Where's the beef?

Digging deeper into the business challenges facing chiropractors
Anthony Lombardi
March 22, 2016
Written by
In October 2015, I wrote an article entitled, "Business is Life," which outlined the oversaturation of chiropractors in Ontario and some of the academic business deficiencies new graduates are facing once they leave chiropractic college.

I received over 300 emails from chiropractors and educators – some of which chastised me, but the vast majority of whom commended my efforts. Regardless, there is a need for business practice reform in Ontario. And, over the last five months, I have been preparing this article so I can stimulate serious conversations that can lead to tangible business practice solutions.

In short, we have an overabundance of chiropractors, but not enough users, and a brand with an identity crisis that lacks proper academic business training.

Ontario chiropractors and students need to understand:

1. Why chiropractic schools finally need to be responsible and reform their academic business programs in the face of overwhelming evidence that they are not doing their part to prepare graduates for financial success.

2. What drives the chiropractic utilization rate – and how to improve it.

3. How we can use what we learn to find long-term solutions that promote growth and development of our practices.

Back to school
In his letter to the editor in October, CMCC president Dr. David Wickes referred to my articles as being riddled with errors and poorly researched material. I respect Dr. Wickes, so I took it upon myself to work harder to find facts that are even more suggestive of the improvements that must occur in business training programs at chiropractic colleges.

I will simply list a series of facts, so that you may draw your own conclusions.

A study published in March 2014 in the Journal of the Canadian Chiropractic Association concluded and reinforced that new graduates are unprepared for practice. "Chiropractic students enter the profession within a context of a competitive healthcare market, possibly saturated consumer demand for chiropractic services, and tightened salary prospects."

In August 2010, Chiropractic & Osteopathy reported that of the California chiropractors who started practicing in the early 1990s, almost 30 per cent of them were leaving the profession due to oversaturation in the state with the highest population of chiropractors.

In Ontario, Canada's province with the highest population of chiropractors, the College of Chiropractors of Ontario (CCO) reported that the number of chiropractors in the province rose dramatically from 3,886 in 2009 to 4,723 in 2015, an increase of 23 per cent. The utilization rate and population of Ontario did not increase at all during this same period, which is a contributing factor to the oversaturation of chiropractors in the province. This oversupply has been responsible for the many raw and unfair associate opportunities that many new DCs encounter after graduation.

According to the U.S. Health Resources and Services Administration (HRSA), chiropractors represent 31 per cent of health professionals who have defaulted on student loan grants from 1978-1999. Dentists represent 18 per cent and medical doctors 24 per cent.

In October 1999, May 2010 and January 2012, more than 50 per cent of the individuals on HRSA's default list had attended chiropractic college. Inversely proportional to this, the average income of practicing chiropractors has been dropping steadily:

In the U.S.:
1989 - $101,000 (Source: American Chiropractic Association)
1997- $86,500 (Source: American Chiropractic Association)
2010 - $87,000 (Chiropractic Economics and U.S. Bureau of Labor Statistics)

In Canada:
2001: $144,254.50 (Source: JCCA, 2005, salary data for Ontario)
2015: $70,000 (Source: PayScale, salary data for Toronto
2015: $66,531 (Source: PayScale, salary data for Canada)

These statistics make sense since the number of chiropractors has been steadily increasing while utilization rate has generally stayed the same – meaning more chiropractors are fishing from an unchanging patient pool.

New York Chiropractic College conducts ongoing chiropractic college alumni surveys, which include responses from alumni of nine other chiropractic institutions. The 2011 report – covering data from 2004, 2006 and 2008 – revealed that when respondents were asked to rate their preparedness for business and practice management on a five-point scale, with 1 being "not prepared" and 5 being "well prepared," the overall rating was 2.02. In 2007, the same survey outlining years 2000, 2002 and 2004, saw alumni give a business/practice management rating of 1.95.

What's concerning is that the survey echoes other surveys demonstrating a drop in net DC income. The chiropractic college survey data of 2004 reported a net income range of US$75,000 to US$89,00. However, the 2008 alumni data reported net incomes in the US$45,000 to US$59,000 range.

Why are loan default rates increasing and net DC incomes decreasing?

To help me answer this question, I requested interviews with all of the chiropractic college presidents/executive directors from all of the schools within a 400-kilometre radius of Ontario's capital city of Toronto. Unfortunately, our leaders did not respond to my requests, except one who wished not to be asked any questions for this column.

