When Practice Management Influences Clinical Management

What did I know about running a small business as I was approaching graduation from Texas Chiropractic College in 1983? Nothing! I took a "practice management" class, but the first day the teacher said that he'd failed in practice more than once, so he recommended we do the opposite of everything he told us. Not really much help.

I was told that the U.S. Small Business Administration offered classes about setting up a business. The class I took was actually offered by the Service Core of Retired Executives (SCORE). It was a great class about types of business entities (sole proprietorships, partnerships, incorporation, etc.), negotiating leases, and hiring accountants and lawyers. It has been a long time, so I don't recall the details of all the topics they covered, but it was a little bit of everything a small-business person needed to know. However, as I am sure you've already guessed, it didn't teach me one thing about operating a health care business.

After I bought a practice, I realized there were many issues I hadn't thought about and SCORE hadn't mentioned. For example, the doctor I bought the practice from had fired a lot of employees, which resulted in the highest rate for the employer contribution to unemployment insurance (an extra 4 percent out of my pocket). I didn't know about getting my staff disability insurance. I didn't know about – seems I could go on forever about what I didn't know. Many of these things I learned the hard way through experience.

I didn't sign up with a practice-management company; however, I did go to quite a few free or inexpensive introductory seminars offered by practice-management companies. In my experience, their purpose was to charm me with the charismatic practice-management guru who owned the company, but of course, wouldn't be my "coach," as they had trained "coaches." In reality, these introductory seminars were quite successful in turning me off to the companies. In some cases, if I didn't agree to sign up for the "program" I'd be insulted and told I would never amount to anything. That kind of response just validated my decision not to become a client.

Nevertheless, I would learn something of value through each of these encounters. Sometimes, what I learned was something I was glad I learned. At every seminar I learned many more things I knew I'd never do and was shocked to see and hear others implement in their practices. Some things I heard were clearly fraud, but the attendees were assured were legal.

There are many important things a practice-management company can teach a young doctor. Most young doctors haven't had to manage staff and really do not know what being a business owner means. Properly coding both diagnosis and CPT codes can be so complicated that there are people who are specialists in this and even get certified.1

There was one practice-management seminar (no practice-management company, just a seminar) I went to that taught me about creating a staff manual. I also saw an example of an office policy manual. The seminar taught me about RVS and how to determine what a reasonable fee for services would be in my area. At that program, my CA learned how to deal with the insurance companies, how to properly fill out insurance forms, etc. My sister was home from college and worked that summer for me as a CA. At the seminar, they taught her how to answer the phone; almost 20 years later, having worked in corporate America, she says that was a valuable lesson she uses to this day.

To fill in more gaps, I bought books on practice management in medical school bookstores. These books taught me about efficient patient intake, and how to write reports and referral letters. There was even a list of suppliers for office forms and other supplies that I'd never seen in chiropractic publications. I bought a subscription to Medical Economics, where I learned a lot of valuable information about running a practice.

I am sure some chiropractic practice-management companies do teach these and other important lessons about how to run an efficient chiropractic practice. The problem, at least with the companies I've learned about (from their seminars, reading their client manuals, and talking to both friends and former students who are or were clients) is that some have the tendency to cross an ethical line in the sand. Actually, it isn't a line in the sand; it is a wall that should never be breached. Some companies try to dictate case management.

I've written previously about the practice-management consultant who told me I was a bad doctor because my PVA was too low. ["Empower Your Patients," Jan. 29, 2007 DC] Clearly, a chiropractic practice is a business and won't survive if it doesn't profit. However, one can't make clinical decisions based upon policy that's purely money-driven and not based on clinical facts. The following are practice-management policies that cross the border between practice management and clinical management:

• Scheduling patients for blocks of treatments (e.g., 12) with the recommendation that nothing about prognosis be discussed during the block of care. The only time the patient is told anything about how they are doing is when they are re-examined at the end of a block of care.
• Making patients sign contracts for long-term care and if the patient doesn't fulfill their commitment, back-billing the patient for all of their completed visits at an exorbitant rate (supposedly the normal, not-discounted rate for prepayment).
• Taking radiographs of every spinal region to be adjusted and even retaking the films every so many weeks.
• Using coercive practices to get patients to continue care – needed or not, wanted or not.
• Forcing the patient's family to come in for treatment as a condition of providing care.
• Establishing any standard set of diagnostic tests that all patients receive without regard to their clinical state.

I am sure I have not covered all of the ethical violations that can translate business management into clinical management. For doctors with more years in practice, these breaches of ethics often have no effect. The doctor is more confident in their clinical skills and ignores the invasion of business into clinic. The problem I hear often from newer graduates is that they are uncertain about what is best clinically and so are more likely to follow these and other unethical recommendations, thus changing their clinical management.