podiatry...I simply want to gauge, albeit crudely, a possible supply/demand trend since I would like to practice here when I graduate. I'm investigating similar statistics for dentistry if it matters...

I'm not exactly sure where but there have to be areas that are over-saturated as there are with anything. But I thought Mo-town was over-saturated and yet, I see new guys coming out and opening up new practices and doing very well. I think one of the biggest issues with our profession right now is training. It's would seem that those with strong surgical training can pretty much go anywhere at this point because they have something unique to offer and encounter very few things that they cannot treat. But on the other end, this could be trouble for a pod who is not as well trained in the area.

I remember going to a meeting in Iowa as a student where a lot of pods were throwing a fit over NP's doing nailcare. I commented to the doc I was with, "Who cares? That means you can concentrate on other stuff." He then stated that, for a lot of those guys, there was no "other stuff." They were strictly non-surgical, palliative care pods and there was only so much to go around.

I do think that there is a place in the profession for non-surgical pods but I also think you'd have to be much more careful about location. I know of some nursing home pods that are cleaning up. One of the biggest contributors to my alum is a non-surgical pod.

But opening up any type of business in a saturated area could be trouble, no matter who you are or what you do. No one is immune to the laws of economics!

 

[Feli]

...No one is immune to the laws of economics!

👍 Bottom line right there^

Having elite skills helps, but if you are a good F&A surgeon, you are a good surgeon. Your skills are definitely needed. There are still areas that have a LOT of good pod surgeons, and they're usually the places that have longstanding high level residency programs (Atlanta, Bay Area CA, Det, Boston, Pitt, etc). I think that it would be hard starting up a solo practice in those places, but it could be done... or joining a group with an established patient base is never out of the question by any means. NC or Idaho are probably that way for F&A ortho surgeons... bad ratio of good FA surgeons to general population and therefore pretty competitive for business. Saturation will always limit what you can charge and how many pts you will get. Whether you are better or not, you just can't charge $500 for an initial office visit when the guy 5 miles away charges $300... it won't work. You just have to use your head; it's the same way you do in any career: supply and demand will dicatate income0.

I totally agree with jon that the dog eat dog mentality is more for minimally trained pods, though. Especially in the pod school cities, even routine pod care business gets competitive due to saturation, and you do see some DPMs struggling. If you have good surgical training, I wouldn't necessarily be hesitant of any pod school area, though (aside from maybe Bay Area or Philly)... all of those non-surg pods have to refer to someone, and a lof of the best F&A surgeons get most of their pts by a referral basis.

This kind of topic should also underscore the importance of wound care; those skills are always needed, and the diabetic population is growing WAY faster than DPMs can keep pace with. Diabetic management skills (VACs, I+D, charcot, etc) plus a multispecialty group equals $$$. You will find when you begin residency that there are programs that do most of their RF cases pods, and there are others that do it mainly with ortho. IMO, a big potential downside to training too much of your residency RF with ortho is that they do fairly little diabetic wound care (they refer most out to gen, vasc, plastic surg, pods wound care center, etc).

 

[HenryH]

Thanks for both of your responses; you two never fail to inform with reliable information! 👍

Would you guys say that there is a particular "formula" that could possibly yield an objective estimate of a particular area's degree of oversaturation (e.g., "One pod for every...people is oversaturation")?

Feli: when you say "RF," are you referring to "rear foot?" Are you saying that many residency programs limit exposure to rear foot cases to orthopedic surgery residents and not podiatry residents, or are you saying that certain programs heavily utilize orthopedic surgeons as teachers, while some programs instead opt to use podiatrists?

Also, about wound care...what, exactly, does a wound care-specialized podiatrist do each day? When I mull the term "wound care" over in my head, I think of red-crusted, slimy, pus-oozing feet caked in layers of pungent gauze. Anyone else want a Hot Pocket? 😀

You mentioned that multispecialty groups will often pay a high to a podiatrist who specializes in wound care; why are these services valued so much more heavily than other facets of podiatric treatment? To obtain one of these positions, is it strongly recommended to complete a fellowship in wound care?

Thanks for your insight!

 

[NatCh]

The last time I looked into the data it took a population of 20,000 to support one podiatrist, so by the data alone your home town would be alright. Of course statistics only tell a small part of the story. If you have special skills then it might not matter if a place is technically saturated or not. Note that "special skills" can mean a lot of things. It may mean advanced surgical skills or it may mean advanced marketing skills, advanced practice management skills, or advanced social skills, any of which can be a boon to business.

In my city we have six (soon to be eight) podiatrists and four F&A Orthopods with a population of 75,000, so I suppose you could call this city hypersaturated. Somehow we are all doing well though. You can increase your take-home pay by either seeing more patients or by decreasing overhead expenses. If there are only so many patients coming in, then you have to figure out how to make your gross income pay your overhead without overspending. It all comes down to the profit & loss sheet.

