Practice Evolution – Steps, Problems and Solutions

Good afternoon. Welcome to today’s elite call. So today, I think we just really, I want to focus a little bit more on some of the big picture with you guys. And I think it’s important to understand, you know, where the the healthcare environment is going, and really what we’re doing. Now, the center really, of what we’re talking about is you and your practice.

Now, what’s happening really is we have a lot of things that are kind of coming at you, opportunity wise, right?

And those things may be seminars, teaching opportunities, TPA work. And say, fellowship growth, right. And that could be associates that could be, you know, a variety of things, maybe we even throw in here.

Tax Planning, and maybe marketing. Right? So what’s the point of all of this? You know, and where as you build, and you grow upward with your practice, we have to figure out where all of these things fit, seminars, your tax planning strategies, your teaching, your marketing and your TPA. Okay, where those fit, and how they evolve with you. That’s probably the number one thing to always consider, right is how are you changing to grow within your practice? And how are all of the things that support your practice? How do they evolve also, because the way that you are tax planning when you’re making $50,000 a year is different than what you’re doing to plan tax plan when you’re making $300,000 a year. Right? And the misconception is, as you grow, some people believe in correctly that as you grow, it gets easier. And in fact, it’s the opposite. Right? As you grow, it gets harder and you have less room for mistakes, believe it or not, right because you’re just running a bigger ship. So in terms of where we’re at, and national supply management group and all of those kinds of things, let’s just talk about where this is all kind of going so that you can be supported okay. So, what we really have here

is national spine management group. And then we have VISTA spine management and these items really these groups are designed to be there to support you. Okay. Now, national spine management group is obviously consulting both the clinical side and the business side and it provides strategies, tools and products that will allow you to market to the medical and the legal communities.

Right. National spine management group also provides continuing education and that is in the format of Clinical Grand Rounds,

seminars, etc. Okay, national spine management also provides fellowship training. Now, this the spine management is going to have a few divisions. Okay, this is where Dr. Edwards and Dr. Lee come in to play. The main thing that VISTA spine management is going to be responsible for is the third party administration.

And they’re also going to be responsible for staffing. Let’s see. Next, Hang on one second. So the third party administration, and staffing I’m going to Chicago the end of the month for a day. And I’m working with Dr. Adam Hutton out there who through his hospital affiliation, had met a pain management doctor that has like 50 clinics in Illinois. And he wants to put a spine management physician, like add them into every one of those clinics. Right? Now, that’s not necessarily going to affect you directly. But it’s important to realize that this training and Vista spine management in particular is going to be providing that service. And we’re doing that by partnering with Parker and Cleveland university right now. The reason I tell you that is because the growth, the natural growth for both of us, okay, you and national spine management is this natural evolution into VISTA? Now, what else? VISTA has the ability to do because of Dr. Edwards, is work directly with the surgical hardware reps. Okay, so we’re in the process of now partnering those reps up with chiropractic offices. Right, and we’re going to be talking more about that in the next few weeks. Okay, so the natural evolution is this sort of strategic partnership, think of national spine management group as the education component, and Vista, spine management more as the people. So when I work with you, we really want to spend our time looking at our strategies and looking at where you’re at and what the next step is. You might say, Okay, listen, I went through the fellowship training, but now I’m looking for an associate. So we can very simply say, Okay, we want to look at the staffing component, how do we put a doctor into your practice? And then how do we get that doctor to go through a fellowship training, so that ultimately it helps you. And then now you can carve out 10 hours a week to do some online TPA work. Okay, but the only way that you can have that staffing work properly, right, is if we are getting referrals. So the marketing plays a role. Okay? And all of those things are really important, but none of the fluff on the outside is going to matter to you guys. Right. So designing what we’re doing from a consulting strategy is probably more about at this point, or eliminating the things that you don’t need now. So that we can concentrate on the two or three things that can get you to the next level in your business. So let me just erase this. So when we look at practice evolution

right. The first thing that we look for is compliance and get In our notes in order, okay, getting them all timely,

