Perspective


6 Secrets of Highly Successful Practices
Perspective
Written by Eric Kaplan D.C.   
Saturday, 28 January 2012 06:15

I
f your practice isn’t exactly the well-oiled machine that it should be, it’s time for some serious maintenance. But you need the right tools – and the best place to look is in the toolkits of practices with proven operations records.

6secretsExperts advise that becoming a practice leader means adopting the following strategies to make your office run more smoothly: 

1. Take care of your staff. Practices with low turnover are places where employees are valued and where there’s a climate of mutual respect. “You can't just be nice to the patient. You have to be nice to the people who work there. Be nice to your neighbors, your landlord, and your co-tenants; be nice to yourself, to one another before you can be nice to the patients.”

Invest in your employees and you’ll reap financial rewards, it’s rare to see a practice where you get that good feeling and find that they’re not doing well financially.  Keep your office happy and your patients and practice will prosper.

Let employees know you value their input, give them respect and you will get respect.  One way to accomplish this is to hold in-service meetings with staff to set mutual goals for the week and month ahead.  This is why I put such an emphasis on statistics.  For every doctor that sends them I look at them, if they don't, I know their practice; their success level is not up to their potential.  Practices where management and staff don't share common goals suffer lots of infighting. We need to be constructive, not destructive, in these meetings.  These are not gripe sessions; they need to be happy and beneficial.  In my office we brought in pizza and made it a fun environment. 

2. Re-strategize, Re-energize your practices. Once you’re clear about the kind of office environment you’re creating, you can employ people who can carry out that vision.  One office, one vision.  For instance, physicians who want to run everything, micro managers, need to hire people who are comfortable with that management style.  However you need to delegate, offer trust to get the maximum from any person.  Otherwise you will always be the one holding the bag.

Whether your practice succeeds can depend on you and your management style.  When hiring always look for candidates with previous health care office experience who are both collegial and proficient as office assistants. It’s nice to have someone who can work with people and who can bring physicians and staff together, but it’s also critical to have someone who understands budgeting and reimbursement issues. 

Rather than sticking to conventional interviewing tactics, I recommend asking potential managers how they would respond to specific incidents that come up in the practice. Create vignettes based on real occurrences to evaluate their judgment and expertise. 

3. Emphasize orientation for new patients. Physicians give lots of lip service to patient satisfaction, but in reality satisfaction levels are very low.  After so many years in practice, why do so many chiropractors need so many new patients?  If patients were happy, if they understood chiropractic, then they should still be coming in once per month.  How many patients do you have on this type of schedule?  We often give one report of findings and expect the patient to stay forever.  No one is that good a salesperson.  The key is not being a salesperson at all.  One way to set a friendlier tone is for the receptionist to take the time to explain procedures and answer basic questions when a patient calls for a first appointment.

Don’t rely too heavily on your automated answering system. Patients want to speak with someone, not always leave voice messages and wait for calls to be returned. Service is the key to keeping patients and getting referrals.  How many referrals did you get last month?  Referrals are your barometer of patient results and satisfaction. 

Find out why you are not getting paid, and you will find the map to payment.

4. Refine records management methods. Don’t let work pile up. Stay current with bills and reports.  You must complete your notes or dictation on the same day you see a particular patient, and have the information transcribed within a day of receipt. Billing people should file all loose papers on the same day they receive them and return every record to the file by the end of the business day. These are simple things that you can do that will make the practice run more smoothly.

5. Streamline data collection procedures. Some physicians think that more is better when it comes to notes, but this is not the case.  Don't hesitate to call Perry or myself to discuss your note system.  Good notes keep you compliant and help collections.

Doctors should ask the billing people to collaborate and conduct a presentation for the office on what they actually need in the notes and develop templates for doctors to use when charting procedures.  Find out why you are not getting paid, and you will find the map to payment.

6. Consult insurance companies for advice. Take advantage of outside resources, including cozying up to your malpractice insurer. Malpractice insurers have legal departments that can be a tremendous help in providing free consultations on such matters as documentation practices and consent forms.

