Podiatry's Medicare bill is largest precisely where diabetes care broke down first. Between 2013 and 2023, Washington DC's Medicare payment per podiatry provider rose from $71,646 to $381,412, a jump that moved the district from 40th in the national ranking to 1st. That's not a billing quirk. It's a signal about what happens downstream when chronic disease management fails upstream.

DC and Arizona Rewrote the National Rankings

Two jurisdictions stand out as the decade's biggest movers. DC's $381,412 payment per provider in 2023 represents a 39-rank climb, the largest in the country. Arizona moved from 35th to 2nd, with payment per provider rising from $78,847 to $338,434 across 365 providers. Texas rose 21 ranks, from 31st to 10th, with payment per provider growing from $81,271 to $115,933.

The losers in this reshuffling are equally telling. Florida ranked 1st in 2013 at $131,538 per provider and fell to 8th by 2023 at $122,788. Florida's absolute number barely moved over a decade while DC's more than quintupled. That divergence suggests the growth isn't simply inflation or coding changes applied uniformly. Something structural shifted in specific markets.

For Medicare, the consequence is direct: higher payment per provider in a jurisdiction means more dollars spent per beneficiary foot problem, regardless of whether outcomes improved. DC's 41 podiatry providers collected a combined $15,637,897 in standardized payments in 2023. That's a concentrated cost in a small provider pool, which makes it easier to audit but also easier to miss if no one is looking.

Rural Areas Are Paying More Per Visit While Seeing Fewer Patients

The rural picture complicates the story further. In the Other/Micropolitan area type, average payment per service rose from $41.11 in 2013 to $55.39 in 2023, a 35% increase. Over the same period, average services per provider fell from 2,217.3 to 1,841.5. Total services across that area type dropped from 32,474,274 to 27,959,422, yet total Medicare payments rose from $1,334,937,431 to $1,548,624,496.

Fewer visits, more money. That combination means the mix of services changed, not just the volume. Whether providers are billing for more complex procedures per visit, or whether the patient population arriving at podiatry offices in smaller markets is sicker on average, the financial result is the same: Medicare pays more per encounter in underserved areas even as those areas see fewer encounters overall.

This matters for rural Medicare beneficiaries because it suggests that access to podiatry care in smaller markets is contracting at the same time that each remaining visit costs the program more. Diabetic foot complications, the leading driver of podiatry utilization in Medicare populations, don't resolve on their own when appointment volume drops.

Nail Removal Still Dominates, But the Mix Is Shifting

Back in 2013, the single largest HCPCS code by Medicare payment was 11721, removal of tissue from six or more nails, at $235,658,028 across 7,364,579 services and 12,015 providers. Established patient office visits (99213) were close behind at $226,160,598 across 4,272,343 services. Nail debridement and routine office management together defined the specialty's Medicare footprint.

The persistence of nail-related codes at the top of the billing distribution reflects the diabetic patient population that drives podiatry utilization. Thickened nails, calluses, and wound debridement are the downstream consequences of years of uncontrolled blood sugar and peripheral neuropathy. Every dollar in that 2013 nail removal total represents a patient whose diabetes was managed well enough to keep them ambulatory but not well enough to prevent chronic foot complications.

What the decade-long shift in payment per provider tells us is that the complexity and cost of those encounters has grown faster than the number of patients receiving them. If that trend continues, Medicare's podiatry spend will keep rising even if provider counts and visit volumes stay flat, because the patients arriving at those appointments will carry heavier disease burdens than the ones who came before them.