Also note that your "draw area" is important. Even if there are a given number of people living in the city limits according to the census, your patients might be coming in from out in the county or even from rural parts of the state. Our practice draws regularly from five cities covering much of the central and eastern half of Oregon, and I've had patients come in from California and Portland because I did a certain procedure that not too many other people did. As I've mentioned before, if you become known for doing something well, then you will get the referrals for whatever that thing is.

Nat

Edit: With respect to Feli, if you participate with Medicare then saturation alone does not control how much you can charge for services. Medicare sets allowable charges and insurances pay based on those figures. You can bill as much as you want but insurance will pay you whatever they want based on fee amounts termed "usual and customary." You tell them how much you want, they pay what they want (nice, huh?). Try that in a restaurant sometime. "Ribeye steak and beverage for $30? Here's $18, take it or leave it." Medicine is about the only professional industry I can the think of that has its fees regulated. Lawyers and Accountants can charge whatever the hell they want per hour. If you opt out of Medicare then you can bill whatever you want, but good luck unless you make a name for yourself with celebrity athletes or movie stars or the like.

Many contracts also forbid you to balance-bill (bill the patient for whatever insurance didn't cover). More-or-less, all docs in an area make about the same amount per CPT code. The practice management game includes learning how to code appropriately for what you do.

Yikes: http://www.jsonline.com/story/index.aspx?id=682326

More edit (I always seem to think of something else to blather on about after I hit save): Practice management is a big numbers game. You want to do a lot of things that reimburse well per time spent. Having 30 c&c's on the day's schedule takes all day long but pays less than doing three ingrown nails in 90 minutes. If you are good at doing total ankles but can only manage to draw in one case per year, that won't pay the bills. You have to market that special skill in a way that it also brings you numerous bunions, neuromas, hammertoes, etc. (i.e., the high quantity stuff).

I don't know why some folks like wound care. It's my least favorite thing. Even if I could make money doing it, I'd dread going to work. Thank god there are those who like it and can receive my referrals.

 

[longstech]

Should we look to focus or "specialize" in certain areas (ie: limb salvage, peds, etc) in our residency that will enable us to provide a specific need for certain patients? Will this open up more opportunities, especially if the state or area is more saturated?

 

[Feli]

...Saturation will always limit what you can charge and how many pts you will get. Whether you are better or not, you just can't charge $500 for an initial office visit when the guy 5 miles away charges $300... it won't work. You just have to use your head; it's the same way you do in any career: supply and demand will dicatate income...

...Edit: With respect to Feli, if you participate with Medicare then saturation alone does not control how much you can charge for services. Medicare sets allowable charges and insurances pay based on those figures. You can bill as much as you want but insurance will pay you whatever they want based on fee amounts termed "usual and customary." You tell them how much you want, they pay what they want (nice, huh?). Try that in a restaurant sometime. "Ribeye steak and beverage for $30? Here's $18, take it or leave it." Medicine is about the only professional industry I can the think of that has its fees regulated. Lawyers and Accountants can charge whatever the hell they want per hour. If you opt out of Medicare then you can bill whatever you want, but good luck unless you make a name for yourself with celebrity athletes or movie stars or the like.

Many contracts also forbid you to balance-bill (bill the patient for whatever insurance didn't cover). More-or-less, all docs in an area make about the same amount per CPT code. The practice management game includes learning how to code appropriately for what you do.

Yikes: http://www.jsonline.com/story/index.aspx?id=682326

More edit (I always seem to think of something else to blather on about after I hit save): Practice management is a big numbers game. You want to do a lot of things that reimburse well per time spent. Having 30 c&c's on the day's schedule takes all day long but pays less than doing three ingrown nails in 90 minutes. If you are good at doing total ankles but can only manage to draw in one case per year, that won't pay the bills. You have to market that special skill in a way that it also brings you numerous bunions, neuromas, hammertoes, etc. (i.e., the high quantity stuff).

I don't know why some folks like wound care. It's my least favorite thing. Even if I could make money doing it, I'd dread going to work. Thank god there are those who like it and can receive my referrals.

