The other day, I received a letter from a doctor lamenting how an insurance company with which she had been dealing was out to get her. The insurance company claimed she had overbilled them for more than $50,000, but indicated they were going to go easy on her and only require a repayment of $25,000. After sending the paperwork to our experts in coding, it became quite apparent that the patients' symptoms did not even match the codes that were entered. This doctor had absolutely shoddy records and NO outcome measurements to justify her requests for compensation for services rendered. Please understand that I have no special affection for the insurance companies; they are just as greedy on their side of the fence. However, I believe we ask for most of our troubles.
Too many of us simply do not appreciate that the age of accountability has arrived at our doors. It's not that the heralds of this revolution have not been trumpeting the changes in our literature - for the past 20 years! Unfortunately, we have frequently turned a deaf ear, as though perhaps this new challenge would go away if we ignored it.
This year at the Research Agenda Conference (RAC), one of the questions introduced during the open session was: "Can you operate a patient-centered practice and still make a living?" I listened intently as a veteran field practitioner took up the microphone and described the dilemma a new chiropractor faces. The verbal picture he painted has stuck in my mind ever since. The new graduate, he pointed out, departs their chiropractic alma mater with such incredible debt and fear of failure that the period between graduation and the first cash flow is the most desperate time in a young professional's life. This sage field doctor described the difficult interlude as the "entrepreneurial gap."
I don't know why that resonated with me so strongly, but it certainly rang my bell. That phrase helped me understand why so many new DCs go to the insurance coding classes offered by many of the major practice-management seminars simply to learn how to survive. The start-up period - the entrepreneurial gap - can be terribly frightening. I'm certainly not against learning how to do a good job coding - just the opposite. However, I cringe when I think about new doctors learning billing procedures that will earn them a letter 10-year hence from an insurance company that wants some or all of its money back! What a nightmare.
Just the opposite syndrome - seniors and new graduates who enter the marketplace without a realistic appreciation of what lies ahead - also is problematic. Lately, I've noticed an entitlement attitude among some of the new graduates who have come into the workforce. This is so contrary to the expectations that my generation held about building a practice. Frugality was valued back then; in my case, I walked to work to save a little money. I didn't have a vehicle my first year in practice and had to borrow my grandmother's car to drive any distance. Today, I see young doctors with newer cars than the one I drive. I can only imagine that some of these recent grads are living on credit, if one may judge by their extravagant lifestyles. It seems as though more money goes into fancy cell phones, iPods and the latest laptops, rather than the clinical equipment that might generate income. Too many members of the next generation do not seem to distinguish between good debt and bad debt.
The biblical lesson of feast and famine has been lost among some of our young. It matters not who you are or where you locate - it takes time to build a stable base of patients. (This assumes you are doing it correctly. That is, discharging patients when they get well. Isn't that what we are supposed to do?) Let me share the "five-year rule" with you. The five-year rule suggests that you must anticipate repeated ups and downs in patient flows (and therefore, revenue flows) during those early days in a new practice. One week, you will be in a state of elation and tempted to buy your first BMW. The next week, you may see your numbers tank. This is quite normal: Patients get well at uneven rates, and it takes a while to generate the magnitude of clientele that can assure some stable cash flow. (This also is one of the reasons one needs enough capital to survive those first few years.) You will make yourself ill if you put too much emphasis on weekly numbers when you are starting out. Concentrate on getting your patients well, and encourage them to let others know if they are satisfied.
Unfortunately, some things never change. When I first started in practice, one of the many patient-management groups came into Minnesota with a vengeance. Two of my closest friends went to their seminar. They were taught to sign up each new patient for at least 70 office calls. For the first six to 12 months, they were rolling in patients and money. I confess that I was tempted to join them. It was only because my senior partner, Dr. Warren Lee, sat me down and explained that their dramatic success would be short-lived. Thank goodness I listened to him!
My close friends made commitments on new houses and new cars (one even bought land and started to build a new office). About a year later, the word had gotten around the patient population that they were being scammed and the doctors' new-patient influx shriveled to almost nothing. One of my friends took such a hit that he had to move to another town and it took him years to recover. The other one languished along until his reputation finally recovered. During their difficult time, my practice exploded - owing largely to my partner's wise advice to stay the course and do what was ethical for the patient.
I advise new graduates not to buy anything nonessential in the beginning. I started with a portable table, and one of my former associates opened his clinic with borrowed furniture from his family. Try being creative and you will be amazed at how much fun you can have. Keep it simple, keep it ethical and stay the course.
I'm pleased to see that an ever greater number of chiropractic colleges are teaching basic business skills to their students. This is a very important step in the right direction. Students - please listen up - learn those clinical skills, but don't overlook the business methods. Be conservative in your expectations. Learn how to serve your patients as you would your own family and you'll find that your patients will take care of you.
