The integrated practice model isn’t for everyone, but it can succeed spectacularly.
Creating an integrated practice that combines the healthcare modalities offered by a chiropractor and a medical doctor is not a decision to be made lightly. Not only is there considerable expense and financial risk involved but building a successful model means drastic changes in how you run your practice and deliver care.
Integrated practices are still in the minority, but a number of factors, including the Affordable Care Act, insurance reimbursements, a growing emphasis on preventive care, and patient interest in overall wellness have more chiropractors considering the move.
In this year’s annual Chiropractic Economics salary survey, about 65 percent of respondents reported operating alone; nearly 30 percent said they operated as a multidisciplinary clinic (a chiropractor and any other alternative medicine practitioner on staff); and 6 percent reported belonging to an integrated practice (chiropractor and medical doctor on staff).
In the same survey, integrated practices reported the highest billings ($753,800); followed by multidisciplinary practices ($532,000); and chiropractic-only practices ($471,000).
That same order held for reported collections: integrated ($641,900); multidisciplinary ($403,400), and chiropractic-only ($281,800).
While every situation is unique, there are best practices that apply to any DC considering starting or joining an integrated practice.
The right motivation
If you are considering practice integration, do a thorough internal self-examination before deciding. Regardless of any anticipated economic benefits, operating an integrated practice entails drastic changes for a chiropractic-only practice. At minimum, it means more employees and paperwork, a change in how the existing practice is run, and additional administrative duties.
It also can mean moving to new offices or remodeling existing quarters, buying new equipment, collaborating more closely with people in different specialties, and new reimbursement struggles and procedures. The new practice and its additional services also need to be marketed to existing patients as well as prospective ones.
So before proceeding, ask yourself not only if you can handle these changes but also if the resulting practice is one to which you’ll want to dedicate yourself.
“If you don’t believe in it, you certainly shouldn’t be doing it,” says Marc Sencer, MD, head of MDs for DCs, a medical staffing company that finds and trains MDs to work in chiropractic offices.
While economics is part of any discussion of integrated practices, the primary motivation, as with all healthcare-related decisions, should be delivering better patient care, Sencer says.
“It’s not for everybody by any means,” says Scott Calzaretta, DC, founder of the integrated Chiro-Medical Group in San Francisco. “You have to be in the right frame of mind. You can’t practice something you don’t believe in.
Prerequisites to practice
Forming a successful integrated practice requires more than just the will to do so, of course. Practice consultants cite a number of prerequisites that can optimize the chances of success.
Sencer says an integrated practice should have a minimum of 12,000 square feet of space and see at least 80 to 100 patients a week. In addition, the practice should have four to six months of financial reserves to cover the additional overhead while the new model gets off the ground.
Adding cash-based services, such as intravenous vitamin injections, weight-loss treatments, and chelation therapy can see the practice through a slow start and contribute to the bottom line as it matures, he says.
Aaron Oxenrider, DC, clinical director of a chiropractic practice and CEO of consulting firm Access 2 Integration, says he does not recommend integration for chiropractic practices with fewer than 50 unique patient visits per week and 15 new patients per month.
Chiropractors can finance an expansion themselves, get investors, or secure loans, says Michael Carberry, DC, president of Advanced Medical Integration and founder of several integrated practices. But, he adds, no one should proceed without a thorough understanding of their existing finances and a realistic model of integrated practice expectations, both short-term and down the road. That model should include attracting at least five new patients a week, he says.
Some consultants recommend scaling up gradually, adding an NP rather than an MD and hiring part-timers before committing to full-time staff with their concomitant expenses. Others say it’s easier to attract patients with an MD than an NP. Consider what additional services you want to offer and whether they will be profitable, and hire accordingly.
Keeping in compliance
An integrated practice can get into trouble before it starts if it’s not set up correctly. And simply because a chiropractor has successfully formed his or her own practice does not make establishing an integrated operation merely a matter of ordering new letterhead and business cards.
The laws regulating integrated practices vary from state to state. Some states have a corporate practice of medicine doctrine, which prohibits anyone who is not a medical physician from owning a medical practice.