You are 100% correct, and your experience and info is extremely valuable (as always).^

Not to argue, but I am in Miami right now. I should have prefaced my statements about saturation and charging high fees since some practices here, pod or otherwise, are certainly the exception and not the rule. Many - well, some - patients here in south Florida don't have insurance... not due to lack of job/money, but because they have so much $ that they don't need it. 15 minutes from Barry Univ, there are Sunny Isles condos starting at over $2M ( http://www.davincimiami.com/ ), penthouses rented for tens of thousands per month (and those are obviously NOT for sale), houses selling for dollar amounts much more obscene than that. There are some practitioners who have structured their practices to cater to those clients, and you do not need very many of them to turn big profits. Maybe you see the same or hear of the same things in SF, SoCal, etc. I remember the discussions on Dr. Levine in NYC ( http://www.institutebeaute.com/dr_levine.htm ) on these forums. One of our Barry Univ pod clinics get a fair number of patients of reasonably high socioeconomic status ( http://www.barry.edu/podiatryclinics/locations/mercy.htm ) and provides an excellent roation for the students and residents training there... excellent with the exception of all those hand written SOAP notes lol 😀

Like you, other DPMs consistently tell me that it's not always about clinical or surgical skills, but how one plays "the game." For 99.x percent of DPMs, you are right that they'd be insane to opt out of Medicare. Still, I've seen/heard it predicted that MediCare will fall during my practicing career and am always thinking of what happens then.

...Not to change the subject, but if/when medicare does collapse, the best strategies I can see (considering my extreme lack of clinical and practice exposure) are:
1) strength in numbers (group practices) for negotiating
2) a service patients need and can reasonably afford (ie podiatry 😎 )
3) business and networking social skills

I would be very interested in your take on the future of Medicare and strategies for (overconfident) youngsters like myself, doc. 👍

 

[NatCh]

You are 100% correct, and your experience and info is extremely valuable (as always).^

Not to argue, but I am in Miami right now. I should have prefaced my statements about saturation and charging high fees since some practices here, pod or otherwise, are certainly the exception and not the rule. Many - well, some - patients here in south Florida don't have insurance... not due to lack of job/money, but because they have so much $ that they don't need it. 15 minutes from Barry Univ, there are Sunny Isles condos starting at over $2M ( http://www.davincimiami.com/ ), penthouses rented for tens of thousands per month (and those are obviously NOT for sale), houses selling for dollar amounts much more obscene than that. There are some practitioners who have structured their practices to cater to those clients, and you do not need very many of them to turn big profits. Maybe you see the same or hear of the same things in SF, SoCal, etc. I remember the discussions on Dr. Levine in NYC ( http://www.institutebeaute.com/dr_levine.htm ) on these forums. One of our Barry Univ pod clinics get a fair number of patients of reasonably high socioeconomic status ( http://www.barry.edu/podiatryclinics/locations/mercy.htm ) and provides an excellent roation for the students and residents training there... excellent with the exception of all those hand written SOAP notes lol 😀

Like you, other DPMs consistently tell me that it's not always about clinical or surgical skills, but how one plays "the game." For 99.x percent of DPMs, you are right that they'd be insane to opt out of Medicare. Still, I've seen/heard it predicted that MediCare will fall during my practicing career and am always thinking of what happens then.

...Not to change the subject, but if/when medicare does collapse, the best strategies I can see (considering my extreme lack of clinical and practice exposure) are:
1) strength in numbers (group practices) for negotiating
2) a service patients need and can reasonably afford (ie podiatry 😎 )
3) business and networking social skills

I would be very interested in your take on the future of Medicare and strategies for (overconfident) youngsters like myself, doc. 👍

I think I wrote my previous post poorly. I did not mean that opting out of Medicare would necessarily be a bad idea; on PM News I occasionally see posts by guys who have opted out and they say it was a great move. What I meant was that if you wanted to charge unusually high fees then probably only the very wealthy would pay for it. If you built a pay out-of-pocket boutique practice in a middle-income neighborhood then people would probably just head to whomever took their insurance so they could get "normal" medical care and skip the frou-frou stuff.

The neighborhood you describe might be the perfect place for a pay-out-of-pocket business model. Some hotshot business analyst a few years ago hypothesized that in the future non-covered boutique services would be the way to offset poor Medicare coverage. A local dentist offers spa services along with dental care. Get a mani and a pedi while they fill your cavity. I don't know how much of that I could take. I have a few high-maintenance wealthy patients and some of them can be very demanding with unrealistic expectations. Taking care of them takes a lot out of me sometimes. I think a sign that you've crossed over into boutique zone is when you "serve clients" rather than "treat patients."

I don't think any of you are overconfident (with one exception - you guys decide who, ha ha). I think that you guys have a great future ahead of you and just the fact that you think about this stuff enough to post here regularly shows that you are keeping your head in the game.

I don't know what the heck the future holds and I don't spend too much time contemplating it. I just try to stay flexible and adapt when necessary. It's worked for me so far thank goodness. I'm a better adapter than predictor.

