Why are some doctors more successful than others in building a referral practice? Success in building a referral practice is based on communication. Simply put, successful doctors continually request referrals from their patients and have staffs that continually request referrals form their patients. Most importantly, they train their staff in how to speak with patients.

How should I respond when a patient compliments my care?

There is nothing more rewarding than when a person acknowledges your value to them as a doctor. When you get a complement, tell the patient how good it feels and do not be shy in saying to the patient “be sure to tell you’re your family and friends.”

I use coupons in my advertising. How can I determine if I actually make any money from these promotions?

Coupons may seem to be a good way of generating business; however, every business that does promotional work needs to analyze the profitability of a promotion to determine whether it has long term value to the business. Chiropractors who offer free or reduced price services can determine the profitability of these promotions by tracking the patients that responded to the promotion over a two year period.

First, list all of the revenue these patients brought into the practice after they had used their free or reduced price services. Next, calculate the cost of this promotion. Your costs include:

• The cost of the preparing the ad.
• The cost of distributing the ad including paper, envelopes, and postage if the ad was mailed.
• The cost (at list price) of providing the free or reduced price services.
• The cost of x-ray supplies.
• The cost of staff time to service the patients administratively.
• The cost of care that was billed, and not paid.

Analyzing your revenue and costs will allow you to understand whether or not your particular promotional activity is benefiting your practice financially.

What is the best way for me to obtain hospital privileges?

A chiropractor is not likely to obtain full admitting privileges at a hospital because, in the event of an emergency, drugs may have to be administered to the patient; and, the administration of drugs is outside a chiropractor’s scope of practice. It is to the advantage of a chiropractor, however, to obtain hospital privileges for the purposes of ordering tests or for the co-management of a patient.

In order to accomplish this, it is necessary for the chiropractor to meet with the hospital administrator to learn the process for obtaining credentials. The chiropractor’s credentialing application is typically reviewed by a screening committee. It is at this point that the process may become frustrating. While many hospitals across Wisconsin have given privileges to chiropractors, there is no legal requirement for them to do so.

If a hospital administrator or the screening committee carries a bias against chiropractic or a particular chiropractor, there is nothing that can be done except to overcome the prejudice by meeting with the appropriate people and helping them to understand the benefits of a relationship with you. If a hospital or their screening committee would like more information about the chiropractic profession, please do not hesitate to contact the WCA’s office for assistance.

Am I allowed to hire someone to solicit patients for my practice?

A chiropractor may hire an individual or organization to do marketing for the practice; however, there are strict rules about how the person or organization may be paid. State law prohibits the splitting of a chiropractic fees. Individuals or organizations that provide marketing services may not be paid a commission, a bonus, a percentage of the revenue generated by the patient, or in any other manner in which the compensation is tied directly or indirectly to the revenue generated from the patient.

Can I give free adjustments to patients in exchange for a referral?

No. The fee-splitting rules prohibit giving anything of value in exchange for a referral.

Is there a cost effective way of sending a newsletter to my patients?

Here are a couple of ideas to offset the printing and postage costs of a newsletter.

Consider asking businesses in the immediate area to place ads in your newsletter.

• Use bulk mail to save money on postage.

• Combine small newsletters with statements.

• Kinko’s has printers that print on 11” x 17” paper which can be folded into newsletter size saving money on both paper and printing.

  Are there effective, tried and true low cost marketing techniques?

  It is usually the small marketing efforts that have the biggest payoff.

  Have patients submit recipes, print one or two a month on small cards that can be picked up at the appointment desk. Make sure your name is on the top of the card ready to remind the patient of you whenever the recipe is used.

  Ask your patients for their favorite recipes. Publish them in an annual cook book. In small towns make sure you have a “celebrity recipe section” featuring recipes from the mayor, the school principal, the clergy etc.

  Sponsor your kids local sports teams. A name on a t-shirt generates long term exposure and awareness.

  Volunteer to be the drop off point for a food drive, a clothing drive, or a “toys for tots” campaign. It costs very little and gives you exposure to the entire community.

  Get involved in the schools in your community. When children come home for school and tell your parents that you were their science or health teacher for the day, it gives the kind of community connection that money cannot buy.

  What is the most important factor influencing the selection of a chiropractor?

  In today’s managed care setting, the most important factors influencing doctor selection are the limitations imposed by manage care.Many managed care plans have limited provider panels with higher patient costs imposed on those who seek a doctor outside the panel. With the imposition of higher costs, most individuals never consider seeing a chiropractor that is not on their managed care panel of “approved” doctors.

  What is the single most effective marketing tool a doctor has at their disposal?

  Since so many people do not know how to go about choosing a doctor, they look to relatives and friends for a referral. If patients have a choice, a referral is the single most effective marketing tool a doctor has.

  How much does the cost of care influence the selection of a doctor?

  This is very difficult to answer because the cost of care could have great impact or little impact on the selection of a doctor. If a doctor offers more convenient hours, a broader range of services, or better quality care, price is not going to be as meaningful. For those patients on a limited budget, price may mean everything without regard to other factors. However, pricing is not inelastic. As a doctor’s price becomes more uncompetitive, the price becomes more important in the selection criteria used by potential patients.

  I had a terrific CA who relocated with her husband. My new CA is very competent but our patient visits are down ever since I hired her. Does a CA really have an impact on the size of a practice?

  The inside appearance of the office, the attitude of the staff, administrative efficiency, and the skill of the doctor are all important factors in the long term success of a practice. These factors do not determine the initial selection of a doctor, but they do help determine if the patient will continue to return and if they will refer other patients to the practice.

  What should be my primary objective in my marketing?

  Your strength comes from the location of your practice. Patients who do not have a referral select their doctor primarily based on the location of the practice relative to their home or place of employment. Therefore, the most productive use of your marketing dollars is to focus your promotional efforts on the homes and businesses in the area surrounding your practice.

  Can newspapers be effectively used to limit “waste” in my marketing message?

  Newspapers, especially those in larger cities, will sell you advertising space based on the zip codes you specify. If available, this can be an effective way to target your marketing message.

  How can advertising done by my competitors potentially help my practice?

