I don't like being the bearer of bad news, but this is something new grads must hear: wherever you go, student loans will find you! 

You may have been granted a grace period following graduation or, like me, deferred loans for a year, but at some point loan repayment will become your reality.

My advice, in retrospect, is this:

• If you don't have to defer or use your grace period - don't. During these times, your unsubsidized loans will continue to accrue interest.  If you can't pay all your loans at once, consider paying down those with higher or adjustable interest rates first while deferring the others. 
• Take advantage of borrower benefit programs if those are available - make your first 12 payments ON TIME and you may have your interest rates reduced 1% (trust me, this adds up!)
• If you are reading this and are still a student, consider stashing away a little money each trimester.  As you are starting your practice, or even in the early months of an associateship, that money can come in handy to cover your loan payments.

You may be wondering how this pertains to business... I can promise that it does When you are applying for a business loan to start your practice (or applying for a mortgage to buy a house) you will need to account for your loan repayment.

The average chiropractic student leaves school with approximately $125,000 in loans. In a 10-year repayment, that works out to about $1,125 a month. It may be tempting for the curernt students or new grads to think "I will cross that bridge when I get there," but  these thoughts can get you into financial trouble in the long run.

Loan repayment can be crippling if you don't realize your full financial commitments.

Although I'm far from conquering this debt, I do have a plan of attack and now I am attacking my plan. And my wife and I are already planning our "Student Loan Repayment Party" for 2019!

If you have any insight on this or wish to share your own battles with student loan repayment, please comment.

This afternoon, one of the chiropractors who practices with me was describing a referral he had earlier today.

He indicated that last week a pain management/anesthesiologist came by the office without appointment to introduce himself and describe his services. It's always been our policy to try and meet those salespeople or professionals who drop in, whether with an appointment or not.

While busy, my colleague took time to meet "Dr. Anesthesia" who recently joined a large medical group in the community and who was obviously impressed. Not only was a new patient referred to us for care, but a needle EMG was also requested and performed.

Years ago, these types of cross referrals (which are now the norm) were non-existent. While this is the type of positive reinforcement we have always sought, whether it's a doctor, lawyer, indian chief, or sales representative, I suggest (whether busy or not) saying "hello" to those who take the time to visit your office and ... if needed, schedule a time for in depth conversation.

Some time management "gurus" may disagree with me, believing that when patient care is being rendered, the doctor should not be interrupted. While understanding the premise, most have the ability to "tie their shoes and chew gum at the same time."  

Common courtesies go a long way. And I'm sure most would agree - and have a fond spot for those who are generous with their time and talents as opposed to hearing, "He's too busy to see you."  

And don't forget ... "What goes around, comes around."

Happy Days!

In a recent ruling by CMS, it has been proposed to cut Medicare rates for chiropractic care by 2% in 2010.  Chiropractic was involved in a Medicare demonstration project to examine the cost-effectiveness of chiropractic care in comparison to medical and physical therapy services. 

Although the results of the demonstration have not been reported at this time, the following is an excerpt of a proposed ruling by CMS. 

Is this a glimpse into the Medicare demonstration project results due to be released later this year?  The comment period closed August 31, 2009.

The July 13, 2009, CMS Federal Register publication of: Medicare Program; Payment Policies Under the Physician Fee Schedule, and Other Revisions to Part B for CY2010; Proposed Rule, is provided for additional information and detail.

Discussion of Chiropractic Services Demonstration
The MMA requires the Secretary to evaluate the feasibility and advisability of expanding coverage for chiropractic services under Medicare.  Under Medicare, coverage for chiropractic services is limited to manual manipulation of the spine to correct a subluxation.  The Demonstrations expanded current coverage to include “care for neuromusculoskeletal conditions typical among eligible beneficiaries and diagnostic and other services that a chiropractor is legally authorized to perform by the State of jurisdiction in which such treatment is provided.”  The 2-year demonstration was conducted in 4 geographically diverse sites; 2 rural and 2 urban.  The demonstration ended 3/31/07.  The PFS for 2006, 2007 and 2008 discussed the BN [Budget Neutral] requirement and how chiropractor fees would be adjusted should the demonstration result in costs higher than those that would occur in the absence of the demonstration. If the demonstration was not BN it was anticipated to make the necessary adjustments during 2010 and 2011.

