Direct Care with a Podiatry Twist

^{This article was originally published on KevinMD.com on July 1, 2022.}

A patient, let’s call him Jay, came to me refusing a leg amputation. He had open sores that were necrotic, foul-smelling as if he had been neglected for a long time. At his consultation, he fought with every cell of his being, refusing to lose his leg as his uncle did. He wanted a second opinion on whether or not his foot could be saved.

Traditional insurance-based medicine has been an incredible resource for patients like him. From emergency room admission to wound care clinic treatments, surgical costs in the operating room, medications, and a lot of the coordinated care amongst various doctors and home care visits are basic benefits of insurance health plans. Many people are involved in caring for one patient, and with that comes a huge bill to the patient and the system.

However, parts of his care were still left unfulfilled in the insurance-based model, which is how the movement towards direct specialty care (DSC) is getting more attention. Doctors know patients need continuous long-term preventive care options. Patients want more time with doctors and quicker access to feel truly cared for and therefore are willing to follow medical recommendations.

Instead, what we have is fragmented health care. A doctor provides the recommendation in a short 7-minute or less visit, and then they move on to the next patient.

Patients are left frustrated, and slowly they start having doubts about the medical care system, refusing treatments that eventually hurt them.

Jay had Type 2 diabetes, peripheral neuropathy, and arterial disease, the terrible triad that significantly increases the risk of leg amputations. He was on his way to developing kidney disease as well. He had stopped trusting the system because he didn’t feel cared for. It was at the encouragement of his family member and one of his trusted doctors who knew about me that he finally came for that second opinion.

I perform foot amputations all the time, and I assist in leg amputations as well. It doesn’t get easier to tell patients what is inevitable, that their disease is too far gone to salvage, and that amputation is the treatment. But I hit a breaking point, where patients were not getting proper preventive foot care after amputation after amputation. They didn’t always get preventive foot care from a podiatrist, which is the number one thing that prevents the risk of amputations. Or they got the care that was fractured, where one doctor only treats certain foot pathology while another does something different. Patients get confused about who does what over time and ultimately don’t go to anyone.

DSC fills in the gaps of insurance-based practices. I tend to the patient’s physical and emotional needs in my holistic approach. Before I could even provide a treatment plan, I had to earn Jay’s trust, starting with listening. Something so easy to do, yet the traditional medical system keeps pressuring doctors to give less time to patients so that we can see more to generate more revenue. The classic see-more-make-more strategy of insurance-based practices is hurting patients and doctors.

Underneath Jay’s resistance to medical recommendations like his follow-up appointments and the recommendation to amputate a necrotic foot was pain and fear. He had health insurance, but it failed to serve him in the most basic way. By failing to allow doctors the autonomy to practice medicine on their terms, doctors don’t have the luxury of time to spend with patients. So patients lose trust in this system and end up in the emergency room, or worse, they die.

Something had to change. I was completely frustrated that I couldn’t help patients with the holistic podiatry care they needed. So I adopted a membership model similar to direct primary care but with a podiatry twist. Once I opted out of insurance, this is what happened in my direct specialty care podiatry practice:

1. I now spend close to 60 minutes with patients, rather than the 7 to 15 minutes allotted by traditional insurance-based practices. The time traditionally spent on bloated charting, billing codes, claim denials, prior authorizations, and completing metrics irrelevant to patient care is gone. When patients pay me directly, my only obligation is the patient’s satisfaction with my care. Therefore, I’m held to a higher standard.
2. I see fewer patients and provide higher quality care, helping patients like Jay avoid preventable leg amputations.
3. In this membership model, everything a patient with diabetes could ever need to prevent leg amputations is included for one price. Preventive foot care like nail care, callus reduction, wound care, and any minor procedures would reduce the risk of diabetic foot ulcers. I can provide office-based care, including surgeries, significantly decreasing care delays and overall expense.
4. I get to be the patient’s health coach to guide them in their medical journey, so they also have autonomy in their care, rather than leaving them feeling they were being brushed off as Jay felt. CPT code not needed.

I have many patients choosing this membership model in addition to having health insurance. If they have insurance, prescriptions, advanced imaging, hospital care, and referrals can still be used. It’s just a matter of time before more and more doctors will choose to opt-out to offer a more sensible option like I did. This membership model is the holistic approach patients like Jay needed to save their legs.

And yes, through my membership, Jay received all the care he needed to avoid the leg amputation. He healed his wounds and remained independent until the last of his days when he left his Earth suit.

This article is written in his memory to honor the loving man that he was and the special privilege I had to be part of his journey.