  A professionally prepared marketing message potentially helps all of the practices in a given market area because those individuals that are positively influenced, but live outside the effective marketing area of the doctor paying for the ad, will select a chiropractor that is more conveniently located. While the doctor paying for the ad may receive little benefit after analyzing the full costs of the ad, others who did not pay anything may gain unanticipated benefits.

  How can I calculate my effective marketing area?

  Since both your time and your marketing resources are limited, targeting those resources to maximize your results is very important. The first step is to plot the current location of your patient’s homes and business in relation to your practice. While the results may be intuitively obvious to you, this is not something that should be estimated. Often your assumptions will be based on latent biases toward where you would like the patient to be from instead of where your patients actually reside or work.

  Purchase a very large city map at a specialty map store. While a large map may be cumbersome, it gives you the area you need for accurate location identification. On the map, use a marker to show the location of all your active patient’s home or work addresses. Always choose the home or work location that is closest to the office.

  When you have finished plotting all of your patients, look at the location of the dots. You will notice that a high percentage of them will fall within a certain radius of your practice. In a big city, the radius might only be a few miles, while in a rural area; the radius might envelop an entire county. By drawing a circle around the 80% of the dots closest to your practice, you have defined your “effective marketing area”. If you want to increase your patient volume, your best opportunity is going to be from within this radius.

  What are the most cost effective means to target my marketing message?

  Imagine how effective you would be if you could have a personal conversation with every person who lived within your effective marketing area. Since door-to-door marketing of health care services is not a viable approach, the next best approach is to find an alternative means to communicate with this group of people. Here are some of your options:

  • Flyers
  • Brochures
  • Newsletters
  • Zip code identified newspaper or magazine advertising
  • Telemarketing

  Each of these is advertising approaches is unique because you are placing a direct marketing message within the home of the consumer. Placing the message only begins to address the problem. You must also hope that the consumer is actually exposed to its content in a positive manner. If the message is not received positively, it can hurt, rather than help, your practice.

  What is the primary advantage and disadvantage of a direct marketing message (junk mail)?

  The primary advantage of a direct marketing message, also known as junk mail, is that you control the content and the style of the advertising. Its primary disadvantage is that some consumers consider direct marketing messages to be an irritating intrusion on their lives.

  Can you help me understand how to use flyers, brochures, and newsletters in a cost effective way?

  The most cost effective way to reach a consumer may be through a flyer, brochure, or newsletter. You control the cost of production, the type of distribution, and the number of homes who receive the item. Desktop publishing is so efficient that simple flyers, brochures, or newsletters can be developed inexpensively. A doctor on a limited budget can get some exercise and save the postage costs by hand delivering them. More costs can be avoided by limiting delivery to the homes or apartments with the greatest potential.

  How can I obtain the address for homes and apartments in my effective marketing area?

  Libraries generally have “reverse directories” which will give you the name and listed phone number organized by street address. An alternative is to contact businesses listed under “mail services” that rent the use of a mailing list. These lists are rented on a “per use” basis. For anyone who expects to do multiple mailings, it is best to develop your own lists from library directories.

  The best way to create a mail list is to set up a data base in your computer. You can obtain a license to use the reverse directory and this can become the resource material for your own data base. If your staff does not have time to type in all of this information, a secretarial service will do it for you based on an hourly or project fee. Having a mail list on your computer allows you to create either personalized letters or mailing labels.

  I have a limited advertising budget. Is it better to spend it all on one big campaign or several smaller ones?

  Repetition is the key to a successful marketing campaign. It is more effective to educate consumers about your practice in small doses, than in one advertising piece. Using this approach, you might want to buy or develop a series of brochures that describe specific types of problems and feature one or two in each brochure. The consumer will respond best if the problems are approached in a non-technical fashion. They are interested in why chiropractic may be more effective than the traditional medical approach to the problem.

  Your goal is to constantly remind the residents of your marketing area that you want to be selected as their chiropractor whenever the need arises. One or two distributions of a flyer, brochure, or newsletter are not going to be sufficient to accomplish your goal. Full color brochures certainly have the most impact, but their cost would normally rule out their use for anyone who is looking at distributing four to six brochures a year. It is far more effective to use lower cost designs so you can produce or buy a greater variety of brochures.

  Telemarketing is used by many businesses. Is there any reason I should be cautious about using it in my marketing efforts?

  Telemarketing has been used by businesses for many years, but only recently by chiropractors to solicit patients. Most of the telemarketing calls are not made by chiropractors or their staffs. Instead, telemarketing firms are hired to canvass consumers and are paid on a per call or per referral basis.

  Telemarketing is a highly intrusive approach to reaching consumers. It has some success when used by those selling magazine subscriptions or collecting money for police or fireman’s charities. Chiropractors, however, should be wary about using telemarketing. Consumers are not used to getting marketing messages about their health from an unknown person over the telephone.

  Are potential patients motivated by coupon offers?

  There is the belief among some practice management companies that a sure fire way to bring in patients is to offer some sort of promotional pricing as part of the advertising message. The offers vary widely but may include:

  • Free initial exams and/or consultations
  • Discounted prices for a package of services
  • Free x-rays
  • Buy some, get some free promotions
  • Discount coupons

  While this type of approach can bring in new patients, its long term effectiveness and profitability are very questionable. The individuals who design these systems get most of their ideas from studying retail operations. Discounting clearly works in the retail sector. A manufacturer knows that a discounted price for a product can motivate the consumer to “stock up” on the product.

  The problem is that this concept does not translate very well to health care. Consumers consider the decisions they make about their health a lot more carefully than the brand of laundry detergent they buy. As a result, the type of consumer who responds to a “free offer” is not usually motivated to become a long term patient.

  Of course, if the patient has health insurance, workers compensation coverage, or is covered under an accident policy, they will use the traditional selection criteria to choose a chiropractor:

  • They will visit their current chiropractor, if they have one
  • They will use the chiropractor required by their managed care plan
  • They will seek a referral from a family member or friend
  • They will choose a chiropractor who is conveniently located and has given them a positive impression

  Discounts or promotions will not influence potential patients who have some type of insurance coverage. It is also not likely to influence those who trust the referrals they receive. Whether true or not, there is a connotation that a health care provider who offers a coupon for their services is either having trouble attracting patients, or will make up the value of the coupon by performing unnecessary services.

