Step by Step Disengagement

by William D. Esteb

As you welcome your last $250 deductible insurance patient into your office and you hear the safety of the gun at your temple release, celebrate what a wonderful decade it's been since insurance equality. Maybe take the office staff out for one last blow out, paid for by the $35 adjustments, $20 ice packs, and $275 Davis series. What's left of many offices resembles the morning after an all night party with the throbbing headache, dirty dishes, and the hollow emptiness the lingers after the last guest leaves. But the dry mouth and blurred vision isn't from enjoying yourself too much. For many, it's the primordial fight or flight kicking in: fear. Fear of the future.

If you've had enough of the paperwork, narratives, lost claims, delaying tactics, and minimum wage clerks passing judgment on your diagnosis and treatment plan, the choice is clear. Decide not to play the game. Decide to disengage from the insurance industry. It will cost you. But then freedom always exacts a price.

Who said you had to accept insurance assignment? Who says the patient expects it? Who says you need a computer? And the latest $3,500 software to run it? And the staff to feed it? And office space to house it? And the hassles? And the frustration of providing a wellness approach to health inside a sickness care model of insurance?

Try to imagine how strange acquiring your insurance-related tools and office procedures must have sounded 10 years ago! It probably feels even more unsettling to entertain the thoughts of abandoning them now. Soon your computer will make an expensive door stop. Your therapy equipment? It probably won't be replaced when it breaks down or wears out. The thousands of square feet of office space? You could easily get by with less. You get the picture. Chiropractic will go through a simplification process. It will be cleansing and it will offer the bravest survivors a sense of freedom and fulfillment that 35 new patients a month with $100 deductibles could never match.

You've been practicing in a "regulated" environment. No one says you have to charge the same $30 usual and customary fee for an adjustment as every one else is, but with one eye on what the insurance companies will pay, it almost seems real. After all, "I'm worth it. I've paid my dues. And anyway, in the long run chiropractic care is less expensive than the back surgery insurance companies seem even more willing to pay for."

So as greed and pride cloud reason, we lose touch with reality. Detroit auto manufacturers who continue to overlook America's artificially low price of gasoline (Japanese drivers pay the equivalent of $3.25 a gallon in 1992), seem unmotivated to make cars with the fuel efficiency needed to face the future. This lack of awareness almost killed Chrysler, and none of the American manufacturers have a healthy balance sheet. By the way, don't expect any loan guarantees or government bailouts for chiropractic!

I'm not a doomsdayer, but some drastic changes will be required of you and your practice. Those who cannot or will not adapt will be forced to leave the profession. Those who had marginal practices with the help of insurance will become "reborn", or become associates for more successful and adaptive doctors. And while many students will emerge from school with a huge debt service, they will not be burdened by expensive lifestyles or insurance-fed habits. Because it will be easier, but more difficult at the same time, those who got into chiropractic for the wrong reasons, lack a strong chiropractic philosophy, or refuse to educate their patients will probably be forced to get out of chiropractic. Similarities of this same shakeout process have already been seen in the computer, airline, and banking industries. The solvent companies swallow up the marginal, faltering smaller companies. The strong survive.

If it's not too late, here are some scenarios you may wish to consider as you consciously plan your escape from the influence of insurance. The common thread through all these approaches is the recognition that increasingly higher deductibles and the growing number of patients without insurance have removed chiropractic care from the reach of many patients who need and want it. Unless you want the stress and confusion that comes from creating a financial hardship arrangement with practically every new patient, it may be time to reorient your fees. Like making sausage, it's not pretty.

1. Financial hardship cases. As soon as virtually every cash patient is on a "hardship arrangement" it would be hard for a jury not to agree with the insurance companies that your hardship fee is your fee. Besides the confusion of tracking everyone's different fees, wait until Mrs. Smith finds out Mrs. Jones is paying less! Abuse this approach because it's expedient and prepare to refund already spent insurance checks!

2. You pay one, I'll pay one. As a few insurance cases linger, this strategy keeps your fees up while still allowing your cash patients to continue care. You simply "pay" for the visits they can't afford. If you thought keeping up with Medicare was fun, this ought to be right up your alley. While it might work in the short term, it's still treating a symptom: your fees are too high. Cash paying patients can't afford you.

3. Case management fees. This is where you offer cash patients a three or four month care program for their initial intensive and rehabilitative care that allows patients to budget equal monthly payments. This turnkey approach bundles any necessary examinations, X-rays, and adjustments into a single care package. During the first month or two visit frequency is high and the patient is ahead of you. During the last month or so they pay the same amount but their visit frequency is reduced, evening out the equation. Can you offer an arrangement like this without implying a cure?

4. Eliminate assignment. You could change this policy tomorrow. Let the patient extricate money from their insurance company. Some suggest helping the patient discover the cut off date on their credit card and charging the card for their care, using the credit card "float" between billing cycles to buy time for the patient to receive the insurance check. I don't remember seeing Financial Manipulation 101 on the chiropractic college catalogs I've reviewed! Worse, wait for the first new patient to storm out of your office because the doctor down the street still takes assignment.

5. Miscellaneous. The jury is still out on some of the other schemes floating around the profession. I don't know if the "buy-eight-visits-get-ten" approach has been tested in court yet. The "bookkeeping discount" for cash paying patients attracts undue attention when it exceeds about 10% which is rarely enough of a price lowering to really help.

Before you jump out a window, relax knowing there is a solution. Cash. Greenbacks. Money. Bread. Dough. Moolah. That's right. The celebrated cash practice will finally arrive. The solution: one fee. Whether it's the patient's first adjustment or 122th adjustment. Whether they have insurance, HMO membership, or cash.

The only problem is your cash fee will probably be only two thirds or less of what your usual and customary charge is now.

Don't panic! And don't throw the baby out with the bath water. You'll know when it's time to deploy your parachute and go strictly to cash. Until then if I were in practice I'd take these preparatory steps:

1. Pay off as many debts as possible while adjusting your personal lifestyle.
2. Lower your overhead as much as possible without compromising patient care.
3. Attend seminars that stress chiropractic philosophy.
4. Commit yourself to optimum patient education.
5. Trust your judgment and avoid radical changes.
6. Visualize your practice full of cash paying patients.

Before the insurance company's final gasps you have the opportunity to adapt to this new practice environment and increase your chances of survival. And while it isn't fashionable to talk about "downward mobility" and "less is more," doctors with their eyes on the horizon and ears to the ground know big changes are coming. The question is, do you have the courage to take the necessary steps now to end your dependency on insurance and assume responsibility for the future?

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My Report of Findings
Originally published in 1993
240 Pages
US $24.95

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