Nat

Edit (again with the edits!):

When Medicare collapses there will still be private insurance. Medicare covers the elderly who might not have health care otherwise. Private insurances base their reimbursements on Medicare rates but they exist apart from Medicare. I don't know how private insurances will calculate rates after Medicare is gone. I think I will retire just about the time Medicare crumbles such that I cannot recoup any of the money I've been contributing every pay period in the form of payroll taxes, grrrrrrr!

Regarding group practices and negotiating strength in numbers: here in Central OR we have an Independent Practice Association (IPA). All docs, whether solo or in a group, become a member of the IPA upon arrival and the IPA negotiates on behalf of all local practices, thus no single practice tries to outbid the other practices on a contract with an insurance provider, and no insurance can contract for unequal payments to different practices. Doing so has maintained good reimbursement for all, and podiatrists here get reimbursed the same per code as other types of docs. In some states they talk about getting reimbursed at such-and-such percent below Medicare. If I get reimbursed at Medicare rates then that's at my low end. Many docs here in town have closed their practice to new Medicare patients because Medicare pays less than almost any local private insurance.

Business and networking skills are always helpful.

 

[NatCh]

Should we look to focus or "specialize" in certain areas (ie: limb salvage, peds, etc) in our residency that will enable us to provide a specific need for certain patients? Will this open up more opportunities, especially if the state or area is more saturated?

I'd say if you find an area of focus that interests you more than other areas, then dive in and get really good at it. If you're really good at something then you'll get those referrals.

 

[RSSC]

I'd say if you find an area of focus that interests you more than other areas, then dive in and get really good at it. If you're really good at something then you'll get those referrals.

(Coming from a Non Pod):
When I shadowed an established Podiatrist in an area that may be deemed as saturated, his doors kept opening with established and new patient starts. In the short time I was there, I saw him remove some ingrown nails, warts and tend to a diabetic ulcer.

He went above and beyong to take care of every patient and sent detailed letters to referring physicians. As a result, this guy has a huge referral base. - both medical and surgical.

Patient Satisfaction + Referring Physician Satisfaction = More Referrals.

Best of Luck

 

[Feli]

(Coming from a Non Pod):
When I shadowed an established Podiatrist in an area that may be deemed as saturated, his doors kept opening with established and new patient starts. In the short time I was there, I saw him remove some ingrown nails, warts and tend to a diabetic ulcer.

He went above and beyong to take care of every patient and sent detailed letters to referring physicians. As a result, this guy has a huge referral base. - both medical and surgical.

Patient Satisfaction + Referring Physician Satisfaction = More Referrals.

Best of Luck

This is exactly right. Great post 👍

I haven't even been in clinics for 2yrs yet, but you can already tell that good customer service and treating patients well is paramount. Keeping the primary care doc or other team members in the loop on foot services rendered also goes a very long way - esp in terms of growing a practice. Patients talk, and docs talk. Word of mouth is definitely the best, and most ethical, local advertising IMO.

 

[NatCh]

(Coming from a Non Pod):
When I shadowed an established Podiatrist in an area that may be deemed as saturated, his doors kept opening with established and new patient starts. In the short time I was there, I saw him remove some ingrown nails, warts and tend to a diabetic ulcer.

He went above and beyong to take care of every patient and sent detailed letters to referring physicians. As a result, this guy has a huge referral base. - both medical and surgical.

Patient Satisfaction + Referring Physician Satisfaction = More Referrals.

Best of Luck

Very good! Being even a little personable helps a lot. A lot of the work we do is stuff that any of us should be able to do (e.g., clip a nail, write a prescription, fix an ingrown, give an injection), so often it comes down to being likable. I don't know about you guys, but when I went to school being likable was a stretch for a lot of students!

Sending a report back to the referring doctor is pretty much standard operating procedure as a professional courtesy. It's also good practice management in that it keeps your name active in the mind of the referrer and the icing on the cake is that if you chart it right you can bill a 99243 (Consultation) rather than a 99203 (New Patient Visit) for higher reimbursement.

Nat

 

[215512]

Very good! Being even a little personable helps a lot. A lot of the work we do is stuff that any of us should be able to do (e.g., clip a nail, write a prescription, fix an ingrown, give an injection), so often it comes down to being likable. I don't know about you guys, but when I went to school being likable was a stretch for a lot of students!

Sending a report back to the referring doctor is pretty much standard operating procedure as a professional courtesy. It's also good practice management in that it keeps your name active in the mind of the referrer and the icing on the cake is that if you chart it right you can bill a 99243 (Consultation) rather than a 99203 (New Patient Visit) for higher reimbursement.

Nat

hey everyone-coming from the perspective of a pre-pod with no business sense other than what I'll gain my next(last) college semester when I'm taking tons of business classes, it really helps to read this and try to grasp how to run a practice a little bit. These are great tips keep them coming! =)