 

Dr. Eric S. Kaplan, a former President COO of  a NASAQ traded public company, which included Nutrisystem, Currently he is CEO of Concierge Coaches, Inc., www.conciergecoaches.com,  a comprehensive coaching firm with a successful, documented history of assisting doctors create profitable practices nationwide, providing over 30 New Patient marketing Programs. Teaching doctors nationally how to develop a successful business in the health care industry of today. . Dr. Kaplan is the best selling author of Dying to be Young, and Lifestyle of the Fit and Famous and Co-developer and President of Discforce and Palm Beach Massage Centers, www.pbmassage.info, the next Generation Chiropractic Practices, massage and Spinal decompression   For more information on coaching or spinal decompression, call 1-561-626-3004.

 
Is There a Minimum Time per Session for Decompression Therapy?
Perspective
Written by Jay Kennedy, D.C.   
Saturday, 28 January 2012 05:51

W
hat is the minimal time per session for successful traction/decompression? Do we need to deliver 15-plus minutes of mechanical traction to have a clinically important outcome…could we instead use just 1-3 minutes and have a similar clinical result?

timelimitOver the last sixty years the application of traction (to create decompression) has been perceived as a time-dependant therapy, i.e. the minimal effective dose tends to be seen as durational, or time-dependant. Like manipulation, massage and other passive interventions, several sessions (of whatever duration used) are probably necessary to be most effective and most studies suggest from 3-12 sessions. However, how long those sessions need to be is perhaps open to debate and this article is simply a discussion of that possibility. Few if any research studies have undertaken a minimum-dose control.

Interestingly, the CPT have never imposed a time frame to traction application. 97012, unlike every other modality traction, has no minimal time. If it lasts twelve hours or twelve seconds it’s the same price. And the reimbursement hovers around $12-16.00 nationally, substantial for two minutes, paltry at thirty.

When we examine the research of traction comparisons of session-duration, we find it has never been undertaken with any sense of precision or focus. With the myriad of disagreements it appears that everyone tends to be in agreement that traction must be done over a relatively extended time frame, at least 20 minutes (often up to 45 minutes). Initially “hospital traction” was done for days or weeks at a time; however, that was the era of seven days of post partum bed rest as well. In a 1996 study by Shealy et al., albeit biased on the nascent DRS system (which eventually spawned the infamous DRX9000), they conclude: “sessions less than 45 minutes tended to give inconsistent results.” Having treated hundreds of patients on a DRS I found that suggestion dubious. Quite the contrary, as patients approached 45-minute sessions (typically at 50% bodyweight plus 10-20 pounds) iatrogenic pain and dysfunction followed almost linearly. Often, sessions would need to be skipped due to an increase of pain.

It is no coincidence that the more expensive the decompression system the longer the manufacturer suggested the sessions last. Leasing a $50,000-125,000.00 system required a defined patient management solution: high patient cost and elongated sessions.

Recently published trials tend to follow a “new” standard approach of approximately 10-15 minutes (the observation that 45 minutes was a necessity was not compelling to those actually using the units). An ongoing University of Colorado study involving 140 patients is also following these shorter parameters. This in my estimation is a good thing; as the old saying goes: “Tradition is what you rely on when time, money and new ideas are unavailable.” Anyone having suffered through a HNP or similar disc-related pain can attest that the traction cure can sometimes be worse than the disease. Many times when trying to arise after having been treated for 30 minutes on either our VAX-D or DRS I questioned the wisdom of lying for that long. I ignored the suggestion in those early years from many patients that less would be preferred (I refused to lose faith in the non-clinicians who sold me the magic machine and admonished me to stick with the program).

decompressiontherapyWhen we examine the how and why of axial traction we are faced with several ineffable physiological and anatomical considerations. Why can’t the disc react to unloading in just 1-3 minutes with a substantive, clinically relevant benefit?  Since we have no definitive answers we’re left with speculation (and future research), but clinical experience can give us some insight. Presently clinicians practicing the Kennedy Technique have been observing patient responses to very short duration sessions and the preliminary results are not disappointing (unless you really love keeping patients on your table).