  It is possible that some patients with insurance coverage will visit a chiropractor who does promotional pricing; but they will likely be a very small part of the respondents. The rest of the respondents will be people who are just looking to take advantage of the deal that is being offered. Here are just a few of the problems this group of patients represents:

• If they are only motivated by the offer, their commitment will last only as long as the free services are given.

• If they are not required to pay for the services on the same day they are rendered, the practice can quickly develop an accounts receivable problem.

I have two choices to locate my practice. The first is on a busy street. The second, only a block away but, not on the busy street. Is it worth a premium, to be on the busy street?

The universal love of convenience will always make the actual location of a practice an important factor. When a person can easily spot your practice, the knowledge is retained for use when they need it. In competitive markets, assuming doctors of equal quality, the best practice locations will more than justify the difference in lease rates.

• Patients may expect instant results from their care. If they do not receive results fast enough, they may discontinue care.

• Chiropractors who do promotional marketing may believe that they do not have the same degree of responsibility to the patient, since the patient is not paying for the services. This is not correct. When doctors accept individuals as patients, they must exercise the same degree of professional responsibility regardless of whether or not they are being paid.

I have run promotional coupons from time to time. How can I tell if they are profitable to my practice?

To analyze the success of a marketing plan which offers free or reduced price services, you must compare the revenue of the patients attracted by the offer to all of the costs associated with that marketing effort. These costs include:

• Stationery expense

• Printing cost

• Newspaper, magazine or postage expense

• Staff salaries to develop the brochures

• Graphic artists fees

• Supplies (x-ray film, headrest paper, etc.) used in delivering free services

• Staff salaries to service patients

• Proportional overhead costs

• Lost income from services rendered

The last three items are those most frequently overlooked in the analysis, with the most important being lost income. A chiropractor’s time is a very valuable commodity. If the doctor were not with the patient performing “no charge” services, they could be occupied with other professional or personal activities. When a doctor’s time is used to perform free services, the lost revenue must be counted as part of the marketing expense. This includes the doctor’s time to perform services and consult with the patient as well as any staff time spent with the patient.

To determine the profitability of this marketing approach add up all of the revenue generated by patients initially attracted by the coupon offer. Subtract all of the costs listed above. If the result is positive, the coupon promotion is a financial success. If negative, the promotion loses money.

How are consumers affected by chiropractic advertising?

Consumers are exposed to many forms of advertising each day. They develop a strong awareness for the hierarchy of these messages. If a chiropractor advertises in the same manner as hospitals, HMO’s and other health care professionals, they will be thought of in the same manner. If they choose to advertise in the same style as fast food outlets or K-Mart, consumers may not equate them with the professionalism exhibited by others in the health care industry.

I am a new doctor and I want to build my practice in an ethical manner. I do not have a lot of extra money and probably won’t for awhile. Is their a marketing approach that can work for me? In a previous question in this chapter, we defined the method to identify your effective marketing area. Use the same maps and mark the location of every nursing home, church, YMCA, health club, and school. Each of these has potential for activities that will form the basis for an effective low cost marketing plan.

If you are serious about developing a strong neighborhood based marketing plan, you have to do more than put a series of “Let Me Introduce Myself and Here is What I Do” brochures in people’s mailboxes. These brochures may be terrific, but they are a one dimensional form of communication. A more powerful statement of commitment to the community is actively participating in activities throughout your community.

Direct participation in community activities is quite time consuming. It rarely has the type of impact that is directly measurable. That is because very few of the people you meet while involved with these activities will have a condition that needs immediate attention. However, repeated contact with the public will build enormous positive awareness. People prefer to select a doctor with whom they are somewhat familiar. Since there are not any factors that require them to select an alternative chiropractor, your participation in community activities will be a long lasting resource for patient referrals. These activities include:

Health classes at:
• Churches
• Health clubs
• YMCA
• Your office
• Schools

Each of these offers defined opportunities to teach people about their health, offers people an opportunity to ask you questions, and creates awareness about your professionalism as a health care provider.

I like the idea of offering health education in my community. What are some tips on making the classes more effective?

Remember that each audience is unique. Age, interests, and backgrounds should be considered as you pick the subject for your discussion. This is especially true of educational programs you offer at schools. Work closely with teachers or program sponsors to insure that your topic will be well received by the audience.

When you consider teaching a health class, you may remember the lectures you attended in chiropractic college. The thought of giving a technical presentation may be quite unappealing. Your experience in the real world can be much more satisfying. The audience for health care topics is likely to be small and quite manageable. People who attend have a genuine interest in the subject, and their enthusiasm will add energy to your presentation. Discussions which involve a lot of audience participation do much better than those in which the doctor lectures and only allows questions at the end of the presentation.

How can I maximize the time I allocate to volunteer activities for the benefit of my practice?

Volunteer activities help a community organization fulfill their goals while you are building positive awareness through your efforts. Since your time is not unlimited, you have to pick the activities which give you the most exposure in the community. Look for opportunities where your name can be displayed to groups of people. A common source is the sponsorship of athletic teams or donations to church or school festivals. If you are allowed to put up a sign with your practice name, be sure that it is professionally prepared to give the best impression.

TV and radio stations are the best place to find out what is happening in the community. If you call each of them they will tell you how they find out about community events and may put you on their mailing list for their events calendar. Newspapers often run a listing of upcoming activities on a weekly, or monthly, basis. If you ask, they may give you the contact names for community leaders. Write or call these individuals and ask if you can get announcements of upcoming events so you can look for ways to participate.

For example, volunteer the use of your clinic as a drop off point for food or clothing drives. Walks, runs, or bicycle events that pass your clinic, give you opportunity to volunteer a water station along the road. Every fund raising event needs volunteer work of some type. If you cannot work at the actual event, there may be activities that you, or your staff, could do at your office.

The groups with the traditional reputations for community activities are the Kiwanis, Jaycees, Eagles, Lions, and Optimists clubs. While you may not normally be inclined to normally join one of these groups, it helps to view it as a way to enhance the long term prospects for your practice. Most groups do not expect a great deal from you. Your objective is to make additional contacts within the community. The business person who asks you a casual question about chiropractic today may be the person who decides which providers will be on their health care panel tomorrow.

