Will we see podiatrists working for WalMart?

[Feli]

THIS thread discussion from 2007, shortly before Western Univ pod opened, is one of the best SDN podiatry threads ever. It was conversational, good points, good discussion, no insults, probably should be a sticky?

The whole thread is awesome, way ahead of its time, and I think posts like this and this are as true today as they were 15+ years ago.
It correctly predicted many things, most notably the upcoming residency shortages and continued lack of selectivity for podiatry admissions.

That is how SDN podiatry usually was back then... good content, much less sarcasm and derailing.

It was also three podiatry schools ago (Western had just been approved and was not yet taking students).
You can tell its age when there are references to $150k-200k being pod avg school debt, new 9th school, 500 residency spots, etc.

Are the concerns even more legit now?

• "...Many schools are already scrapping the bottom of the barrel to fill the class..."
• "...problem with having so many pods that are not up to snuff is that they become disgruntled with the profession like what happened several years ago when there were not enough residencies to go around..."
• "...more students than residency programs..."
• "... If the council of deans make up the AACPM and the CPME how can they make unbiased decisions?..."
• "...DPM on ever corner and two working in the local WalMart..."

The reidency shortage did happen shortly after Western Univ Podiatry began churning out grads.
The ROI for podiatry is significantly lower now (tuition rose much faster than salaries) than the 15 year old thread.
The podiatrist organizations are still intertwined with clear conflicts of interest (deans and residency directors on CPME, APMA owning/funding CPME, etc).

...but, the (many) million dollar question: Will DPMs be working for Walmart? And when?

There are optometrists (OD), obviously PharmDs, a few dentists (DDS), counselors, very rare destitute MD/DO, counselors, and a lot of midlevels working for Walmart.
The public and private equity companies will use cheap labor if they can profit at clinics, urgent care, wound care, home care, whatever.
Many private equity groups employ DPMs, and a lot of MSGs have added them... on their own or due to the DPM cold calling for a job.
Some podiatrists work for mobile health corporations. Podiatry supergroups are on the rise. We have skills corps can use for billing.
Podiatry is on the verge of having the highest graduate numbers ever. There is no reason that, if we are in high supply and affordable, we would not be able to be plugged into "the machine" at more and more places.

With increasing podiatry saturation, I would say yes: DPMs will join the ODs and midlevels and PharmDs... yes, working at WalMart.
This will happen in all of our lifetimes. It is a matter of when, but it'll happen.
There even will be fellowship-trained DPMs with a Walmart badge (just like some fellowship PharmDs).
I would predict this happens shortly after the two newest schools, LECOM and UTRGV, begin graduaing residents 2030.

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[Adam Smasher]

Make an option for "foot care nurses successfully lobby to bill insurance for routine care; walmart employs them to conduct trim-and-tidy visits; demand for graduating dpms plummet"

 

[Utvolsdpm]

More like USFAS once they acquire everyone’s practice. Will be more similar to aspen dental or eyeglass world.

 

[Adam Smasher]

I still think that a pod school in Texas (UT) would be great; they have a solid residency already and the university has the capable faculty, funding, and facilities to make a dynamite program. It sounds like many current Texas DPMs are doing great business and probably wouldn't appreciate it very much if a school nearby began pumping out podiatrists, though... certainly can't blame them when you hear about the relative DPM saturation in NYC or north Cali.

Foreshadowing?

 

[Feli]

Foreshadowing?

Haha, yeah... back in 2007, I was probably more imagining a new pod school at one of the real UT campuses (Austin or Houston... at minimum San Antonio) and closing down one of the laggard non-integrated pod schools for its place/seats.

Instead of doing a school in Houston with good DPMs, leave it to podiatry to put a Texas podiatry school in basically the worst and least visible place in the state at RGV and fill it with largely unimpressive faculty... and of course, press a residency shortage by not shutting down any other schools/seats to do it. Lol.

 

[Adam Smasher]

A real response:

I don't believe DPMs will ever work for Wal-Mart, not unless times become truly desperate. We all talk about the ROI problem with the DPM degree from a student perspective. What about from a employer/owner perspective? Podiatry is a bad investment. Those of you who are hospital employed have written about the 99% rejection rates you've run into. And that's assuming you can generate spillover revenue ordering PT/MRIs etc.