What can’t be ignored is the fact that many traction studies often show little real benefit anyway, and often show more negative reactions than other modalities. Clearly too much force and too much time could be the culprits. As to the pain-gate relief achieved with any joint ‘motion’ therapy the durational component may not be ultimately important.

Anatomically, decompression is osmosis, i.e. fluid moving from high pressure to low pressure through a semi-permeable membrane. Changes in gravitational stress alter fluid inflow, assuming the proteoglycans matrix of the nucleus is intact (not degenerative). Any recumbent posture begins the process (both hyper-extension and flexion decompress the disc and restore height).

The process is potentially expedited dramatically with the addition of (dis)traction. Flexion tends to raise intradiscal pressure, linear distraction reduces it. Less forced flexion and more distraction leads to the most mechanically feasible means of rapid reduction of IDP. However, a decreased IDP then leads to an increased osmosis and fluid in-flow pressure, especially after arising.

This begs the question: Where does the fluid diffused via osmosis go once it has entered the nucleus? Doesn’t it then in fact act as an annular-distender, pressurizing the damage zone and increasing pain when upright? It would seem the negative IDP of the initial few traction pulls would achieve this effect, with further pulls possibly being superfluous.

This is the confusion of traction. Wouldn’t it be more reasonable to distract the spine once or twice (for 45-60 seconds) and release, then arise? We speculate that collagenazation and movement of nutrients occurs during decompression (and this is likely true). What actually happens internal in the disc is only speculative. Bogduk has maintained that any elongation is lost within 20 minutes after arising and thus the effect from traction must be a “phasic phenomena”, i.e. momentary and not from any resultant effect post (though the tissues and the CNS may continue to react over time, enhancing the initial benefit as well). 

The relevant clinical question is whether these effects occur immediately and need not require redundant application over 10-20 minutes. I’ll keep you posted as to any new findings, but as for now we suggest (like the SAID principal): Use the lowest time/force necessary to achieve an effect (“first do no harm”), further imposition of time and force may be unnecessary or possibly, in some cases, detrimental.

 

References

  1. Adams, M., Bogduk, N., Burton, K., & Dolan, P. (2006). The Biomechanics of Back Pain. 2nd ed. Edinburgh: Churchill Livingstone. p. 177-194.
  2. Fritz, J.M., Thackeray, A., Childs, J.D., Brennan, J.P. (2010). A randomized clinical trial of the effectiveness of mechanical traction for sub-groups of patients with low back pain: study methods and rationale.  BMC Musculoskeletal Disorders, 11, p. 81.
  3. Shealy, C.N., & Leroy, P.L. (1998). New concepts in back pain management: Decompression, reduction and stabilization. Pain Management A Practical Guide for Clinicians, Vol. 1, Fifth Edition. St. Lucie Press: Boca Raton, FL.

 

Kennedy is a 1987 graduate of Palmer Chiropractic College and maintains a full time practice in western Pennsylvaina. He is the principal developer of the Kennedy Decompression Technique. Dr. Kennedy teaches his non-machine specific technique to practitioners who want to learn clinical expertise required to apply this increasingly mainstream therapy.

Kennedy Decompression Technique Seminars are approved for CE through various Chiropractic Colleges.  The author can be contacted @ This e-mail address is being protected from spambots. You need JavaScript enabled to view it

 
Are Runners Welcomed at Your Office?
Perspective
Written by Kirk Lee, DC   
Saturday, 28 January 2012 04:30