Is it a good idea to solicit for business while I am involved as a volunteer at a community activity?

It is counterproductive, and may damage your image, if you solicit for business while participating in community activities. Most of the people who volunteer their time for charitable events expect the activities to be primarily social. You certainly want to introduce yourself as a chiropractor but the best tactic is to wait for people to approach you with their questions about chiropractic. And they will. When they do, be sure to treat them as professionally as they expect by not assessing their condition in an off hand fashion. Evaluations should be done in your office where you have the tools to do the job properly.

Why should I consider directing some of my marketing activities to businesses?

Even though managed care is very prevalent, more than 50% of all businesses do not offer managed care plans to their employees. These businesses are potential sources of patients. You can identify them by using the map that defined your effective market area. Once you have your map, you can identify the businesses on the same drive that identifies the churches, schools and other facilities that are important to your other marketing activities. Your initial efforts should:

1. Identify each business by name and type of business. Try to be specific. The “World of Values” could be anything from a junk yard to a retail store. This information will be important to you as you plan your marketing activities.

2. Estimate the number of individuals employed by the company. Simple descriptions like “just a couple” to “quite a few” are perfectly acceptable. When it comes time to deciding which businesses to approach first, this will help you prioritize your activities.

3. Make special note of the locations of other chiropractors, orthopedists, neurologists, physical therapists or family practitioners. Part of your direct marketing activities will involve establishing working relationships with as many of these providers as possible.

As you can learn from other questions throughout this chapter, patients choose their chiropractors based on the convenience of the practice location to both their home and place of work. Collecting this information on index cards or stored as part of a computer data base allows you to begin the last segment of your marketing activities.

Your goal is to have each of these businesses get to know you as a reliable health care professional. Your first incentive is workers compensation. Every business has employees who can potentially be injured while at work. You have the training and skill to offer the employer advice about how to reduce the risk of injury in the work place.

You have an additional incentive because a small business will eventually be solicited to offer a managed care plan to its employees. As this happens, small businesses will have to make decisions on the providers they want to treat their employees. If they do not have any established relationships, they will merely accept the panel of providers offered by the HMO or PPO. But if you have an established relationship with that business, you have the inside track of being asked to serve on the provider panel of whatever managed care company they ultimately choose.

A small business that offers its employees health care benefits has a more paternalistic relationship with its employees than a large company. They are not just after the provider with the lowest prices. They care more about the quality of care their employees receive. A chiropractor they know personally is an important resource to them. Because of your relationship, it is likely you will be called on to provide advice to them as they decide which managed care organization to join.

 

What is the most effective way of contact a small business with whom I wish to develop a relationship?

Most small business marketing must be done in person. Mailing letters of introduction or brochures will not be all that helpful. Information sent by mail is likely to be treated as junk mail, unless you have met the management personally before you send literature or information.

The method of your initial contacts should vary with the size and type of company. Smaller operations, particularly retail stores, can be visited without an appointment. Manufacturing companies should be telephoned in advance to learn the name of the owner or the person responsible for insurance or plant safety. Regardless of size, your objectives when visiting a business are the same:

1. Introduce yourself. Remember that what makes you unique is that you are a chiropractor from the same area that wants to network with other area businesses.

2. Focus on their business. Your greatest chance for long term success is to identify ways you can be helpful to them. If possible, ignore how they might be helpful to you. That will come with time, after your relationship is established.

3. Offer to learn the jobs done by their employees. The hardest part about developing a business relationship is the unwillingness by many people to show that they are qualified to have the business. You can win this battle by doing more than talking about the work environment of the employees. Demonstrate what you are talking about by working alongside the employees for a period of time.

4. Treat everyone like they are the owner. In small companies, employees often wear several hats and their responsibilities frequently overlap. The owner may be guided by advice offered by the employees. The impression you make on each employee will matter as much as the information you communicate to the boss.

5. Relationships take a long time to develop. Be particularly patient with large companies. They have established relationships which may have been developed over a period of years. It takes much patience and hard work to develop a long lasting business relationship, but long term relationships are your goal.

6. Send mail only after a personal meeting.

I have met some business managers through different community activities. What are effective ways to keep my name noticeable to them without being intrusive? You can retain contact through:

• Newsletters
• Positive articles on chiropractic
• New research studies which demonstrate the effectiveness of chiropractic

If you mail these items, you may want to add a personal note to anything you send.

I have a pretty talented staff that currently does nothing but administrative work. Is it a good idea for me to use them in my marketing efforts?

If you ask your staff to use part of their time to help you in any community activity, it is possible that they may resist or even resent the request. This is to be expected unless you explain your rationale for participation.

In the competitive environment of health care a doctor can no longer sit back and wait for patients to appear at the door. They must proactively seek out patients in an ethical manner. Marketing the practice must be a team effort. The more knowledge a patient has about a particular chiropractor, the more likely that doctor is to be chosen when the individual develops a need.

Patients are not going to select a certain practice just because the doctor or staff volunteers at community activities. They select a doctor based on the amount of positive awareness they have about a practice. The staff can add substantially to the goodwill generated by the practice if they also participate in community activities. If the staff is friendly and helpful, this reflects positively upon the doctor. Unfortunately, the opposite is also true. A cold or unresponsive staff does not inspire an individual to select that particular practice for care.

In this area, you are no different from any other business. You cannot survive unless your current base of patients continues to grow. Too many patients move, switch to a managed care plan, or end care for a chiropractor to be able to survive financially with the same group of patients. Your staff has a vital role in the growth of a practice.

Each individual on the staff needs to be continually reminded that their job is more than just their assigned day to day activities. That may mean they are periodically assigned marketing activities because these activities, are needed to maintain the growth of the practice.

Do I have to worry that my marketing efforts are going to be replicated by my competitors?

As you read these strategies for developing your practice, it may occur to you that other chiropractors who practice in your area may decide to act on a similar strategy. As difficult as it may be, your best course of action is to be aware of what other chiropractors are doing while focusing most of your attention on your own plans.

Your advantage is that no one can control the amount of energy you put into your marketing efforts. Human nature being what it is, if you work exceedingly hard at developing your practice, your competitors are not likely to match your efforts. There will always be a significant number of doctors who expect their practices to grow by themselves or are only willing to put a small amount of energy into marketing activities.