Two approaches in examining the BN were used; the All Neuromusculoskeletal Analysis (NMS) and the Chiropractic User Analysis.  The results of both analyses were not budget neutral.  The total effect of the demonstration to Medicare was $50 million.  Because the costs of the demonstration were higher than expected, it is proposed to recoup the $50 million in expenditures over a 5 year period.

Therefore, it is proposed to reduce the payment amount under the PFS for CPT 98940-98942 by 2%.

 

Every professional designer will tell you that the 3 F's to observe while space planning are function, form and flow.  This post will deal with form ... flow and function to follow in later blogs.

What exactly do we mean by form? 

Form is defined as "the subtle instrument that controls and supports the flow of human activity in an office".  Form establishes the framework for flow.  Simply, it is the vehicle that carries a patient through your space with comfort and mobility.

Form directs and guides patients and staff to/from the primary areas in the office.  An office that outlines the course of space and appeals to the physical senses choreographs movement within the space.

A patient's first impression of his/her experience in your office is established in the reception area.  The well designed communication area should welcome the patient reflecting warmth and professionalism.  This can be achieved by lighting, texture, and passages.

So I can hear you saying, "WHAT is she talking about?"

Create a mental picture ... the patient enters your office.  They see a straight wall, a door to the right (a solid door I might add) and a big glass window to the left.  There are overhead light panels, popcorn ceiling and the chairs have "rough" utilitarian coverings.

That, I would say, doesn't "fit" a good form!

If you are building out space, a curved wall isn't any harder to build than a straight one.  A glass panel door removes that old "what's behind the secret door" mentality.  Yes, glass is becoming necessary with privacy issues. But why not have the patient center behind the glass sliding window rather than on the reception side? 

It's all about planning the FORM! 

The form of ergonomically designed treatment areas should not be just to enhance the efficiency for the doctor and staff.  Patients need to feel embraced and comforted by a setting that puts them at ease.  The result is a more relaxed and cooperative patient. 

The industry that seems to have captured the best form is the spa industry.  You enter into serene space ... the counters are rounded. All the "business" is done in private space away from the entry. You go to serene rooms.  The good spas are very busy, but you never feel rushed.  You feel at ease.  

These are just a couple "teasers" to identifying form.  The FORM and shape of the entire office creates the framework for flow and function.

To be continued ....

At NCMIC, we value our role as your partner for your success.  As such, we are continually working to enhance the resources and information available to you through StartingIntoPractice.com.

We have recently added some fantastic resources to help you down the path of success with your chiropractic career. 

Under the Tools & Resources tab at on this site, you will see two new tools. 

• The Financial Success Planner - a comprehensive set of spreadsheets designed to frame your finances, budgets and plans.

• The new Starting Into Practice Guide - a comprehensive, step-by-step tutorial on the business side of chiropractic practice.

 These resources are available to you free of charge and are designed to help you succeed. 

Good luck!

Ahh ... the infamous job search. Surely you've done it before. Some random wait staff or retail clerk gig where you punched away for minimum wage and decided you were definitely going to college!  

Here you are a few years later, educated and ready to go! You've decided an associateship is the option for you, so now what?  The basics haven't changed, but you've graduated (literally) to a new level in the work force.  

Here are a few tips to get you thinking.

1. Where to go?  A place you'd like to settle eventually?  Look for associate positions with buy-out options.  Want a place to get your feet wet before starting you own office?  Look at short-term options, like working in an office where you're needed for non-permanent disability or vacation coverage. 
2. How is the practice worth determined?  Make sure it is an un-biased figure. 40 years of hard work is invaluable to the retiring D.C., but 40-year-old equipment and patients that may leave when he/she does will greatly affect you.  I would recommend having this 'appraisal' done before you've had an impact on the practice.  Are you buying the practice as it stands now or the one you'll build up over the course of a few years?  
3. When is the doctor planning to retire?  Is that time frame yet to be determined? Are you alright with that?
4. Is there real-estate involved? Will you be buying the practice and the building/land? Could you lease the building from him/her for a period of time to decrease the amount of money you borrow from the bank?  Is he/she willing to finance it for you?
5. What happens to the staff?  Are they willing to stay for the transition?  Are you willing to keep them?  
6. What are the reasonable expectations for patient retention?  A prolonged transition period will greatly assist you in this, so don't be so hasty to get the retiring Doc out the door.    
7. What if the doctor 'misses' practice and decides to open up down the street in 6 months?  This would be the time to discuss a non-compete clause.  Maybe you could hire him/her back for part-time or fill-in coverage?        

