A patient walked into a small-town office and a piece of bone fell out of a wound in their foot. The nearest alternative was a 20-mile drive most of these patients can never make. Vascular surgeon Devin Zarkowsky runs a solo practice in Fallbrook, California, and Jason McKittrick, who leads the Office-Based Facility Association, explains the payment formula quietly closing offices like it. When local care disappears, the limb does too.

⏱️ Chapters:
0:00 Introduction
0:35 The town where a black toe still means a 20-mile drive
2:43 Why solo vascular practice almost stopped existing
3:37 The formula that pays a surgeon less than the supplies cost
6:41 Writing a check for a seventh of your bank account
8:00 The four-figure devices buried inside one Medicare code
9:14 When the limb is dying, driving is not an option
11:57 The bill in Congress that could keep the doors open
12:52 Why this surgeon stays when leaving pays more
14:46 Take home messages

About this episode:
Devin Zarkowsky is a vascular surgeon who left the academic track to run a solo office-based practice in Fallbrook, a San Diego County town hit hard by hospital consolidation, where peripheral arterial disease patients had nowhere local to turn. He explains how the endovascular revolution moved complex artery work out of the hospital and into the office under local anesthetic, then describes the catch: Medicare bundles four-figure devices like atherectomy catheters and intravascular lithotripsy into a physician fee schedule that pays less than the supplies cost, forcing him to write a check for a seventh of his bank account to keep the office equipped. Jason McKittrick, executive director of the Office-Based Facility Association, traces the structural flaw, the practice expense money that stayed with hospitals even as the technology left them, and argues the fix is to pay for office-based practice expense the way hospitals are paid. He points to recent congressional hearings, including one where a member raised this exact issue, as the first real sign of movement. Zarkowsky grounds the policy in patients who cannot drive because the limb itself is failing, and in a heat map of amputations his mentor first drew in 2013. He closes on why he stays, a solo dentist father, a community whose medical fabric he wants to rebuild, and a conviction that the doctor-patient relationship cannot be scaled away. The result is a clear look at why care close to home is disappearing, and what it costs the people who need it most.

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