Fee Systems

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                   Chiropractic fee systems are perhaps as diverse as the types of chiropractic practices.  Medical fees are pretty much fee-for-service.  Either per visit or per procedure is the way most M.D.’s practice.  But in chiropractic it is different.  There are cooperative fee systems; some using a box, others where the patient determines his/her fee and gives it to the doctor or C.A.  There are monthly fees, yearly fees, per visit fees, co-pay, sliding fee systems, family fees, the list is almost endless.  Of course most mixers consistently follow the medical model and charge for each modality.  But perhaps many of us who are not mixers are also following the outside-in principles of medicine.

          I have always avoided discussions of fee systems because I felt it was a personal choice and no one should be told how to set their fees or be criticized for it.  I still feel that way but I have come to realize that there are certain application of those principles can be left up to the individual chiropractor.  I probably would not even address the issue now if it were not for a few ignorant and rude practice management consultants who go around belittling people who have a fee system they do not feel is in keeping with their image of chiropractic.  Of course my system was one that was criticized.  Perhaps judging the source I should feel proud that I must be doing something right.  In evaluating our systems there are a few principles to examine with regard to compensation for the practice of chiropractic.

          There are two philosophies with regard to compensation for chiropractic care.  The inside-out philosophy says that the compensation for chiropractic should be based upon the intrinsic value of the care.  That is, the price should be based on the factors making up the cost of the care.  By analogy, in buying a men’s suit, the cost of the suit is established by the cost of the material,  the quality of the workmanship as well as the other costs of doing business.  This is the proper approach, the value determines the price

          The second approach, an outside-in one, says that an arbitrary cost should be set, usually what the “traffic will bear” and that will establish the value of the service or goods.  In other words if it costs more it must be of more value – the price determines the value.  The difference is clear, one is more valuable because of its intrinsic worth, the other is more valuable because it only appears to be in the mind of the consumer.  Putting a $800 price tag on a J.C. Penney suit off the rack doesn’t make it a better suit, it just appears to be to the uninitiated, those who are not knowledgeable about men’s suits.  Sadly, a good many people are cheated out of their hard-earned money these days because they believe that something that costs more must be better.  Perhaps many chiropractors are part of taking people’s hard-earned money for a service of artificially inflated value.  External factors do not determine value, internal factors do.

          We have chiropractors with an outside-in philosophy who believe that if you charge more for chiropractic care that somehow it will become more valuable.  A J.C. Penney suit will not become an Armani suit merely by giving it an Armani price tag.  Does charging for an adjustment what a gall bladder operation costs make it as valuable as a gall bladder operation?  If that adjustment enables the body to work better thus eliminating the need for an operation, it is worth much more!  You see the problem with setting fees consistent with medical fees.  You cannot compare an Armani suit with a J.C. Penney suit in any way, including price.  You cannot compare the value of chiropractic and medicine.  A good automobile costs more than a years worth of groceries.  Which is more valuable?  You can live without a car, not without food.  I have actually heard practice management consultants say that charging higher fees makes patients have more respect for chiropractic care and that low fees or no fees causes them to think the care is not that valuable.  I am not sure that anyone but practice management consultants think that way, but even if people do, is that right?  Is an adjustment worth less if it is free than if it cost $30?  If people believe that, them perhaps we chiropractors should begin to educate them differently.  We definitely should not reinforce distorted values in out patients.  Part of straight chiropractic involves teaching people proper values and proper perspectives in life, that’s what above-down, inside-out is all about.

          Now if you charge more for your care and in doing so begin to give more, that’s a different story.  But that would suppose that what you were giving before was not sufficient.  Some chiropractors will raise their fees and then add more modalities.  But we are talking about straight chiropractic care.  If you are giving a competent adjustment, you are doing all you can and no raising of fees will make it better.  If you are not doing your best, well, the fee charged has nothing to do with it.

          What are the internal factors that determine the value of a straight chiropractic visit?  The intrinsic value of an adjustment is not one.  It cannot be measured.  How much is it worth to have nerve interference of the body to better express itself?  Obviously no price can be put on it.  If the intrinsic value of an adjustment were a criteria, no one would be able to set a fee.  But there are measurable factors.  The cost of your education and the years spent in acquiring it are a factor.  However, if you amortize it over the career of the chiropractor, it would probably amount to less than a dollar a patient visit!  Overhead expenses are a factor.  However, the chiropractor must be careful to not make and internal factor an outside-in one .  For example, having furnishings in your waiting room that are extravagant, more than what the patient needs or wants and then expecting them to pay for it, is not right.  Is it for the patient or for the D.C.’s ego?  If it is for you, perhaps your priorities need an adjustment.  In any case the patient should not be expected to pay for the chiropractor’s exotic or expensive tastes.

          This essay was not meant to be a line item critique of chiropractic fee systems.   But it is intended to get the straight chiropractor thinking about everything in his/her practice from a position of principle.  Our above-down inside-out philosophy should be reflected in every aspect of our lives, including our fee systems.  There is perhaps one more principle in chiropractic philosophy that can be applied.  Chiropractors recognize people as individuals who should not be forced into  a national average.  The value of a chiropractic  visit  is probably as varied as the number of patients.  What if the patient does not need to be adjusted on the visit?  I wonder how many D.C.’s charge a high fee because an adjustment is so valuable to health, and do not charge if an adjustment is not needed?  In the earlier hypothetical example of an adjustment that prevents gall bladder surgery being more valuable than the cost of the surgery, let us look at the opposite situation (and to say that chiropractic prevents anything is always a hypothetical situation).  What if the patient need gall bladder surgery?  They still need to be adjusted, but which is more valuable to them?  the point is the value of care is as varied in patients as is the value of removing interference to the expression of innate intelligence.  It depends upon the individual.  Any chiropractor, no matter what his/her system, who says “there are no patients who want and need cre and know the value of an adjustment and cannot afford it” is divorced from reality.  Perhaps we need to think about these things when establishing fee systems. v9n5

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