For many chiropractors, multi-discipline practice is an ideal means of riding the rising tide of “alternative” medical care. In addition to being able to offer patients more services, one of the biggest reasons more chiropractors are entering multi-discipline practice is economics.
Chiropractors are well-educated, entrepreneurial, talented professionals, who would command high salaries, benefits and bonuses if they worked in corporate America. Why then, do so many chiropractors settle for stagnant or eroding salaries in their own practices or associate positions?
If you are not experiencing at least a 20% annual increase in practice income, you are in a crisis situation. Even with a 20% increase, 10% is eaten up by the cost of living and increases in operating expenses, leaving you a 10% salary increase. This is at least what you would earn in a comparable management position in private industry. Ironically, you probably work harder in your own practice than you would in senior or middle management elsewhere. For many practitioners who have “hit the wall” financially, a holistic multi-discipline practice can offer consistent economic growth with fewer cash flow problems.
Holistic multi-discipline offices can help stimulate cash flow, because many holistic services are not medically (nor chiropractically) reimbursable. This is an advantage from a collections standpoint. In this era of capitation and diluted reimbursement from managed care carriers, achieving and maintaining cash flow that reflects the quantity and quality of services rendered has become increasingly difficult. Reduced dependence upon third-party payors can translate into fewer administrative headaches and improved efficiency within the office.
If you are thinking of establishing a multi-discipline practice, you will save time and money by being as informed as possible about the specific protocols and procedures you must follow. By knowing more about establishing and maintaining a holistic multi-discipline facility, you will have a better idea of whether this type of practice is for you.
As more Americans turn to alternative medical care, it is increasingly important for chiropractors and other health-care practitioners to be knowledgeable about the various types of alternative treatment, including the benefits and indications for use.
In 1998, the New England Journal of Medicine (NEJM) published an article in which researchers estimated that as many as 60 million people had participated in alternative medical care. According to the 1998 Landmark Report, four out of every 10 adults had used some kind of alternative therapy by 1996.
As early as 1990, the NEJM reported that more patients saw alternative medical practitioners than allopathic doctors, with consumers spending an estimated $10.3 billion on non-conventional treatments. In the same year, consumers spent $3.3 billion on supplements and herbal remedies; that figure increased to $6.5 billion by 1996.
Patients seek non-conventional treatments for a variety of reasons, but the most prevalent is the perceived inability of conventional medical techniques to relieve certain chronic or multi-symptom conditions, such as chronic pain, allergies and headaches. Some patients turn to alternative treatments as a last resort, while others find they receive more individualized attention from non-traditional practitioners.
Chiropractors often view themselves as leaders among alternative-based doctors, yet statistics tell us otherwise. The fact is, considerably more holistically based health-care services are rendered by allopathic physicians than chiropractors. This stumbling block can be corrected if doctors of chiropractic realize their practices can expand commensurate to an increase in profit centers (i.e., the types of services rendered). The ideal means of offering additional services is through a multi-discipline practice.
Playing by the Rules
If you are properly managing and working in a holistic multi-discipline facility, there is no need to be employed by and managing a separate chiropractic practice. This poses a possible conflict of interest with respect to self-referral laws, and offers you no benefit from a legal or clinical perspective.
In establishing a multi-discipline practice, a funding corporation owned by you or someone you wish to designate will protect the accounts receivables by virtue of a primary lien position. This is an extremely important corporation and should be the financing arm for the practice.
In a multi-discipline clinical environment, the medical/osteopathic physician must perform the initial intake, including but not limited to, examination of all patients who are to be treated medically. This does not prevent the chiropractor from performing a musculo-skeletal evaluation. Additional practitioners may also perform their respective evaluations. All evaluations would then be evaluated by the MD/DO to form an aggregate analysis and diagnosis. This diagnosis is the basis for all medical treatment and/or diagnostic procedures that follow.
Upon completion of the initial consultation, examination and applicable testing, treatment is rendered in accordance with the needs of each specific patient. Bear in mind that all treatment must be rendered either by the medical/osteopathic physician or “incident to” his or her treatment of the patient. It is inappropriate, unethical and fraudulent (illegal) for “medical” treatment to be rendered based upon the diagnosis and examination of a chiropractor.
A chiropractor employed by a multi-discipline practice may perform chiropractic treatment, but not medical treatment. In other words, the fact that an MD/DO happens to be employed by a medical corporation does not empower a chiropractor to practice medicine. Therefore, if the medical physician is not on site, medical services should not be rendered, except in the case of a physician extender who is licensed to provide such treatment.
The medical director (MD or DO) is the progenitor of all medical services and therefore will need to be, in all likelihood, an employee of the medical corporation (or in some cases, the business corporation).
The Internal Revenue Service (IRS) has a specific test to determine if an employee meets the criteria of an independent contractor; as a general rule, the medical director will not meet these criteria. There are accrued penalties that will be invoked by the IRS if you violate its rules. If you are in doubt as to whether a staff member (including yourself) is an employee or independent contractor, consult your accountant. When in doubt, consider the staff member an employee – it is the more conservative position and will almost always be the most practical solution.
Managing a multi-discipline, holistic facility can be difficult if you do not have a clearly understood, easy-to-follow “recipe.” An implementation check-list and instruction manual are mandatory. The manual should address compliance issues. Do not attempt to establish a holistic multi-discipline practice without guidance unless you have considerable experience in group practice arrangements; mistakes can be extremely costly. Be certain your practice is set up in compliance with federal and state regulations.
A step-by-step procedural manual should help you keep mistakes to a minimum and it will give you a source to refer to. A well-written manual will address the following:
- legal structure
- holistic services
- forms and letters
- patient flow
- billing and coding
- medicare tutorial
- marketing and public relations.
Managing the Practice
Once you are actively engaged in the daily management of a holistic multi-discipline practice, you will most likely find you are busy throughout the day. You may find it more cost-efficient to hire another chiropractor, rather than performing chiropractic treatments yourself.
If however, you wish to continue rendering treatment, you would be well-advised to hire a manager who has a sales or public relations background to perform the daily management and entrepreneurial activities. You should not try to perform all those functions. It will almost certainly slow the growth of the practice.
What we have discussed here is only an overview of several critical points in the correct management of a holistic multi-discipline practice. This type of practice can be tremendously rewarding, but you must adhere to rules and clinical issues to keep the business running smoothly and profitably.