What is your background?
I graduated from the University of Miami and graduated in 1988 from Palmer College of Chiropractic. I was an associate in the Miami area for two years when an opportunity with a managed care organization arose. It was a chance to manage my own patients and have a secure salary.
How did you become salaried by a HMO (health maintenance organization)?
About nine years ago, the doctor I associated with started a network of chiropractic providers. He began networking with various managed care plans and HMOs, but had two of his own practices to deal with.
I was in the right place at the right time because I was “between jobs” as they say. This doctor was happy with the associate work I did for him and recommended me. Our thoughts were, “We don’t know exactly where this is going. They might say in one month, ‘Thank you very much, we don’t need you anymore.'” We just didn’t know. Now nine years later, we’re still there.
How do you feel about it now?
It turned out to be a win-win situation for everybody involved. The patients get their chiropractic care under the same roof as all their other care. It’s also a steady position for the chiropractors who are involved and the managed care organization saves money.
How did this managed care company evolve?
The concept of the HMO is something that has been around in other countries for a long timeCuba in this case. I believe they brought the company to Miami in 1970 before the whole HMO “wave” came through.
The population in South Florida and Miami is over half Hispanic. The largest demographic group is Cuban-Americans, who are used to this kind of medical model where they go to one place and all the specialists are there. Later the HMO was purchased by a larger company that expanded it, and that’s where we are now.
How did chiropractic evolve within your HMO group?
When the chiropractic network first started, I was the only DC who traveled to the HMO’s different medical centers. As it caught on, we had to hire more Doctors of Chiropractic. We essentially created this position.
What do you consider an advantage to this plan?
One positive aspect is many patients who are seeing me may never have thought of seeing a chiropractor. When you consider that only 10% of the population currently sees a chiropractor, we try to get to the rest of the “pie.” I have found that three out of four of my patients are referred by other doctors in the HMO group.
How do you orient your patients to chiropractic?
One of the first questions I ask is, “Have you ever been to a chiropractor?” If they haven’t, I give a brief orientation and try to be a good ambassador for chiropractic by explaining our profession to somebody who probably would have never gone. However, in this setting, it is easy for them.
Please describe how this HMO’s medical center is set up?
It’s like a mini hospital with an urgent care center, which is similar to an emergency room; a reception area where patients check in; nurses’ stations and doctor’s offices for various specialties.
How many different specialties are in your center?
We have about everything you can think of such as: a psychiatrist, gynecologist, orthopedist, general surgeon, dermatologist, internist, neurologist and optometrist.
Are you the only DC in the group?
Yes, in this particular clinic I am. However, I am contracted with an entire network of providers and the HMO has half a dozen different clinics, each with their own chiropractor. However, I’m not an isolated doctor. I’m a member of my local, state and national organizations and was a board member of my local society for several years. I try to contribute.
Is your office different than the other doctors in the group?
I basically have a Hi-lo table, a desk and chair and so forth. My room is actually bigger than the other doctors’ because of my table.
How many patients do you typically see?
On an average day I might see 25 to 35 patients. I’m not bogged downI’m given about 15 minutes per patient. There might be walk-ins or emergencies and other patients might not show up, so it all evens out.
Do you take your own x-rays and so forth?
I recommend x-rays, but don’t have to take them myself because there’s an x-ray department. For lab work, they go to the medical center’s lab or I may recommend they go to the physical therapy department, but I don’t have to do it myself.
If I want a referral, I write out what specialist I want the patient to see and they get an appointment. For me, the stress level is low. I do what I was trained to do, which is take care of my patients.
Do you get calls for emergency care?
No; if it’s an emergency the patient first goes to the urgent care center for treatment and they’ll send the patient to see me the next time I’m open. I don’t get called in the middle of the night.
How does your salary compare with a solo chiropractic doctor?
It tends to be lower. I believe you’ll make more money in practice by yourself, but you have to take the good with the bad.
Our surveys indicate a solo DC’s net income range is $60,000 to $75,000. How does a salaried position compare?
It falls into that range. You’re making an average income, but the stress level is lower. You pay for it in the sense that you’re not making tons of money, but that’s not the reason I got into this profession in the first place.
Is there a bonus system for seeing more patients?
Before this HMO was purchased by a national organization, we received bonuses. For example, patients may not have been members of the HMO; such as Medicare patients, and I would get bonuses every quarter for seeing them. It was about $500 to $700 extra, but now it’s a straight salary.
Do you have other perks such as insurance or retirement plans?
No, because I’m a subcontractor to the HMO. I’m contracted by the chiropractic network, which is contracted by the HMO. Since I’m not an employee, I don’t receive benefits, although I have incorporated myself and pay my salary from the corporation.
Do you pay your own continuing education and malpractice insurance expenses?
Yes, I pay everything myself. Because I’m incorporated, these are my business expenses and I gain the best tax advantage.
Did you undergo an approval process to join the network?
Yes; every year I have to renew my credentials.
Do you have freedom in treating your patients?
Yes, nobody’s looking over my shoulder. I know some HMOs in New York limit the number of chiropractic visits. However, since I’ve worked for this company, nobody has told me I can’t see a person more than “x” number of times. I manage the care completely. If I want someone to come in three times a week, I’ll schedule them. I try to find out what the patient needs and wants. After they’re out of the acute stage, I give the option of continuing on a wellness basis.
Is money an issue between you and your patients?
Until recently, there was never a financial burden between doctor and patient, although now they’re starting to make co-payments.
I like what I do and I like people. I’m dealing with people, but I’m not confronting them about money. It’s not an issue that comes between usall that matters is getting them better.
