Thinking Twice About Revenue Enhancement Opportunities
Revenue enhancement was a popular theme in the exhibit hall at the APMA national meeting last August. Every other booth seemed to offer an enhancement gimmick. These exhibits were popular, especially with the younger doctors. This brought to mind a novel I read in the mid-‘70s. It was called Five Smooth Stones and was written by Anne Fairbairn. The story was about relationships but the underlying theme was, "You pay for your luck." The idea was some good things and some bad things will come your way in life. There should be a balance. If you’re out of balance to the good or to the bad, fate will even things out. This has been a good lesson in life for me, especially as a young doctor. Some services, such as X-ray and surgical procedures, produce more revenue than they cost. These should help to defray the cost of services that lose revenue like care of indigent patients and routine foot care. In an ideal world, there is balance. Doctors make an adequate living and patients get good and necessary care. Revenue enhancement gimmicks are a way of tipping the balance toward increased profit for the doctor. Examples of these gimmicks are diabetic shoes, portable ultrasound machines, magnetic insoles and vitamins dispensed by the doctor. None of these are necessarily bad but they throw off the balance. You pay for your luck. The typical sales pitch at these exhibits includes a brief description of the product or device. One exhibitor showed me how to visualize the plantar fascia with a portable ultrasound machine. "That’s cool," I said, "but I kind of knew it was there already." "But look," he said, "you can tell it’s inflamed by the thickness." "I already kind of assumed it was inflamed because it hurts when you press it." "You can bill $180 for studies on both feet," the excited salesman exclaimed. He then gave me a brochure with the CPT codes for billing insurance companies. "You can also do another study to show when it’s healed and that’s another imaging fee." "I thought if the heel just quit hurting …" The eager salesman went on to tell me just three studies a month would make the payment on the $14,000 machine and if I did 10 studies a month, I would earn an extra $2,000. I walked off as he was trying to copy my name off my nametag. Then I stopped at a booth displaying prescription shoes for diabetics. They appeared to be standard running shoes and cheap knockoffs of a quality deep last shoe. The sales guy asked if I would be interested in making another $5,000 a month by dispensing prescription shoes to diabetics. "It’s covered by Medicare and our company does all the billing," he said. I walked away while he continued his pitch with a younger doctor. I send my patients to a quality pedorthotist who measures feet and has shoes for them to try before they walk out. About half of the patients don’t like the shoes and curse the poor pedorthotist on their next visit to me. At least they’re not cursing me. Ultrasound machines, prescription shoes, vitamins and magnetic insoles all have their purpose. When doctors use these things to enhance practice revenue, the balance is thrown off and is usually not in the patient’s favor. The doctors are going to pay for that in the end. Our role as objective scientific experts on foot care is voided when we peddle gimmicks to enhance our profits. There is a dangerous side to this as well. A doctor who takes a weekend course on using diagnostic ultrasound will likely miss a diagnosis in the near future. The round mass that looks like a ganglionic cyst might turn out to be a synovial sarcoma. Interpretation of diagnostic ultrasound images still belongs in the hands of a skilled radiologist and a trained ultrasound technologist should do the study. We have to think carefully about adding revenue enhancement gimmicks to our podiatry practices. When a small group of doctors throws off the balance, we will all pay in the end. A good test is to list what would benefit each patient without regard to the patient’s financial resources or insurance. The profitability of the service should also not be a deciding factor. We should provide the service only if it is more affordable, more convenient and facilitates better quality care for the patient. I have always found that when I evaluate my patient services in that manner, profit takes care of itself. I also sleep better and can face myself in the mirror the next morning. Dr.