Private Equity / Venture Capital and Podiatry

[Hybrocure]

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 feel the same but in PP.

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[Feli]

Anything you can do fast + efficient for fair/good pay is generally good.
("efficient" includes being in/near hospital or ASC, having block time, getting OR started on time, minimizing turnover times, scheduling and prior auth well, doing the OR case pretty fast, having the office recovery be smooth)

For me, the Lapidus/Akin/Weil or MPJ fusions or forefoot salvages or forefoot slams or whatever are somewhat worth it in and of themselves (I did a ton in residency, pretty fast and good at that stuff)... but they become totally worth it with the e/m initial visit and maybe back to discuss XRs or other visits, lvl 4 + pre op for pre op visit, evenUp otc + comp stocking + then powersteps when back to shoes, etc. I usually see bunions post op 1wk, 2wk, 4wk, 2mo (then out of global... usually 3.5mo and 6mo or longer, if needed for PT or prolonged recovery, etc). Their visits are all in a double book besides the 2wks (suture removal).

Elective surgery also generates a lot of easy HWRs (fairly good $/hr).
Trauma does too, but those HWRs can be marginal $/hr as they are often harder or complicated.

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.

You probably need to change your technique and how you do your elective... make elective need wound care after? 🙃

Inpatient cases are fine and good when you're a whipper fresh outta training and/or if you're slow in office. For a little while. Mebbe? Sooner rather than later, you'll be busy with good refers... and you'll hate to see ER or inpt unit on the call ID. You want the pts [with good insurance] to come to you to the greatest extent possible. The only exception I can think of is if you have residents to chase down the ER/unit consults and/or you're hospital FTE on wRVU where insurance matters little or none. Those consults are a recipe for burnout and low/no pay patients for PP/collections. 🤢

 

[air bud]

Anything you can do fast + efficient for fair/good pay is generally good.
("efficient" includes being in/near hospital or ASC, having block time, getting OR started on time, minimizing turnover times, scheduling and prior auth well, doing the OR case pretty fast, having the office recovery be smooth)

For me, the Lapidus/Akin/Weil or MPJ fusions or forefoot salvages or forefoot slams or whatever are somewhat worth it in and of themselves (I did a ton in residency, pretty fast and good at that stuff)... but they become totally worth it with the e/m initial visit and maybe back to discuss XRs or other visits, lvl 4 + pre op for pre op visit, evenUp otc + comp stocking + then powersteps when back to shoes, etc. I usually see bunions post op 1wk, 2wk, 4wk, 2mo (then out of global... usually 3.5mo and 6mo or longer, if needed for PT or prolonged recovery, etc). Their visits are all in a double book besides the 2wks (suture removal).

Elective surgery also generates a lot of easy HWRs (fairly good $/hr).
Trauma does too, but those HWRs can be marginal $/hr as they are often harder or complicated.


You probably need to change your technique and how you do your elective... make elective need wound care after? 🙃

Inpatient cases are fine and good when you're a whipper fresh outta training and/or if you're slow in office. For a little while. Mebbe? Sooner rather than later, you'll be busy with good refers... and you'll hate to see ER or inpt unit on the call ID. You want the pts [with good insurance] to come to you to the greatest extent possible. The only exception I can think of is if you have residents to chase down the ER/unit consults and/or you're hospital FTE on wRVU where insurance matters little or none. Those consults are a recipe for burnout and low/no pay patients for PP/collections. 🤢

Are you doing surgery or dating them? and I guess when you use use non anatomic thick ass 1/3 tubular plates for everything those can be prominent and painful. I don't ever remove elective hardware....

 

[dtrack22]

I usually see bunions post op 1wk, 2wk, 4wk, 2mo (then out of global... usually 3.5mo and 6mo or longer, if needed for PT or prolonged recovery, etc).

I found your problem. You have twice as many post op visits during the global period than what is necessary for a bunion.

 

[Hybrocure]

I always hope to god I never have to remove the hardware

 

[Bluecollarmed]

I found your problem. You have twice as many post op visits during the global period than what is necessary for a bunion.

Lol I ditched the 1 week visit pretty quick unless it's someone I'm even remotely worried about from a trauma standpoint. Its 2wk for suture removal, 6 wk for progression of PT/walking/activities, and 12 weeks for finals on most things. Bigger rearfoot stuff I'll see one more time out of global for finals. This obviously is based on expected healing without complications. I could probably move my 12 week visit out of global too but I'm at a rural hospital with like 20 patients max per day without nail care so it doesn't really burden my schedule.

