Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 185

From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time.

“YOUR medical team”

The above grammer is not a typographical error or an obnoxious way to depict medical specialists. It is meant to underscore the fact that neurosurgeons, neuroradiologists, orthopedists and neuroradiologists are part of your team, not the other way around.
In consultation #13, I wrote about creating your team and just this morning, 3 years after I wrote that piece, a doctor in the western part of the country underscored the significance of needing that team in creating the best care for your patient and you being the best-of-the-best. This morning, the doctor had a patient that was in an accident a short time ago and had severe cognitive loss. In fact, the patient’s memory was severely impaired.
First, let me digress and discuss being a good doctor. Being a doctor does not mean being a good adjustor and being a good adjustor is not mutually exclusive from being a good doctor. In the case cited above, the doctor wanted to know if he should order an MRI or CAT scan. My answer was that the patient should, post-haste, see a neurologist or neurosurgeon, as there could be an epidural or subdural hematoma putting pressure on the brain causing the memory impairment, similar to Natasha Richardson, the young actress that had a minor fall on a ski slope and died suddenly for no apparent reason the next day. Her diagnosis was a slow bleed in the brain called the “talk and die syndrome.”
Does this patient have the same problem or another serious condition? The answer one knows right now and this is within the scope of the neurosurgeon or neurologist. The chiropractor I spoke to this morning has not yet developed a relationship with either sub-specialty and sent this patient to his primary medical doctor as a result.  The problem is that this condition is far from the expertise of the primary care physician. As a result, the chiropractor cannot accurately work with anyone to develop an accurate diagnosis, prognosis or treatment plan in a timely manner in an urgent situation. The bottom line is there is no level of clinical excellence because the chiropractor has a patient who can be walking down the street at noon today and be dead by 12:01 PM and it could have been prevented. Will that happen? Probably not, but you don’t know. Just ask Liam Neeson, Natasha Richardson’s widow and the bereaved children. 
That is your level of responsibility if you are going to care for trauma cases and if you want to be a good doctor, no, the best doctor through clinical excellence. I am speaking from experience as I had, many years ago, a patient get out of her car in my home office parking lot and as I got to her in the lot, she collapsed in my arms with a pulmonary embolism and died. I wish today that I could have had the knowledge or technology then to be able to prognosticate that event and could have prevented it. Truthfully, the technology in the 1980’s was not available to be able to prognosticate that patient, but the technology today is available for the doctor’s patient I have been discussing.
The answer for today’s doctor is that the chiropractor must have his/her team in place before he/she has a 911 issue. For this doctor, he has to create those relationships, under urgent conditions, to protect his patient. This patient does not belong in the primary care physicians’s office because it might be too late by the time the patient gets to the medical specialist and THE CHIROPRACTOR could have prevented it. That is what being a good doctor means. 
From a business perspective, how can you expect to get medical referrals if the medical specialists do not know you exist and you cannot exercise any leverage over them with your referrals? Your referrals are your currency in healthcare and you need to use them wisely. Therefore, from a posture of clinical excellence, you help your patients at the highest level and you win financially!
The following is an article I wrote on this very subject that was published in the American Chiropractor magazine in July, 2010 that underscores the issue.

 Paying Medical Doctors for Referrals


The question has been asked by doctors nationally in many ways, “Can I pay the medical doctor in some sort of veiled monetary manner to get referrals?” The answer according to STARK, anti-kickback regulations, Medicare Office of Inspector General (OIG) and probably every other regulatory and disciplinary board, is a resounding, “NO!”
In fact, the OIG even has monetary guidelines of approximately $10 for a pen. That is the limit of what you can spend.  You are not even allowed to offer space in your facility unless it is under contract at “fair market value” and is an “arms-length” agreement. The days of an EMG company coming in and paying you $2000 for 2 hours, or backing into the pre-arranged price per test, is long over and has been deemed improper and, in many instances, very illegal.
With that being said, there is one commodity that can be compliantly used for getting referrals and that is your referrals. There is no law in the country that prevents doctors from cross-referring as long as each doctor has confidence in the other with no tangible strings attached. The solution is a simple cross-referral, when clinically indicated.
For too many years, medical specialists have been sucking the patients from the chiropractic profession on a one-way street. In many cases, they are getting your referral and, in turn, sending your patient to physical therapy after they are done, never to get adjusted again. As far as I am concerned, those days are LONG are over. I have spent 25 of my 30 years in chiropractic being made the fool by very nice “medical specialists” who have laughed all the way to the bank at my expense. For me, those days are no more and you need to put an end to this as well, immediately.
A few years ago, a friend shared with me that in relationships there are “hammers and nails.” The insurance companies, historically, are hammers because they have the money and you are the nail because you want that money. They can nail you whenever they choose because they have what you want. In the relationship with medical specialists, you are the hammer because you have what they want, the referrals. This gives you the control if you exercise it.
Your referral to a medical specialist often has a much larger price tag associated because chiropractor care has no surgeries, hospital inclusions, or multiple expensive tests. Our referrals usually involve the spine and associated pathology and the medical specialists need these referrals for their survival. In fact, neurosurgeons in New York pay over $300,000 for malpractice alone. They need your referrals to survive.
When you communicate with your current medical specialist who you have been referring to for years or will be referring to, it is time for a face-to-face meeting. I had these types of meetings many times and always did so with a successful conclusion because I realized that I was the hammer and they needed me much more than I needed them. Actually, I had nothing to lose as I already had the patient with many choices of where to refer.
The conversation is short and the message quite simple, “I respect the incredible level of expertise that you give my referred patients. However, I have been referring many patients to you and my expectation is that you respect my level of expertise and honor a cross-referring relationship. I am not saying that you need to go 1-for-1 with me. However, as clinically indicated within your patient population  I expect to see some referrals from you on a consistent basis in order to maintain my relationship with you.”
This type of relationship historically is how the majority of practices have survived for generations and you are not breaking new ground or any laws. Remember, you are the hammer in this relationship and I always bordered on “veiled arrogance” in the conversation to let the medical specialist understand my resolve. I no longer chose to be taken advantage of and I no longer chose for chiropractic to be pushed around.
Be the hammer and do not let yourself be exploited by the medical specialists at the expense of your practice.

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