When local doctors disappear, patients pay the price [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

A patient with a dying leg won’t drive 20 miles for care. In Devin Zarkowsky’s town, that’s not a hypothetical. Vascular surgeon Devin Zarkowsky runs a solo office-based practice in a San Diego County town where peripheral arterial disease patients had nowhere local to go, and Jason McKitrick is the executive director of the Office-Based Facility Association. They discuss the KevinMD article “Why local care matters for peripheral arterial disease.” You will hear how the Medicare physician fee schedule pays hospitals for big-ticket equipment but pays solo doctors out of the same bundled rate they use to cover staff and wire and drapes, why a four-figure atherectomy or Shockwave catheter swallows a week of revenue when there is no separate reimbursement, and why Congress is finally looking at fixing it after years of small fixes that did not close the gap. You will hear what local care actually means when a patient cannot drive and the limb cannot wait.

Partner with me on the KevinMD platform. With over three million monthly readers and half a million social media followers, I give you direct access to the doctors and patients who matter most. Whether you need a sponsored article, email campaign, video interview, or a spot right here on the podcast, I offer the trusted space your brand deserves to be heard. Let’s work together to tell your story.

PARTNER WITH KEVINMD → https://kevinmd.com/influencer

SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at kevinmd.com/podcast. Today, welcome Devin Zarkowsky and Jason McKitrick. Devin is a vascular surgeon. Jason is the executive director for the Office-Based Facility Association. The KevinMD article we’re talking about today is “Why local care matters for peripheral arterial disease.”

Devin and Jason, welcome to the show.

Devin Zarkowsky: Thank you very much, Kevin. We sincerely appreciate it.

Jason McKitrick: Thank you very much.

Kevin Pho: All right. So I’m just going to ask both of you to briefly introduce yourselves, and then we’ll kick off with the article. Devin, why don’t you go first?

Devin Zarkowsky: Well, thank you, Kevin, for having us here. We appreciate the opportunity to talk on this podcast.

I am a vascular surgeon. I have a solo practice office-based facility in Fallbrook, California. I’ve been in Southern California for several years now, and there’s a lot of underserved peripheral arterial disease patients that we’re hoping to take care of.

Kevin Pho: All right. And Jason, you’ve been on the show before, but for those who forgot who you were, just give us a little reminder and briefly share your story.

Jason McKitrick: Jason McKitrick, Liberty Partners Group principal and the executive director of the Office-Based Facility Association.

Kevin Pho: All right. So the article we’re talking about is “Why local care matters for peripheral arterial disease.” Devin, for those who didn’t get a chance to read this article, just share why you decided to write it, and then about the article itself for those that didn’t get a chance to read it yet.

Devin Zarkowsky: Yeah, absolutely. I think over the course of my training through medical school, residency, fellowship, I’ve been an academic, I’ve been a private practice doctor, but I did a lot of work early on looking at barriers to care, disparities in care. I had a particularly important mentor of mine, Philip Goodney at Dartmouth, who had a map in a 2013 article showing areas that, you know, were underserved and had a lot of amputations associated with peripheral arterial disease and diabetes.

It happens that I landed in an area of the world where that is occurring. Something I learned in residency was that folks tend not to want to leave too far from where they live to go seek care, and that’s a pattern in Southern California that holds true. I have people in my town that don’t want to drive more than 15, 20 minutes even though they might have a black toe, and that’s happened again and again.

As I’ve decided where to lay roots, it’s been in an area of San Diego County that just is unusually underserved. And so that’s what brings us here today to discuss how best to bring care to underserved environments.

Kevin Pho: So Devin, just to follow up, you mentioned that you have an individual private practice. So as a vascular surgeon, how common is that in the United States for vascular surgeons to have solo practices like the one you have?

Devin Zarkowsky: Phenomenal question. I want it to be more common. I tell my friends all the time, you know, this style of practice really brings you back to your roots. It’s you and the patient talking about medicine.

The classic vascular surgeon over the last 30 years has been a hospital-based doctor. You know, the surgeries that we do for open care, they’re complex. These patients are very sick. They require a hospital setting if you make an incision. What’s interesting about the last 20, 25 years of the endovascular revolution is technology has really made it possible for us to do this in an office-based setting under local anesthetic.

And so all of that complexity falls away when you don’t have the physiologic dyscrasia associated with open surgery. And so it is becoming more and more common for vascular specialists to practice in the manner that I practice.

