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February 2000

Massage Therapy: Is Your Practice Ready?
By Peter G. Fernandez, DC

Should you add a massage therapist to your practice? Will you realize any financial benefit by adding one? Chances are you will see a positive effect on your bottom line - but the most important motive for adding a licensed massage therapist is the in-creased benefits you will be able to offer your patients.

Massage therapy eases muscle spasms, increases circulation, decreases pain and increases muscle strength. Of all the therapies you could add to your practice, your patients' number-one choice will almost always be massage therapy.

The Basics
Massage therapy doesn't require as much space as you might think. It can be done in a therapy suite or a 7-foot by 10-foot room. Because of the creams used in massage therapy, it is wise to have tile or linoleum floors in a massage therapy room rather than carpet. This makes any necessary clean-up a whole lot easier.

Whether you should hire a full- or part-time massage therapist depends on your patient flow. Most chiropractors are usually busiest between 8-10 a.m. and 4-7 p.m. If this is the case in your office, two part-time massage therapists should be adequate to cover your busy times. However, you may choose to hire a full-time massage therapist who performs neuromuscular massage during busy times, and relaxing Esalen massage during the not-so-busy times.

Just like chiropractic, massage therapy can be performed correctly or incorrectly, and it can help or it can hurt. Before hiring a massage therapist, make sure she is:

· a graduate of a licensed massage school;

· has state board licensure or American Massage Therapy Association (AMTA) qualifications; and

· is up-to-date with continuing education credits (CEUs).

When you interview candidates, talk to them about their health-care beliefs and how they would view their role in your practice. You want to make sure you find someone who doesn't think he knows more about healthcare than you do. You are legally responsible for any health-care advice your massage therapist shares with your patients.

Be sure to hire a massage therapist who dresses professionally when applying for the position. Make sure his basic beliefs mesh well with yours.

Protect your patients and yourself. Be sure to verify credentials and references before hiring a massage therapist.

Office Procedures
It is your responsibility to prescribe which muscle areas are to be massaged and the amount of time for the therapy. However, prior to prescribing massage treatment, you may choose to have the massage therapist examine the patient and make specific massage recommendations. (Most massage therapists are qualified in more than one type of massage). You can then prescribe the muscle area you want massaged, and the massage therapist gives a spot (local) massage of that prescribed area.

The massage therapist also writes detailed office notes concerning the muscles she found in spasm and the type of massage therapy used to correct the spasm, improve the range of motion, etc.

Scheduling Guidelines
You may prescribe massage treatment to be given either before an adjustment or after. The massage therapist is usually scheduled for three 15-minute spot massages per hour, with an additional five-minute room clean-up time in between each massage.

If you have a consistently busy practice, it's wise to hire a massage assistant to help the massage therapist by placing patients on the tables, transcribing the therapist's office visit notes, cleaning up the massage room, etc. With an assistant, the massage therapist will be able to massage four patients per hour.

Be careful to avoid bottlenecks when using massage therapy. As discussed, a massage therapist can usually take care of three spot massages per hour, or with the help of an assistant, four. Most doctors of chiropractic treat eight to 12 patients per hour during their busy times. Let's assume you need to prescribe massage therapy for nine of these patients, and you only have one therapist. This means six patients will have to wait 30 minutes to an hour and a half for this service. Obviously, that won't work. In this case, you would need three massage therapists to efficiently provide the service you prescribe. In a busy practice, you should consider hiring extra part-time massage therapists to properly care for your patients.

If a massage therapist wants to give one- or two-hour massages (total body massages), he can do so during your lunch hour, hours or days you don't practice, or during slow times in your schedule. However, as with all therapies performed in your clinic, you must pre-approve each massage treatment.

Words to the Wise
The massage therapist should:

· not give any health-care advice to patients without your permission.

· only treat the area of injury as prescribed by you and should not give massages in any other areas.

· notify you when a new problem arises, before attempting to treat it.

· not talk about the new problem until you have examined and reached a diagnosis for the problem.

· not change your prescribed massages or exercises without talking to you and getting your approval.

· keep productively busy the entire work day. If the therapist is not massaging patients, she can wash and dry gowns, help file patient records, and place recall telephone calls.

· not do massage therapy anywhere else in town other than your office. (You don't want the massage therapist taking patients out of your office to treat them at home or in any other location. This is unprofessional, a possible detriment to your patients' health since you cannot oversee their massage treatments, and a loss of service income to you.)

· teach a spinal conditioning class to your patients.

Avoiding Problems
Avoid potential problems by following this advice:

· If you have more than one massage therapist, do not allow your associates, CAs or physical therapists to choose which massage therapist to use. You should assign the massage therapist at the time massage therapy is prescribed. This assures your patients receive the best care, and that you make maximum use of all your massage therapists.