Other states allow anyone to own a corporation that provides medical care, but require the corporation to employ a medical physician who is responsible for making all healthcare-related decisions. In those cases, the owner of the medical corporation, unless a medical doctor or osteopath, cannot play any role in medical decisions concerning any patient.
“It is easier to set up an integrative office in some states than others,” Oxenrider says. “Some states allow the chiropractor to be the 100 percent owner of the medical corporation. In other states, an MD has to be a percentage owner, ranging from 1 percent to 51 percent, depending on the state.”
Compliance can require forming a medical professional corporation, a management company, and a funding company.
It’s essential to research the regulations governing integrated practices and work with an attorney who is experienced with the requirements in your state. The legal complexities and the necessity of getting the corporate structure right are one of the reasons many chiropractors hire attorneys and consultants to handle the paperwork.
And compliance doesn’t end after the corporation is established. Before adding a service, research the relevant state regulations, including who can perform it, in what setting, and how it can be billed. Assume everything will be audited and prepare accordingly.
While states gradually are loosening regulations in this area, it’s always dangerous to assume something is in compliance without making sure. “Compliance is everything,” Carberry says.
An expanded practice also means more billing and paperwork. Some integrated practices will hire management firms to handle the administrative chores. At minimum, if your practice is thinking of making the switch, make sure your EHR system is up to the task.
Finding the right partner to invite into a practice, whether an MD, DO, NP, or PT, is another challenge.
“We have seen many chiropractors struggle to find the right fit, which is very expensive and time consuming,” Oxenrider says. “This can be the difference between success and failure. The second-biggest challenge is the ongoing training and management of the MD and NP by the chiropractor once they join the team. The chiropractor now has to keep everyone on the same page and engaged in practicing as a cohesive unit.”
The long struggle to have chiropractic accepted by the medical community and the dim view some MDs and physical therapists take of chiropractors makes finding the right matches crucial, Sencer says. In addition, the complicated corporate structures of these practices, which are owned by chiropractors, but where medical decisions are made by employee MDs, can be fertile ground for conflict.
“It’s important that you have an MD who’s a team player. Everyone in the practice has to be on the same team,” Sencer says. “But different points of view are fine if there is open dialogue.”
“It’s important to keep an open mind during treatment discussions,” Calzaretta says. “You may not ultimately agree with a decision, but you can learn from it.”
Sencer notes that MDs’ long-standing prejudices against chiropractic are fading: “I think MDs are being educated about what chiropractors do. I think medical doctors are finally more comfortable in a clinical situation with chiropractors.”
Other DCs say they are seeing more referrals from MDs.
Consultants like Sencer often play matchmaker, providing integrated practices with MDs and NPs pre- screened for the right attitude toward chiropractic and trained in the realities of integrated practices.
Calzaretta has integrated a variety of medical professionals into his practice, including MDs, DOs, and physical therapists, but says he never hires anyone without multiple interviews and checking carefully to ensure they have the proper outlook.
“For me, it’s first and foremost: Do they fit our mold? They have to be good people and they have to be enthusiastic about our model of care,” he says.
An integrated future?
The barriers to integrated practices— regulatory, administrative, financial, and ideological—are considerable and these practices are likely to remain in the minority for a long time to come. But the number of integrated and multidisciplinary practices will continue to grow, largely due to economic pressures. Many DCs are just realizing that the existing chiropractic-only model can’t last.
“They want to be able to continue to practice they way they have been. They have to change something,” Sencer says. “If they don’t integrate, all they can bill for is chiropractic services.
And when those get cut, they have no way to fill back up.”
But money isn’t the only factor, Oxenrider says: “Many chiropractors are looking to become the one-stop- shop healthcare alternative for their patients. Having a provider in the office who is licensed to take patients off their medication or offer a more natural alternative is appealing to many.”
The ultimate tipping point could be the preference of patients, aka: consumers. They are largely unaware of and unconcerned with prejudices and rivalries among the various medical professions and simply want the best and most convenient care.
“My patients like being able to go down the hall for additional care,” Calzaretta says. “They are wondering why we didn’t do this before.”
JAMES F. SWEENEY is a freelance writer in Cleveland. He is a former newspaper and magazine reporter and editor. He can be contacted at firstname.lastname@example.org.