The Chiropractic Trojan Horse

by William D. Esteb

There's an unseen partner in the examination room with you and your new patient. This silent partner evaluates your recommendations for long-term care very carefully, advises your new patient on the need for X-rays, and strongly influences the decision to refer others to your office. Your willingness to accommodate this third party by providing quality service at a fair price will significantly affect the short- and long-term relationship you have with your new patient.

How much do you pay?

This unspoken dimension to many patient decisions is your fees. While it is easy to philosophize about the importance of good health, it has a price. And since you receive your chiropractic care without any impact on your monthly budget, it makes it difficult for you to understand a new patient's concerns.

For most practitioners and most new patients, insurance usually figures into the mix. Some suggest that insurance has opened the doors to chiropractic to many who would not have otherwise pursued it. Yet thousands of doctors had thriving practices before insurance acceptance, and will likely thrive when higher deductibles, HMOs, and PPOs reduce the role of insurance in the future. Even if insurance acceptance has "validated" chiropractic in the eyes of the public, third-party payers have become something of a Trojan Horse.

The medical model, equating sickness with obvious symptoms, combined with the myopic vision of the insurance industry, has distorted the duration and cost of chiropractic care. Doctors who associated their self worth with a financial statement have greedily set their fees to the upward reaches of the figure accepted by insurance carriers. Catering to the standards suggested by the short-term vision of the insurance industry turns attention away from patient education and a cultivation of the post-insurance patient. After all, with a seemingly endless supply of low deductible new patients, why bother?

Insurance addicts

The implications of this trend are profound. First, the mindless cultivation of short-term insurance cases has created a generation of "insurance junkies." Addicts rationalize that short-term relief care, with assembly-line paperwork and the financial rewards stemming from the easy-to-document symptomatic improvement, is all patients want. They seem to drop out when their insurance coverage is exhausted anyhow! Continuing care would constitute over-utilization, wouldn't it? Providing rehabilitative care requires education and a different kind of clinical expertise. And who said rehabilitative care is even possible? How can you prove the patient needs it? Or document progress? Moreover, does rehabilitative care even work? It's hard to ignore the fact that the frequent visits and X-rays during Initial Intensive Care are simply more profitable (and affirming) than rehabilitative cases that test the doctor's communication skills. Providing symptomatic relief only becomes a self-fulfilling prophecy.

Besides seemingly relinquishing the length and type of patient care to the dictates of insurance carriers, a financial dependency emerges. The financial futures of thousands of chiropractic doctors are figuratively and literally "in the mail," resting on the tenuous future of an industry on the verge of major turmoil and change. More and more policies are offering higher deductibles in order to lower premiums. Municipalities are having to "self-insure" themselves because liability insurance is too high. Rural medical doctors are limiting their practices to "safer" cases, referring even routine obstetric patients to larger cities miles away because of the escalating cost of malpractice insurance. Significant changes in the insurance industry will affect the stock market, the justice system, and the health care community at large. The sky isn't falling, but prudence suggests a closer look at the long-term implications of an unnecessarily high dependence on insurance, simply "because it's there" or "everybody does it" or it's easy.

Ignoring reality

After building a practice and assuming a lifestyle fed on insurance revenues, extricating oneself is difficult, but not impossible. For many, apathy sets in. It's like the American automobile manufacturing executive driving his American-built car to his Detroit office in 1973. Looking out every window as he drives to work he sees nothing but other American-built cars driven by other American automobile executives. And he says to himself, "No Japanese car problem here." Yet the Japanese invasion was well underway 2,000 miles away in California.

How do you encourage patients to continue care beyond short-term insurance coverage? How do you offer more then merely a taste of chiropractic? How can you make spinal rehabilitation a financial reality for a growing number of patients who are wellness oriented? How can you disband the escalating overhead of an expensive insurance processing staff? How do you start easing away from an assembly line pain clinic? How do you avoid the stress created by the need for a constant flow of new patients? How can you end the giveaways, expensive advertising, and other non-therapeutic distractions needed to sustain an insurance-based practice?

Perhaps you first need to recognize that not everyone is available for wellness care. But there may be more patients than you think who merely get lost in the critical transition between insurance and cash. There aren't a lot of good answers to wrong questions, but look at insurance and fees from a patient's perspective.

Avoid misunderstandings

The hocus pocus about fees usually begins on the telephone as patients try to determine how much their care will cost. The automobile repair industry has gotten a black eye from supplying inaccurate estimates, and so can you. In fact, in many states car repair estimates have been legislated. Mechanics must provide a written estimate and the charges may not exceed that figure without approval from the owner. Not only does this make good business sense, it requires ongoing communication between the two parties; this avoids misunderstandings and manipulative dependencies, and allows the owner to participate in directing the extent of repairs to be made. It all boils down to communication.

Recognize that when prospective patients call your office asking about your fees, they are not necessarily shopping for the cheapest chiropractic care. New to chiropractic, they may simply be wondering if they need to get a second mortgage on the house to pay the bill. Any unwillingness to share your fees over the phone, or presenting such a wide range that it becomes non-information, unnecessarily turns patients away. It is unlikely that someone who has been in pain for a couple of days is going down the yellow page listings to save a couple of bucks.

"But the cost of the initial consultation varies depending upon their problem," I can almost hear you say. Or, "How can I compete when someone else down the street is giving away everything for free?" Good questions.

Even if the doctor down the street isn't "playing by the rules," qualify your fees. Make sure your staff can adequately explain to patients the value of the services you offer. What is the difference between a free spinal examination and a regular spinal examination? Of course there will always be those who respond to anything free. But as a rule, most people recognize that you get what you pay for. Of course the initial consultation fee varies, but what does it average?

Why not go back over your last 100 new patients? What was the lowest entry fee? What was the highest? Now, throw out the 10 lowest figures and the 10 highest figures. What was the average of the remaining 80%? Imagine the credibility you build when your staff volunteers over the phone something like,

"...Of course, fees vary according to your age, lifestyle, and problem. Many new patients ask what to expect, so we recently reviewed the costs incurred by 100 new patients. We discovered the lowest fee was $85 and the highest was $320, yet 80% of patients averaged $120, which included the usual X-rays and complete neurological and orthopedic testing."

Include your usual number of X-rays! It seems like a separate, extremely variable aspect of your care, but that's just the point. X-rays are optional only if you think they're optional. Are you hesitant or modifying your policy dependent upon how much fuss a patient makes about X-rays? Most patients just want to know how much it costs.

When you offer full disclosure without apology or hesitation, patients sense they've selected a professional, organized office, that is open, trustworthy, and prepared to respond. If your fees are presented rationally and ethically, and you still hear a "Thank you" and click at the other end of the phone, imagine the collections grief you've just avoided!

Buy the book
A Patient's Point of View
Originally published in 1992
240 Pages
US $19.95

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