Excuse me, but we’re doctors, too, is something you occasionally want to say when you hear comparisons made between MDs and DCs.
After all, you have much of the same training, and in the area of neuromuscular and spinal health, you’re a specialist. But when it comes to pre-employment and fitness-for-duty examinations, you’ll find what amounts to a level playing field.
This didn’t happen by accident. As you can imagine, the powerful lobbyists representing the medical community would prefer doctors of chiropractic not perform tasks assigned to “physicians,” and your ability to perform certain types of physical examinations was a hard-won right.
And the fight is ongoing. Exactly which exams you are allowed to perform, what additional training and certification is needed, or whether such testing lies outside your scope of practice varies by state—you will need to do a bit of research to be certain where you stand. That caveat aside, in the majority of states you will be within your scope of practice. In the event you aren’t, work with your state associations and legislators. The numbers are on your side.
What’s in it for you
There are actually quite a few solid reasons why you might want to get certified to perform commercial driver’s license physical examinations.
Michael Megehee, DC, helps doctors of chiropractic and other healthcare professionals qualify to perform these types of physicals. He notes that for one thing, they raise your stature and generate respect for the chiropractic profession. “This is a great way to do that,” he says. “You’re helping commercial drivers—and competitively—and you’re doing a good job according to reports that I hear.”
Megehee helped develop one of the first training programs for DCs who want to offer the Department of Transportation (DOT) commercial driver’s license (CDL) physical exam. These exams have to be conducted by someone listed on the Federal Motor Carrier Safety Administration (FMCSA) National Registry of Certified Medical Examiners. Don’t let the word “medical” make you think you can’t qualify, as the FMCSA’s definition includes MDs, DOs, PAs, APNs, and DCs, among others.
In addition to DOT CDL exams, you can also perform the new FAA BasicMed medical exam for certain general aviation pilots, and physicals for the private sector, testing school bus drivers, race car drivers, scuba divers, crane operators, and commercial bus drivers, among others. “When you’re doing these, it really promotes a broad scope of chiropractic practice,” Megehee says. “It makes us more generally recognized as health- care providers with skills.”
Many professions require pre-employment and random drug testing, particularly for safety-sensitive transportation employees. Being accredited to perform these tests can open up additional lines of income, too. Amy Evans, director of business development for Lifeloc Technologies, says it’s a great opportunity that’s not driven by insurance payments. “Doctors can set their own rates, because payment isn’t going through a third party.
Offering urine drug testing for physicals widens your clientele.” She says that your fees will partly depend on the market and your competition, but figure about $20 to $25 for drug screening collection only, and from $45 up to $100 if you’re offering evidential breath testing (EBT).
Setting up shop
If you have a treatment room, you have almost everything you need to administer physical exams. But there are a few things you’ll need to add. First, of course, depending on the type of physical exam or drug testing you do, you may need to attend required training to become certified.
To perform CDL physical exams, you’ll have to pay to take a FMCSA-accredited training course and pass the FMCSA National
Registry certification test. To qualify to administer drug and alcohol testing you only have to attend the required training. For the FAA BasicMed examination, you have to be a state- licensed chiropractic physician. There are 32 states that allow DCs to use the term “chiropractic physician,” and the FAA recommends that doctors contact their state licensing board for verification of their “physician” status.
To offer the DOT CDL exam, DCs in 47 states can become a Certified Medical Examiner in the National Registry. DCs in New York, Washington, and Michigan are excluded due to a limitation in scope of practice that does not allow performing physical exams.
“Washington and Michigan, as far as I know, haven’t demonstrated a recent desire to change this stance, and in New York there was a lawsuit that removed DC eligibility,” Megehee says.
For the drug and alcohol testing component, you’ll need a separate accreditation obtained by completing the DOT-required training.
Evans explains further: “The breath alcohol technician (BAT) qualification and training can be supplied by the manufacturer of your EBT equipment or a manufacturer-authorized trainer. There’s also webcam training that can be done live on the internet. You get a five-year certification, and then you’ll have to renew.”
This training will walk you through the rules and regulations, equipment proficiency, mock tests that have to be done without error, and calibration procedures that will apply to the device you’ve selected. The DOT tightly controls this area. If there’s a positive result to a screen, it’s a big deal and they’ll want a lot more information about it, because a person’s livelihood and public safety are at stake.
Although fewer requirements are necessary to provide FAA BasicMed exams as long as you qualify under your state’s definition as being a state-licensed physician, it would be wise to take an orientation course, which isn’t expensive and only takes a few hours to complete.
The CDL exams are more likely to be a steady source of income, as DOT rules mandate fitness, drug, and alcohol testing for every new hire or transfer employee in a safety-sensitive position, of whom there are approximately 7 to 12 million in the U.S.
Many of these individuals require pre-employment, post-accident, reasonable suspicion, return-to-duty, and randomized drug and alcohol testing.
“For the CDL and BasicMed phys- icals, the only thing a typical DC wouldn’t have are urinalysis dipsticks. You need a scale. That’s pretty much it,” Megehee says. For the drug-testing portion, the lab you select will provide you with kits (usually for free—they charge for the processing when the sample is sent to the lab).
If you’re conducting exams that require a blood draw, Cheryl Burdette, ND, president of Dunwoody Labs says you’ll either have a phlebotomist who is drawing in-house, and a lab supplying the tubes, needles, and syringes for the person who does the draws, or, you’ll have relationship with a nearby draw station, like Quest. In some states, DCs can perform a blood draw under their chiropractic license.
