Private Equity / Venture Capital and Podiatry

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Poddy2Hotty

Striving for Podometric Excellence
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I hear about more and more private practices being bought out by private equity / venture capital companies like upperline

Funding Round•May 9, 2023
Upperline Health raised $28,349,960
I'm assuming these investors are going to want returns...economies of scale can only bring so much revenue.
Wondering how profits are increased in these models? less staff? more grafts? biopsies? DME?


Anyone on here currently employed with these groups that does not hold shares/ownership your input is welcome


Read these articles and wanted to see what peoples thoughts and experiences were.



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"Venture Capital loves Podiatry". You're correct, they will want a good ROI (ironic, right?) The only way I see that happening is through high volume clinics with bunches of associates all earning less than 200k. By the way this is not just a podiatry problem, it's RAMPANT in the current healthcare system, which is broken.
 
Another way is the centralize a lot of stuff, like they have HR and and EMR that you use as well as their health insurance. So instead of 20 different policies they have 1 which makes it cheaper. I believe they do the ordering too which they can negotiate lower prices.
 
Members don't see this ad :)
People have to eat. That’s the sad reality on why so many podiatrists unbundle, overbill, and commit fraud. Then people like @ExperiencedDPM think you’re the worst person in the world just for trying to pay the bills and feed your family.
 
I'm currently employed by a PE owned practice. They push grafts HARD. Also, they are trying to expand ancillary services. They are looking into adding an imaging center and vascular lab
 
The biggest money makers are underpaid associates and selling "shares" of the group to said associates.
 
Hint for how this plays out in terms of cutting costs, it's not by hiring more podiatrists. They have not made ER staffing work for them by hiring more doctors, it's more APPs.
 
Hint for how this plays out in terms of cutting costs, it's not by hiring more podiatrists. They have not made ER staffing work for them by hiring more doctors, it's more APPs.

How can they make that happen if a real doctor needs to supervise an APP?
 
How can they make that happen if a real doctor needs to supervise an APP?
Bring in a retired doc in admin role to supervise, plenty of states with independent practitioners...there is a way don't underestimate their desire to drive returns.
 
Members don't see this ad :)
What I still want to know is how much theses guys were getting from private equity to sell. Like one 2 or 3 locations, 1 or 2 partners and 3 or 4 associates. Something worth selling. What are they walking away with?
 
How can they make that happen if a real doctor needs to supervise an APP?

The Genie is already out of the bottle...just a matter of time before PAs lobby for same

"This second designation will allow nurse practitioners full practice authority, without any setting restrictions. And in theory, nurse practitioners would be able to open their own medical practice. Given the phased-in approach, eligible nurse practitioners will likely obtain full independence around January of 2026."

In theory they could be trained to replace a non-surgical podiatrist, but it may be difficult sell as many podiatrists make less than an NP already

 
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The Genie is already out of the bottle...just a matter of time before PAs lobby for same

"This second designation will allow nurse practitioners full practice authority, without any setting restrictions. And in theory, nurse practitioners would be able to open their own medical practice. Given the phased-in approach, eligible nurse practitioners will likely obtain full independence around January of 2026."

In theory they could be trained to replace a non-surgical podiatrist, but it may be difficult sell as many podiatrists make less than an NP already


NPs have been practicing independently all over the country for years. Surprised this is new to CA
 
They already are replacing non-surgical podiatrist. There's zero reason for a non-surgical podiatrist.

Ok there is one reason for a non surgical podiatrist. Something a NP won't do....nail Care.

Because it all comes back to 💅
 
They already are replacing non-surgical podiatrist. There's zero reason for a non-surgical podiatrist.

Ok there is one reason for a non surgical podiatrist. Something a NP won't do....nail Care.

Because it all comes back to 💅

Yup. Especially when it’s run by Private Equity who also owns ancillary service lines. One thing that NPs and PAs have been shown to do is order more tests/labs/referrals than physicians. You want a Podiatry associate who might use some clinical judgement on wether advanced imaging, or vascular workup, or neuro workup is even necessary? Or you want an NP that’s gonna fire off all those tests at once on way too many patients? Remember, you’re only goal is to make your investors money…
 
I hear about more and more private practices being bought out by private equity / venture capital companies ...