etc. Right now, as an example, when you first when we first start practice, we’re doing all of that, we’re examining the patient, we’re doing our notes, we’re putting the charges in, and we’re billing. But eventually you’re gonna get to a certain level where now you have the money to hire a scribe, to complete the same task, but with you less involved, okay, so the evolution of your business has to be automation, and a movement away from you being involved in those day to day tasks. Okay? So we want to build and then we want to delegate we want to build and then we want to delegate we want to build and then we want to delegate. Okay, then once our notes are good, we’re increasing our marketing and our outreach. Right, we’re starting to meet lawyers, we’re starting to meet doctors, we’re sharing our notes, we’re doing all of the things that and SMD strategies have taught us. Okay? Once you have those relationships, then you’re really just kind of in maintenance mode, right. But then we’re really looking truthfully, to be able to maintain medical and legal relationships without very much effort. Right, so you’re going to strategically market to like minded people, and you’re going to revisit the people that you’ve had long term relationships, just to maintain that, then the next step in the practice evolution is your administrative professional, okay, your working spouse, the person that’s going to trust, put their trust in you and that you can rely upon in the short and long term, somebody that absolutely has your back and will go to the ends of the earth to defend you. That’s the person you want. Okay, you want to have that person. When you’re at that kind of larger growth phase, when you’re looking to go, I would say, typically 150 to 300 visits a week, that’s where this administrative person starts to become something that we’re thinking about. Okay, because the administrative person that got you to 150 visits a week is not the same one, that’s going to get you to 300. All right.

Now, that’s not to say that’s always the rule. But this is the person that you want to pay.

Right, you have to invest in the human being, that is going to be your administrative Captain, you do that before anything else. You don’t look at an associate, you don’t look at adding locations, you don’t do any of that stuff. Until your practice is big enough, from a financial standpoint, to invest in an executive level person for your practice. Now, that doesn’t mean that you know, you’re spending, you’re paying them $200,000 A year, right. But if you go to And you put in administrative assistant, that’s what you want to look up and look up what the hourly and annual pay scale is for that professional in yours zip code. That’ll give you a really good idea as to what they’re worth, okay. And you need to market for that person and interview that person. And here’s the thing, right? Just because you’re interviewing doesn’t mean you’re hiring. Okay. So if you’re a year away, start interviewing. Okay, find those people. Right. It’s important that their personality and their ethics match your mission. I just had a conversation with a client earlier in the week. And, you know, he’s been inundated with millennials in terms of who he’s hiring. And all of them are quitting on him. And what we have to understand is Millennials have no loyalty. Okay? The only loyalty if they have loyalty, the only loyalty they have is to the mission of your practice. Why are you doing it? They could care less about the widget the product, what they care about is why. Okay? So especially when you’re getting into the, the millennial work, let me see here. Let’s just see I’m googling here real quick to see

how old are millennials Millennials are 26 to 41 years of age right now. Okay, so typically, those are going to be the people that are interviewing for your position at your clinic now.

Remember that 41 is kind of on the cusp of Gen X, okay. 26 is on the cusp of Gen Z. So the more that you slide into the middle, the more of a millennial they’re going to be, right. So I would say avoid people that are 30 to 35. Okay, you want a 40 to 45 year old person that’s looking for a change that has administrative experience. This is the person that’s going to help you with all of your systems, they’re going to handle all of your office tack, right, your emails, your SharePoint, or your OneDrive site where all of your documents are stored, they’re going to handle all of that stuff. And they’re going to build it and refine it for you. This person, your admin should be the person that’s there before you and is there at the office, after you write, if you start at 830, you should walk into that practice at 20. After eight, drop your bags in your office and get to work because people are already set up. soon as you’re done touching that last patient you should split, let them close it up, let them vacuum, whatever they’re doing. Okay, that’s your first step and self reliance, where you become strictly a clinician. Once that transition is in place, and you’re stable. Then your fourth component is now you bring in a doctor. You sweat from exam, re evaluations and treatment to just exams and rebounds. Okay, that doctor is going to treat. So what I tell patients now. So when I see a new patient, I’d say look, you know, I’m in charge of managing your case and your spine pain. I have three other doctors in the practice here that helped me with treatment. So I’m gonna dis I’m gonna assign you to Dr. Rivera. And Dr. Rivera is going to see you three visits a week for the next four weeks on that 13th visit.