 

[deleted1162946]

I’m probably the only one who does this but I won’t take sutures out until 3 weeks. Usually go 1 week and then 3 weeks on post ops for elective cases. Then depends on what was done

 

[MicroPod]

I do either 2 or 3 weeks for sutures usually. Sometimes more for diabetic foot cases. I see them at 1 week postop because I’m still new and too scared to wait 2 weeks most of the time.

 

[Feli]

I do either 2 or 3 weeks for sutures usually. Sometimes more for diabetic foot cases. I see them at 1 week postop because I’m still new and too scared to wait 2 weeks most of the time.

The 1wk visit is mainly to get new clean + dry dsg on (try keeping a foot dsg clean for a week - much less 2wks), dry out the incisions with clean gauze and alc around incisions +/- betadine wipe. You also need to refill their narc Rx typically (different states allow diff quantity/length of narc Rx).

Mainly, you also have to catch any cellulitis or hematoma or non-compliance early (catch lack of pt understanding on WB status, meds, etc)... obviously can be detrimental if you do not. You can't really tell the patient "just call if your wound is getting all macerated or if you get a hematoma." A whole lot can happen in 2wks... but easy to take a 1wk look.

Also nice to have the 1wk visit in case pt pt was obviously walking a lot... or if PACU had missed XR for some reason (you need immed post op for ABFAS).

I’m probably the only one who does this but I won’t take sutures out until 3 weeks. Usually go 1 week and then 3 weeks on post ops for elective cases. Then depends on what was done

I do 2-3wks only because my office/pts are at pretty high elevation.

 

[air bud]

The 1wk visit is mainly to get new clean + dry dsg on (try keeping a foot dsg clean for a week - much less 2wks), dry out the incisions with clean gauze and alc around incisions +/- betadine wipe. You also need to refill their narc Rx typically (different states allow diff quantity/length of narc Rx).

Mainly, you also have to catch any cellulitis or hematoma or non-compliance early (catch lack of pt understanding on WB status, meds, etc)... obviously can be detrimental if you do not. You can't really tell the patient "just call if your wound is getting all macerated or if you get a hematoma." A whole lot can happen in 2wks... but easy to take a 1wk look.

Also nice to have the 1wk visit in case pt pt was obviously walking a lot... or if PACU had missed XR for some reason (you need immed post op for ABFAS).


I do 2-3wks only because my office/pts are at pretty high elevation.

Agree on 1 week...

 

[Hybrocure]

I’m probably the only one who does this but I won’t take sutures out until 3 weeks. Usually go 1 week and then 3 weeks on post ops for elective cases. Then depends on what was done

I find myself doing 3 week suture removal more often than 2 week. Sometimes I see them at the 14 day mark and the incision looks a bit iffy for me to want to remove them. Either it’s macerated or just looks like it needs to heal a bit more.

I’m a 1 week then 2 week guy. But running into the above I’m considering just switching to 1 week and 3 week


Also - this is totally TFP thread material 😂

 

[Bluecollarmed]

fluoro pics count as immediate postop for abfas so I prefer the images I get in the OR rather than the 3 obliques from pacu. Steri strips on if I'm hesitant on the incision at 2 weeks. Now obviously there's no one size fits all. I have some at 1 week follow up and some that aren't quite ready at 2 weeks but my staff and xray like to have established protocols so they know when to order xrays and such based on their post op week.

 

[DYK343]

Im 1 and 3 week guy.

1 week to make sure no infection/hematoma/complication.

If infection I want to see it at 5ish days post op not 14 days post op.

I remove stitches at 3 weeks. Doesnt hurt to leave them in a bit longer.

Then usually somewhere between 6-8 weeks.

Then 12 weeks.

Ive found post op visits are relatively fast and straight forward.

Always call the next morning too to make sure they are not in 10/10 pain and doing well. Patients love this.

I refuse to give my cell number tho. Hard nope on this. Im not that nice.

 

[Hybrocure]

Im 1 and 3 week guy.

1 week to make sure no infection/hematoma/complication.

If infection I want to see it at 5ish days post op not 14 days post op.

I remove stitches at 3 weeks. Doesnt hurt to leave them in a bit longer.

Then usually somewhere between 6-8 weeks.

Then 12 weeks.

Ive found post op visits are relatively fast and straight forward.

Always call the next morning too to make sure they are not in 10/10 pain and doing well. Patients love this.

I refuse to give my cell number tho. Hard nope on this. Im not that nice.

