Beyond the Box on The Wall

by William D. Esteb

Even doctors who stress patient education, do regular patient lectures, and consider themselves excellent communicators find that patients drop out of care. The fact that this "premature dismissal" generally coincides with the patient reaching symptomatic improvement can lead many doctors to think that rehabilitative and wellness care is something no one wants. But that would over simplify and ignore a very important issue that becomes more obvious when you see your practice through the eyes of a typical patient.

In the "old days" before insurance equality, but after the donation box-on-the-wall method of chiropractic compensation, there was generally one fee for an adjustment. Didn't matter if it was the patient's first adjustment or their hundredth. The fee was the fee and it was largely determined by what the market would bear and influenced by the local cost of living. If you practiced in Westchester County, New York you generally charged more for an adjustment than if you practiced in Billings, Montana.

It was a good time for chiropractic because there was focus. Doctors were not distracted by narratives that go unread, the expense and overhead caused by computers, nor were they combating the latest foot-dragging tactics of the insurance companies. The staff was few in number and didn't require seminars, bonuses, and incentives to fuel their commitment. It was a simpler time and the emphasis was on the chiropractic adjustment and personal service. Chiropractic was more likely to be a family affair for most patients. Entire families would file into the adjusting room to receive their care. It was a time of huge practices. Some chiropractors even had private airstrips to accommodate patients that would fly in from around the world. Chiropractors who had gone to jail for practicing their healing art were still fresh in everyone's memory.

Today, the vision of many chiropractic doctors is so limited they don't even bother printing their telephone area code on their business cards or letterhead!

Some would claim that insurance equality laws opened the doors of chiropractic to patients who would have never tried it. Others suggest that the insurance industry "legitimized" chiropractic. Both are probably correct to some degree. Yet this same industry is a contributing factor in the prevailing sickness orientation seen in most chiropractic offices and the decrease in the number of families, children, and maintenance care patients receiving care today. If chiropractic gets limited to the 12 visit-symptomatic-relief-only box suggested by the RAND Study and a growing number of state legislatures are suggesting, it will be because of this all too willing alignment with the insurance industry.

As the number of patients with insurance dwindles and their deductibles rise, making a "chiropractic lifestyle" affordable for cash paying patients should be a prime concern of doctors interested in surviving and thriving in the years ahead. Keeping patients will become as important as getting new ones. Bragging rights at chiropractic get togethers won't be centered on new patient statistics, but retention and patient visit averages. For most offices, besides relentless patient education, it will require developing and implementing some type of wellness care fee system for people who want non-symptomatic maintenance care. Many patients drop out because they simply can't afford or justify paying your usual and customary sickness care fees when they're feeling fine. Until you make wellness (maintenance) care affordable, don't expect to enjoy the referrals, financial security, and satisfaction that comes from serving well patients who understand and respect what you do.

If chiropractic had never attained insurance "equality," there would be little need for a way to help make post symptomatic care affordable for people after they exhaust their insurance benefits.

All too many chiropractic doctors have become accustomed to $30, $40, or $50 adjustments. Still others add additional physical therapy charges (because insurance pays for it). Total visit charges in the $60-$90 range or higher are not unusual. X-rays with a 800% mark-up are common. And why not? The insurance company will pay it. When chiropractors allow themselves to be so strongly influenced by the "sickness care" mentality of insurance companies and start thinking anyone would gladly pay $30 for an adjustment, even when they feel fine, you have the crisis in chiropractic that we see today.

If all insurance coverage for chiropractic were eliminated tomorrow do you really think your fee structure would remain the same? Oh, maybe for a week or two, but in a "deregulated" practice environment more in touch with reality it wouldn't be business as usual. Doctors who are over-staffed or living a highly-leveraged lifestyle would like to believe otherwise. "I deserve it," they rationalize. "I endured four winters in Davenport," they moan. With the violins weeping, they set their fees to the upper reaches reported by Fee Facts or what a quick phone survey of other doctors in their area uncovers. Then they greedily take whatever they can bill and collect for. Physical therapy? Does insurance pay for it? Let's do it. Rehab equipment? Does insurance pay for it? Let's get some. Mineral supplements? Does insurance pay for it? Let's add those too. Suddenly anything that fell under the state's scope of practice laws and was reimbursable by the patient's insurance policy became part of the patient's treatment plan. Interestingly, if the patient didn't have insurance or their policy limited these adjunctive procedures, they often weren't performed. The easiest way to predict a patient's care program would be to read the patient's insurance policy.

That's wrong.

Physical therapy isn't the issue. It's using a patient's financial resources as a guideline for making clinical recommendations. All the rationalizations in the world cannot cover up the fact that this is a form of stealing.

Is this why doctors these days have such a reluctance to look a patient in the eye and present their fees? Is this why staff members have such difficulty collecting money, unconsciously siding with patients because they know they couldn't afford to pay what they're being asked to collect?

The fact is chiropractors exist in an isolating subculture. Most enjoy a better standard of living than their patients. You've had a well-grounded education in physiology, so you understand the danger of aberrant spinal biomechanics. But perhaps more dangerous is the fact that you probably get your once a week or twice a month wellness adjustment without any impact to your monthly budget. Nor do you have to endure a crowded reception room at 5:30 to get it. This distorts your ability to see your practice the way a cash-paying "well" patient sees your practice.

You're too expensive.

This financial myopia has turned chiropractic into an expensive form of non-invasive pain relief. It's the last resort before back surgery. And increasingly the patient looks to their "you're-in-good-hands" insurance company for recommendations about appropriate chiropractic care.

If you want to divorce yourself from practicing medicine (treating symptoms and patients dismissing themselves), then develop ways patients can afford your care on a non-symptomatic basis. Create ways patients can afford wellness chiropractic care on the same visit frequency you do. Get real.

This generation of chiropractic patients, (and probably the next), bring a medical model of health with them to your office. Wellness care is a new idea for most. In fact, simply being healthy is a new idea! Because of this, most patients don't want to be truly healthy, they just want to live without pain or discomfort. That's why patient education is so important.

But incredible patient education isn't enough. Have you priced organically grown produce recently? Been shopping for meat and poultry raised without antibiotics and growth hormones? It's cheaper, easier, and faster to go to McDonald's. It's expensive to really care about your health. Cost creates a barrier that prevents the patients who understand and want continued chiropractic care from getting it. Sure, patients should drive a less expensive car so they could afford to pay your fees. But they don't. And patients should be willing to delay gratification and be willing to pay for the often intangible and not immediately recognized benefits of wellness care. But they don't.

Your response to what your patients should do versus what your patients actually do will determine the impact of your practice in years ahead. Perhaps it's time to take a more pragmatic view and question the status quo.

Of course patient education is paramount. Without patient education you could offer wellness care for free and still not have any takers. While we can cling to our philosophical "rightness" and expect insurance companies to pay for wellness care and desire true health for their customers, this is not the case. Yes, they will gladly pay thousands for ineffective back surgery, but not pay for the most minimal amounts of preventive care. Looking to an insurance company (a business--not a public utility) for any type of guidance is futile.

Hope springs eternal. If you're thinking some type of nationalized health care is going to be the solution, don't hold your breath. Remember, whatever emerges will be from the same folks who brought you Medicare!

Until chiropractic is better understood, utilized, and accepted by the general public, it will always be easy to cap it, limit it, or exclude it. Just ask doctors in Oregon, Colorado, Minnesota, and Canada.

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My Report of Findings
Originally published in 1993
240 Pages
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