Did you find a lot of ignorance regarding chiropractic when you first started?
Sure, although over time I really haven’t had to explain it a lot to the other staff and doctors. I make the patients feel better and they go back to the other doctors and tell them how they feel. My best advertisement is my patients. I don’t do anything special, I just do what I was taught in school.
Is there a place where you can interact with the other staff members?
Yes, there’s a lounge where we can eat lunch together and socialize. I have the benefit of interacting with other specialists on a casual basis. When you’re on your own, things come up, but here if I want a dermatologist to look at a skin lesion for example, it’s easy to refer. It’s low stress and very rewarding.
What is the general patient flow?
The patient checks in with the receptionist who then brings the patient’s file to my office. I call the patient after they’ve been “triaged,” meaning their vitals have been takentemperature, pulse and respiration rateplus blood pressure and weight. When they’re done they make another appointment.
No exchange of money is necessary?
It depends on the particular plan. I am a member of this HMO for my personal health insurance and pay about $120 per month. I get everything I need for that including optometry, chiropractic care, podiatry, mental health and even some dental.
Either the patients or their employers are paying a fixed monthly premium, depending on the group’s plan. It’s like a socialist type of system, but for the average working person, it works out. It’s better than not being able to afford insurance and have something catastrophic happen.
Do you pay for your prescriptions?
I don’t because I have the premium plan, but if someone wants to pay a little bit less, they pay for their own medications.
What is the biggest drawback for the HMO members?
The patient loses choice of doctor, but they have the option of purchsing a PPO plan with the same company.
Do you have any say in who your staff is?
The nurses, receptionists, medical assistants and so forth are considered employees, but I don’t hire anybody.
So you don’t have the staffing headaches?
Right, I don’t have to do any of that.
Is your receptionist shared?
She serves me and maybe two or three other doctors at the same time. In my case, on some days it’s a psychiatrist and a gynecologist who are right next to me. Other days it’s the general surgeon and ultrasound person. It’s great to meet people from different specialtiesI get to introduce chiropractic to people who may not have a very good understanding of it.
Do you have to complete reports for the HMO?
No, the administrators track how many patients I’ve seen and the number of no-shows, etc. There is a lot of documentation involved and I do a lot of writing for each patient visit. Everybody has to document, but I have to a little more than the private doctor.
Can you use a computer program for that?
I have to hand-write it all myself; I can’t use one of those SOAP note computers.
Is that because of the HMO?
When I get a patient’s file, it’s for all of their care. A new sheet of paper is placed on top and the one behind could have been from the podiatrist or optometrist. What we’re using is the medical protocol.
By law, everybody in Florida is supposed to be documenting subjective/ objective/assessment/plan and that’s something I do on a daily basis.
What happens if you feel you need more staff?
Since I don’t have control over hiring, I can make a recommendation, but I don’t have the power to say I need more staff. An HMO is going to try to control costs, and we’ve managed fine the way it is.
Your PVA doesn’t sound too unwieldy…
Maybe it is different in other places, but it’s normal where I work. I might even have more time per patient than some solo chiropractors.
Do you feel you build a better rapport with your patients?
Yes, definitely, due to spending the additional time.
Is your patient compliance better?
Yes, absolutely.
What is your typical patient profile?
I see everybodychildren, teenagers, families, retired peoplethe whole gamut. My typical patient is not unlike the latest surveys: females between the ages of 40 and 50.
What income range do your patients fall into?
People who join HMOs generally are concerned about finances, but I do have all groups. There’s Medicaid patients and a lot of Medicare people, but the majority are middle class.
Are the other doctors your patients?
Yes, everybody is a patientfrom the administrators to some of the nurses. They do take advantage of me, believe me. Even the orthopedist I work with sends his wife in.
Not all of the medical doctors in the group are totally in tune with what I do, but the ones who take the time to get educated understand what I do and appreciate it. They know they aren’t trained to do it and they’re glad I am. Everybody has their own job; I don’t take away from what they do. We’re all there for the benefit of the patient.
I don’t want to sound too “medical” because I’m not. I’m pure chiropractic. I speak with every patient about chiropractic and our philosophy. I tell them their body has innate intelligence that does the healing and all I do is take away the interference so their body can function better.
If someone has never been to a chiropractor, I tell them I’m a little bit different and I don’t give medications or do surgery. I’m going to try to help them in a natural way.
Did you see the managed care trend coming before you became involved with the HMO?
During the early 90’s, I saw that managed care was not going to be transientand it grew incredibly. Now the pendulum is actually swinging the other way a little bit. HMO’s are starting to ask for co-payments and are offering more products so the patient has a little more control over choice of provider. They have to pay a bit more, but the network of providers is larger.
Have your peers been interested in contracting with your HMO?
Nine years ago, my friends would ask why I didn’t just open my own practice, but I saw what was happening. I saw that managed care kept growing and I wanted to be in on the ground floor. Now those same people are asking me how they can get in. It’s mostly the younger people who are interested rather than the ones who have established practices.
What do you feel is a concern when contracting?
If the managed care organization hires one chiropractor to serve thousands and thousands of lives, it is not a good thing. However, if the patients can’t get an appointment, they will go outside for care.
What do you suggest to others who are considering a salaried position?
Make sure it’s commensurate with your personal goals, your personality and what you’d like to achieve. Give yourself a time limit because you get comfortable and you never know when your contract is going to end.
The salaried position I have isn’t for everybody for many different reasons, but for me things seemed to have worked out. The business of chiropractic is not my forte, which may be a reflection of what is lacking in chiropractic education.