W
hen you developed your yearly marketing program, you probably thought about how to attract more children or geriatric patients to your office. Have you ever considered trying to attract more athletes, especially runners? There is a large, growing population of runners that could use your expertise and care. According to Running USA’s “State of the Sport” report, from 2008 to 2009 the running population increased 18 percent to more than an estimated 35 million people. There was also a 15 percent increase in trail runners (almost 5 million people). While the overall sports industry’s growth declined or remained flat in 2009, retail sales dollars of the running/jogging category of footwear were up 5 percent (to $2.3 billion). (1)

runningandchiropracticWe are great at spreading the word about chiropractic: about how healthy eating habits, regular exercise and chiropractic adjustments will help you live a healthy lifestyle. We are great at educating our patients about how subluxation complexes can lead to degeneration, restricted ranges of motion and pain, just to name a few. It is second nature to educate the patient that neurologically it is “above, down and inside out,” and biomechanically it is from the ground up. That is simple anatomy, physiology and biomechanics. But what if a runner asks you how asymmetrical biomechanics of her gait cycle can cause symptoms of low back pain, mid back pain, neck pain, plantar fascitis, chondromalasia, iliotibial band syndrome, tibial stress syndrome or greater trochanteric bursitis? Or better yet, if she has no signs or symptoms, could you tell her why she needs chiropractic care?

Let’s consider developing a wellness-based practice and the time it takes to educate a patient on the importance of wellness. Who do you think is easier to educate and take hold of the principle: the couch potato, whose life revolves around going to work, eating and watching television, or the runner who eats healthy and exercises regularly? I think the answer is quite clear – THE RUNNER. Want to attract excellent wellness patients? Attract those runners!

Case Study

Mary Jane is a 38-year-old female who has changed from what she calls the “boring runs on pavement” to the unlevel, changing of surface thrill of the trails. She previously notes a history of mild tibial stress syndromes, but changing of shoes and more stretching has helped. Since switching to trail running, she has noticed an increase in her tibial stress syndrome. She again has tried several types of shoes, more stretching, and self medications with the thought process that it will go away. In addition, she gives mention to several falls from tripping over tree roots, but nothing that caused her to discontinue her running.

Or better yet, if she has no signs or symptoms, could you tell her why she needs chiropractic care?

Orthopaedic and neurological exams showed no significant findings. Functional examination did note decreased strength of the abductor muscles on the left. Gait appeared normal with symmetrical heel-to-toe transition. Radiographs demonstrated mild lumbar degenerative changes with mild axial rotation in the lumbars. A-P pelvic view shows a left leg insufficiency of 12mm at the iliac crest and 15mm at the femoral heads. Foot scan shows asymmetry or an imbalance of the three arches. Her Pronation/Stability Index™ number is 110, indicating moderate pronation. Body assessment screen indicates Mary Jane’s left foot as 57 percent, while her right foot indicates 43 percent. These findings are also supported by the left leg insufficiency noted on the A-P pelvic film, indicating more weight bearing on the left leg.

Since Mary Jane is a runner, we performed a video gait analysis that included walking and running. Findings from the gait analysis showed a decreased stride on the left leg compared to the right. The video analysis also pointed out excessive pronation on midstance of the gait cycle, which was more pronounced on the left. All findings are consistent with previous ones noted.

Comparing all our clinical findings, the recommendations for Mary Jane included:

  1. Stabilizing orthotics to create symmetry and balance of the foot and the rest of the kinetic chain.
  2. Rehabilitation exercises to strengthen her core with special focus on the weak abductors.
  3. Soft tissue techniques to help reduce pain in the anterior and posterior compartments’ musculature (tibial stress syndrome).
  4. Chiropractic manipulative therapy to reduce subluxation complexes and restore joint integrity.

Runners are a growing section of the population that could benefit from your care. They can turn to you for treatment when they are injured, or they could just be looking for help to stay healthy and fit. How do you find more runners? Contact your local running clubs and do a lecture on proper gait biomechanics. Explain how asymmetry of the normal movement patterns of the gait cycle lead to overuse injuries, resulting in subluxation complexes and the other common injuries that are experienced by runners. Reaching out to your community to help runners is one more way that you can help serve others with chiropractic.

 

Reference:

  1. Running USA: “State Of The Sport 2009.” Published: Jul 15, 2009. www.running.competitor.com/2009/07/news/running-usas-state-of-the-sport-2009_3711.

 

A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.