...I'm assuming these investors are going to want returns...economies of scale can only bring so much revenue.
Wondering how profits are increased in these models? less staff? more grafts? biopsies? DME?...
You basically hit it on the last part.
The supergroups / VC don't lose money on the podiatry, but they are basically just feeders for other services they own...

These groups just buy/create a path lab, vascular center, DME shop, PT place, etc.... sometimes all of those or other stuff... or even multiples of them depending on how big/small the supergroup. They are often almost over-staffed and over-managed to fill out all the referrals, auths, etc to try to facilitate the many refer goals of the group. They have terrible cost inefficiencies but try to make it up on high ticket items, volume, buying in bulk, productive offices float vacant offices or new spending, and other stuff like that.

They pay the DPM associates maybe 25-40% depending on service type, they keep maybe 20%... so they win no matter what. But that's not the end game. They will tend to give more incentive to the things they make a lot on (vasc refers, "grafts," path lab, etc) and less on the basics (DME or PT or basic pod stuff and OTC).

I worked for one of these for about a year near where I practice now, but they are trying to be multi-state. I had talked to other such midwest and eastern groups in the past in other states. Some are more ethical or well-run than others, but they are all the same model:
In addition to them snipping about 20% of all basic collections, it's basically refer-for-profit without being overt about it on their bigger ticket items (you "can" send Rx DME to other places, you "can" send specimens to another path lab or decline to do them, you "could" send your PAD pts to vascular surgery instead of their vasc cath guy, etc... but you would not get your "bonus" and they wouldn't be very happy about any of it. It's all about collections in supergroups, esp for the big ticket refers that they own.

You will see some VERY interesting results from a lot of these groups: pts sent for Rx DM shoes +insoles comes back with the shoes... plus bilateral drop foot braces you didn't ever Rx or even the orthotist asking for Rx for a back brace, a list of patients you see who are eligible for bogus wound "grafts" shows up mysteriously every month in your email even if they're already healed or amped, the new interv radiologist the group hired who was let go by Modern Vascular is introduced as an expert the group should sent all PVD pts to, pt sent Rx ABI end up with multiple caths... then comp custom stockings, etc. I found that surgery is almost discouraged (they want max DME, and surgery does little or nothing for them unless you do DME or nonsense wound grafts after). You will also get all kinds of supergroup patients - both yours and other docs in the group - coming in complaining about their bill, "$900 just to cut nails (path lab)," "why do I have to drive 150miles for a brace (because my group owns the brace shop)," "I don't want to go 100 miles for that vascular ultrasound when I could just do it at the hospital (group owns vasc place)," etc.

The VC supergroups are a mighty good deal for original owner (buyout and then admin fees, sit back and press services while associates do the work and face the music of the billing complaints and DME issues, etc), and of course it's a dandy deal for the VC.

They're a permanent worker bee stop if you're the associate. Pay can be ok or good, mainly depending on how much you choose to feed the referral trains. Most are mills, but job security all depends on $ (how much you want to keep and how much you create for them).
The group I left cut pay of some docs and let others go... they have a bunch of grad residents coming on this summer (and every summer). Rinse and repeat. They try to put in non-competes even in states where that is not enforced. The new docs come in because the base is a bit higher than a normal pod PP (and because podiatry's job market sucks), but they are trading away having autonomy/stability and any shot at partnership/buyout and mentorship that a smaller pod group might have. The supergroup DPM associates can also get ping-ponged around between group's offices on a whim, contracts changed, almost zero bargaining power due to merely a replaceable cog in the wheel, etc. They also don't know the base will disappear or get changed. Many see the fairly good base and then take on roots or big car payment or whatever and tend to get trapped awhile treading water trying to do those refer services the group owned as much as they can and/or commuting a lot. It's sad.