Kevin Pho: So Jason, you are the policy expert kind of bringing that perspective to this discussion. Tell us about some of the threats from a policy standpoint that solo practitioners like Dr. Zarkowsky are facing today.

Jason McKitrick: Well, one of the reasons I’m grateful to be back on your show, Dr. Kevin, is that you may recall previously we had an interventional radiologist on. But there are many kinds of office-based specialists. IRs in the case of Dr. Zarkowsky, vascular surgeons, interventional cardiologists. And even going outside of endovascular, radiation oncology, urology, many, many kinds of specialists that are similarly situated to Dr. Zarkowsky.

So what we’re seeing in the office-based setting, which is really not well understood relative to what happens in a hospital or an ASC, in the office-based setting you can do a lot of these really advanced technologies minimally invasively with, as Dr. Zarkowsky said, you know, moderate sedation. And do it as a lowest cost option. But because of the really significant hospital health system consolidation over the years, many of those options are going away as an option, particularly in rural areas. So that’s a big threat and something we’re working hard to reverse.

Kevin Pho: So Jason, tell us specifically about the policy threats that we’re talking about that make practices like Dr. Zarkowsky’s very difficult to find and spread.

Jason McKitrick: Well, you know, there’s been a lot of talk in recent years about what’s called the Medicare physician fee schedule and how badly it needs to be reformed.

And what has happened over the years is as these high-tech but higher cost, you know, supplies and equipment have come out of the hospitals to allow guys like Dr. Zarkowsky to do their job, the physician fee schedule, Medicare physician fee schedule, there’s been a lot of discussion about reforming it in recent years. And the reason that, the fundamental reason why it needs reform is that as high-tech equipment and supplies have come out of the hospital and gone into the office-based setting to allow guys like Dr. Zarkowsky to do their job, the money from a reimbursement standpoint has not gone with it.

And so the physician fee schedule effectively has been subsidizing the hospital setting for years. And so we think if that’s the problem, then the answer is to fix that, and to pull those practice expenses out of the physician fee schedule and pay for those practice expenses in the same kind of way that we pay for practice expense in the hospital. That would go a long way to stabilizing office-based care and a long way towards parity between those two settings.

Kevin Pho: So Devin, as you run your solo practice, just tell us what it’s like on the ground about some of these policy implications that Jason’s describing. How does that affect you individually? Maybe give us some stories about how those policy changes affect you on an individual level.

Devin Zarkowsky: Great segue because I was just going to say I wrote a check this morning for about one-seventh of my bank account that I have to run my practice to support equipment costs. And so I think what Mr. McKitrick is getting at is the necessary expenditures that are associated with properly equipping a safe outpatient office. And I take this seriously. You know, I want to make sure that when a person comes into my office for care, that the experience is going to be equivalent to or better than ambulatory surgery center, hospital setting that they might be exposed to otherwise, and that comes with a significant cost.

And so when Mr. McKitrick talks about stabilizing the practice fee structure for physicians, this is exactly what he’s getting at. I would, you know, I’m always looking at how to make endovascular care better. And to be able to have equal footing at least with, you know, hospital systems and ambulatory surgery centers in the area would be a boom.

I’ll give you an example. When we have somebody with recalcitrant calcium, and I’m thinking about a case from earlier this week, we have wire, sheath, drapes, and staff which are par for the course. Those are not necessarily the big-ticket items. But to really get a good result, there’s atherectomy catheter, and now thankfully at the turn of the year, we have Shockwave, which is an intravascular lithotripsy device. And both of those devices are four-figure expenditures that are reimbursed as part of the RVU structure from Medicare. If there was a way that we could segment them out similar to the way the hospitals and ASCs do, you know, I’m thinking about this case earlier this week, it would’ve made a significant difference in how I’m able to run my practice and staff it.

And so I think ultimately what we’re getting at is restoring the medical fabric in this particular town, Fallbrook, which has been affected by all of the consolidation in the area. You know, the patients that I take care of come to me for this sort of procedure because they have to drive, you know, 15, 20 miles in either direction. And I’m glad to be there, and I hope to be there for years and years to come and reestablish the medical fabric in that community.

Kevin Pho: Devin, you wrote about a patient’s story in your article. So if you weren’t around to provide that local care, just give us a sense of how removal of that option would affect patients. If you weren’t available, where would patients go for vascular care?