Don't worry though, it seems chiropractic colleges are, in fact, indirectly getting the message.

According to data from the U.S. Integrated Post-Secondary Education Data System (IPEDS), from 1995 to 2013 chiropractic college enrollment peaked at 15,000 students in 1996, and then dropped continuously until 2002 to an average of 9,957 students – a 33 per cent reduction. Enrollment has remained flat at an average of 9,980 from 2002 to 2013.

Commenting on the issue, Dr. Dan Krueger, a chiropractor from Kelowna, B.C. says, "I already had an MBA from the University of Calgary before attending chiropractic college. My specialization was in entrepreneurship and venture development. If anyone should feel comfortable with 'business,' it should be somebody like myself. It is precisely from that perspective that I felt that our 'business training' in chiropractic school was minimal at best."

Back to basics
In the last few months I openly asked for suggestions on how we should increase our utilization rate in Ontario. The responses I received were more philosophical and largely theoretical rather than practical and applicable. So, I'm going to give you my five cents (two cents are now obsolete in Canada) because it's a business solution for a business problem using a clinical approach – and it works.

Consumers in general spend their money according to their needs – and much money is spent without much conscious thought. For instance, let's try some brand association: When I say coffee, you think? Where would you go to get a sheet of plywood? Where can we get an ice cream cone on a warm summers evening?

When people get back, neck or other musculoskeletal pain, the first place the majority of people think of is their medical doctors' office. So, the logical solution is to educate MDs and demonstrate to them how we can help their patients. This is by far the easiest and most direct way to increase utilization of chiropractic services across North America.

Krueger says, "Many feel their MD speaks only gospel. If the MD recommends something, the patient usually complies, without question."

The concept is simple. For instance, if my drain is clogged in my restroom sink, I could spend hours YouTube-ing how to unclog it, or I can go to a place that I trust will sell Drano. That's why commercial brands vie to be on Walmart's shelves more than anywhere else. Because like the person who goes to their MD at the first sign of a back injury, Walmart is the first place most people think of when they need a household item.

Walmart isn't particulary interested in which drain unclogger is better – all they care about is that the product creates the desired result and makes their customers happy. Much like Tim Hortons, Home Depot and Dairy Queen – Drano finds ways into people's homes because they position themselves in a place where people look for solutions to their needs.

Results = Referrals
MDs are not concerned about the feud between mixers and straight chiropractors – and neither are their patients. The debate is irrelevant to the vast majority of the developed world because most people have never even been to a chiropractor. To gain our trust, like any commercial product, we must provide initial results to the new user in a reasonable amount of time in order to make them believers. MDs are the Walmart – the meeting place for the majority of people with musculoskeletal injuries looking for solutions. MDs have endorsed my services and referred me patients when I have demonstrated that I can provide results to their patients' needs. Remember, chiropractors themselves can't understand one another when it comes to philosophy – so MDs will surely be lost in translation. What's more, MDs are frankly too busy to care about our philosophical differences; they simply want safe and effective reproducible results for their patients.

Chiro chameleon
Building the utilization rate effectively can only be successful and reproducible on an individual basis and at a grassroots level. This is because each new patient usually has a totally different experience of the chiropractic brand. In essence, this is what is happening within our profession, because chiropractors and the techniques they use are vastly diverse from one DC to the next.

Appropriately, I searched the archives and I found a 1983 interview from the American Chiropractic Association Journal who questioned famous chiropractic critic Dr. Stephen Barrett. Barrett, who went on to establish www.quackwatch.com, made some very accurate points in this interview – many of which echo my writings today.

In the ACAJ piece, Barret noted, "I did send a number of people, in one study, to chiropractic offices. They were instructed to answer the chiropractor's questions as truthfully as possible. The only thing they were instructed not to tell the chiropractors was who sent them. If they had known I had sent them, the chiropractors might have acted differently (all visits were taped with concealed audio recorders). There were three patients, all healthy. They visited a total of 16 different chiropractors, not any two chiropractors found the same thing wrong or recommended the same treatment. One woman went to seven different places and they found seven different things wrong with her. They recommended seven different types if treatment."

If a product aspires to get on Walmart's shelves they have to play by Walmart's rules. If you aspire to get referrals from medical doctors you have to do what medical doctors expect from a treatment. Using my clinical approaches I have been able to foster a viable relationship with MDs in my area and now they send me an average of four new patients per week.

Back in Alberta
If Ontario is to increase its utilization rate, a good place to start is at the top. In the summer of 2015, I interviewed Alberta College and Association of Chiropractors president Dr. Chad Kulak and he reported Alberta's utilization rate to be 27 per cent. Some of their success can be attributed to educating the public, and their alliances with community organizations and professional/amateur athletic clubs. In doing so, they fulfill their mission of furthering awareness and understanding of the benefits of chiropractic care among Albertans.

However, my argument is that Alberta's high utilization rate has nothing to do with what ACAC or any other association has done – because the utilization rate is totally economy-driven. Albertans' average earnings are more than their counterparts in all of the other provinces (just over $60,000 in Alberta vs $42,000 in Ontario). In addition to using chiropractic care more than any other province in Canada, Alberta spends more money than any province in Canada on the following: health care, personal care, recreation, tobacco and alcohol, household furnishings, transportation, clothing, newspapers, lotteries and charitable donations.

So, are all of the above sectors of industry doing an excellent job of furthering awareness and understanding of their products to Albertans or is it simply because Albertans have more money to spend?

In 2010, Davis et al published a paper in the Health Services Research Journal which studied the economic demographic of chiropractic patients for a period of 10 years. In that time, the average American earned US$37,725 and the average chiropractic patient earned US$39,536.

Krueger, who is a MBA degree holder, agrees with my argument: "Utilization rates are definitely money-driven. Research indicates that people with higher discretionary income use complementary-and-alternative medicine with greater frequency and regularity."

Solution: Imitate, Investigate, Facilitate
Imitate
The easiest way to achieve success is to reproduce a model that already exists. Physiotherapists have demonstrated that nearly all of their referrals come directly from MDs. In fact, according to the Canadian Physiotherapy and Ontario Physiotherapy Association, the most recent statistic known reveals the utilization rate of physiotherapy is surprisingly only seven per cent. Interestingly this makes sense because typically this service is used only when there is a need, not as a way of life. There are 17,000 physiotherapists in Canada and only 40 per cent are in solo practice settings. Of those in solo practice, another 42 per cent focus on musculoskeletal cases. This only leaves 2,800 physiotherapists in private clinics who provide focused, musculoskeletal services to incoming patients. The majority of patients will seek a physiotherapist only when their family MD tells them to. So, you can appreciate the notion that if you, the chiropractor, make a concerted effort to make yourself known to the MDs in your vicinity, then eventually you will reap the benefits that physiotherapists have been cultivating for decades. We need to position ourselves to MDs the way Drano positions themselves in Walmart – the place where the traffic is.

Investigate
When you are looking to start or move your practice, please be aware of where the money is. Affluent areas are more likely to embrace alternative products whether its a $7-coffee or a chiropractic adjustment. Early on, Starbucks learned that their customers were upper-middle class, college/university educated people who lived in the suburbs or high-income areas. In addition, houses close to a Starbucks actually cost more than the national average, and homes near the coffee giant appreciate faster than the average home. By doing your homework on the demographics you can better plan for a viable future. Like Starbucks, do your research and make sure you are in close proximity to those who most often use chiropractic services.

Facilitate
Most people go to dentists every six months for dental checkups – but did you ever wonder where that recommendation came from? Surely it was a landmark study or a cross-sectional research project done over several years. Nope. It originated in a book written by Pierre Fauchard called, The Surgeon Dentist, which was published before Canada or the U.S. even existed – in 1746. In the book he merely suggests that people should have their teeth examined by a dentist two to three times per year. The truth is, as outlined in several issues of Evidence-Based Dentistry Journal, there actually isn't any evidence that twice per year dental checkups are necessary. Dentists are simply advised to make their maintenance recommendations on a case-by-case basis.

So, why aren't people seeing chiropractors as often as dentists? Surely chiropractic has the evidence to demonstrate that mechanical dysfunction and muscle inhibition can occur over several months due to repeated strain, overuse and even prolonged sitting. Naturally, it seems both logical and reasonable to patients that we recommend regular supportive care based on this premise alone. So why don't we?

Jeff Romansky, owner of SecurePlan Insurance Solutions, was able to help me gain some perspective. In 2014, 24 million Canadians had private supplementary health benefits and almost 100 per cent of the plans included dental and chiropractic services together. Of those with benefit plans plus the others who make up the 35 million Canadians – 26 million people visit the dentist annually but only 5.25 million go to the chiropractor.

If 24 million Canadians have chiropractic benefits then why aren't they being utilized?

