Where does your practice stand on the 2019 chiropractic fees and reimbursement survey?
IN 2017 AND 2018, WE SAW AN OVERALL LEVELING OF FEES AND REIMBURSEMENTS, and this trend has continued this year among our survey participants.
Chiropractic has been seen as a viable option to fight the opioid epidemic, and we have seen ample research to back up its effectiveness. In particular, in 2019, chiropractic continues to be elevated as a viable solution for pain management by the medical community. For example, the bill H.R. 3654, the Chiropractic Medicare Coverage Modernization Act of 2019, was introduced in the U.S. House of Representatives in July; if passed it will enable seniors to receive as covered benefits all services chiropractors are licensed to provide, instead of just manual spinal manipulation. This could allow patients to use their chiropractors for primary-care services previously only covered by Medicare if they visited an MD.
The results from our survey show a slight decline of several trends we have been seeing over the past few years. Fees remained about the same from $69 in 2017 to $72 in 2018, but dropped to $61 in 2019. Reimbursement averages dropped to $38 this year, after a slight decline from $46 to $45 in 2018. These trends reflect leveling off or slight decline in the chiropractic industry.
According to the data collected from chiropractic school enrollments, it’s apparent that more women have started entering the industry. Over the past few years, we have started to see those numbers trend positively in our survey, as more women have responded to our calls to take the survey. This year we had the highest number of women respondents seen yet at 30% of total replies. Statistics point to more women entering the chiropractic field in coming years and closing the gender gap.
Although the economy as a whole is looking strong in terms of growth and employment, with inflation in check, the health care industry (MDs, DCs and specialists) has been in a holding pattern. It is possible that uncertainty in the insurance markets, along with rising co-pays and deductibles, have consumers skittish about health care services in general, presenting a countervailing headwind against positive economic trends.
It is likely, then, that if and when some measure of certainty and stability return to the health care environment, an upturn in business can be expected.
As always, our survey is subject to statistical variation, and all figures herein presented should be considered as approximate. Normal fluctuations in most categories occur year over year, and we suggest that our results are best used for spotting general trends to guide strategic planning.
Here are several key points from this year’s Fees and Reimbursements survey:
Midwest pulls ahead
In this year’s survey, the East reported the highest reimbursement rates at 71%. This finding is a bit lower than last year’s findings, where the West had the highest reimbursement rate at 73%.
This year 21% of respondents reported operating in a group setting. This dropped 3% from last year, where 24% reported working in a group, which was the highest percentage of group practice participants recorded in 19 years.
The most common specialist in the group was a licensed massage therapist, which was indicated by 36% of groups with specialists on board. This finding suggests that the percentage of chiropractors in groups working with specialists is on the rise.
This year’s survey
During August and early September 2019, Chiropractic Economics extended an invitation to readers to complete a web-based survey on fees and reimbursements. Additionally, we encouraged a number of state, national and alumni associations to distribute the survey to their members.
We limited survey participants to practicing chiropractors or their designated office managers or CAs to ensure accuracy.
• Number of participants: This year’s analysis is based on responses from 240 respondents.
• Regional distribution: Participants hailed from the Midwest (28.5%), the West (27%), the South (26%) and the East (18.5%).
• Averages: Unless indicated otherwise, all numbers are given as averages.
• Cash-only practices: Cash-only practices reported fees only.
Our survey results are provided for informational purposes only. They are not intended to be used as a recommendation for setting fee levels.
Additionally, group practices had average fees of $65 and average reimbursements of $39, while solo practices had average fees and reimbursements of $57 and $41.
Cash-based practices had been on the decline for the past few years, according to Chiropractic Economics survey results, before making a jump last year.
In 2016, 13% of practices were cash-only, decreasing to about 10% in 2017. In 2018, that number leapt to 19.9%, and then dropped this year to 16%.
According to our 2019 data, 58% of chiropractors offer patients payment plans. Discounts for cash continue to be a popular option; our survey results showed that about 30% of DCs currently offer this type of plan.
Regional fee comparisons
Across the nation, average fees and reimbursements among chiropractic practices continue to vary by region. The East reported the highest reimbursement rate in 2019 at 71%. This year the Midwest followed close behind at 67%.
While overall fees ($61) decreased this year, reimbursements stayed the same as last year’s at $38. The reimbursement rate is 61.7%, which is an increase from last year’s average reimbursement rate of 50%.
The South had the highest average fees but trailed the other regions with an average reimbursement rate of 59%, down from last year’s 66%. The Midwest’s reimbursement rate of 67% represents an increase from the previous year at 65% in the chiropractic fees survey,
Fees and reimbursements
In 2017 and 2018 we described an era of increased confidence in the chiropractic industry, with an overall leveling of fees and reimbursements post-recession. Generally, however, fees and reimbursements decreased among our 2019 survey participants.
Our 2019 annual survey showed that fees decreased from $72 in 2018 to $61 in 2019.
Reimbursement followed a similar trend, with a $45 average in 2018 to $38 in 2019. The overall reimbursement dipped a bit, from 63.8% last year to 61.7%this year.
The last three years’ reimbursement rates have held steady between approximately 61-65%; this year we saw the numbers remain among those averages. While only time will tell how major changes in health care will affect the industry, this year’s results show a consistency that indicates a relatively stable chiropractic market for the time being.
Among our survey participants this year, 21% reported operating in a group setting. This dipped slightly from 2018, where 24% reported working in a group, which was the highest percentage of group practice participants recorded in 19 years.
We had fewer responses from associates this year, which made up for a total of 4% of responses, and about 7% indicate they’re working as independent contractors in a practice. At 69%, DCs with solo practices made up the vast majority of our survey respondents.