Supergroup practice is growing, and it's essentially podiatry's version of PharmDs working Walgreens retail or ODs working Walmart optical. You have no say in anything and have to exist in somebody else's structure and constantly be told you need to see more pts and collect more. As if having one boss in PP is not enough, in supergroup, you get to deal with multiple remote managers and marketers (for the refer places owned by group) trying to call the shots and decide staffing and "train" your office with little knowledge of what's actually going on in the individual locations. There tends to be a lot of video meetings and circle jerking among the admins to tout their newest and latest moneymaker ideas and the "protocols." It's sorta as if PP jobs and hospital employ jobs had a weird special needs child. Not ideal... although not totally uselesssss if it's an area where non-competes don't hold up and you want to make a bit more than a typical PP associate and then... yaa. 🙂
 
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I'm currently employed by a PE owned practice. They push grafts HARD. Also, they are trying to expand ancillary services. They are looking into adding an imaging center and vascular lab
Yeah, yours is in its infancy if they don't have that stuff yet... and DME shop, path lab (nail path and ENFD or any high pay codes), PT places, sometimes surgery center. Vascular lab is the big one for most $upergroups... although they can arrange kickbacks from existing vasc company also. It's not exactly straight and narrow.

Tell them you know lots of residents and want to be an "admin" ? 🤣

The biggest money makers are underpaid associates and selling "shares" of the group to said associates.
This is a new one... most just keep dangling a percent more or a new service to say how you can increase your collections and therefore your take home.

At the one I left, they don't do the OTC stuff towards associate collections. I told the owner that should change since those would barely sell without the docs... he told me if I did more ABIs, he would think about counting arch supports towards my collections. Greed knows no limits. Lol.
 
he told me if I did more ABIs, he would think about counting arch supports towards my collections. Greed knows no limits. Lol.
It's funny how little for-profit healthcare actually considers the needs of the patient, and yet insurance companies have brainwashed Americans into thinking the American healthcare system is somehow better than any country with a socialized medicine system.
 
In 10yrs or so, we will see the threads and discussions "podiatry supergroups to avoid" instead of "associate mills to avoid."

I wouldn't doubt if they become the most common type of DPM job coming out of training... or even most common overall.

I agree. People I meet at conferences, workshops etc etc tell me they’re gunning for the Upperline, Balance Health, Optum job on the daily but I’m not sure if they’re aware of what it truly entails. They’re focused on the higher base pay
 
Oh the irony of laughing at an associate for working for another podiatrist when you’re working for a bean counter with less education than you who doesn’t know what a foot is
 
People have to eat. That’s the sad reality on why so many podiatrists unbundle, overbill, and commit fraud. Then people like @ExperiencedDPM think you’re the worst person in the world just for trying to pay the bills and feed your family.
This has got to be one of the most inappropriate comments I’ve ever read on this site.

So are you saying that to pay your bills it’s okay to “unbundle, overbill, and commit fraud”?
Is that really what you inferred. And then you actually tell others what I will think?

Are you my spokesperson?

So if you rob a bank, that’s okay if it means you have to pay your bills?

Are you too dense to realize fraud and unbundling COST us all money?
 
I agree. People I meet at conferences, workshops etc etc tell me they’re gunning for the Upperline, Balance Health, Optum job on the daily but I’m not sure if they’re aware of what it truly entails. They’re focused on the higher base pay
Can you blame them? There is not much to gun for outside of hospital jobs, especially in desirable locations in this profession. The well run podiatry group with a fair opportunity for partner is a good option, but there are not that many of those either.

It is mainly this or mustache pod employment.

Compared to mustache pod employment your chances are higher to:

1. Get your numbers for boards....ups your chances for an organizational job.

2. Learn what ancillary services, DME and cash pay services are very profitable....useful should you open your office.

3. Earn a slightly or potentially much better salary with better benefits.
 
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Bump this one for new job search cycle...
Very important info for pgy2 and pgy3s.

The job needing CAQ in moon gravity to design space boots are <<<1%, but understanding the mustache jobs vs supergroups vs hospital jobs vs DIY cold call jobs is what every grad with 300k or 400k debt is actually dealing with.
 
Bringing this thread back from its ~2-year old death...

But it seems like every dang private practice in the states I am looking for jobs in have been bought by USFAS, Upperline, etc.
Most of the PE-owned practices seemed to be in the South or east coast a couple of years ago, but now I am seeing a bunch in the west coast too.