The way Wal-Mart makes it make sense is if they have a toenail clinic (obviously they give it a better title than that) where they pay a foot care RN 65k to trim the nails and do a foot screening. Forget mid-levels, this is beneath their skills. Obviously Wal-Mart needs to overhaul the nursing legal scope of practice, but we're predicting the future so why not? The RN then refers the pt to the foot care section to purchase some dr scholl gel inserts and an antifungal/moisturizing potion/lotion.

DPMs are too expensive to employ. We'd end up doing xr and treating the 10% of actual pathology that comes in. Times would be really desperate for us if it actually happened.

 

[GreenHousePub]

Once again, like every other cases, Walmart wants people that can do many different procedures. The scope for podiatry is too limited to justify hiring one.

 

[podourology]

They can’t even get enough RNs to cover hospitals and PA/NPs to cover Family medicine deficits. Podiatry’s only downfall are podiatrists who spent the last 20-30 year committing Medicare/medicaid fraud.

 

[PTPuser]

If we were like Dentists or how old generation pods used to be where they were doing large amount of cases in-office I can see it happening. But the spectrum for us in every aspect is just too large. We have good grads, bad grads. Good pay, bad pay. Good jobs, and god awful jobs. Surgical and non-surgical...

We are all over the place.

And people will brag about this and wear like it's a badge of honor cause " We do it all!"

I would love this a lot if were like dentist / oral surgeon where almost everything is in-office and if that was the case I can see Walmart really happening.

 

[Feli]

...DPMs are too expensive to employ...

There are thousands of DPMs working for 100k or thereabouts at associate mills, mobile pod companies, podiatry schools, etc. Most of them get little to no benefits.

I'm consistently amazed how many apps podiatry jobs for even 125k-150k MSG or associate gigs in decent areas get. 150-200k supergroup or MSG jobs are truly sought after. 200k+ offers mean it's time to move to undesirable locations. We even covet VA jobs... at the bottom of their physicians' pay scale.

....Walmart wants people that can do many different procedures. The scope for podiatry is too limited to justify hiring one.

This is true.

Optometry and dent and pharmacy are services over 50% of ppl will utilize, many annually - or even monthly. Podiatry is maybe 20-25% max - lifetime.

Podiatry would have to be a once or twice weekly thing at some WMT locations. They'd want 10 nail trims, 5 DFEs, 5 injects, 5 pairs insoles sold daily to make it worth the time.

Once they realize how cheap hiring a DPM can be, they can probably make it work, though. They do it with optometry, counselor, etc services- esp in bigger cities.

Pharmacy gripes and bemoans retail Walmart, CVS, Walgreens jobs... yet they keep taking them.

The perceived stability and being in or near metro location of a Walmart clinic would be attractive to podiatrists, given our job options/market. Just like VAs, I bet they'd be largely ignored by MD yet heavily applied by DPMs.

More like USFAS once they acquire everyone’s practice. Will be more similar to aspen dental or eyeglass world.

Yes, USFAS and FASMA and HealthDrive and UpperLine employing hundreds and countless regional supergroups employing dozens of pods are already well on their way to being the LasikPlus and Heartland Dental or TeamHealth of podiatry.

The supergroup DPM associate is absolutely the fastest-growing piece of the podiatry employer pie chart, especially for new DPM grads. A fair number of experienced pods - associate and partners- end up there too via buyouts.

It's going to be interesting to see if the supergroup end games are to profit on the group itself and refers within... or to sell out to hospital/insurance groups (Sutter, Optum, Christus, Baptist, Kaiser, etc).

 

[bloxxeeey]

I don't necessarily think these big groups are bad, they offer very fair salaries. I've spoken with a couple and they'll offer PTO, benefits and about 120-130k salary with bonus 30-35% at 3x collections. They'll negotiate a bit on these things too. Versus podiatry groups, I've talked with some that offer deals that pay less than this and expect 4x collections for bonuses around 20-30%. Heck I talked with one group that offered 120k with bonus at 4x and 15%. These groups/practices were strict with their offers, no room to negotiate.

Also if you're paying a nurse 65k to work at a Wal-Mart, they may as well splurge and spend 80k because in some desirable metro's that will buy you a pod. Especially since they'll offer things like benefits I assume.

