In 2011, 2013, 2015, 2017, and 2019, I wrote in The American Chiropractor magazine, “Why is a life in Tennessee, South Dakota, and Texas worth more than a life in Hawaii or New York?” There is no reason other than the insurance companies and elected state politicians allow it to be. We are a country of laws and regulations per visit, and these laws dictate the marketplace and how doctors are reimbursed for their services. In most states, it is based upon the usual, customary fees of the doctors and carriers paying a percentage of those fees. However, in Hawaii, the state sets the doctors’ fees, and politics drives them.
The collections listed in the following table depict what chiropractors are collecting as of December 2021 on a per-visit basis for a typical treatment versus what they collected in 2011, 2013, 2015, 2017, and 2019, and are rated against the cost of living for each state in comparison to other states. The dollar amounts exclude examinations, X-rays, supports, and any other ancillary services or testing and are limited to only services performed by the chiropractor in a private clinical setting for treatment inclusive of the adjustment, modalities, and rehabilitation.
The number of reporting doctors in all states does not reflect a large enough cohort (sample size) to reflect statistically accurate averages. However, based on survey sampling and conversations in all 50 states, the numbers are what was reported and can be trusted as a guide. The dollar amounts accurately reflect what is currently being collected for personal injury cases on a “visit basis” in all 50 states nationally, and I gathered the information.
As I established in previous articles documenting 2011, 2013, 2015, 2017, and 2019, cost of living is not an indicator for reimbursement in personal injury, as one would logically conclude. In a fair and equitable system, the more it costs to rent an office and run a business, the more a doctor should be entitled to charge and collect. Unfortunately, politics too often determine your fees on a stateby-state basis, and the stronger the insurance lobby, the lower the reimbursable fees. As was reported previously, Hawaii is one of the most expensive states in which to live yet has the lowest reimbursement levels nationally. Previously, the lowest reimbursable state nationally was New York, but it recently got its first substantial fee increase. In October 2020, downstate New York chiropractors could realize approximately $114 per visit for New York City and its vicinity. Upstate New York is reimbursed at a lower rate. The New York legislature controls the state’s personal injury fees.
A 50-state reimbursement comparison between 2019 and 2021 revealed an 8.7% increase in collections, and between 2011 and 2021, a 113% increase was reported for a personal injury visit at a chiropractic office. This statistic showed a trend in the chiropractic profession, which verifies that the personal injury population of patients is a financially stable sector within the industry. Also, when managed care and other financial classes in the profession are shrinking in reimbursement, personal injury is the one sector consistently growing. (Please note that this author does not suggest that doctors maximize their charges inappropriately and that only clinically indicated services should be performed based on clinical necessity.)
Many doctors will read this report and feel that they must increase those portions of their practices with personal injury patients. That would appear to make sense from a reimbursement perspective and business plan. However, is that doctor qualified? Treating trauma cases requires a particular skill set and training no different from any health care specialty. You wouldn’t want a psychiatrist performing open-heart surgery without the requisite training or an OB/GYN doing brain surgery. In the past, all a doctor of chiropractic would need beyond doctoral training was advanced education in MRI interpretation because of improper MRI interpretations by general radiologists. Herzog et al. (2017) reported a 43.6% error rate of general radiologists misreporting the MRI findings, something a doctor of chiropractic relies on to deliver care. To compete and be considered an expert today, formal education in spinal biomechanics, connective tissue pathology, and accident engineering are also required.
Understanding the differences between herniated, bulged, protruded, extruded, migrated, or sequestered discs is critical in creating an accurate diagnosis, prognosis, and treatment plan in triaging and guiding the patient through care. Although the delivery of chiropractic may not change, when you can and cannot treat your patient might change because collaborative care with a medical specialist and or surgery might be indicated. The etiology of pain in a trauma case is often dramatically different for a geriatric or pediatric patient — training and credentials matter.
Comparison of Collections vs. Cost-of-Living Analysis
2011 -2021
After consulting and educating chiropractors for 20 years nationally, 100% of the doctors who have tried to be trained and compete in the “personal injury space” have succeeded. Although the reported levels of success have varied, all now consider themselves better doctors and experts, allowing themselves to be successful and make their competition irrelevant in personal injury. That is our goal for the doctors we train.
Also, our profession has been exposed to many “get-rich-quick” schemes in personal injury. These are typically a “false bill of goods” with offers of “magic reports and research articles” to garner referrals. There is no substitute for credentials, knowledge, and a strategic business plan to get your referral sources to run after you. That is the solution for chiropractic practices in 2022 and beyond, a fact that has been confirmed by extensive market research.
Too many doctors of chiropractic bypass the diagnosis and prognosis stages and delve directly into treatment. Too often, this step is taken to the detriment of the patient. If the patient has pain radiating down their arms or legs with or without associated motor weakness before you touch that patient, the first question should be, “What is causing that problem?” If you do not know, do not guess. Beyond your clinical examination, consider advanced imaging if clinically warranted without shying away from the carriers’ often “fictitious” rules of approving the advanced images. Once again, the hard, non-negotiable “Studin Rule” rule is “if you do not know, do not guess.”
The only way to spiral upward is through clinical excellence by acquiring knowledge and credentials. Based on the literature, chiropractic outcomes have outpaced other forms of treatment for spinal conditions within our scope. For mechanical spine pain, both physical therapy and medicine have far poorer outcomes with an increased incidence of secondary disabilities, increased opiate use, and significantly higher costs than chiropractic care.
As a profession, the most direct avenue for these published studies to help increase utilization is for each doctor to be expert and credentialed in the area of desired practice. Treating personal injury patients is included in this formula. It mandates formal credentials at the postdoctoral level, so choose your courses wisely as a stepping-stone to what you want your practice to be tomorrow.
With personal injury or any financial category, fair and equitable reimbursements will determine if a doctor can afford to live in any community nationally, and wise legislators should consider doctor’s reimbursements or soon realize there is a doctor shortage in their respective state. Therefore, for those states below the national average, the chiropractic political organizations should strengthen their lobbying efforts with a unified chiropractic voice (organization), which should happen at the state and national levels.
Don’t lose sight that there can never be a pharmacological solution to a mechanical problem. Therein lies the genesis of part of the opioid crisis.
For references please turn to page 55.
Dr. Mark Studin is the founder of the Academy of Chiropractic and the Doctors PI Program. He teaches chiropractic and medical at various levels and creates strategic business strategies for chiropractors, medical doctors, hospitals, and lawyers nationally. Reach Dr. Studin at [email protected] or 631-786-4253.
