A Symbiosis: Pedorthists & Podiatrists Working Together

With low insurance reimbursements and competition for patients, the relationship between pedorthists and podiatrists can be, well, strained at times. "Everyone is chasing the same buck, especially with reimbursements the way they are," says Dean Mason, CPed, CO/L, OST , vice president of the Pedorthic Footcare Association (PFA). There has even been some backlash to the decision by the American Podiatric Medical Association (APMA) to enter into an agreement to hold its 2015 annual symposium in conjunction with PFA's symposium. "There was a controversy when I came out in favor of the meeting," says James McGuire, DPM, CPed , director of the Leonard S. Abrams Center for Advanced Wound Healing at Temple University's School of Podiatric Medicine. "I got negative feedback from a few podiatrists who felt that they didn't need pedorthists and that they were competition for their practice." That's not the case though, he says. "A pedorthist working with you or as a close referral source can actually enhance your practice, and in many instances can do things you would rather not be bothered with in your office, freeing you up to concentrate on aspects of your practice that are more lucrative." The truth is that a good pedorthist-podiatrist relationship can benefit everyone, the experts say. The pedorthist and podiatrist can each increase their business revenue, get more referrals, and best of all, the patient has the benefit of a medical team working alongside one another for the best possible care. "Podiatrists don't need to be threatened by pedorthists, and pedorthists don't need to be threatened by podiatrists," says McGuire. "The work they do is complementary." Instead of competing, pedorthists and podiatrists should work to understand each other's natural strengths and be willing to team up for the benefit of everyone, Mason says. "We feel that pedorthists and podiatrists are a natural fit, and the more we do together will be a win-win for everybody." Good for Pedorthists For pedorthists, a good working relationship with a podiatrist can mean more referrals, better patient care, and an overall better bottom line, the experts say. Maureen Kaljeskie, CPed , who works at Syracuse Orthopedic Specialists, New York, has been working with podiatrists for almost all of her 28-year career. She started her career as a medical assistant to a podiatrist, and about ten years ago, the podiatrist sent her to school to become a pedorthist. Her clinical experience helped with her classes, and soon she was certified and working with her former employer. They complement each other, she says. "Podiatrists are medically and clinically geared [toward] making the diagnosis and devising a treatment plan," Kaljeskie says. "Then...the pedorthist implements the podiatrist's treatment plan. This is an added benefit of practicing together; it ensures the patients get the care they need as soon as possible, allowing us to resolve the patients' problems much quicker." Sarah Garcia, CPed , and Mitchell Waskin, DPM, FACFAS, ASPS , with the Foot & Ankle Center, Richmond, Virginia, have such a good working relationship that he paid for her pedorthic education. Because of the partnership, Garcia has learned new things, advanced her career, and contributed to a medical practice that she cares about. Waskin refers patients to Garcia, and she sends referrals to him when patients come to her needing more care than she can provide. "I rarely see [Waskin], but he sends patients over here and we get along well," she says. "Once you earn trust from a doctor, they will trust that you will do your best too." In turn, a good working relationship can help pedorthists increase their profits, McGuire says. Once he started working closely with a pedorthic practice, the pedorthists would talk to him about devices that were both economical and would work well for patients. Once he knew that, McGuire says he was more likely to prescribe the proper orthosis the first time. Good for Podiatrists For podiatrists, working with a pedorthist often means more referrals, more business, and another person to look out for the health of patients. Garcia says that she is not the only one who gets referrals by having a working relationship with a podiatrist. "Sometimes a patient will come in, say an amputee, and have an active wound" on his or her remaining foot, she says. "I will send them right to the doctor while they are still here." Beyond additional referrals, McGuire says that working closely with a pedorthist, whether or not in the same building, just makes good business sense. "If you share the community with another successful person, everybody benefits," he says. "There's enough business for two, and having a pedorthist around doing what you used to do frees you up to do other things that are probably more lucrative than what you would make otherwise." Also, he says, working with a trusted pedorthist helps keep the patients coming back. "They weren't going to an outside person who might refer them somewhere else," McGuire says. "It was a way to keep them at home." A pedorthist will have the expertise to help a podiatric practice's bottom line, says Waskin. "The pedorthist will naturally increase the services in the clinic beyond what I would have expected because of their training," he says. "They look into other areas that will pull in income, and it's a product or service that we've never thought of before. We've had the chance to increase our products and services because a pedorthist is involved." Good for Patients Overall, a good pedorthist-podiatrist relationship benefits the patients, the experts say. "Convenience [for] the patient is the best thing," Garcia says. "They don't have to go anywhere else. They don't have to get referred out or even leave the building." That helps ensure the patients get the care they need as soon as possible, Kaljeskie says. "The patients feel like there's a team helping them, and if they are seeking help, they want to get better yesterday." In cases where a pedorthist is in the same office, he or she also has access to medical records that will help in the assessment of patients, Kaljeskie says. "Often a pedorthist will have to rely on