Your own personal style is your second advantage. Even if someone else matches elements of your marketing plan, they cannot duplicate your unique way of relating to people. As you reach out in various ways to the people and businesses in your area, you will establish a rapport with them. Not everyone will be overwhelmed by you at first. In fact, it is better if they are not. You want them to get to know you over a period of time as a unique and caring professional.

If others are using a similar approach, the individual who works the hardest will have the advantage. You have complete control over the level of your commitment. The level of your success will depend on your willingness to share your thoughts and beliefs about chiropractic with everyone in your marketing area. The work you do through brochures is important, but your personal contacts will have much more impact on the growth of your practice.

Measure your success not against the number of victories scored by the competition, but the number of victories you have achieved for yourself. In practical terms, this means to measure your success in terms of how your practice is growing without dwelling on the accomplishments of other chiropractors. That does not mean you should ignore their activities. Always feel free to incorporate the best of what you see in another doctor’s practice or marketing activities. Just remember, the ultimate factor is your relationship with your patients. Once you attract them to your practice, it is the quality of care they receive which will keep them coming back.

How does a cash practice allow me to be more devoted to a patient’s health care need?

All too often a health insurance policy only allows a doctor to treat the symptom experienced by the patient. Because the underlying cause of the problem goes untreated, the patient may be setting themselves up for a lifetime cycle of problems. A cash practice allows chiropractors to devote themselves to what the patient and the doctor agree is in the best long term interest of the patient.

How does a cash practice allow me to focus on productive not defensive patient assessment?

Chiropractors who are not reliant on insurance reimbursement can spend their time doing productive patient assessments, instead of defensive assessments to get the claim approved by the insurance company. Insurance companies are increasingly asking for “proof” that treatment was necessary. The fact that the patient believes the care was necessary and beneficial is not important to the insurance company. A major benefit of a cash practice is the quality time spent with the patient in assessing their unique needs.

Can a cash practice reduce my staff costs and related overhead expenses?

Much of the large increase in the administrative cost of running a practice over the past 10 - 15 years has been due to the personnel required to handle insurance documentation requests. Eliminating this expense will save the practice the salary expense, as well as the related costs of vacation pay, insurance, workers compensation, and social security expenses. Indirectly, the doctor also benefits because his or her time is not needed for training or meetings to discuss problems with reimbursement.

How can a cash practice help me developing long term patients?

A cash practice allows a doctor to develop a practice with patients of his or her choosing instead of those directed to you by an insurance or managed care company. The work associated with the establishment of a cash practice is substantial. However, there is a distinct difference in dealing with patients who are motivated to maintain their health as opposed to patients whose motivation is to resolve a specific problem.

Does it take unique skills to operate a cash practice?

Some chiropractors do not realize that it takes a special type of personality to operate a cash practice. Over the last decade, doctors have grown accustomed to merely accepting the patients that have called for appointments. Educating patients about their long term health care needs and aggressively asking for referrals is somewhat of a lost art. If a chiropractor does not enjoy intensive personal contact with patients, he or she is not likely to be able to develop a successful cash practice.

What are the primary motivations for a person giving up insurance reimbursement and converting to a cash practice?

The two most prominent motivations for converting to a cash practice are the frustrations of dealing with insurance companies and the requirements for documenting patient care.

Dealing with insurance companies is complicated because it involves the overlapping issues of personnel management and compensation. Here is the cycle:

1. A doctor is frustrated because too much time is spent managing insurance receivables.

because ....

2. The person responsible for receivables has not received adequate training.

because ....

3. The doctor either does not have the experience in this area to train the person or is not inclined to do so.

To solve the problem ....

4. The doctor could pay the market rate for a person who has appropriate experience in managing receivables.

however ....

5. They do not feel they can do this because a person with those skills typically earns more than the doctor wishes to pay for a staff member.

and ....

6. They do not feel they can afford this individual because their prices are not high enough to cover this additional expense.

as a result .....

7. The cycle continues.

a. as the doctor replaces one staff person after another.

b. until the doctor adopts a prudent management philosophy which allows for pricing services at a rate that will allow for hiring appropriate staff to manage the receivables function.

c. Until the doctor gives up and coverts to a cash practice.

The second frustration is the documentation required to justify the care rendered to the patient. Unfortunately, while other staff members may be the solution to the frustration with receivables, documentation is entirely the chiropractor’s responsibility.

 

Every time the work of a chiropractor is reviewed adversely by an insurance company consultant, that doctor is required to defend his or her care. Because the chiropractic profession does not have a standard for the examination, diagnosis, or treatment of a patient, each adverse IME requires the doctor to review every entry in the patient record to justify the care that was rendered. It is quite likely that these obtrusive and wasteful requirements are the primary motivating factor behind a chiropractor’s desire to have a cash practice.

What are the complications in a cash practice for patients who file their own insurance claims and then ask me for help when the insurance company rejects their claim?

With a cash practice you partially eliminate the need to respond to insurance companies. However, some patients with insurance benefits will decide to file insurance claims on their own. If they do, eventually the insurance company will review those claims in the same way they would if they were submitted directly by the doctor. Patients do not have the specialized education they need to understand their diagnosis or treatment plan. They will come to you for answers to the questions posed by their insurance company.

The insurance CA is normally the individual that serves as an interface between the doctor and the insurance company. In a cash practice, the insurance company will ask the patient for records to determine the medical necessity of their care. The EOBs denying that care will be sent directly to the patient. The patient will not understand the games played by insurance companies as part of the process of paying claims. Because the doctor will have eliminated the insurance CA staff position, patients will not have this person as a resource and will go directly to the doctor with their questions.

When this occurs, it will take a lot more time for the doctor to explain the technical necessity for care to the patient than it would for a CA to communicate with an insurance company. If a doctor is not willing to provide that information to the patient, you can be sure the patient is going to seek care from another doctor.

Are there malpractice implications for a cash practice?

Eliminating insurance reimbursement does not change the nature of the doctor’s responsibility to the patient. The doctor always has the obligation to act in accordance with the training he or she received and in compliance with the statutes and rules that govern the chiropractic practice. This means that while a doctor’s records may not have to be oriented to the reimbursement requirements of an insurance company, they still need to substantiate the basis for each clinical decision that is made.