When researching fill-in work, ask questions like: 

• How will you be compensated?  A per-patient rate or a flat rate for your availability and time in the office. Yes, you are keeping the office running, but you're building your skills essentially at their expense, (in regards to overhead) so the 'fairness' of this number can vary from one situation to the next.                         
• Can you fit in?  For the sake of patient retention, technique, personality, and work ethic all come into play here.  It's a short-term arrangement, so you'll need to adapt to the practice for the time you'll be there. Do NOT walk into a fully functional practice and preach your dislikes. This applies to any associate position - short or long term.  Open your eyes, ears, heart & hands. Shut your mouth.  Consider this time an extension of your college clinic experience ... with a paycheck.    
• Don't forget to make sure you and the hiring Dr. have adequate malpractice coverage.   
• Insurance companies need to be informed about the additional provider in the office. No, you cannot bill under their name and NPI number.       

This month will mark the third anniversary that my office has been "paperless."  I use the quotation marks as it felt like I did more "paperwork" than ever the last 3 years! 

So what are the advantages of using electronic medical records?

• Efficiency - legible and professional notes to referring physicians are faxed within the hour of seeing the patient. 
• Quality- good record-keeping is not only important for malpractice purposes but also for audits. 
• Ease - all of our diagnostic reports are scanned into the computer which makes it easier to review.
• Consistency - record keeping is part of the process when seeing or consulting with a patient.
• Savings - in the long run, I think I save money by not paying for the dictation but that is my office and others may have more efficient dictation methods.

So what are the negative aspects of going paperless?

• Busy days - there is efficiency of getting the notes out to referring physicians but in my experience, it makes a busy schedule seem even crazier.  I still see the same amount of patients in a business day, but I have added hours and limited the lunch/dinner breaks.
• Consistency of records - this can be bad if every note looks the same.  This is easily avoided if the time is taken in the beginning to set the program up well.
• Computer dependency - this can be detrimental if something breaks down.  We still have a paper schedule as well as the computer schedule in case the computer crashes.  Paranoia can create a lot of extra work!

Looking back, the one thing I would change is that I should have had the people who installed the program come to the office a few months prior and evaluate my office set up and recommend any modifications that would make the transition easier.  In the beginning, I felt like we were trying to cram a square peg into a round hole!

I am sure that there are more pro's and con's but these are the most obvious in my practice.  I can address any specific concerns or questions that anyone has but in general I am happy that I made the move!

When outfitting a new office or preparing for your opening in these tough economic times, think out of the box. Here are some quick tips to get you going before opening day.

• Visit the area you wish to practice in and drop by local DC offices for a tour. Before you leave ask the DC if they might have any equipment they’d like to get rid of. One DC I know was able to get reception room chairs, a desk and a high-low table that needed recovering. Total savings? About $8,000!
• Check second hand furniture stores for good quality furniture that you can paint to last until you can afford the dream things you want.
• Barter.
• Offer to write a column for a local paper in exchange for advertising.
• Check to see if you have a graphic design school in a local college and see if you can get your “sign” designed for free as a student project.
• Spend some time doing something you love to do in the neighborhood you hope to practice in. It might be helping with a one time “Bike for the Cure” or a little league softball tournament. Activities like this can get your name and reputation off to a good start even before you open your doors and give you an outlet for a little fun before you buckle down to business.
• Contact your local library and “check out” art work you can display on your office walls on a rotating basis.
• You can get music CD’s and videos for your waiting room as well at no cost!

Don’t be shy! Ask. Use secondhand items.

You’ll reach your breakeven point and begin to make a profit much quicker!