Devin Zarkowsky: So I had a patient last week who had bone fall out of a wound in their foot in my office. And so the answer in many cases is they won’t. The savvy consumer of health care, which unfortunately a lot of my patient population is not, would drive. There’s a 20-mile drive north, a 20-mile drive south that they could make. But in my particular patient population, that is challenging because the limb is dying, and it’s hard to get around if you can’t walk, let alone drive.

And so when we talk about the heat map, like Dr. Goodney drew in 2013, the issue is multifaceted. It is being a good consumer, it is having the resources, it is being mobile to get to the place, and then having the wherewithal to work within a system that is complicated to get the care that you need. By being in the town that I’m in, I provide that resource without much effort. Does that answer your question? It’s a long-winded answer, I apologize.

Kevin Pho: No, absolutely. I’m interested in hearing, of course, what we’re talking about as to how it relates to patients, because really, that’s the core issue, and that’s what it comes down to, of course. Jason, from a policy standpoint, are we making any headway? Because I know that we’ve had a similar conversation a few months ago. Anything on the horizon from the policy standpoints? Do our policymakers and legislatures, is this on their radar? Do you expect some movement regarding this going forward?

Jason McKitrick: There actually is, I’m glad to say. I mean, the 2026 physician fee schedule reversed some of the bad news. We talked on a previous podcast how in the physician fee schedule in 2025 there were 300 office-based interventional services where the reimbursement was literally less than the cost to do them. The 2026 physician fee schedule that started January 1 of this year helped to reverse some of that.

But Congress does actually, it looks like they may try to do something much more fundamental going forward. There was a hearing, a couple hearings in the Congress this past week, one with Ways and Means and one with Energy and Commerce Committee. And in the Energy and Commerce Committee, they actually talked about the very issue we’re talking about, that the practice expense portion of the physician fee schedule is flawed. And one of the members, Congressman Joyce, talked about this very concept about paying for practice expense in the office-based setting more like we pay for practice expense in the hospital-based setting.

So everything we’ve been talking about, the Congress has actually really taken a hard look at, and we may just very well see some movement here later this year, which would be amazing.

Kevin Pho: We’re talking to Devin Zarkowsky and Jason McKitrick. Devin is a vascular surgeon. Jason is the executive director for the Office-Based Facility Association. The KevinMD article we’re talking about today is “Why local care matters for peripheral arterial disease.” Now I’m going to ask each of you just to end with some take-home messages that you want to share with the KevinMD audience. Jason, I’m going to have you go first, and then we’ll end with Devin.

Jason McKitrick: Well, I think the take-home message here is that after many, many years of talking about reform to the physician fee schedule and, more broadly, about these concerns about hospital consolidation and what that means for patient cost shares and patient access, particularly in rural areas, it looks like Congress may very well try to tackle those issues, which would be gratifying and ultimately, as you said, Dr. Devin, would really be great for the patients. So, fingers crossed.

Kevin Pho: And Devin, before you share your take-home message, just explain to us why you still do what you do despite the financial headwinds. I’m sure it would be easier financially for you to join a bigger group in a bigger city. So tell us why you do what you do and then end off with your take-home messages.

Devin Zarkowsky: My father was a solo practice dentist for 40 years in a small town. This is unusual, but I thought I was going to be an academic ivory tower kind of guy. It just didn’t turn out to be me. I’m slowly turning into my father, quite frankly, and it’s the nature versus nurture argument there. I’ve just found that I’m happier on my own out in this corner of the world, you know, plowing a field. It’s just a me thing. It’s not really necessarily everyone. So, that’s what I would say.

You know, takeaway here, physicians, we need to unite. We need to find our common voice. These communities that we work in, there is a fabric that we need to restore by rediscovering the root of medicine, which is the doctor and patient relationship. I mean, this is not scalable. AI will never supplant it. We can’t listen to people telling us that we’re not good at business. I mean, we memorize the various renal tubular acidoses and what the Edinger-Westphal complex does, so we can use AI to create a balance sheet and a P&L statement for goodness sakes.

You know, the route forward is through taking control of our future as a profession, and stabilizing practice payments in favor of outpatient treatment is the way to do it. You know, I think Mr. McKitrick is exactly right on that point.

Kevin Pho: Devin and Jason, thank you so much for sharing your stories, time, and insight. Thanks again for coming on the show.

Devin Zarkowsky: Thank you very much, Dr. Pho. Appreciate it.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes