A breakdown of chiropractic fees and reimbursements across the industry for 2017
If the hypothesis that the professional class is the last to recover from a recession is true, then these survey results show that the chiropractic industry is on track for future growth. Key indicators are firming and economic prospects are improving.
It has been about ten years since the 2008 recession caused the global economy to shift into a financial crisis.1
As a result, the U.S. adopted government programs to help get the economy back on track, and lower-wage positions were the first to enter back into the workforce. As chiropractors are in an elevated professional status, we saw this economic shift reflected in the industry’s declining reimbursements from 2009 to 2013. We are just now starting to see the professional class—and the chiropractic profession particularly—start to improve.
The results in this year’s survey not only confirm this hypothesis, but suggest stabilization in the industry that will lead to future growth. The average reimbursement rate grew this year from 64 percent in 2016 to 65 percent in 2017. Additionally, fees rose but reimbursement rates declined at $68 and $43.5, respectively. These trends reflect financial growth for the chiropractic industry, but are not quite on the same trajectory as those for MDs.
One of the biggest successes for chiropractic occurred in early 2017, when The American College of Physicians published in the Annals of Internal Medicine a guideline and suggestion for noninvasive treatment of low back pain.2
This study targeted all clinicians, and it also targeted the patient population, including people with varying levels of back pain, ranging from minor to chronic. This was a huge win for chiropractic. It concluded that clinicians should only consider opioids or invasive surgeries as a last option and should initially select “nonpharmacologic treatment, massage, acupuncture, or spinal manipulation” or a treatment with exercise such as yoga or low level laser therapy.3
As this was a nod from the MD community, saying that chiropractic care should be taken into consideration before embarking on surgeries, the practice of chiropractic is gaining the attention and credibility of medical peers as well as the public. Hopefully, as more time passes, more MDs as well as the public will start to acknowledge the overall health benefits of quality chiropractic care.
Research along these lines will help pave the way for those who hold their beliefs in the doctrine of evidence-based results and proven patient outcomes.
Here are several key points from this year’s Fee’s and Reimbursements survey:
Rise of the Midwest. This year, our survey found that practitioners in the Midwest had the highest reimbursement rate at 66.6 percent. This surpasses last year’s reimbursement rate of 61.5 percent.
Making the dream work. In 2017, 28 percent of respondents reported working in a group practice. This number has continued to grow from 24 percent in 2015 and 27 percent in 2016. Additionally, the percentage of chiropractors working in a multidisciplinary setting has been increasing. This year, 53 percent of chiropractors reported working with massage therapists compared to 41 percent of chiropractors in solo practice. The rising number of chiropractors in groups working with specialists is a clear trend.
Additionally, reimbursement rates were higher among chiropractors working in groups, averaging about $46 versus solo practitioners at $43.
Cash only. Cash-based practices have been on the decline for the past few years, according to Chiropractic Economics survey results. In 2016, 13 percent of practices were cash only, and this year that number is 10 percent. This number has decreased from 19 percent in 2014 and 16 percent in 2015.
Payment plans. Although payment plans have been declining over the past few years, this year the overall percentage rose by 2 percent. Perhaps this only reflects patient’s need for financial assistance. However, nearly 40 percent of DCs have started looking at payment plans on a case-by-case basis and negotiation. This number has increased by about 10 percent since 2016.
Breaking it into regions
Across the nation, the average fees and reimbursements among chiropractic practices continue to vary by region. Unlike the past two years, where the South reported the highest average reimbursement rates, the Midwest was reported as the highest in 2017. This year, the West followed closely behind.
This year, overall fees ($68.2) increased slightly, but reimbursements fell ($43.5) for an average reimbursement rate of 65 percent, which was an increase from 64 percent in 2016.
The West reported the second- highest average reimbursement rate at 65 percent (up from 64.8 percent last year). Fees climbed to $74 with reimbursements at $48 in this year’s survey.
The East had the second-highest average fees but trailed the West with an average reimbursement rate of 60 percent, unchanged last year.
The Midwest had a reimbursement rate of 66.6 percent—up from the previous year—and average fees and reimbursements remained about the same from last year $64 and $39 respectively.
The fees in the South region increased to $68 from $66 last year, and increased its reimbursements from $43 to $44.
Regional variations likely reflect general demographic trends.
Keeping on track
Last year we described an era of increased confidence in the chiropractic industry with an overall leveling of fees and reimbursements post-recession. That consistency remained true among our 2017 survey participants, with some additional signs of growth.