· Keep an eye on your average service per visit (ASV). The addition of massage therapy to a practice usually increases an office visit by $30 or more. This increase may make your average service per visit (ASV) so high that it causes a red flag with insurance companies.

· Don't exchange one type of therapy for another. Quite often doctors who add massage therapy to an office visit will simultaneously drop the use of a physical therapy. Doctors who do this do not understand the use of massage therapy. Massage therapy is not a replacement for any other physical therapy. Massage therapy has a separate beneficial effect for the chiropractic patient.

· Watch your collection percentage. If the insurance companies don't pay for massage and your patients don't pay for it, don't do it. You cannot afford to pay a massage therapist's salary and not collect for it. Any extra time and money you have are better spent in educating patients about the many health benefits of chiropractic care.

· Be sure you constantly reinforce the chiropractic philosophy with patients. If, after you add a massage therapist, a patient asks you for a massage only, this is a warning that your effective conveyance of the chiropractic philosophy has waned. Massage therapy in a DC's office is only to be used for what it is, an adjunct to a chiropractic adjustment, an aid in relaxing the body so the body can accept the adjustment, to relax muscle spasms, to break up adhesions, etc. If a patient only wants massage therapy and not an adjustment, you blew it. You and everyone on your staff must understand and stress that the adjustment is primary, the muscles are secondary.

· Avoid any possibility of fraud. You must conduct a chiropractic exam, reach a diagnosis and determine that massage therapy is an appropriate treatment for your patient prior to completing any insurance forms regarding massage treatment. If a massage therapist refers a massage-only patient to your office and asks you to fill out insurance forms on that patient without performing an exam, don't do it - it's fraud.

Independent Contractor or Employee?
You can hire a massage therapist as an independent contractor if you have an extra room or rooms in your office that aren't needed for your patient flow. As an independent contractor, the massage therapist must rent the room from you, provide her own table, linens, etc., have her own clientele, collect her own fees and set her own hours.

If you decide who the massage therapist is going to massage and when he is going to do it, and if you pay the massage therapist, there's no doubt that the massage therapist in this case is an employee. If you were to hire this therapist under these conditions as an independent contractor, he could face some stiff Internal Revenue Service (IRS) penalties, interest and back taxes. For some reason, the IRS has targeted massage therapists regarding their independent contractor status and have ruled most of their independent contractor contracts void. When this happens, it's not the massage therapist who pays; it's the doctor who did the hiring.

When you hire a massage therapist as an employee, you should require an associate-type contract with a non-competition clause. You don't want to fill up your massage therapist's schedule and then have her go down the street with your patients.

Types of Compensation
How much you charge for massage therapy depends on which area of the country you practice in, and whether you're in the country or the city. Average charges range from $35 to $50 per spot massage, and $60 to $80 for a full body massage.

As an employee, there are many ways a massage therapist can be paid. Some of the most common are: 1) the massage therapist is paid $6 for every 15 minute-massage; 2) the massage therapist is paid 20% of his collections; 3) larger practitioners sometimes pay their massage therapists a monthly base of $1,000 plus 20% of their collections over $5,000 a month; 4) the massage therapist is paid $12 to $14 an hour.

Unfortunately, a number of the massage therapy schools are telling their students they should be paid 50% of all massage fees collected. However, I have found that the average chiropractor's overhead is about 60%. If you paid the massage therapist 50% with an overhead of 60%, your total overhead on all massage therapy provided in your office would be 110%. It doesn't take long to realize you're losing money at that rate.

The expected earned income as recommended by massage therapy schools is correct for those graduates who have their own office space, and pay their own overhead. These massage therapists would probably have a 50% to 60% overhead. However, when a massage therapist works in your office where you pay the rent and utilities, your CAs make all the appointments, and your insurance department does all the billing and collecting, the massage therapist cannot be paid 50%.

Malpractice Insurance
The massage therapist can get her own malpractice insurance, which lists you as an "additional insured," specifically naming you as someone who is also covered under the therapist's policy.

As an alternative, you may choose to include the massage therapist in your malpractice insurance policy. The additional premium amount you pay should be deducted from the massage therapist's pay.

Filling the Schedule
How do you fill up your massage therapist's treatment schedule? You'll be amazed at how quickly and easily this happens. Any patient who has muscle spasms can benefit from massage therapy. Any patient who has muscle contractures can benefit from massage therapy. Any patient who has a restricted range of motion can benefit from massage therapy. The list goes on and on.

Chiropractic and massage therapy create a natural symbiosis. Patients will be happy with the results - and so will you.

Dr. Fernandez has been a practice management consultant for the past 20 years and has taught approximately 10,000 DCs and 20,000 CAs. He can be reached at: 7777 131st St. N, Suite 15, Seminole, FL 33776; 800-882-4476; fax: 727-392-0489;;

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