The very next one, I’m going to see you again and we’re going to go through his entire exam, and we’re going to talk about how you’re responding. And I’m going to make sure that you’re taking care of now, during the treatment. Dr. Rivera will also be available to go over your imaging. And if you need additional consults with other providers, you’ll be responsible for that. Okay, now, for me, I had further step back when we brought Dr. Rivera on right. So think about this right. Jody is an important part of the practice. The consulting had built itself to the point where I really needed them doing the exact same thing here that I would do for my practice. But I’m doing that also for the consulting company because it makes sense, right? It’s the foundation. It’s the science of business, right? So Jodi, moved over to national spine management group, and I hired Clemente, who is the operations director now for the clinic. Right so we took God space. When we brought Dr. Rivera on the fourth doctor in the practice. I stepped away from even doing exams and re exam so that I could focus completely on the consulting. The reason I’m back right now doing exams and re exams is because Dr. Curtin had her fourth child and is off on maternity leave until May 23. Once she’s back, I am removing myself from the practice. We’re working with Jodi to build the administrative side. And on the consulting, we just hired Jen, who is in charge now of taking and posting the content, right. So just like number four here, were in a clinical practice, there’s exams, re exams and treatment. When you bring in a helper, that helper is designed to replace what you’re doing, right, your fellow is going to start taking some of those cases off you so you’re not stuck in a treatment room all day. Because you can’t grow your clinic if you’re in a treatment room all day. Right? So the reason you’re investing in hiring that new fellow to come in, is to take away some of the reasons that you can’t get out and build. That’s where your growth becomes exponential. Because now, okay, like for our practice, we do about 100 emails a month. Okay, so between new patients and re exams, we’re looking at about roughly 25 a week. So think about your exams and re exams. So for for me now. And for Nicole, when she comes back, let’s just say those combined evals and or evals, we would average 30 minutes, okay, across the board, right? Some are more complicated than others. But let’s, let’s just say 30 minutes, right? So for me, I am in that clinic right now, in a room doing clinical work 12 and a half hours a week. Now, when Nicole comes back, I’m out. Right? So if you had to think about where your practice is now, and think about your volume, and think about once you have your admin, okay, and you’re looking at probably 75 to $85,000 a year for that position, then you build, okay, and you wash that income, right? Because now you’re investing in somebody you’re able to build and recover that. Okay, through practice growth. And by the way, your practice growth really should be about eight to 15%. Okay, eight to 15% growth, on a quarterly basis, is a great sort of rule of thumb. Now, once your admin is there, and you’re getting busier, okay, you want to look at bringing on a fellow now, a fellow is going to be on a fellowship based fee schedule or salary, right, that’s $50,000 per year. Right. So that’s going to happen right around, you should be looking at that at the above the 250 P V,

225. Ish, a week. Bring that fellow on and you’ll have him for two years at $50,000 a year plus a couple extra bucks per hour for the training and all that that’s where VISTA is going to come in. Okay, it’s gonna work kind of like a staffing company. Right? So whatever, let’s just say $50,000 a year, we see your $50,000 a year divided by 12 50,000 divided by 12 is 4100. So I’d say 4200. A month divided by four is 1050 divided by 40. So as 27 $26 an hour, okay, is what that works out to be. Now, you might be paying an extra three or $4 an hour on top of that for the training and all of that kind of stuff. But that’s kind of where we’re going with all this. Okay. So that practice evolution. Now think about what you could get done in terms of meeting with medical doctors, doing continuing legal education, if you are in your practice 12 and a half hours a week. Okay, but you can’t even begin to talk about that. Unless you have compliant notes. your marketing and your outreach has been going for some time, and you have an administration in your practice that you can absolutely rely on that that practice is going to open on time. Okay, they’re going to be making sure the billing goes out all of the stuff that would just crush you. Okay, so that when you get to that 250 A week threshold now you can afford, both from a time perspective and an income perspective, to bring on a doctor to free You up to build to the next level. Okay, so for us, in my clinic, I am stepping away when Nicole comes back because I was essentially covering for her right for her maternity leave, she’s going to take over the exams and the RE exams. And my focus for the practice is now our second location, which is 25 minutes south of us on the southern edge of the city, we’re putting our clinic into a large primary care office. And I’m already talking about that to the lawyers. And they’re all over it, because there’s nobody in that area that practices like us. Right. And those referrals, will will start immediately. We’re planning on doing that in the fall. So we’re already starting the words, but I couldn’t be able to do that. If I didn’t have Jody, historically. And I didn’t have Clem now. Okay, because he’s in charge of that operation, right? So what you have to constantly do is build reliability into your business. Because you cannot grow if you’re doing everything. And you have to do everything unless you can have somebody in there that is buying into your system. Okay.