I give my cell and call the night of surgery. I need the peace of mind because if something goes wrong they’re gonna find a way to get ahold of you regardless lol

 

[Feli]

I give my cell and call the night of surgery. I need the peace of mind because if something goes wrong they’re gonna find a way to get ahold of you regardless lol

Same... no surer way to PO a patient than they can't reach you or have to go to ER for something easy (wet bandage, out of Rx, rash from abx, etc). I have the rare inpt or ER person I don't want to have my number, but all elective and most trauma pts and DM wound/amp get it also.

( I have my office do the check phone call that afternoon... they get me if a question they can't answer, but they know the usual mantra of ice behind knee, keep boot on, use walker, elevate, use Rx, etc etc)

...I'd say the rate of pts calling or texting me is below 5%... probably well below 2% or 3% over the years. It's typically real stuff if they text: bled through bandage, had a fall, low on Rx, foot still numb 2 days after surgery, pain not controlled with Rx, etc. (I do tell them when I give my cell to try office first if it's office hours).

I have had just a couple of them who text and want to ask me what brand of compress stockings is best or want to tell me their cousin sprained their ankle, but I just politely put a quick stop to that ("we can talk in the office, but my cell was mostly for emergencies right after your surgery). That's 0.1% nonsense.

 

[dtrack22]

2 weeks for all elective and trauma (assuming closure is obtained, any cases with residual wounds or vacs get seen ~5 days later). Most diabetic offloading wound procedures I see at one week and again at 2 weeks because I can bill for excisional debridement at those appointments. Then again at 6 weeks and then again 2 months after that. So two post op visits in the global for just about all elective surgery.

I do one narc Rx refill but that’s done through the EMR so no need for them to come in to get a paper script. Haven’t had any issues with post-op infections or hematomas in my elective folks. I’m ok with sterile bandages placed in the OR over a closed incision site that wasn’t actively bleeding being on for 13 days.

I do remove sutures at 3-4 weeks for virtually all amputations. I have maybe had a toe amp that was good at 2 weeks but I don’t trust any of them so more time is better.

None of my patients have my cell phone. They can go to the UC or ED if there is a problem and our docs there can decide whether I need to be called or not. I don’t call them after surgery. They can let the office know if pain is not controlled the next day. I would probably call patients and ask em how things are going if I was in a different practice setting, like if I wasn’t the only option for 40-180 miles, or the only one taking Medicaid, and/or if google reviews mattered. I spend plenty of time with the patients prior to surgery, they are well educated, they know I care about them…probably…

 

[Utvolsdpm]

I bake a plate of foot cookies and deliver the day after surgery in my diabetic shoe delivery van. Patients love this.

 

[Bluecollarmed]

I bake a plate of foot cookies and deliver the day after surgery in my diabetic shoe delivery van. Patients love this.

I am wholly serious when I say my rural hospital bakes a loaf of bread and gives it to all day surgery and inpatients upon discharge.

 

[DYK343]

Haven’t had any issues with post-op infections or hematomas in my elective folks.

You've never had a post operative infection?
Or just never had one you couldnt manage at 2 weeks?

None of my patients have my cell phone. They can go to the UC or ED if there is a problem and our docs there can decide whether I need to be called or not.

Im 100% with you. I have a google number I call them the next morning on.

I refuse to interupt my family time on the weekend to deal with constant calls. I operate electively on Fridays. Average 5ish cases every friday. If I gave out my cell im guarenteed to be blown up over weekend.

Weekends are my time for the wife/kids. Bunion surgery hurts. Elevate and Ice. Take the meds I prescribed.

But I do call them the next day. If 10/10 pain they get an extra 5 oxycodone instant release.

Im pro ibuprofen for the first 3-5 days then I tell them to stop for fusions.

I gave out my number early on and it was mega abused. I learned right away that the public is *****ic and will call with every little detail. Ive never practiced in a highly affluent patient population.

 

[dtrack22]

You've never had a post operative infection?
Or just never had one you couldnt manage at 2 weeks?

The latter. Though our hospital tracks all post-op infections and we get updates on our own rates. I’m between 1-2% including diabetic foot stuff. So I’m rarely seeing them to begin with.

 

[Sole Badguy]

For bunions, I do follow-ups at 1, 2, and 6 weeks for reasons as mentioned above. Is the 12 week follow-up necessary? I just tell them to follow up if needed around that time, and they usually don't. As was suggested, I think it could definitely be done outside global but IDK