It wasn’t until my son shattered his collar bone and I experienced hospital emergency room conditions that I truly understood why it has been so easy to bring a medical doctor into a chiropractic environment. Medical doctors are experiencing the effects of managed care in much the same way as many of us do. In some cases, it’s hitting them even harder. Group practices now outweigh solo practices by three to one and it’s escalating like never before. Managed care is the culprit. If you’re in a market with over 40% managed care, you’ve lost patients and money. But you’re still in business. The medical doctors literally had nothing to fall back on and if they were unable to secure managed care contracts, then they got away from the solo practice and either joined a group or took a position at an emergency room, walk-in clinic or some other facility. There are currently tens of thousands of medical doctors working for hourly salaries.
Imagine yourself being a medical doctor with no place to hang your hat. Your best options are limited to taking an hourly wage position and working under the auspices of governed protocol. This is a far cry from the dream once held by physicians to own and operate their own lucrative medical practice. Now imagine working a 12 to 14 hour shift under emergency conditions. When my son was in the ER for his shoulder injury, we spent four and a half hours waiting to get a doctor to prescribe a clavicle brace. I took the x-rays in my own office, but quite frankly, I panicked when I saw how bad the fracture was and I thought the hospital was the best place to take this type of injury.
The swelling on my son’s clavicle was the size of a softball, he had 103.5 degree fever, was flushed, nauseous and suffering fainting episodes.
The ER staff was very courteous, however the place was packed and we had to wait our turn. All the while I was carefully witnessing the activities of the ER doctors. Let me tell you, it’s no picnic. These guys are running around handling all sorts of emergencies for only 55 bucks an hour. When the staff doctor got a chance to talk to me, I told him I was holding the grand opening of my own new multi-disciplined facility in ten days and invited him to attend. He said he couldn’t because he’s working 14 hour shifts. I asked him why would an MD work such ridiculous hours under such duress for so little pay? He asked me if I could do better. I told him I’d pay him the same money… $55 an hour… but I would eliminate the 14 hour shifts and eliminate the weekend hours and best of all, eliminate the emergencies. He said; “I’ll take it!” It’s that simple. These MDs truly long for the work conditions they can experience when joined in a group environment with natural chiropractic care. It sure beats the heck out of working at the ER or walk-in clinic.
You have certainly heard the phrase, “If it seems too good to be true, then it probably is.” As with regulatory agencies or in dealing with bureaucracies, red tape aboundsespecially in the health care market and insurance industries. However, my philosophy is that there are still things that are truly good and we must look for them and change our viewpoint too. If it is good, then you deserve it. Of course you must approach them fully advised. There are always exceptions, even to suppressive bureaucracies. For example, a senator named Stark introduced into legislature an amendment to prevent a physician from referring a patient to a business in which he had ownership. To this legislation were born exceptions called Safe Harbors. Certain acts of referrals were safe under these harbors. The exceptions permitted a physician to refer for additional services when the referral went to another member of his group. Hence, group practices were born. I am not speaking as an attorney, but that is the story in a nutshell.
The key to maintaining legal rudiments is predicated upon maintaining the legal scope of practice which defines the group. Individual states and the federal government define the group. The definitions vary. If you are dealing with Medicare, Medicaid, Champus, Chamus, etc., you must abide by the federal guidelines which constitute a legal group practice. For example, in order to be part of the group, each physician is required to spend a certain percentage of his working time in the group. If he does not meet the time allocation for the federal definition of a group, then it is not a group practice. This is the area where I see the most mistakes. Therefore, an MD cannot spend the majority of his time outside the MD/DC relationship and still meet the qualifications of a group. Some chiropractors who do not realize this are in violation of either the state or federal Safe Harbor Acts and Stark Amendment. This is the biggest area where problems develop. My suggestion is simple. If you are looking for an MD on a limited basis, then look for a retired MD. No matter how little time he spends with you, you don’t have to worry about the group concept since he is not working anywhere else.
How to hire an MD
One of the best and perhaps easiest places to find and hire a medical doctor is by direct contact with physicians employed in ERs. The next option would be to go directly to the walk-in clinics. You can certainly attempt to network through any local physicians, or any ones that you have relationships with, asking if they have an interest or if they have any qualified colleagues they could introduce you to. A simple ad can be placed, either in local medical journals, in the classified section of your large city Sunday newspaper editions, or in a regional medical trade magazine. Often times, this is enough.