Dr. Bennett, you had a question about what is the difference of administrative assistants one, two, and three, I can you clarify that a little bit, I don’t necessarily understand what you mean. And here’s the thing, and here’s the reality, what I see happening in the chiropractic profession, especially in terms of where the world is starting to see where we’re useful is, chiropractors are either going to be positioned in their practice to grow. Or they’re going to get crushed by the world sending you patients that you can’t handle, or just avoiding you altogether. Okay, so for me, there’s a real danger in our perfection right now, too, for all of the weaker practices to not last. And I don’t mean weakness in the practice in terms of the care that you provide. I’m talking about weakness, fundamental structural weakness within that system. Okay, because think about where you’re at right now, do you have the people in place to handle 40 more visits, even 50 visits a week? Okay, what if you added three more new patients per day to your to your practice? Where would you be with the people you have? Where would you be with the electronic records you have? Where would you be with the marketing and outreach? I would venture a guess that 50 visits a week or two or three new cases a day would would crush most practices. Okay, because what we do is, we always focus on where we’re at. And that’s where our infrastructure is. We don’t think about building where we want to get right because we buy, say, an electronic record system. When we have no patients when we’re starting zero. And then we build to 120 a week, which is the 80 to 120 is the national average. Okay, then we’re trying to grow to 200 so that we can start thinking about bringing another doctor in, but we don’t have the administrative people that can grow, right that even the EMR, that EMR is now peaked, because it was an entry level EMR that was designed for the average chiropractic office 80 to 120. Right. Once you’re at 120, that electronic system is maxed on last. It’s built to evolve past that. So everything that we start with, typically hits the glass ceiling at 120 visits, our note system, our marketing and outreach. Our administrative people are clinical people they were all designed to start with, but our company is not a startup anymore. Right? Our company is at 120 visits a week is generating 350 to $550,000 a year, but we’re maxed with who we have. So you have to look not at changing those strategies when you’re at 120 visits a week, but you want to stay are implementing the updated new EMR system, looking for your administrative people, when you’re at 80 visits a week. So by the time you get to 120, those people are already in place for you to go from 120 to 225. Right. So you have to preemptively evolve to the next level that you want to get to before you’re at that level. Right? Does that make sense? So I’m the consulting, I moved Jody over. And now I hired Jen. Because I have to remove myself from posting content, I want to create the content, and now I’m giving it to Jen, Jen is going to post it on the site, etc, etc. That’s what we’re working on over the next two months. Okay, but the strategy is still the same. I don’t want to wait until the TPA hits to hire Jen to teach her how to do content. I’m anticipating that growth phase, and we can anticipate it because we’re in control of it. Okay, so you’re never going to be less busy, you’re just going to be busy doing other stuff. Okay. On has an admin assistant then ratings? Yeah, I’m not really sure how salary does that. But I would just kind of look as a ballpark for the entry level salary, because then you’re gonna, you know, offer them bonuses, etc. Okay.

And, you know, we’re really running a fine tuned machine, right. I mean, we’re back to this was the first month post pandemic, that the staff was bonused. Right. And we have new patient visits, and we have total patient visits. To for them to hit, they have to hit both. Okay. And then each month, we tack on a percent. That’s our growth, right. So their bonus coming out of the pandemic, we wanted to hit 35 News, and 1200 patient visits for the month. Okay. And we did that. Right. So all the staff, including the doctors, everybody’s the same, they get 50 bucks, cash if we need it. If we exceed it, they get $75 cash. So at our staff meeting on Friday, we just lay out $50 bills, and everybody gets to take one home. Next month, we’re going up a percent. So we do 35 times 8%. Okay, that’s 35 plus 2.8, which is really three. So we’re looking at 38 News. And 1200 times 8% is 12 196. patient visits. Right? So 96 divided by four that’s an extra 24 visits a week. Right? So that’s kind of how it’s going to evolve. That’s what we’re looking for. Right? Now, are we going to be able to go up a percent every month? Probably not. Because there’s there’s a point to where you can’t really exceed that. Right. So as we evolve, everybody is concerned about that. So the doctors are going to be looking at making sure people have follow up to the front desk, people are going to be looking to get their, their visits in. Okay, and now we actually automated our review process because our phone system we’re using we’ve now when the pay as soon as the patient leaves within an hour, they get an alert to give us a review. Right. So our goal this year is to hit 500 reviews on Google. But that’s automated. I don’t have anything to do with that, because it’s automated. So those systems that we put in place are designed to get us to the next level. Okay. So start to look at this look at where your next phase of growth is. And look at what you have now. Are you reaching? Are you at the point where the people and the infrastructure that you have couldn’t handle an extra 50 visits a week? If not, then we need to talk about that. So when I meet with you next week, let’s really have a discussion about where your next phase of growth is and what we need to do to get there. Okay. All right, guys. Have a great day and hopefully I will see you on the fellowship

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