It is not sufficient for a doctor to say that the patient agreed with the doctor’s recommendations for care. In the event that the doctor is sued for malpractice, the justification for each decision must be documented in the patient’s records or the doctor will lose the case. The belief that there is no risk of malpractice in a cash practice is simply not true. There is always the possibility, however small, that an individual may inadvertently be misdiagnosed or harmed by a chiropractor. Contemporaneous notes are the only useful method of defending the care rendered to a patient.

I am committed to starting a cash practice. Are there cost effective ways to accomplish my marketing?

Because the cash practice does not have as many revenue sources to draw upon, the marketing efforts must be sharply focused. The practice must create an appeal that will show some differentiation from other chiropractors. The possibilities include:

• Practice Hours

• Facility appearance

• Clinical specialty

• Modalities utilized

• Practice location

• Rehabilitation services

• Payment terms

• Price

Every time a practice distinguishes itself from another, it merely offers the potential for appealing to more patients. Depending on the competitive situation in a market area, any one of the above items could be more important than another. For example, a doctor may decide to stay open until 11:00 pm. three nights a week. That may appear to be a competitive advantage, but only if there are patients who want to visit their chiropractor at that hour of the night. If the practice happens to be located next to a large manufacturing facility that operates a second shift, the strategy may be very effective. Otherwise, the doctor is likely to be wasting a great deal of time and effort.

There are two ways to distinguish a practice from others that are not included in the list above. Each is dependent on the practice style or personality of the doctor. The first is to develop a reputation for providing highly efficient care. This does not necessarily mean price reductions. In fact, a doctor who provides quality efficient care needs adequate pricing every bit as much as other doctors.

Individuals who do not have health care coverage are very concerned with the cost of getting well. A chiropractor can be of great service to this type of patient, because chiropractic is the most cost effective method for treating neuro-musculoskeletal problems. In addition, the chiropractor can work actively with the patient to suggest lifestyle modifications that can help prevent the problem from recurring.

A patient concerned about the cost of his or her care is apt to terminate care before the doctor thinks it advisable. The doctor will want to take special care to fully inform the patient of his or her prognosis at every stage of treatment. The patient’s records should indicate what could happen if the patient terminated care before the doctor’s release. At no time should a patient be led to believe that efficient care means that the doctor will take short cuts. Patients may take an active role in the development of their treatment plans, but the doctor has the final responsibility for all patient care.

The patient’s records should indicate what could happen if the patient terminated care before the doctor’s release. At no time should a patient be led to believe that efficient care

In a cash practice, how does the willingness to explain the function of the body in a non-technical manner help to build my practice?

Chiropractors who insist on discussing a patient’s condition by using terminology directly out of the textbooks, are likely to impress the patient with their vocabulary, but they miss the opportunity to make the patient a partner in the treatment plan. Patients have to believe in the treatment plan before they can commit to it. They cannot possibly believe in something they do not understand. Expressing chiropractic terminology in a style that is easily understood takes both time and patience.

A good way of checking your progress is to involve the patient in the discussion. If you ask patients whether they understand what you are saying, you will get the usual positive response. If you really want them to understand, involve your patients in the discussion by using props, diagrams and asking their opinions about what they think is going on in their bodies. Even things as simple as having patients touch the problem areas on their x-rays or manipulate the vertebrate on your model spinal column, can open the communications process significantly.

Is long term patient education important to the development of a cash practice?

Doctors with cash practices must commit to the long term education of their patients. This goes beyond the typical exchanges during a visit. Education will continuously support the reasons behind the treatment plan and reinforce the excellent decision patients have made about their health.

The communications strategy should include personal phone calls by the doctor after the initial care of any new patient. Newsletters and personalized mailings also provide an opportunity for additional health information and involve patients in the ongoing activities of the practice. The chiropractic assistant has an extremely important role in this activity. By maintaining patient information cards that include personal data and key dates in the patient’s life, a CA can form a closer personal bond with the patient. The most underutilized technique in developing a relationship is also one of the most effective - the art of simple conversation. It is not enough to offer a patient a friendly greeting and a question such as, ‘How are you feeling today?’ Real linkage comes when patients are engaged in conversations which allow them to tell you what is happening in their lives.

In smaller offices, the doctor might be concerned about the falloff in productivity if the CA is spending much of her time talking to patients. As long as patients has the undivided attention of the CA when they are initially greeted, they will not object to the CA doing administrative tasks during this conversation. Naturally, CAs must be instructed that part of this conversation should reinforce the importance of the treatment plan.

 

Do cash patients expected to be treated differently than those that have insurance?

Patients like to visit busy practices. It confirms that their doctor is sought after and well respected. Once in the office, however, patients want to be treated like someone special – especially someone who is paying for care out of their own pocket. After all, with cash you can choose anyone to treat you. It is more than just taking time to answer their questions patiently. The doctor must find ways to relate to patients on a personal basis.

CAs can be helpful by sharing personal information they have learned during their conversations with patients. Doctors will almost never have time to have long conversions with patients, and patients do not expect it. But they will be more committed to a doctor who has genuine concern for everything in their life, not just their current health problem.

I want to convert to a cash practice. How do I make the transition?

Before any successful business tries to change its operational structure, they focus on correcting any of their weaknesses before the transition begins. Since so much of the success of a cash practice depends on interpersonal communication, it is essential to develop this skill before a transition is attempted. Doctors who think their personal style of dealing with patients will automatically improve once they convert to a cash practice are not likely to succeed. Effective communication takes practice. If a person does not have a naturally social personality, he or she should spend a great deal of time learning how to respond to patients on a more personal level.

Retraining the staff may be as difficult a job as reorienting the doctor. Because the staff does not own the practice, their motivation must be continuous. Knowing how to balance the administrative tasks of the practice with the constant need to interact with patients is a difficult task that could take months of training. For a doctor willing to put in the effort, the results will show up in many long term patients.

To increase the likelihood of a successful transition from an insurance to a cash practice:

1. Make the transition in stages. An abrupt change will leave you without income from insurance patients before you have established a base of cash patients.