Our annual survey showed that fees climbed from $63.2 in 2016 to $68 in 2017. Reimbursement followed a similar trend, with the numbers remaining at $44 from 2016 to $44 once again in 2017. The overall reimbursement rates increased slightly, from 63.8 percent last year to 64.7 percent in 2017. There were no great surprises.
The last three years worth of reimbursement rate data have held steady between around 61 and 65 percent, and this year we saw the numbers are remaining among those averages. While only time will tell how major changes in healthcare will affect the industry, this years results show a consistency that indicates a stable chiropractic market for the time being.
Among our survey participants this year, 27 percent reported operating in a group setting. This remained relatively the same from 2016, when 27 percent reported working in a group, and is up from 24 percent in 2015. It is the highest percentage of group practice participants recorded in 19 years.
A total of 3 percent of responses were from associates this year. At 65 percent, DCs with solo practices made up the vast majority of our survey respondents with about 6 percent representing independent contractors in a practice.
On average, group practices reported higher fees, reimbursements, and reimbursement rates than solo operations in 2016. Group practices had average fees of $70 and average reimbursements of $46, while solo practices had average fees and reimbursements of $66 and $43, respectively.
Reimbursement rates in solo practices remained relatively level with last year’s 67 percent, and reimbursement rates in group settings remained quite similar to last year’s 69 percent.
As expected, group practices reported a significantly higher percentage of specialists working in their clinics. And 51 percent of solo DCs answered “none” when asked what specialists they employed, versus 24 percent of group practitioners.
DCs and MDs: a level playing field
The ebb and flow of reimbursements in the chiropractic field often mirror what’s happening in the healthcare industry as a whole but to a different or lesser extent. These parallels can be observed by evaluating the common codes shared by both MDs and DCs, specifically 99201 (evaluation and management for new patients) and its variations including 99202, 99203, and 99204.
For example, last year the overall decline in MD reimbursements recorded by Physicians Practice, a business journal for medical doctors, was in contrast with the slight growth or leveling of these same codes for DCs.
While dollar value of MD reimbursements for these codes remained a bit higher on average than those values reported by their DC counterparts (even with the declining reimbursements), the results showed a shrinking financial gap between the professions with regard to these core codes.
Optimistically, in 2017, DCs (per this survey) and MDs (according to Physicians Practice) reported higher reimbursements on average for all four codes. DC fees for all four codes were higher than MDs but MDs were reimbursed at a higher rate.
The increase in reimbursements reported by MDs was markedly steeper than the growth indicated by chiropractors. So, while both industries saw improvement, the 2016-17 results illustrate a return to a broader cleft dividing the industries, with MDs experiencing a recession recovery at perhaps a faster rate.
Because Physicians Practice now reports solely on reimbursements, our comparisons will be limited to DC reimbursements as well. The breakdown of specific codes in 2017 is as follows:
For code 99201, DCs averaged reimbursements of $49, while MDs’ reimbursements were $66. This is down from $50 (DCs) and remained the same $66 (MDs) from last year.
For code 99202, MDs’ reimbursements were $82, up from $81 the previous year, and DCs reported an average of $63, down slightly from $64 in 2016.
For code 99203, MDs’ reimbursements decreased slightly from $101 last year to $98 this year. DCs’ reimbursements were unchanged from $86 last year to $84 this year.
For code 99204, MDs reported a reimbursement average of $131, a slight increase from last year’s $130. Chiropractors reported average reimbursements of $110, which was a slight jump from last year.
Speaking of specialties
In May 2017, our annual Salary and Expense Survey showed that teaming up with complementary specialists clearly boosts a DC’s total compensation and salary. Those salary survey participants with specialists working within their practice reported average earnings of approximately $139,470 compared to the $91,066 reported by strictly solo operations.
In addition, multidisciplinary practices participating in this survey reported higher fees and reimbursements than those without specialists. The results demonstrate the multifaceted benefits of running a practice with diverse specialties.
Specifically, practices with specialists reported average fees and reimbursements of $68 and $45, while non-specialist practices reported average fees and reimbursements of $61 and $42, respectively.
For multidisciplinary practices, licensed massage therapists (LMTs) remained the most popular practice add-on, with 46 percent having one on board. LMT was followed by acupuncture (13 percent), fitness trainer (9 percent), MD/DO (8 percent), physical therapist (8 percent), nutritionist (8 percent), and naturopathic doctor (2 percent). The 3 percent that answered “other” specified working with such specialists as a psychologist, occupational therapist, and a yoga instructor.
The model operation
Although we saw an increase in survey participants reporting as franchises over the past three years, in 2017 that percentage dropped to 4 percent of respondents (about the same as last year).
The financial picture for franchisees decreased slightly from last year’s survey. The average reimbursement decreased from 77 percent last year to 69 percent this year. However, fees increased from $62 to $65 this year. Reimbursements were at $43 this year, compared to $49 last year.
But wait: there’s more
This year’s survey indicates that franchise owners are slightly younger than the overall average age (45 years old compared to 50 years old). In addition, 80 percent of respondents reporting as franchisees in 2017 were male.
The average franchise owner has been practicing for 20 years (compared to the 22 year average among all respondents), owns one practice, and is licensed in one state.
This year’s survey showed that the vast majority of franchise owners are still operating a solo practice (60 percent). But those running a group practice held steady at 40 percent in 2017.
Cash only, please
Although the percentage of cash-only practice survey participants decreased from 13 percent in 2016 to 10 percent this year, those DCs who did report operating a cash-based practice fared well in their collections.
For cash-based practices, average fees were reported at $77, a value that is $11 more than overall average fees. In 2015, cash fees came in at $76, then decreased slightly to $74 in 2016, so this year’s data serves as an indication that cash collections are now seen to be rising.
By strict definition, a cash-based practice would have no reimbursements. So, fees in a cash-only practice are equivalent to reimbursements (collections). Cash-only practice fees of $77 are 61 percent more than the overall average reimbursement rate of $47.
This year we asked what percentage of your collections is in cash to dig deeper into this type of practice.
Almost 35 percent of you answered that your practice had less than 25 percent cash income. Twenty-seven percent had 25-50 percent cash and 20 percent had 50-75 percent cash collections.
Your typical cash-only practice respondent is male (77 percent), with women making up 23 percent of this group. Cash-based practice survey participants had an average age of 50, and typically work in a solo clinic (92 percent). These respondents have been working as a practitioner for 20 years on average.
Regarding cash-only practice offerings:
Ladies and gentlemen
Over the past few years, the number of female survey respondents has hovered around one-quarter of all participants. In 2012, we saw an all-time high of 28 percent, and this year, 22 percent of our respondents were female.
Female chiropractors reported slightly lower average fees than male DCs ($63 compared to $66), with slightly higher reimbursement averages ($44 to $43). Female practitioners also reported somewhat lower reimbursement rates than male DCs (64 percent to almost 66 percent).
The 66 percent reimbursement rate for men is down from 69 percent last year, whereas reimbursement rates for women remained in line with averages from 2016.
Women respondents reported younger ages (49), compared to men (51). In addition, female DCs reported being in practice for fewer years (18), while male respondents have been in practice for an average of 22 years.
With regard to modalities, instrument adjusting and ultrasound were the most popular among men. A greater percentage of female practitioners reported offering instrument adjusting than male practitioners, making
it the second most popular modality among women. Nutrition and ultrasound were also popular among female DCs as was kinesiotaping.
Follow the money
The number of doctors offering payment plans to patients this year increased overall (53 percent compared to 51 percent in 2016). The 2016 results appear to be climbing back since 2010 and 2011 when nearly 70 percent of DCs had such plans.
The biggest improvement this year is in DCs negotiating a payment plan per case. In 2016, nearly 28% of DCs had such a plan. This year, about 39% of DCs have this type of plan in place for patients.
And while discounts for cash saw a decline from nearly 40 percent of DCs offering it in 2013 to only 29 percent in 2015, that number grew slightly in 2016 at 35% and then declined once again to 32% in 2017.
The remaining responses were “negotiate per case” (38 percent), “down payment” (21 percent), “patient financing” (18 percent), and “other” (16 percent).
Reporting on codes
Year to year, we ask doctors of chiropractic to report on three additional codes: 95851, range-of-motion testing; 95831, muscle testing; and 97750, physical-performance evaluation. It should be noted that we did include these codes when calculating the fees and reimbursement averages for the other sections, not including the regional comparison chart.
Average fees for range-of-motion testing were $65, while average reimbursements were $40—a reimbursement rate of 62 percent.
Average fees for muscle testing were $62, with an average reimbursement of $32—a reimbursement rate of 52 percent.
Average fees for physical-performance evaluation were $60, with an average reimbursement of $35, and a reimbursement rate of 58 percent.
1 Havermann J. “The Great Recession of 2008-09: Year In Review 2009.” Encyclopedia Britannica. https://www.britannica.com/topic/Great- Recession-of-2008-2009-The-1661642. Updated Sept. 2017. Accessed Sept. 2017.
2 Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. Published March 2017. Accessed Sept. 2017.