 
Chiropractic Growth vs. Attrition: Current Trends and a History Lesson
Perspective
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Wednesday, 26 October 2011 22:14
F
oreman and Stahl wrote in Chiropractic and Osteopathy in 2010 that, due to a myriad of reasons, the 10 year attrition rate of chiropractic in California rose from 10% for graduates licensed in 1970 to 20-25% for those licensed between 1992 and 1998. In New York, the number of new chiropractic license applications are down approximately 20% over the last 5 years compared to a similar, prior time frame, according to the former Legal Counsel to the New York State Higher Education Committee to the New York State Senate. 
 
growthvsattritionThese statistics mean there are less chiropractors practicing in both of these states, and as a result the Cleveland Chiropractic College has closed its California division. The question that remains is how do we reverse this trend? Recently, in a conversation with a chiropractic college administrator, I heard that if the leadership in our profession was more pro-active and we had read the signs 20 years ago, chiropractic would be in a better place. I agree.
 
I am one of those leaders who, 20 years ago, splintered the profession in New York by helping create a new (second) organization in the state. The end result was abject failure in every legislative initiative that both organizations attempted to pass. For a period of time, there were three organizations in New York and we all failed legislatively. Over the years, we thought the enemies were part of the medical society, businessmen's associations and unions. The truth was we were the true enemies. We were all fighting so hard for our piece of the "turf" that we neutralized each other and got nothing done, but spent a lot of hard-earned money and supported a lot of legislative campaigns; in retrospect a failed strategy. 
 
The legislators, lobbyists and administrators of both organizations laughed all the way to the bank because one thing we were good at was creating two and three jobs to accomplish one task which was paid for by our hard-earned dues in difficult economic times. Today, those two organizations, the New York State Chiropractic Association and the New York Chiropractic Council, have promised their members that there will be a dissolution of the two organizations with one unified organization in their place, similar to the successful Michigan merger. Unfortunately, it is now almost 4 years later and for reasons that do not matter there are still two viable active organizations and that is unacceptable and shortsighted, a perfect example of the poor leadership cited by the chiropractic school administrator previously mentioned.
 
Being just one doctor in a large state gives me but one voice and with that voice I am putting these organizations on notice. If by January 1, 2012 they haven't created one organization, I will send e-mails and letters to every doctor in the State of New York urging them to quit both organizations. Why not? Without a unified profession in New York, doctors of chiropractic will simply be getting more of the same, NOTHING. Perhaps this is because of personal agendas of those that provide the leadership. Conversely, should the leaders put their personal agendas aside, I will vigorously work on getting every doctor of chiropractic to join the one state organization because that is the solution in New York, which is also is a microcosm of the national picture. 
 
A group of "well meaning" but misguided doctors in Wisconsin is currently considering the creation of a new, second organization because of leadership issues in the current organization. These doctors need to realize that Wisconsin needs clearer leadership that will meet the needs of all DCs in Wisconsin and not create division. Look at both the successful Michigan model and the current failure model of New York for the end result of multiple organizations and learn from others’ mistakes. The best plan of action is to infiltrate the current organization and fix whatever needs to be fixed, as the end result is to protect the DCs and afford every citizen in Wisconsin the right to see a chiropractor. 
 
The formula is simple and I have said it before. We need one organization in our nation with 50 chapters and if you don't like the direction of that one administration, fix it from the inside. Years ago, many republicans did not like President Carter. Did they start a new republic? No. They worked hard and got him voted out of office. More recently, the democrats did not like the direction that President Bush took the country in. Did they start a new government? No. They worked hard and got President Obama elected. The message is simple; it is called balance of power and requires very smart people working within the system to fix the issues. 

REFERENCE:
  1. Foreman, S. M., & Stahl, M. J. (2010). The attrition rate of licensed chiropractors in California: An exploratory ecological investigation of time-trend data. Chiropractic & Osteopathy, 18(24), Retrieved from http://chiromt.com/content/pdf/1746-1340-18-24.pdf
 
True or False? Discounting Your Fees Is Illegal
User Rating: / 2
PoorBest 
Perspective
Written by Dr. Ray Foxworth   
Tuesday, 23 August 2011 20:04

A simple true or false would be nice. Unfortunately, it depends on who you ask, what state you are in, if the patient is federally insured, AND their particular circumstances. So much for straight answers to a simple question!