2. Focus on interpersonal communication skills. Concentrate on current cash patients and test your ability to obtain referrals.

3. Analyze your financial situation. Examine at the rate at which your current cash patients come in for care. By calculating the average number of times a patient comes in for care, you can extrapolate how many new patients have to be attracted to the practice. It would be a mistake to assume that once you are strictly a cash practice the retention or visit rate of patients will improve.

4. Replace staff, if necessary. If you need a different sort of staff person because of the demands of a cash practice, personnel moves should be made as early as possible to allow sufficient orientation time for the new staff members.

5. Begin your marketing efforts. You will have the greatest chance for success if you add new cash patients to the practice before you discontinue your insurance patients. Once your practice is full, you can begin the transition of replacing insurance patients with cash patients. Discontinuing insurance patients before having sufficient cash patients will subject you to enormous financial pressure.

6. Complete the administrative transition. Once you accept only cash patients, you may wish to consider eliminating or reassigning the staff responsible for insurance activities. It is better to delay this part of the transition until your insurance accounts receivable is well under control.

7. Continuously re-energize your marketing activities. There can never be a day when the attention of you and your staff is not focused on marketing and re-marketing the practice. Providing excellent care is the core ingredient; however, your goal must always be to find and develop new patient sources.

Is it necessary to make reminder calls to patients about their appointments?

No, it is not necessary to make reminder calls about an upcoming appointment. It is also not necessary to remember patient’s birthdays or to hand out articles and news stories about chiropractic. But, when you do all of these things, chiropractic becomes more than an afterthought to a patient and the probability that they will complete their treatment plan and refer patients to you increases proportionate to your efforts.

How important is it that I mention the technique I use as part of my marketing efforts?

Naming the technique you use as part of your marketing efforts may actually hurt your marketing efforts. The technique used by a doctor will be important to a patient only if they have been a patient of another doctor and have developed a preference for the way they were treated. A patient who relocates to a different city may call different offices seeking a doctor who uses a particular technique. Since there are many equally effective ways of treating a condition, a chiropractor may be able to explain that an alternative technique may be quite suitable for the patient’s needs. Listing your technique in your marketing materials may cost you patients if they feel that you cannot accommodate their needs.

How can advertising done by my competitors potentially hurt my practice?

Unprofessional advertising has a converse impact on the profession. Just like its positive counterpart, an unprofessional message creates awareness in the public. Unfortunately, while a professional message helps all of the chiropractors in an area, an unprofessional message can hurt the same group. An unprofessional message tarnishes the image of the profession as a whole. While the person paying for the ad will suffer the most, his/her colleagues will also feel some of the pain from patients who might have chosen a chiropractor for their health care needs but made a different choice based on a poor quality of unprofessional marketing message.

How likely is it that my marketing efforts will convince a person to leave their current chiropractor for me?

If an individual is an established patient of another chiropractor, that relationship is likely to remain intact. Study after study indicates that individuals are very satisfied with their health care providers – both in and out of managed care plans. If patients have a choice, they will stay with a provider unless they become displeased with the quality of their care. This is generally true even if the patient moves, as long as the relocation is within a reasonable distance of their current chiropractor’s office.

A patient came in today and made a passing comment about the appearance of my building indicating they thought it looked “a little rundown”. Do you think this hurts me financially?

If you have competition, location is not enough to attract patients. The appearance of the practice itself will be part of the selection criteria employed by a potential patient. If the exterior of your office is rundown or in need of maintenance, it may well influence a patient’s choice. A patient does not get to know how competent a doctor may be until after they have scheduled their first appointment. The marketing advantage goes to chiropractors with well-maintained offices over those that need work.

It is difficult enough to get a person to answer questions about their health when they are in the privacy of your office. When they are asked questions about their health over the telephone, you may get more than just a rejection. A consumer’s negative association with that call may be so strong, that the person will make a conscientious decision not to visit a chiropractor who uses telemarketing. Even worse, they may pass along their negative comments to their relatives and neighbors.

I have two choices to locate my practice. The first is on a busy street. The second, only a block away but, not on the busy street. Is it worth a premium, to be on the busy street?

The universal love of convenience will always make the actual location of a practice an important factor. When a person can easily spot your practice, the knowledge is retained for use when they need it. In competitive markets, assuming doctors of equal quality, the best practice locations will more than justify the difference in lease rates.

Why is TV and radio advertising most often a waste for a single practice doctor?

TV and radio advertising is often a waste for a chiropractor in a single location because much of the advertising message is “wasted” on potential patients who cannot act on it efficiently. Your goal is to target your advertising message directly to the people who are most likely to use your services. In both TV and radio advertising you are paying to have your message played as widely as the TV and radio signals will reach.

Once that message gets outside of your effective marketing area, the message is wasted. Individuals who may be positively influenced by the message may select a chiropractor, but more than likely that chiropractor will be someone more conveniently located to their home of place of employment.

Obviously I would like more patients from my marketing efforts, but is there a shorter range goal that will impact my efforts?

Your ultimate short range goal is to have such a positive reputation that you are the logical choice when any individual in your market area needs a chiropractor. With that goal in mind, you can prioritize the opportunities you have to make contact with those individuals. The most obvious opportunity is to target people in their homes, apartments, or condominiums.

I have seen a lot of brochures and I am wondering, is simpler better?

Some doctors are tempted to cram as much information as possible into their brochure figuring the more information, the more opportunity to entice a potential patient. This is not a good idea. Most individuals are not readers. They want a message to be convincing because of its simplicity. If you want examples of the type of marketing that works, look through magazines or newspapers and tear out the types of ads which appeal to you. Ads that are jammed full of copy are generally only effective for discount retailers and, the public does not respond to a health care professional the way they respond to Wal-Mart.

The most effective message is one that uses simple direct language surrounded by a good deal of white space. Remember, the average person does not have a college education. Even in those neighborhoods where there are a lot of college graduates, their degrees are not usually in technical areas. An individual with a liberal arts background is not trained to understand the anatomy and physiology of the body. Your message has to appeal to them at a level they can understand. If your copy is full of technical language, you can assume it will be ignored.

Should I consider a charge to attend my educational classes?