Any one still working for one have any incite if its worth it for a first job at least? I am considering one but not sure if I would stay long-term.

Also, what is PreferredPodiatryGroup and Aria Care? Are they a PE-backed practice too? I see jobs all over the place for them, but they seem like companies that just contract with SNF's for nails and not actual brick-and-mortar clinics correct?
 
Bringing this thread back from its ~2-year old death...

But it seems like every dang private practice in the states I am looking for jobs in have been bought by USFAS, Upperline, etc.
Most of the PE-owned practices seemed to be in the South or east coast a couple of years ago, but now I am seeing a bunch in the west coast too.

Any one still working for one have any incite if its worth it for a first job at least? I am considering one but not sure if I would stay long-term.

Also, what is PreferredPodiatryGroup and Aria Care? Are they a PE-backed practice too? I see jobs all over the place for them, but they seem like companies that just contract with SNF's for nails and not actual brick-and-mortar clinics correct?
You just answered one of your own questions
 
Bringing this thread back from its ~2-year old death...

But it seems like every dang private practice in the states I am looking for jobs in have been bought by USFAS, Upperline, etc.
Most of the PE-owned practices seemed to be in the South or east coast a couple of years ago, but now I am seeing a bunch in the west coast too.

Any one still working for one have any incite if its worth it for a first job at least? I am considering one but not sure if I would stay long-term.

Also, what is PreferredPodiatryGroup and Aria Care? Are they a PE-backed practice too? I see jobs all over the place for them, but they seem like companies that just contract with SNF's for nails and not actual brick-and-mortar clinics correct?
The ppg and aria group, yes- nail care jobs

Private equity is taking over America, not just podiatry. For a first job you could probably do worse. I can't imagine working for them is great but basic PP podiatrists would probably **** you harder
 
Yet another nail in the coffin for the podiatric profession when you think about it. For the 65-75% of us who aren't hospital employed, the path to financial independence lies in ownership of your own practice. But if supergroup offices crowd out the small groups and solo providers, that path soon might not be viable either.

I guess the solo provider will deliver a better patient experience, just because it's YOUR business and YOUR reputation on the line, as opposed to the supergroup employee who can just shrug and say "sorry ma'am, I only work here." But spending your career working extra hard is a funny way to win
 
I talked to upperline as a potential first job. They kind of strung me along for four months during my third year of residency. They were going to start a practice in a dream location for me. As soon as I accepted my first job they came back around.. 2 little too late. Blessing in disguise.
 
I talked to upperline as a potential first job. They kind of strung me along for four months during my third year of residency. They were going to start a practice in a dream location for me. As soon as I accepted my first job they came back around.. 2 little too late. Blessing in disguise.
Are they worse than your basic PE group
 
"Of all the residents who have rotated in our ER over the last few years (of which we have many), the best have been podiatry residents. Yep—you heard me right. The hardest working, most driven to learn, the most attentive residents we have had over the last year are all podiatry residents. Not internal medicine, or family practice, general surgery or transitional (going into derm or radiology or anesthesiology) but are podiatry residents. I’m actually starting to think they may be stealing some of the “best and the brightest” from our medical schools. Their aptitude and work ethic, their drive to succeed, in a way reminds me of the old school medical students who have seemed to have faded into the vapor of the American medical past."
 
"Of all the residents who have rotated in our ER over the last few years (of which we have many), the best have been podiatry residents. Yep—you heard me right. The hardest working, most driven to learn, the most attentive residents we have had over the last year are all podiatry residents. Not internal medicine, or family practice, general surgery or transitional (going into derm or radiology or anesthesiology) but are podiatry residents. I’m actually starting to think they may be stealing some of the “best and the brightest” from our medical schools. Their aptitude and work ethic, their drive to succeed, in a way reminds me of the old school medical students who have seemed to have faded into the vapor of the American medical past."
Yes, this was the only part that I had to laugh out loud at.
 
Yet another nail in the coffin for the podiatric profession when you think about it. For the 65-75% of us who aren't hospital employed, the path to financial independence lies in ownership of your own practice. But if supergroup offices crowd out the small groups and solo providers, that path soon might not be viable either.