When consultants do answer questions about discounting , it is usually followed by “consult with your health care attorney before offering any type of discounts”. This would be great advice , except most of us do not have a health care attorney.  Others will tell you discounting is perfectly legal, as long as it is done consistently and in accordance with your written compliance program. More  great advice, but the reality is many of us still haven't put a full compliance plan in place.

So who cares if the answer is True or False?

What’s all the fuss about discounting anyway? Can’t you charge what you want to whomever you want? Can’t you just down code your adjustments, exams or X-rays  to save a patient some money? What’s the big deal in charging more for PI, Workers Comp and insurance patients than you do for cash? All you are doing is trying to help a patient right? It’s no big deal…right?

WRONG!

discountingfeesIn the days before insurance, third party reimbursement, state and federal payers, things were simpler. When someone else is paying part or all of the costs for health care, especially the government, rules change and regulations apply. This is when discounting the wrong way can cost you.  It’s called doing the right thing the wrong way.

You may be trying to help an uninsured or underinsured patient by offering discounts, but many doctors end up putting themselves at risk in the process.

Dual fees schedules, (charging more to insurance companies than you do to your cash patients), improper time of service discounts, (reductions that are really MORE than a reasonable bookkeeping reduction), are illegal in most states . Offering discounts that do not fall into one of Medicare’s safe harbors can cause an inducement and is absolutely a violation of federal regulations in EVERY state, subject to a $10,000 fine PER OCCURRENCE!

Violation of state and federal regulations against inducements or triggering anti-kickback statutes can lead to serious fines and career ending penalties as well.

So what is the right answer to the True or False question?

Discounting your fees CAN be illegal, if you do it the wrong way! Keep reading and find out how to offer discounts the RIGHT way, in every state and for any patient group.

Follow the rules.

1. Document correctly. The rules in this area are quite clear and there are many resources and guidelines to follow.

2. Code correctly. Again, follow the rules. Do not up code for more reimbursement when insurance is available and do not down code to reflect lower charges as a means to offer discounts. It is just as improper and illegal as up coding.

3. Discount correctly. That is a new one for most doctors.

Here is how you offer discounts the RIGHT way. Hire a health care attorney if you’d like, put your compliance plan in place…AND, if you don’t do anything else, consider joining, and encourage your patients to join a Discount Medical Plan Organization (DMPO). DMPO’s are regulated by the Department of Insurance in most states and have been around for years.

Why a DMPO? Simple. These plans use the contract model similar to what you use now, which  allow you to contract with multiple insurance companies for different rates on the same codes  without it being a “dual fee schedule”. Using a DMPO, you can still bill your UCR fees and have the protection of a “contract” that allows you to offer network-based discounts to your cash and underinsured patients. Most all patients are familiar with “buying clubs” such as Sam’s Club  and they are familiar with networks. Experience shows they do not hesitate to join these network plans to save money!

Using a DMPO really is one of the most logical, legal, and ethical ways to allow you to accept a lower fee than your normal UCR clinic fees. It helps you help your patient, and it does not put you at risk!  A good cash discount plan solves so many of the potential problems for you and really helps the patient…the RIGHT way!

 

Article submitted by ChiroHealthUSA.

Dr. Ray Foxworth is a certified Medical Compliance Specialist and is President of ChiroHealthUSA.

 
«StartPrev123456NextEnd»

Page 4 of 6
 
TAC Cover
TCA Cover

Click on image above
to view the
Digital Edition


Advertisement

Advertisement

Advertisement

Advertisement

requestmagazinebutton

 

TAC Publications

The American Chiropractor Magazine: Digital Issues | Past Issues | Buyer's Guide

 

More Information

TAC Editorial: About | Circulation | Contact

Sales: Advertising | Subscriptions | Media Kit