While you always have the right to charge for any of your services, consider how your community might react to a charge for an educational class. In some situations, such as educational classes done at elementary and secondary schools,the decision not to charge is obvious. In others, such as classes offered in your office, fees could be appropriate based on the length of the program. Most health care classes offered by hospitals or medical clinics are offered without a charge. Since your goal is positive exposure in the community, fees are not usually a good idea unless your class is done in an environment which normally charges students, such as a community college.

I really do not believe in actively marketing my practice but I would not mind more patients. Besides referrals, can a doctor grow a practice just by being a good doctor?

Yes, but it will take longer if you take a more laid back approach. Without a direct reason to choose a doctor, an individual will select the practice in which they have the highest positive awareness. The awareness can be nothing more than a positive impression about the “looks” of the practice, or it could be considerably stronger based on an accumulation of positive impressions. The stronger the image, the more likely a practice will be selected.

How does a cash practice eliminate the need for narrative reports?

While a chiropractor must always document the care provided to a patient, narrative reports are often just a restatement of what is in the clinical records. Insurance companies insist on narrative reports because they are easier to read and interpret than exam forms. Eliminating the time spent dictating narratives to an insurance company has a positive affect on the quality of the doctors professional and personal life. Because so much report writing is done on a doctor’s personal time, eliminating this task allows the doctor more time for their social life.

Why are other chiropractors and medical doctors important to my marketing efforts?

Other chiropractors and MD’s are important to your marketing efforts because, from a pure business perspective the hours, fees, and specialties of your competitors should always be of interest to you. These factors help you understand what they are offering to patients and give you solid facts upon which to base your business decisions. Knowing their specialties will give you the opportunity to form professional relationships to discuss difficult cases and provide referral opportunities for your practice.

Managed care is forcing greater cooperation between chiropractors, medical doctors, and other health care providers. In some communities it is still difficult to establish a working relationship with a medical doctor. But those MDs who have accepted chiropractic can be an important source of referrals. They are more likely to refer to a neighborhood doctor that they know than to someone across town with whom they have no relationship.

I do a lot of volunteer work and it has really helped my practice. I would like to encourage my patients and, at the same time, let them know that I really believe in our community. What approach can I use to accomplish this?

Let your patients know that you are an active member of the community by posting all the announcements of upcoming events on a message board in your waiting room. If you lead an exercise class at the nursing home, let people know by posting pictures of the class. Your patients will get vicarious pleasure out of knowing that “their doctor” is an active member of the community. Also, it never hurts to let your patients know when volunteers are needed for an upcoming event.

If you have a community message board in your lobby, be sure that your staff is responsible for placing and removing any announcements. If members of the community are allowed to do it themselves, your message board will quickly become cluttered and unattractive.

Is it more difficult to do marketing in a cash practice environment?

Having a cash practice makes the marketing more difficult. The effective marketing of a practice area does not expand as a result of having a cash practice. Since all doctors are willing to accept cash patients, the fact that some are exclusively cash is not a competitive advantage for the cash practice. If you compare two practices, one which accepts all types of patients and another which only accepts cash patients, you can easily see that the practice which accepts all types of patients has a distinct competitive advantage.

Eliminating patients who are covered by insurance, managed care, worker’s compensation, Medicare, or Medicaid means the doctor will have to compete much harder for those individuals who remain. Doctors may hope to profit from patients who are dissatisfied with the choice of providers selected by the managed care company and willing to pay for their care out of their own pocket. There is no reason to believe that these patients will disproportionately select the exclusively cash practice doctor.

Will converting to a cash practice cause my practice income to decrease?

A chiropractor who converts from insurance reimbursement to cash patients could see a significant loss in income, particularly in the early stages of the transition. The doctor is giving up access to patients with group health insurance, managed care plans, worker’s compensation, and potentially Medicare and Medicaid.

When you relinquish these sources of patient revenue, you give up the income from insurance payers who pay claims quickly, along with those that abuse the profession. Building a network of cash patient referrals is a long term marketing project. The amount you save by reducing your administrative staff is likely to be quite a bit smaller than the loss of revenue.

I want to do marketing but I just can’t seem to find a way to block time for this work. The truth is I probably find excuses to avoid it. But I am committed and need a plan. Can you help?

Whether you are just getting started or have an established practice, it is important to block off time on your schedule for your marketing work. It is the only way to know that this very important work is getting proper attention.

There is the tendency by a chiropractor who has recently entered practice to want to be in the office every minute, just in case a patient should happen to call. What they may not realize is that the patient who calls has no idea what the doctor’s appointment book looks like. If the patient is told that the doctor can see them at 11:00 a.m., they are not aware that the doctor is scheduled to be out doing practice marketing for the two hours before the patient’s appointment.

It is just as important for the established doctor to block time for marketing activities. As the size of a practice grows, there is a natural tendency to cut back on marketing and practice development. While this will be necessary to some degree, eliminating the activities entirely would be a mistake. It is very difficult to sustain the size of a practice without some practice development activities. Disciplining yourself to maintain these activities will pay dividends throughout your career.

How can eliminating direct contact with insurance companies with a cash practice improve the quality of care I offer to patients?

No interruptions of patient visits with phone calls, no claim forms, no correspondence, and best of all, no more letters denying care because the medical necessity has not been established are all benefits of eliminating contact with insurance companies. In a typical office, the demands of complying with the requirements of an insurance company do not allow for much personal interaction with the patient. Eliminating the source of this problem allows for a deeper understanding of the patient’s lifestyle and how chiropractic can offer them a better quality of life.

In a cash practice, how does effective listening help to build my practice?

You cannot underestimate the importance of taking the time to fully understand the patient’s health. Patients, who want a chiropractor to take an active role in maintaining their health, expect that the doctor will understand the activities important to their lives. They also want their doctor to understand lifestyle habits that may limit their ability to partake in those activities. Busy insurance practices do not always spend the extra time with patients that demonstrate commitment to their total health.

In a cash practice, how does patience in answering all patient questions, no matter how repetitive, help to build my practice?

It takes a lot of courage for patients to ask questions about their care. A busy chiropractor may take a direct approach to communications and provide only the information essential to answering patient’s questions. Chiropractors who want patients to be completely committed to their treatment plans try to understand why a patient is asking the question and provide background information before the question is answered directly.