I guess the solo provider will deliver a better patient experience, just because it's YOUR business and YOUR reputation on the line, as opposed to the supergroup employee who can just shrug and say "sorry ma'am, I only work here." But spending your career working extra hard is a funny way to win
Nah. This will never happen.
PP will always be viable (unless payers only want to negotiate with large/mega groups and hospitals... ie hospitals own the health plans?).
It'll be fairly hard to compete with VC/supergroups in some areas, but it's entirely possible. Plenty of mediocre DPMs do it well.
If anything, those supergroups are actually awesome in areas that don't allow doc non-compete... they let ppl in the area, get some $ and exp... voila!

There is always a place for small/solo offices, though... podiatry and otherwise.
People will always want alternatives. And as long as some MDs are in PP, they'll prefer to refer to specialists who are too.
The hardest areas to compete in PP are actually the ones where there are a lot of other good PPs to compete with (major metros) and/or hospitals/systems run many of the main health plans.

It's mainly a quality of care thing, though:
  • The underpaid associates will just barely ever have the spirit and drive that PP owners/partners do. Some associates start that way, but they burn out fast once they are underpaid awhile and can't implement any of their own ideas for staff, supplies, system. They realize their career peaked (low) at age 35 or whatever.
  • Hospital employ DPMs (or MSG/ortho ones) are also usually buried in forced internal refers from their own facility/system, and they're hard for patients to access (park ramp, large building, etc). Just like the large/supergroup pods, the patients get bombed with heavy fees and a front/MA/biller/admin team that may or may not be very good.
  • As for VA/IHS and other models that are mostly just salary (Canada, etc), we all know it's 99% chance docs there are doing the minimum pretty soon after hire... they're not marketing or picking up any more patients than they absolutely have to.
  • Other good PPs = your toughest competition for refers, imo.

...In family med, it's the cash pay ("consierge") model, but in podiatry, people largely won't or can't go for that... but there's still plenty of ppl who don't want to see the associate mill / supergroup / hospital.
 
"Of all the residents who have rotated in our ER over the last few years (of which we have many), the best have been podiatry residents. Yep—you heard me right. The hardest working, most driven to learn, the most attentive residents we have had over the last year are all podiatry residents. Not internal medicine, or family practice, general surgery or transitional (going into derm or radiology or anesthesiology) but are podiatry residents. I’m actually starting to think they may be stealing some of the “best and the brightest” from our medical schools. Their aptitude and work ethic, their drive to succeed, in a way reminds me of the old school medical students who have seemed to have faded into the vapor of the American medical past."
Great to see an Ascension doctor recognizing podiatry for the quality of its residents. No gimmicks, no hype, no TikTok. Just hard work, sharp minds, and showing up ready. Podiatry moves forward when graduates raise the bar and earn respect where it matters most.
 
Great to see an Ascension doctor recognizing podiatry for the quality of its residents. No gimmicks, no hype, no TikTok. Just hard work, sharp minds, and showing up ready. Podiatry moves forward when graduates raise the bar and earn respect where it matters most.
Yeah absolutely. I know a ton of podiatrists that are well respected members of the hospital/org...but it just takes one.. like a restaurant. Have 10 happy customers that tell 1 person, have one unhappy and they tell 10 people
 
It's a very nice article, but much as I hate to interrupt the love fest, l can't help but notice what he didn't say about podiatrists.

You would think an emergency doctor who presumably sees patients with musculoskeletal trauma would comment on podiatrists' competence at managing foot and ankle trauma. Hell, he mentioned foot screenings to clear patients for kidney transplants, but not fractures?

I suppose it's not his point, but the primary care foot screening aspects of podiatry that he praises are things that are for me the least rewarding, most monotonous, lowest reimbursing, and lowest value to patients. ("You need to moisturize your feet and wear supportive shoes.") I would rather be recognized as a professional for my specialty training and things no one else can do, not merely things no one else wants to do.