If you are lucky enough to live near a medical university or college, teaching institution or medical school, you can announce to the local medical personnel through bulletin boards. You can place flyers indicating your desire to hire a medical practitioner on the bulletin boards as well as your local hospitals, emergency rooms, medical libraries, or medical cafeterias. These are excellent sources of contacts for medical practitioners seeking employment opportunities.
Sample phone script which can also be adapted for use as a print ad:
This is Dr.________________. I would appreciate it if you would route me to your attending physician on a personal matterand would you please tell me the name of the doctor on Duty?
________________ (Dr.’s name)
Hi! This is Dr._______________. We are opening a physical medicine and out patient center (with rehab), and are looking for a medical director on a part-time basis to perform physical exams. We have flexible hours10 to 15 per weekmore if possible. There are no emergencies and no weekend hours. We supply all the patients. If you would be interested, I’d like to set a time to meet and discuss this.
(If no interest, ask if they may know someone who would be interested).
In your print ad, you may opt to list any qualification criteria you have for your MD such as: must be board certified or eligible, must be willing to accept walk-ins or minor emergencies. You should request a faxed copy of a resume or curriculum vitae. The objective here is to bring in as many applicants for interview as possible.
How to conduct the interview
When you meet with the medical doctor, explain to him your ideal situation. Inform the MD that you are expanding into multi-discipline services or that you are opening a rehab center. Inform the MD that you would like to refer patients for evaluations and examinations. Let the MD know that you already have the patients and you will be supplying all the support staff, materials, equipment, and the marketing.
Talk to the MD as a person, not just as a doctor or someone that you are looking to hire as an employee. Ask questions about his family, children, the type of person he is, his reason for becoming a MD. Make sure to obtain and review his curriculum vitae. Ask the doctor if he has any questions that he would like to ask you and make this a personable meeting as well as a business meeting. Be sure to obtain a copy of the MD’s malpractice insurance contract. Then explain to the MD the program that you intend to run in your new clinic. Describe your new environment in as much detail as you can, covering the increased services that you wish to offer with the MD as an additional provider. When explaining your new service interest to your MD, it would be helpful if you could actually show him (in person or via pictures) the services that you intend to add, for example equipment and diagnostics. If you have new TV commercials ready to air, or other marketing or advertising campaigns and programs, you can make them available for review. You could show any drawings of the new facility to include office space layout design, the new medical equipment, or the new rehab equipment. You can review with the MD any or all of your concepts, exam forms, or the patient file folders including the physician referral form. Use all of this to gain ease and familiarity with each other. There are tremendous opportunities and options to consider regarding the expansion of your service delivery. That is another topic.
When undertaking your search for a MD, you are likely to have multiple applications. In fact, in some cases you will have to make a choice. That decision can be based upon the physician’s experience, salary consideration, availability, willingness to cooperate with you, and how well your personalities gel together. I am sure that if you are in business as a chiropractor and you are thinking about adding a MD, you will be able to decide for yourself which one of the applicants will be the most suitable for you. So, by getting to know the MD through casual conversation, you begin to develop a sense of camaraderie. Use the interview as a preview to determine compatibility.
New service options available through the new DC/MD group
Most of the services that your MD will provide will be focused upon evaluations, examinations, diagnostic testing procedures, and some assistance with public relations. It is a fallacy to believe that the chiropractor loses control. Quite the contrary. You establish the services that you wish to perform, the case protocol, the treatment criteria, and for the most part, your MD will be the diagnostician, examining and referring physician. The physician can also serve as “gatekeeper” when physician referral is required.
A built-in benefit of adding medical services to your current practice is that you can recall many of your patients who left because their chiropractic insurance coverage was terminated. They may be able to receive additional medical-related services which can be billed under the new MD provider number. You will certainly inform your patients, both current and discharged, that you now offer medical services. Your patients may now find it convenient to come to your office for both their chiropractic care and various other standard medical care, such as cold treatment, flu shots, vaccinations, or school exams, so on and so forth. You may also venture into walk-in clinic care services or perhaps even minor emergencies.
