As the Detroit Lions’ team chiropractor for almost 15 years, Sol Cogan, DC, has seen the benefits of patients receiving care from multiple health care providers who work together.
“Combining the skills of providers who share the goal of putting the patient first results in better health care,” he says.
A particular collaboration patients can benefit from is one formed between their chiropractor and physical therapist. “Although chiropractors can do many things, they don’t have the time to spend 30 to 60 minutes at every patient visit administering therapies, whereas a physical therapist does,” Cogan says. “When you combine the power of chiropractic care with the attention of a physical therapist, it can really benefit certain patients.”
Stephanie Higashi, DC, also sees many advantages to chiropractors and physical therapists teaming up. “Patients will get muscular rehabilitation in combination with skeletal adjustments—which will make the adjustments more effective,” she says. “If you only give an adjustment but don’t stretch and strengthen the muscles that keep pulling the bones out of alignment, it will be a recurring problem.”
Likewise, if a physical therapist is stretching and strengthening skeletal muscles and an underlying skeletal misalignment exists, then the problem will never fully resolve. “From a patient’s aspect, seeing both of these providers is the optimal solution for achieving the desired results after an injury or accident, or if they have a chronic condition,” Higashi says.
Furthermore, economically speaking, if a chiropractor and physical therapist work together in one practice, then that entity can generate revenue as a group rather than having to refer out to an unrelated corporation and miss capturing all of the revenue, Higashi adds.
Another reason for a chiropractor and physical therapist to collaborate is that chiropractors are better trained and equipped to treat certain conditions, such as axial back and disc conditions, and physical therapists excel in treating other conditions, says Alan K. Sokoloff, DC.
Bringing a PT on board
By adding a physical therapist to your practice, you’ll add another dimension to it, because they don’t do what chiropractors do. “Ultimately, two heads are better than one,” Cogan says.
Higashi notes that some physical therapists have specialty training in specific physical medicine and rehabilitation protocols that can enhance what a practice provides. For example, some physical therapists specialize in pre- and post-surgical knee rehabilitation, hand therapies, female pelvic floor balancing, and fertility.
Depending on the state, Deborah A. Green, Esq., says a physical therapist might have a broader scope of practice than a chiropractor does. In New York State, for example, a chiropractor is limited to treating the spine, whereas a physical therapist can treat the arms, legs, shoulders, and more.
After adding a physical therapist to his practice, Sokoloff began getting even more referrals from primary care physicians. He’s found that some physicians don’t know who to refer patients to when they have back or neck pain. “Now they can refer to our practice, and we decide who can best treat a patient’s condition.”
Effective collaboration
When looking to join forces with a physical therapist, look for someone whom you think you’ll enjoy working with. “Find one who understands your philosophy and the basic premise of chiropractic care,” Cogan says. Decide whether or not you want to work at the same facility and, if so, whether your office space allows for that. Also, check with a health care attorney to be certain your desired arrangement is legal in your state.
If both providers are located in the same building, it will be easier to keep an open line of communication and provide better patient care. In addition, the fewer times a patient has
to move to see a provider, the better their compliance will be. “That’s why medical complexes have different specialties working in the same location,” Cogan says. “Proximity makes life easier.”
You’ll also want to seek legal counsel on how the arrangement must be structured in terms of billing, reimbursement, and so forth, Higashi says. “Different state and federal laws exist and health care is highly regulated. Specific laws should be reviewed such as anti-kickback laws, Stark laws, and fee-splitting laws.”
When interviewing physical therapist candidates, make sure their specialties are a good fit for your practice’s needs. Higashi recommends that both providers educate the other
on what each profession brings to the table. “If that conversation doesn’t occur, each provider will work in a silo, and they won’t collaborate or messages will become mixed,” she says. Taking this a step further, an uneducated chiropractor or physical therapist could deter a patient from seeing the other provider. The arrangement could end up working against the practice.
To facilitate learning about each other’s skill sets, Higashi suggests providers schedule meetings for educational discussions. “Tell the other provider about your profession and things they might not know about it. Debunk any myths about your profession.” If indicated, you could take this a step further and have providers treat each other—which will reinforce their abilities and provide a better understanding of what the other one does and the benefits of their care.
When working in a multidisciplinary environment, someone should be the quarterback, Cogan says. He thinks a chiropractor is in the perfect position to diagnose a patient’s condition and determine the course of action. “Then, decide how and when to use a physical therapist,” he says. “Tell the physical therapist about the specific treatment you will provide, and keep the PT apprised of results as you proceed.”
Educating employees is also key. “Even if they don’t understand clinically what each profession does, staff members should understand that each provider excels in treating different things,” Sokoloff says. “Patients also have to understand why they are seeing a chiropractor and not a physical therapist, or vice versa.”