I had a good month when I was on EM. I liked the variety, and it was a change of pace. I was really flattered when my EM attending had me repair a pt's facial lacerations and she was genuinely impressed with my work. But an article like this just comes across as patronizing.
 
Its weird hearing other people's takes. My problems are

1. Perpetually decreasing reimbursement.
2. Perpetually increasing business costs.

If I could
(a) drop my EHR price by 3%
(b) stop new unexpected "government insurances" from reimbursing less than Medicare
(c) and achieve even moderate positive rates over Medicare from all commercial insurances

I'd be fine. I don't need unique services. Most people seem to suck at what we do. The other day I revised a matrixectomy on a surgery tech from a small hospital down the road. General surgery did it and botched it. The patient loved my work. The problem - I got paid $147 for the procedure - which is less than Medicare. The year before the same employee would have been worth $253. She told me she hoped to come back and have her bunion done. The year before the bunion would have been worth $1400. Now its worth $600.

I think we're very much approaching a point where the reimbursement is below the price of liability. The facility gets an APC 5115 for a lapidus and I get 90 days of follow-up.
 
I think we're very much approaching a point where the reimbursement is below the price of liability. The facility gets an APC 5115 for a lapidus and I get 90 days of follow-up.
yep looked at my numbers recently and I make way more in clinic than *elective* cases. Inpatient cases pay well and they usually require a lot of wound care after. But bunions aren’t paying.

If I had a private practice I’m not sure I’d ever want to do elective cases.
 
It's a very nice article, but much as I hate to interrupt the love fest, l can't help but notice what he didn't say about podiatrists.

You would think an emergency doctor who presumably sees patients with musculoskeletal trauma would comment on podiatrists' competence at managing foot and ankle trauma. Hell, he mentioned foot screenings to clear patients for kidney transplants, but not fractures?

I suppose it's not his point, but the primary care foot screening aspects of podiatry that he praises are things that are for me the least rewarding, most monotonous, lowest reimbursing, and lowest value to patients. ("You need to moisturize your feet and wear supportive shoes.") I would rather be recognized as a professional for my specialty training and things no one else can do, not merely things no one else wants to do.

I had a good month when I was on EM. I liked the variety, and it was a change of pace. I was really flattered when my EM attending had me repair a pt's facial lacerations and she was genuinely impressed with my work. But an article like this just comes across as patronizing.
Well there is just no pleasing you.
 
Its weird hearing other people's takes. My problems are

1. Perpetually decreasing reimbursement.
2. Perpetually increasing business costs.

If I could
(a) drop my EHR price by 3%
(b) stop new unexpected "government insurances" from reimbursing less than Medicare
(c) and achieve even moderate positive rates over Medicare from all commercial insurances

I'd be fine. I don't need unique services. Most people seem to suck at what we do. The other day I revised a matrixectomy on a surgery tech from a small hospital down the road. General surgery did it and botched it. The patient loved my work. The problem - I got paid $147 for the procedure - which is less than Medicare. The year before the same employee would have been worth $253. She told me she hoped to come back and have her bunion done. The year before the bunion would have been worth $1400. Now its worth $600.

I think we're very much approaching a point where the reimbursement is below the price of liability. The facility gets an APC 5115 for a lapidus and I get 90 days of follow-up.
I hate fixing bunions or any elective case at this point. I have been getting $400-450 payment for bunions (RVU) for years. I guess I have no overhead so I shouldnt complain. But its simply not worth it to me to fix a bunion, spend +/- an hour doing it plus time before/after/talking with family/90 day global.

Meanwhile the RVUs for those DFUs just keep stacking up. Most dont have global either.
 
I hate fixing bunions or any elective case at this point. I have been getting $400-450 payment for bunions (RVU) for years. I guess I have no overhead so I shouldnt complain. But its simply not worth it to me to fix a bunion, spend +/- an hour doing it plus time before/after/talking with family/90 day global.

Meanwhile the RVUs for those DFUs just keep stacking up. Most dont have global either.
I get it. I hate it, but I get it. I still enjoy the look on a patient's face when they are blown away by how straight their toe is, but I'm literally writing a sheet in my mind to give to people that says "Sorry, I can't do elective surgery on you".
 
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