Introducing the new services
The next area is how to begin incorporating your MD into your practice. The forms on the following page offer an example of some of the services you could provide with an MD, as well as enlightening you as to the process used when the MD examines and evaluates the patient and then refers them back to you for the performance of the services.
After the MD performs the evaluation, he will complete the Outpatient Rehabilitation form [Figure One] and return it with authorization to treat the patient. This is the “gatekeeper” form. It also contains a list of the various services that can be performed by the chiropractor. Similarly, there are forms intended strictly for MD services as well as accompanying fee slips. Also shown is the Clinical History form [Figure Two] with the Social History section enlarged for your review. This is to demonstrate that the medical entrance history covers a bit more detail for the purpose of identifying Coronary Heart Disease risk. If you are going to have rehab in addition to your new services, then there is a Coronary Heart Disease (CHD) evaluation that is required on all patients before they are placed on rehab programs. Rehab programs require exercising against resistive weights. To fully maximize the body’s ability to increase strength and endurance under rehab programs, it is necessary to exercise at a targeted heart rate. To reach a targeted heart rate requires a cardiovascular regimen, usually a treadmill, exercise bike, stair climb, or a combination of all. To get the body to reach its target heart rate, there is a CHD risk factor involved. This is especially true of older patients. It is common that all females over 50 and males over 40 be evaluated for risk of CHD prior to placement in a rehab program. This requires a 12 lead resting EKG and a spirometry test, which is performed by the MD. If a patient is known to be at high risk, for example, abnormal heart sounds, palpitation, or blood pressure, or daily activities that would put someone at risk such as excessive caffeine, aspirins, alcohol, nicotine, or family history of CHD, or known hypolipidemia, or endocrine, or metabolic disorders, then again these patients must be cleared by the MD prior to placement on the rehab program. So your MD will not only do exams and evaluations, but he will also perform the CHD risk factor assessment.
Now let’s talk about training and reimbursing the MD
Salaries for the MD range from as low as $50 per hour to as high as $150 per hour. The norm nationwide is $55 per hour salary, with the higher salaries reserved for specialists.
The minimal use of the MD would be to examine, evaluate and refer the patients back to you for treatment, serving not only as a “gatekeeper” but also as another professional to render a diagnosis… kind of like getting the expert diagnosis of a MD combined with natural chiropractic treatment all in one facility. Depending upon the scope of services you wish to deliver, you can add additional medical services to expand the use of your MD.
Let’s take a look at the number of hours the MD would be required to work.
On average, with considerations for examining and evaluating, testing and performing diagnostics, taking a history, re-evaluating, working with you on some screening programs, and outreach public relations campaigns, it is estimated that your MD would be required to work 90 minutes for each new patient that you obtain per month. For example, 20 new patients per month times 90 minutes equals 1800 minutes. Divide that by 60 minutes in an hour, and you get 30 hours a month. A general breakdown of the time spent by MD services follows:
40% of his allotted time on new patients
20% of his allotted time on re-evaluating patients
20% of his time working with you on your public relations or outreach campaigns
15% of his time ordering and reviewing diagnostic tests
5% of his time working with screenings or hardships
As you expand services, or increase your marketing to bring in additional new patients, obviously your MD would be required to work additional hours.
Example of return on MD investment
As stated previously, salaries range from $50-$150 per hour. The following billing scenario for MD services offers a look at a return on investment for the MD portion of the new group. These procedures would generally be performed under the MD auspices. Please note the disclaimer regarding fee-for-services. Also, note that it may not be necessary to perform all of these procedures on all patients at all times. Additionally, there are other procedures that can also be performed. This is intended only as a scenario. (See Billing Scenario for MD Services below).
Develop a favorable working relationship
You may personally experience that your new MD will express a wish to be the chiropractor instead of being the MD. Attorneys may prefer MDs over chiropractors, but the public in large prefers chiropractors over medical doctors. MDs have a deep respect for the personal one-on-one relationships that chiropractors have learned to develop with their patients. MDs do not often get this opportunity. They usually are in deep admiration of this bond that is typical between a chiropractor and his patient. I don’t think you are going to have a problem with a medical doctor trying to take over or dominate your practice.
