David S. Singer
In this article I will go over how to accomplish the most successful "bottom line" without compromising your ethics or placing greed above patient need. By "bottom line" I mean: How many people can you help? How much fun and enjoyment can you have in practice? And finally, how much income can you take home to provide for your family? A book could be written on each of these areas:
- helping as many people as possible;
- having as much fun as possible; and
- being as profitable as you can.
In this article I will focus on the bottom line of profitability. The viewpoints I am about to present were evolved from both first-hand experience in practice and also from working personally as a consultant to nearly 5,000 chiropractors in the U.S., Canada, Australia, New Zealand, and Belgium.
When a doctor hires a consultant, he or she does so to increase either fun in practice, the volume of people seen, overall profit, or a combination of these. To accomplish the goals of fun, profit and volume, there are ways that work which are ethical and honest. There are also methods that simply do not work. And there are still other procedures that are actually detrimental to the doctor's integrity as well as harmful to the credibility of chiropractic as a profession.
To increase your profit, you can either increase your gross income (collected receipts) while keeping the overhead within reason, or by keeping the gross income the same while drastically reducing the overhead.
There are only three methods to increase your gross income:
- treat more people;
- charge higher fees for the same services; or
- increase the amount of diagnostic or therapeutic services.
Let us now examine closely for workability each of these methods to increase income, while viewing the ethical traps inherent within each.
Increasing the Number of Visits Weekly
This can be accomplished by increasing the number of new patients, or increasing the number of visits a patient uses your services.
There are ethical and unethical ways to get new patients. Unethical ways (and the most flagrant offenses) include advertising in a manner that degrades your fellow chiropractors, makes chiropractic care appear to be of no value, or promises a result or service that is, in fact, not obtainable. An unethical doctor could also increase the number of visits for the same patient by recommending needless visits and using methods of intimidation.
On the other hand, you can advertise in a manner that will enhance the image of chiropractic overall. You can advertise only what you know you can deliver. And you can increase the number of visits per patient by taking the time to educate the patient honestly and serving the patient with quality care. The patient would thus return year after year and use you as their non-drug family doctor.
Charging Higher Fees
A doctor can raise his fees only so high before creating a brick wall that prevents patients from entering the office. People will talk, and the most often asked question when a patient refers someone is, "How much does the doctor charge?" You can attempt to hide your fee by charging one large fee to insurance carriers and another low fee to cash patients without insurance. However, I must warn you "there is absolutely no legal method to charge a cash patient a different fee than an insurance carrier for the same service. If anyone tells you there is, believe me there isn't." Don't get caught in this trap.
Increasing the Number of Diagnostic or Therapeutic Services
There are some doctors who decide which service a patient needs to receive based on the type of insurance the patient has, rather than on the type of spinal subluxation problem the patient has. If you simply treat all patients the way you would want yourself or your own family treated, then it is hard to get too far away from what is ethical. You can use a diagnostic instrument (such as x-ray, EMG, etc.) to increase only income, or to provide a better service to the patient. The machine is innocent. It is the intent of the doctor using the machine which is in question. If a therapy machine or diagnostic instrument is recommended or used as purely a source of extra income, then this is no different than an MD recommending needless surgery to increase his income. There is no way to legislate intent. It is purely a personal decision.
The inherent problem in a high-fee multi-therapeutic practice or high-fee diagnostic practice is that it lends itself to a high overhead and a large staff. Now, I know that some readers are already in disagreement and that it would appear I am recommending no therapy or simple diagnostic procedures. But please read on. It would be unethical for a doctor to ascertain clinically that a patient needed more x-rays or other diagnostic testing, and then not provide it simply to keep fees low or reduce overhead. But, since I brought up low overhead, let's address that subject.
Low Overhead
The primary runaway expenses in a practice are as follows: Staff, advertising, loans (equipment included), and for some, rent. Too many staff members also increase telephone costs, supplies, etc., since the more people working in an office, the more resources are used. The secret to low overhead is maximum use of space and efficient staff utilization. A doctor who boasts a million dollar income may have a $950,000 overhead. Bigger is not always better. Efficiency and profitability often lead to less stress, more fun, and a feeling of living to work, rather than feeling that you must work to make a living.
Chiropractors "down under" (Australia and New Zealand) and chiropractors "up above" (Canada) traditionally enjoy a much higher profit ratio. A 30% overhead is very common amongst my clients in those areas. They usually charge half the fees of their U.S. counterparts, but take home more profit.
Statistics reveal the following: Higher fees equal more staff, higher overhead, and a nightmare of paperwork. Doctors in such practices are pulled consistently into administrative problems and have a constant running battle with the insurance industry. They are continually fighting and dealing with conflict. There are, of course, exceptions to the rule. Remember, $45 per visit in Beverly Hills, California or Park Avenue, in Manhattan, is in fact a low or moderate fee for those areas.
Low overhead practices generally run as cash practices and increased income comes through full utilization. These doctors are in fact booked up. They expand their capacity through greater efficiency, better use of the appointment book, better design of office space, improved patient education, and delegation of duties to assistants or associates.
To sum up, there are obviously different strategies to improve the bottom line in a practice. In implementing these various strategies, you can either compromise your ethics and become involved in less-than-honorable methods; or you can maintain a high standard of ethics and treat your patients the way you would want to be treated yourself, with the highest quality health care at a reasonable fee. It is the responsibility of the individual doctor to make the appropriate ethical decision.