calling and leaving a message for a podiatrist if they have any questions," she says. "I will pull a patient's chart before I see them, and I understand it all. With all of the new [Health Insurance Portability and Accountability Act] laws, it's harder to get records to an outside source." In emergency situations, this relationship is especially helpful, says Garcia. If a pedorthist has an appointment with a patient who needs immediate care, it's accessible right there. It also works the other way around, she says. "If he [Waskin] has a patient who has a bad ulcer, he's able to send that person a couple of hundred feet away, and I can make something for them right away," Garcia says. "I do work off of a schedule, but if it's an emergency, we can work around it." The Partnership Model A successful relationship between a pedorthist and podiatrist can take many forms. For many years, McGuire and his associates shared an office building with a separate pedorthic practice. The two practices worked closely together, routinely discussed patient problems and solutions, and cross-referred patients on a regular basis. For them, the model of separate practices working in concert worked well. McGuire says, "They were able to provide a great service for our patients, and I believe we were able to enhance the level of pedorthic service they were able to provide. The extra traffic in the office [building] definitely increased business for us," he says. He also liked it because his practice didn't have to worry about the Centers for Medicare & Medicaid Services (CMS) durable medical equipment, prosthetics, orthotics, and supplies paperwork associated with providing their own pedorthic services, and even though the podiatry practice missed out on that revenue stream, it ended up making more money because the partnership allowed the physicians to focus on higher-revenue opportunities. "We were busy enough with the medical and surgical aspects of our practice that we didn't need to take the time out of our practice to become experts in the effort it takes to really run a top-notch pedorthic service," McGuire adds. At the Foot & Ankle Center, Garcia is Waskin's employee. For her, this is a perfect situation, she says. "I have no desire to start my own practice," she says. "The overhead, having to get referrals from other physicians-I've known pedorthists on their own, and for most of them the business ends up closing down. This is the perfect solution. He pays me a salary, he gives me good benefits, and he sends me patients." Plus, she says, she went into the business to treat patients, not to do paperwork. "I'm more into helping people and that's pretty much what I do," Garcia says. Waskin says that having Garcia as an employee also benefits him because the revenue stream she generates stays within the practice. "The way you make money is by having people work for you," he says. "By having a pedorthist, it allows the podiatrist to be seeing other patients and generating revenue for the practice while at the same time the pedorthist is generating revenue." Legally, Waskin says, the pedorthist-employee model could be set up either with a separate tax identification number for the pedorthic side of the business, which essentially makes it another business, or with the same tax identification number, which keeps it legally tied to the podiatry practice. For a number of reasons, he says, it's better to have the pedorthic side of the business under the same tax identification number. "With a lot of the self-referral regulations, and in the case of bidding for durable medical equipment, it would be much more difficult to have the pedorthic side as a completely separate business," Waskin explains. "For bids, you are competing against large entities in the industry, and the bigger your business is, the greater the competitive edge." Making It Work Trust and experience are the keys to a successful pedorthist-podiatrist relationship, the experts say. For Waskin and Garcia, the pair were lucky enough to have already worked together before she became a pedorthist. Afterward, it was a matter of getting used to the new relationship and learning how to work together. "It worked exactly as it would with any new person I hired," Waskin says. "Anyone who comes in the clinic will have some oversight for a period of time so I can see how they do things, and [they can] learn how I like them done. At some point, we understand our respective duties, and it gets to the point where oversight is rarely needed." The experience of all those years working with Waskin also helps, Garcia says. "I think because I was his assistant for at least six years and I was by his side in the office [and] in the treatment rooms, I knew what he wanted," she says. "It's now gotten to the point where I talk just like him." McGuire says it only took a couple of months for their practice to be completely comfortable with the pedorthic practice in the building. "After only a few months of working together, we'd simply send over a script and that was it," he says. "We got to the point where we wrote it right the first time, and they would make it right the first time. [It was] less stress for all of us, and the patients were happy with the results." One way to help build that relationship is for the pedorthist to support the podiatrist, Mason says. He says that patients often blame the physician if they aren't feeling right, even if it's the fault of the patient. "Patients are very good at selective hearing," he says. "Ultimately, if something doesn't succeed, the doctor will be blamed, and our job is to protect the doctor's reputation." To help do that, aside from supporting podiatrists when they are working with patients, pedorthists also have to do their jobs well so the patients have nothing to complain about. "By performing well, we make the doctor a hero in the eyes of the patient," he says. "I want the doctors to know that 'we got your back.'" As long as everyone is doing their jobs well, everyone wins, McGuire says. "What I've found in my lifetime is that if you help other people to make a good living, they help you." Maria St. Louis-Sanchez can be reached at msantray@yahoo.com .

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