Most medical doctors now understand that patients want personal contact which MDs do not provide in the typical medical practice. The MD is quick to understand that his role will be to examine and evaluate, refer to you for treatment, and then re-examine and re-evaluate, and continue to refer.
Now if you take a look at the majority of the services that are going to be provided, most of them (whether in sports, accidents and injuries, or just pain relief) will involve the spine, neck, and back. Those conditions are treated superiorly by chiropractors than by medical doctors.
There will certainly be some cases when pain medication will be necessary and your MD can prescribe it. There may be some emergencies where patients will be in acute distress and require taping, wrapping, bracing, splitting, rest, elevation and compression techniques that an MD would be more familiar with. But for the most part, the services to be delivered will be established by the owner of the facility, who is the DC. So, there is very little to worry about regarding who runs the show and which services will be delivered.
Additional services to consider through the DC/MD relationship
A routine service that a MD could deliver is diagnostic testing. Many multi-discipline offices perform Electronic Muscle Testing, Nerve Conduction Velocity and Evoked Potential. The MD’s license, expertise and time can be utilized to perform or prescribe these procedures. There you have another use for your MD without interfering with normal chiropractic day-to-day operations.
As you develop the relationship with your MD further and evaluate the demographics of your area, you may want to establish your own walk-in clinic services. For example, would you like to handle flu’s, colds and normal every day family type medicine? Do you have an interest in being able to prescribe medications, antibiotics, or pain relievers? Would you consider performing minor surgeries, stitches, or doing casting for certain fractures? Keeping in mind that the more services you develop, the easier it will be for you to capture managed care contracts.
If your MD is board eligible or board certified, you will have a much greater chance to capture managed care contracts. Imagine a managed care facility such as an MD/DC facility where you can evaluate the acute patient, perform minor emergency care, eyewash stations, stitches, fractures, minor surgery, acute medication prescription, plus chiropractic and rehab care. These are the facilities that are winning the managed care contracts across the board. You have got a tremendous opportunity to expand your services and in doing so, your service income will be increased. Your reimbursement schedule will be tremendously expanded by the fact that you now have a new additional provider number to bill under when insurance poses a problem under straight chiropractic care.
A very popular concept right now is one called “Centers of Excellence.” You may desire to establish a “Center of Excellence for Headaches,” “Neck and Back Pain,” or for “Accident Victims.” You may venture into nutritional programs, weight loss and diet programs, stop smoking programs, or pain control programs.
You have the opportunity now to move into industrial medicine/rehab, NIOSH and OSHA procedures, Functional Capacity Evaluations, and more advanced Workers Compensation programs. The sky is the limit here with multi-discipline. Let’s face it, a busy chiropractor is a happy chiropractor. Increased services and new ways of doing business are essential in this health care market.
The medical file and daily notes
It is very easy to set up the files and to manage the patient. The examination and the entrance history on a patient in a multi-discipline facility is different from that of the chiropractic facility. You have to look deeper into patient’s histories for general health problems and risk of Coronary Heart Disease. The entrance history is more comprehensive in evaluating body organs and systems in addition to familial tendencies to illnesses. You will keep separate files and daily S.O.A.P. notes for your MD, as well as your chiropractor. One fee slip is all that is necessary, with each individual practitioner signing off on the procedures that he performed. The bills will be submitted by the medical corporation (sample: S.O.A.P. notes submitted).
The solo practice is on its way out. The group practice is here to stay.
Look for the group practice, for it is truly the practice of the future. The solo practice is on its way out. The main reason is because it is becoming too difficult now with policy coverage limits, fee capping, and managed care. The group practice is here to stay. Getting in on it now is the smart thing to do. Marketing opportunities abound with multi-discipline. Patients certainly enjoy the convenience of one-stop shopping in regards to health care.
At some point you can begin to establish a network with other providers in your area as you increase and expand your services to offer multi-discipline and rehab services in your community. You will find a lot of assistance available through your Chamber of Commerce and your local media when it comes time to announce the addition of your new service center. You will also gain tremendous support from community members through the added visibility and momentum that the group multi-discipline practice will bring to you. You will find that work now becomes more enjoyable as you have created a more wholesome, holistic approach to bring patients into this new environment. This should create and generate much more excitement for yourself and your staff as you literally reinvent your practice future through the multi-discipline group practice concept.