Bearing in mind your scope of practice is circumscribed by your state laws, you may be able to offer additional types of testing required by various professions. Burdette notes that you might order a test for educational purposes, to see what’s going on with a patient, but not to render a formal diagnosis. “Typically, for wellness exams, you might want a complete blood count (CBC) and a chem screen to look at basic profiles. Are they anemic, having liver failure? That’s what a DC would want to know. But general vocation testing are things you’d want to add on,” Burdette says.
And Evans adds to that, noting some companies might want prospec- tive and current employees checked for their fitness for duty. “Like a FedEx truck driver, at certain inter- vals, might need a health check to see if they can safely lift a required minimum weight, or take a heart stress test.”
For a standard CDL physical, which is likely to be your bread-and-butter offering, there are two phases: First, the driver fills out a form. This contains standard personal informa- tion and a health history. There’s a questionnaire covering health ques- tions that have bearing on a driver’s fitness to drive, with 32 entries.
Megehee says this normally takes from 10 to 40 minutes to complete, and the driver can do it unattended in the waiting area.
The next portion of the form is filled out by the attending doctor and staff. Staff members can perform certain parts of the examination such as measuring blood pressure and performing the urinalysis, height, weight, and visual acuity portions.
You review the questionnaire and self-reported health statements with the driver, then conduct a basic physical where you note if the driver’s various body systems are normal or not. The presence of an abnormal condition is not necessarily a disqualification from driving, as the examiner has discretion in this regard. This part that only the physician can perform takes about 15 minutes for healthy drivers. The intake, checkout, and other portions of the exam can be handled by your staff and this takes about another 15 to 20 minutes.
One point Megehee notes is that you and your staff need to have a high level of courtesy and good bedside manner. Few drivers look forward to what they consider a bureau- cratic intrusion. “Not many of them are happy,” he says. “This is the only physical exam some drivers are going to get, and they’re fine with it, but others feel burdened.”
Especially in cases where a driver hasn’t been treated well in the past, expect some grumbling. “But if you treat them fairly, honestly, and ethically, there will be a place for you.”
If you’re conducting drug and alcohol testing, testing kits come with detailed instructions on how to perform the tests. “These will note whether things need to be prepped, stored, and how to ship,” Burdette says.
And even though you may be certified to perform CDL physical exams, according to 49 CFR Part 40, every staff member in your practice who will be conducting urine collections for DOT drug testing or using EBT devices for alcohol testing must complete the required training. This will run approximately $350 to $450 per employee, but the certification is good for five years, so you’ll recoup this cost quickly.
Your largest investment is likely to be the EBT device itself, which must be chosen from the DOT’s list of approved devices. These start at around $1,200 and go up to $6,000 depending on the model. Anyone who performs the testing must have training on this specific device, and certifications are usually from $300 to $500 per person.
These are also good for five years.
Regarding the FAA BasicMed exam (which you can provide for private pilots, student pilots, flight instructors, and recreational pilots), the Aircraft Owners and Pilots Association (AOPA) reports that pilots are complaining it’s hard to find a provider for the BasicMed exam. “The MDs may be steering away because FAA regulations are strict,” Megehee said. But DCs can do the drug and alcohol tests required by the FAA, and the exam is almost identical to that for the DOT CDL. “But there’s a significant difference in determining whether a driver is safe to drive and whether a pilot is safe to fly—the decision process is quite different,” Megehee says.
So how do you start bringing in business once you are up and running to give these types of exams? As you gain experience and familiarity with the procedures and paperwork, potentially you’ll be looking to give CDL and FAA physicals, and beyond that perhaps exams for FTA bus drivers, mechanics, federal pipeline employees, and employees who work in sensitive industries like poultry processors.
The training companies that certify you will often have a web portal for applicants looking for a provider nearest to them, and you’ll be entered on that listing automatically. Some large companies may already have arrangements with a provider, but as a DC you may be able to offer a highly competitive rate compared to an MD thanks to your lower overhead costs.
“It’s almost impossible to out-compete a DC who is offering this service,” Megehee says. “Drivers may need to be seen soon—and you may be able to offer same-day service, another plus.” He says you absolutely should have a sign outside stating you offer these services. Given that the average exam ranges between $60 and $200, depending on your location and competition, and that signage likely won’t be much more than $200, you’ll recoup this cost in short order.
Of course you’ll post this information on your practice’s website and web traffic will send some business your way. Signage in your practice will alert your current patient base, some of whom will likely need this testing anyway, and they’ll be thrilled to have one-stop shopping available.
Location can be a huge factor. “If you’re near a truck stop, this could be good business. If you’re close to an airport, you’d potentially be the one they’d call in the event of a concern or accident,” Megehee says. And Evans adds that some DCs have set up mobile shops so they can travel to where the customers are.
An excellent adjunct
Evans says there are some clinics that specialize in this area. She says that for the average practice, exams are about 10 percent of business, and drug and alcohol testing is up to 25 percent. “But for just about everything, the DOT wants a drug panel. And most companies are looking to screen for the most common five abused substances,” she says. Megehee has seen one practice that performs upward of 12,000 phys- ical exams a year. “Several do 5,000 a year, but here’s the thing: You almost always make more giving these exams than you can from chiropractic treatments, there’s no insurance to deal with, and when you’re ready to retire, it can make your practice worth more,” he says.
Because these exams are occupationally related, they generally aren’t billed to insurance. But in some cases, if a driver has insurance that pays for an annual physical, it can be billed.
For large corporations, the motor carrier will pay for the exam. Most owner-operators pay for it themselves. “That’s about 35 to 40 percent per year,” Megehee says. As these are almost entirely cash-based services, they give you a good return on your set-up costs.
In some ways, giving physical exams for professional certifications can look and feel more like what an allopathic practitioner does. Rather than seeing this as running against your philosophy of care, however, consider how this might raise your visibility and demonstrate your value in enhancing safety in your community.