Since the early 1990s, managed care has increasingly constrained billing practices of DCs and MDs alike. Doctors simply have had to tighten their metaphoric belts because there are only so many patients to care for, and the annual numbers of visits, office visits, and procedures and coverage seem to dwindle continuously.
From my own vantage point, the economics of chiropractic is a problem of national proportion, while individual states struggle with their own special problems, such as changing personal-injury laws, cuts in workers' compensation inclusion, threats to limit or redefine scope of practice, etc. Every day I get e-mail and phone calls from DCs all over the U.S. It's a tough world out there, and it's likely to get tougher.
So, is there a way out of the mire for you? Actually, yes. Consider a couple of facts. First, no matter how bad things might appear, the light at the end of the tunnel isn't really that far away. Experts in money matters will tell you to focus on two doing things: cutting your overhead and increasing your income. While obvious, the first can sometimes be painful, but if things aren't turning around, it's probably time for a change. As for income, you don't need a miracle, just a steady infusion of new business, which is already out there in your community. It just needs a conduit. Second, a lot of DCs are still doing very well in practice. I know, because many are former students who keep in touch. How do they manage? For some it is simply a matter of thinking outside the chiropractic table (box); in other words, thinking about other streams of revenue without leaving the profession.
A couple of years ago, we [the Spine Research Institute of San Diego] conducted a random phone survey across the U.S. We queried 2,500 households. We discovered that 36 percent of those who suffer a whiplash injury seek the care of a chiropractor. That may sound unimpressive because it means that about two-thirds of the people who need chiropractic services the most never benefit from them. On the other hand, DCs had the largest single share of the pie. No other health care providers by specialty approached 36 percent. Nevertheless, with approximately 3 million such injuries occurring each year in the U.S., half of which develop into long-term pain, that means as many as 2 million acute-injury patients and DCs fail to ever make the critical connection. The growing population of people with chronic pain is another potential source of patients. Our research indicated that as much as 45 percent of all chronic cervical-spine pain begins with motor-vehicle trauma.1
The good news is that there are strategically effective ways of connecting with this important patient base. An approach many doctors are finding hugely successful is to become a community leader in automotive safety. Work with your county medical director, fire and police departments, schools, EMS services and other community agencies. It's a public-health community service and great PR for you and your profession. (I should also mention that there are methods that should be rigorously avoided, such as buying police rosters of people who have been involved in collisions and cold-calling them. This is unethical and projects a poor image of the profession. I'd also pass on television, radio or print ads because they are simply a waste of money.)
Another way to think outside the table is to become a polymath expert in traumatology. Consider the possibilities. There are doctor experts. There are accident-reconstruction experts. There are biomechanical experts. Imagine if you were all three. This rare breed is, by far, the most effective and unmovable expert, hands down. Attorneys will need to invest in only one expert, rather than three. Does this mean obtaining a PhD in reconstruction or biomechanics? No. Accident-reconstruction courses range from weekends to a few weeks at most. As for biomechanics, as a DC, you are partially qualified already. Federal Rules of Evidence 702 says: "If scientific, technical, or other specialized knowledge will assist the trier of fact [i.e., jury, arbitrator, or judge] to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education may testify thereto in the form of an opinion or otherwise." Note that you need not possess all five to qualify. You don't need a masters degree or higher in biomechanics. I always qualify as a biomechanist in court.
It is also worth considering that forensics is one area unaffected by managed care. No one sets your fee schedule when you are an expert. With 3 million injuries every year, there will always be a need for trained, qualified experts to settle medicolegal disputes.
Meanwhile, there is minimal overhead in forensic work, and competent experts often earn upwards of seven figures. Mind you, it takes years to build up to that level, so don't close your office Monday and hang out your "Forensic Expert" shingle and expect to survive. Realistically, it makes sense to take one step at a time. Keep your day job and concentrate on pulling in new PI cases by becoming your community's auto-safety advocate. At the same time, embark on a new self-education program. Reinvent yourself. It's never too late. Do some reading every day, get some additional training in reconstruction, biomechanics and traumatology. You can gradually transmogrify into the top forensic expert in town.
It takes work and dedication, but it is a great hedge against an uncertain future. It indemnifies you against the relentless juggernaut of managed care. Additionally, for those of you with an already painful back, neck or shoulders, it just might keep you working and productive for another 10 or 20 years. As I like to say, there's no sin in getting weary; the only sin is in giving up. Oh, and did I mention that the majority of this work is done in a La-Z-Boy?
If you'd like to see an accident-reconstruction recommended reading list, biomechanics textbooks or training programs, or for other questions, just send me an e-mail.
Click here for previous articles by Arthur Croft, DC, MS, MPH, FACO.