On average, group practices reported higher fees, reimbursements and reimbursement rates than solo operations in 2019. Group practices had average fees of $49 and average reimbursements of $39, while solo practices had average fees and reimbursements of $48 and $41, respectively, in the chiropractic fees survey,
Reimbursement rates in group practices increased from last year’s 52% to 60% this year, and solo practices increased from 67% to 72% over the same period.
As expected, group practices reported a higher percentage of specialists working in their clinics. About 88% of solo DCs answered “none” when asked what specialists they employed, while just 12% of group practitioners answered the same. The most common specialist in a group practice is an LMT, which 33% of group practitioners reported.
DCs and MDs
The ebb and flow of reimbursements in the chiropractic field often mirrors what’s happening in the health care industry as a whole, albeit to a different or lesser extent.
These parallels can be seen when evaluating the common codes shared by DCs and MDs alike, specifically code 99201 (evaluation and management for new patients) and its variations including 99202, 99203 and 99204.
For example, in 2018, an overall stagnation in MD reimbursements noted 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 higher on average than those values reported by their DC counterparts, our results show a financial gap between the professions with regard to these core codes.
Specializing pays off
In May 2019, our annual Salary and Expense Survey showed multidisciplinary and integrated practices achieving new levels of success, and increased salaries and reimbursement rates have followed. That said, chiropractors who have been in the industry longer have seen the larger paychecks that come with more experience.
Those salary survey participants with specialists working within their practice reported average total compensation of more than $146,830, compared to the $104,300 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 $86 and $58, compared to the overall average fee of $61 and reimbursement of $38 in the chiropractic fees survey,
Licensed massage therapists (LMT) remained the most popular practice add-on, with 36% having one on board. LMT was followed by acupuncturist (10.6%); MD or DO (9%); nutritionist (7.8%); physical therapist (6.9%); fitness trainer (6.4%); and nurse or nurse practitioner (5.5%). Fewer than 5% of participants employed a naturopath or physician’s assistant.
Although we saw an increase in survey participants reporting as franchises over the three years prior, we saw the percentage drop slightly in 2018 to 5%.
This year, that number essentially stayed the same at 4.9%. The financial picture for franchisees decreased slightly from last year’s survey. The average reimbursement decreased from 67% in 2018 to 47% this year. Also, average fees decreased from $76 to $44 this year.
This year’s survey indicates that franchise owners are the same average age as the overall group of chiropractors (50 years old).
The average franchise owner is male, has been practicing for 20 years, owns one practice, and is licensed in one state. This year’s survey showed that 6% of franchise owners are operating a solo practice. Twenty percent of respondents in a franchise were independent contractors in a practice.
Although the percentage of cash-only practice survey participants increased from 10% in 2017 to 19.9% in 2018, the percentage of cash-only practices decreased a bit this year to 16% in the chiropractic fees survey,
For cash-based practices, average fees were reported at $50, an amount that is less than overall average fees of $61. In 2017, cash fees came in at $77, then decreased slightly to $74 in 2018, so this year’s data serves as an indication that cash collections have declined.
This year we asked what percentage of your collections is cash-based to dig deeper into this type of practice. Almost 41% answered that their practice had less than 25% cash income. Twenty-five percent had 25–50% cash, and 18% had 76–100% cash collections.
Your typical cash-only practice respondent is male (84%), with women making up 15.5% of this group. Cash based practice survey participants had an average age of 50, and typically work in a solo clinic (84%). These respondents have been working as a practitioner for 21 years on average.
Regarding cash-only practices: 15% offer instrument adjusting, 9% offer ultrasound, 11% offer electrotherapy, 15% offer nutrition, 17% offer kinesiology taping, 12% offer exercise programs, 12% offer massage therapy, 8% offer physical therapy, 14% offer laser therapy, 18% offer instrument assisted soft tissue mobilization, 12% offer acupuncture, and 22% offer homeopathy.
Chiropractic and gender
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%, and last year, 27% of our respondents were female. In 2019, we are pleased to see that number rise once again, reaching 30% female respondents in the chiropractic fees survey,
Female chiropractors reported slightly lower average fees than male DCs ($61 compared to $63), with lower reimbursement averages ($43 to $39). Female practitioners also reported lower reimbursement rates than male DCs (63% compared to 68%).
The 68% reimbursement rate for men is up from 56% last year, and reimbursement rate for women this year is 63%, also up a bit from last year in the chiropractic fees survey,
Women respondents reported an average younger age (47), compared to men (52). In addition, female DCs reported being in practice for fewer years (16), while male respondents have been in practice for an average of 23 years.
With regard to modalities, kinesiology taping (18%), laser therapy (14%) and IASTM (9%) were the most popular among women. The most popular modality reported by male practitioners was also kinesiology taping (35%). Laser therapy was another popular modality among males (28%) as well as decompression (25%).
How patients pay
The number of doctors offering payment plans to patients this year increased almost 10% (58% in 2019 compared to 49% in 2018).
A significant number of chiropractors also offer discounts when patients pay in cash. Last year, DCs saw a 33% discount for cash, and this year about 30% of DCs have this type of payment option in place.
Negotiations per case saw a decline from nearly 26% last year to 23% this year. Although this is a slight setback, the numbers should fall into place within the next few years and reach an equilibrium.
The remaining responses were “prepay” (27%), “patient financing” (20%), “down payment” (11%), “discount medical plan organization” (8%) and “other” (3.3%).
3 more codes
Every 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 $13, while average reimbursements were $9 — a reimbursement rate of 67%.
Average fees for muscle testing were $21, with an average reimbursement of $6 — a reimbursement rate of 27%.
Average fees for physical-performance evaluation were $61, with an average reimbursement of $41, and a reimbursement rate of 66%.