Personally, I feel this responsibility falls on the respective chiropractic associations who have the budgets to spread this message to the masses. Almost 70 per cent of Canadians have some form of chiropractic insurance coverage yet our utilization rate is around 12 to 15 per cent. In the past, I think associations have been guilty of being too conservative and not having a message the public really understands. Campaigns need to spell out the message loud and clear: "Did you know you likely have chiropractic health insurance through your work? Get your spine checked. See your chiropractor." It's not enough to be suggestive – ¬the association advertising campaigns need to be front and center so there is no doubt the message will be received and understood.

As individuals, improving the utilization rate is something we can all contribute to. Whether it's making strides to increase referrals to our practices, learning how to set targets based on socio-economics, or expressing ourselves to our alma maters and current chiropractic associations – know your influence can make changes if you use your voices. Stimulate the conversation and write to your association, chiropractic school or submit a letter to the editor.

Reform for better practice opportunities will happen if we influence the authorities that guide our profession.

Comments  

 
+1 #8 Dr E Dubarry 2017-01-13 09:56
What a great article well done, realistic and breaking down many myths.
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+2 #7 David I. Graber, DC 2016-04-27 08:37
I found Dr. Lombardi's article, "Where's The Beef?" in the recent issue of The Canadian Chiropractor a breath of real world fresh air in opening a real discussion on the challenges North American Chiropractors are currently facing in developing and maintaining an economically successful practice. He brings to fore facts, clear thinking, and a perspective from one who is thriving in a competitive healthcare marketplace.

Too often we in the Chiropractic profession, personally and organizationall y, spend an inordinate amount of our time defending our positions rather than on advancing it. I am on the board of the Association of New Jersey Chiropractors and I will be disseminating Dr. Lombardi's article to our board, as well as sharing it with my colleagues. I learned a lot from his brief article. I would like to see him expand on it further in upcoming columns.

David I. Graber, DC, DACBSP
Mountain Lakes, NJ
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+2 #6 Dr. Anthony Lombardi 2016-04-08 10:30
And who goes to chiropractic school? University students! Brock University Career Services posted the article on their Facebook page:

https://www.facebook.com/brockcareerserv/?fref=ts

If schools and associations son't change then the economy will change them.
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+1 #5 Dr. Anthony Lombardi 2016-04-05 23:22
Joanne - regarding your MD question. The biggest thing that carries most weight with MD's is getting quality clinical results and making them aware that you don't just "crack" every patient that walks through the door. MD's tell me that their first objective is to do no harm. So, if they think chiropractors "crack" everyone then they tend to shy away from sending patients who are elderly, osteoporotic, stenotic patients due to DJD, and any patient who has had previous backor neck surgeries. The key lies in. educating MD's that each of our patient cases is individual and unique with its own distinct treatment approach (ie. Soft tissue, modalities, acupuncture, activator etc, etc) and joint manipulation is only one option and not for everybody.
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0 #4 Dr. Anthony Lombardi 2016-04-05 23:22
Thank you CD and Joanne for your feedback and your kind words. It is important for us to collectively change the business practice. culture in our profession. This can only be done by practicing chiropractors who voice their concerns with chiropractic schools and their provincial chiropractic associations. Thank you both for taking the time to comment. Its DC's like yourselves that are needed to step up and have the courage to take the lead and make their thoughts known - this is how we change policies.
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+4 #3 Dan 2016-04-04 21:40
Forgot to mention that association, college and insurance keeps going up.
What do we get for it. Lower wages?
Keep up the great articles!!
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0 #2 joanne welham 2016-04-01 15:57
Hi Anthony,
I was one of the 300 who wrote previously and have been waiting for your follow up. Excellent (!) article. It's tough to argue with the research that you have quoted.

It actually offers some comfort to know that my income is actually "average" compared to other chiros, and my low salary does not say that "my skills suck." It was seriously a thought.

I would love to know the specific conversations that you had with the medical doctors in your area to get them to refer to you. I have a number of people who stand up to the GP's in our area when they are told that "I don't want you to see the Chiropractor". There still are a number of people, though, who tell me that they can't come anymore because their doctor told them not to. If you will reply, I would love to hear from you!
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+2 #1 CD 2016-04-01 09:24
Great article Anthony. Glad to see that you are pushing this agenda. The CMCC academics seem to feel that flooding the market with chiros will create the demand and increase awareness about chiropractors. Unfortunately as you have shown in your article all it is doing is lowering chiropractic incomes and causing mass price competition between them. Keep up the good work... I really enjoy your articles.
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