If a chiropractor or physical therapist works with a patient for more than two weeks without a positive response, then Sokoloff starts to document where deficiencies are and builds a case for another provider to treat them if warranted.
Structuring the contract
State laws differ regarding how chiropractors and physical therapists can work together. In the state of New York, for example, a chiropractor and a physical therapist can open a professional limited liability corporation (PLLC) together in which they are both owners and have an interest in the PLLC, but they can’t open a professional corporation together nor can they provide services as a general business corporation, Green says.
Florida’s laws are lenient compared to those in New York, Green says, as she is licensed in both states. In the state of Florida, a chiropractor can own a general business corporation and can hire a physical therapist, but there is a limit on the number of visits a patient can have without a referral from a medical doctor.
The rest of the states’ laws fall somewhere in the middle. “Some states allow a chiropractor and physical therapist to own a practice together and refer to each other and others have their own glitches,” Green says. “It’s all across the board.”
Regarding whether a chiropractor and physical therapist can refer to each other, Cogan says that in most states a physical therapist needs to get a prescription from an osteopathic or medical physician—so a chiropractor may not be able to refer to a physical therapist.
Another area where you’ll want to be cautious concerns how you arrange compensation, employment agreements, and whether you charge a physical therapist rent, Higashi says.
“Rent will need to be based on fair market value and not just what comes in for collections that month. Again, it’s important to review this with an attorney.”
Risks in the relationship
When it comes to collaborating, Green has found that some practitioners start exceeding the scope of their practice. “They think that because they own their practice, they should be able to make decisions regarding the services offered,” she says. “But you cannot exceed the scope of your own practice.”
In addition, Higashi says chiropractors with smaller practices might think they are under the legal radar, when in fact they are not. Or, because one chiropractor heard of another one doing a certain type of arrangement, they assume it’s legal and do the same thing. “Why not make sure you do things correctly and legally from the onset, so you can grow as big as you want and not have to worry,” she says.
Cogan concurs. “Make sure everything you do is always in compliance with the law,” he says. “More often than not, when chiropractors get into trouble, it’s because they didn’t do their due diligence to hire an experienced health care attorney to make sure that they didn’t violate any state or federal laws.”
In addition to ensuring that everything you do is legal when adding a physical therapist to your practice, your budget will have to allow for the expense of another practitioner. You may need to enlarge the space of your practice to accommodate a physical therapist’s needs, because they tend to require a larger room than a chiropractor does. If you’re sharing a space, make sure that both providers can agree on a schedule for using it.
In addition, you may need to invest in physical therapy equipment. If so, make sure the physical therapist will have enough patients to justify the expense and that you’ll get an adequate return on your investment. “A good way to start out is to purchase low-tech rehabilitation equipment,” Higashi says. “Then, after the therapist has proven to be an asset to your practice and it looks like they will stay, you can invest in more expensive advanced equipment.”
Another risk involves adding a provider who might not be a good fit for a practice. “If you buy a lot of physical therapy equipment or renovate your facility to accommodate a specific physical therapist and that provider quits, then you’ll be stuck with money out of your pocket and space taken out of your practice if you can’t quickly line up another physical therapist,” Higashi says. She recommends mitigating these risks by having two part-time physical therapists. If one doesn’t work out, the other one might be able to take over the other’s load. “The key is to avoid putting all your eggs in one basket so in case the law changes, and you can no longer work with a physical therapist in your state, you are diversified.”
Moreover, personalities among providers can become problematic, just as in any human relationship. “If the first collaboration doesn’t work out, you don’t have to give up,” Higashi says. “Try again.”
Avoiding competition
Despite the benefits of teaming up, chiropractors and physical therapists can wind up competing with each other. But when providers educate each other on what they do best, they can avoid this. For example, if a physical therapist who works outside of your practice knows your strengths, then he or she can help generate referrals. Although Sokoloff has two in-house physical therapists, he sometimes refers patients to outside ones if they need a modality that his therapists don’t offer, such as vestibular rehabilitation.
Sokoloff also notes the importance of educating patients on whether or not their insurance will cover them being treated by both a chiropractor and physical therapist on the same day. Many insurers limit the number of the procedures that they will cover during one visit.
Ultimately, when looking at the country’s economic climate and changes in health insurance coverage, Higashi thinks chiropractors will need to diversify their portfolios to remain profitable. Many insurance carriers have excluded chiropractic benefits or have opted for extremely low reimbursement; many policies have no out-of-network chiropractic benefits. Collaboration with other health care providers, such as physical therapists, is one way to achieve practice diversification.
Karen Appold is a medical writer in Pennsylvania. She can be contacted at 610-812-3040, kappold@msn.com, or through writenowservices.com.