 

[heybrother]

You are experiencing anchoring bias. 30-35% is still bad.

 

[bloxxeeey]

You are experiencing anchoring bias. 30-35% is still bad.

It is but from what I understand most practices have high expenses. For example one group I was talking with said overhead is 60% so 30% is reasonable pay to me since they are only profiting 10% off my work but taking on huge risks.

 

[heybrother]

It is but from what I understand most practices have high expenses. For example one group I was talking with said overhead is 60% so 30% is reasonable pay to me since they are only profiting 10% off my work but taking on huge risks.

The real problem here is they set the pay and you get to take it or leave it.

All those things they said to you are the usual half truths that owners say. The cost of a podiatry associate in most instances isn't that much or a "huge financial risk" because they aren't actually paying you anything. Malpractice on a new grad doesn't cost much (it does go up). Many groups pay for near zero benefits though I will concede that my practice is almost assuredly dropping our health insurance next year because of its sky rocketing price against our own inability to increase prices. Our health insurance plan went up 8%. No insurance company increased our reimbursement by that much and Medicare cut our reimbursement.

The biggest risk on a new associate is that they don't actually have enough patients for you (common) and by shifting patients from their schedule to your schedule that you'll bill/treat less aggressively than they would have. They pay you a smaller percentage of the service than they would have kept for themselves but since you billed less aggressively the total revenue decreases. This is what adamsmasher referred to in another thread where he described a theoretical new associate who just punts all MSK problems to physical therapy. In a fee for service world the practice stays in business by offering more.

When I was hired my owner did the usual "overhead is 65%" story. Many expenses of a practice are fixed so when you bring in new revenue without dramatic new costs the overhead decreases as the ratio of income against expenses improves. The building is already being paid for on the collections of whoever is already working. If the practice keeps the same number of MAs, coders, office managers, etc and they work the same number of hours the costs stay the same. Other costs unfortunately are linear like EHRs that charge based on collections. Within a year of hiring me my owner had increased the percentage of his collections that he was paying himself and the office manager was telling me it was "the practice's best year yet".

Practices often have unreasonable expenses that they are unwilling to address ie legacy costs they won't shake or don't want to change like overpriced IT, EHR etc. People get fixed in their ways and no one questions that gloves from Henry Schein cost 3x what they cost from Costco. While we joke about the office manager who is also the spouse, this is another opportunity for an owner to generate wealth for their family while creating the appearance of increased overhead for the practice.

 

[Feli]

...from what I understand most practices have high expenses. For example one group I was talking with said overhead is 60% so 30% is reasonable pay to me since they are only profiting 10% off my work but taking on huge risks.

This stuff is tale as old as time.

Employers lying to associates about:
-how high overhead is
-how busy they will be (and what their collections "should be")
-how well the office runs or they'll be staffed/marketed/etc
-how there is a ton of surgery waiting for them
-how they will be offered partnership

Overhead's not 60%. It is not that much for even an inefficient solo practice.
It's probably not 60% even on the first 200k you bring in (to pay back your salary, malprac, licenses, etc).
It is definitely not 60% overhead after that... usually not even 50% in multi-doc practices... especially if insurance payers are fair or good.

The split should be much closer to 50% overhead / 20% to owner / 30% to doc. Maybe 45% / 15-20% / 35-40%.
In bigger groups or supergroups, it is probably under 50% unless they are really inefficient in terms of admin costs.

I have had both DPM groups and MSGs pay me 45% collections back when I was employed... so overhead's certainly not 60%.
The MSG was a flat 45% for 1099 (so it's more like 40% as I was paying malprac and licensing, but I also had tax shields) with 50% on hospital surgery/inpatient/wound work and anything after $400k... and 55% after 600k.
My first job group was a tiered 33% (my base) until $240k, then 40% until 400k, and 45% collections over 400k.
Another 3-doc pod group was 35% over 250k and 40% over 400k.
The point is, they sure weren't losing money on me.
Overhead is not 60%... that Kool Aid is long-expired.
Once you get out there, start working, and inevitably start doing the math, you will see firsthand how silly 30% or 35% is.

 

[p100]

Walmart can't be any worse than private practice associate.

 

[Shiyuan]

Walmart can't be any worse than private practice associate.

Prob would be better 🤷🏻‍♂️