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121: Cookie Cutter Care Schedule

chiropractic business strategies Apr 30, 2023
Kats Consultants
121: Cookie Cutter Care Schedule

The Cookie-Cutter Care Schedule


Hi everybody. Welcome to the KC CHIROpulse Podcast, brought to you by Kats Consultants. I'm one of your hosts, Dr. Michael Perusich, and I'm joined with my other host, Dr. Troy Fox. Troy, you always lead the topic. What are we talking about today? 

We're talking about the cactus sticking out of the top of my head.

I, I need to move my chair. I don't know. No. What we're gonna talk about today, so you, you and I were talking, uh, off air just a little while ago, and you had received an email from a group of PI attorneys that you work with, with a really interesting topic about chiropractors being sued for cookie cutter treatment schedule.

So what I wanna talk about today, one, tell us a little bit about the email you received, but then I want to talk about how do we derive an app? Where do we derive our appropriate care schedule from? What are the parts of that? So yeah, sure. First, tell me about this email. I, this is fascinating to me.

Yeah, so a couple of the insurance companies, PI based insurance companies, so auto insurance mm-hmm. , um, apparently, Giving chiropractors and I, and I don't know where, I don't know. Mm-hmm.  what part of the country or if it's nationwide or what, um, and when I say nationwide, I, I'm not talking about Nationwide Insurance.

I'm not Right. I'm not bringing up insurance names right now, but Right. They're giving chiropractors, they're hassling chiropractors over the fact that so many treatment plans look the. , same number of visits, same type of care, et cetera, et cetera. Mm-hmm. . And, you know, when you stop and think about that, it, it's actually kind of interesting, um, because I, we probably should get hassled for doing stuff like that because why do we have this preconceived notion of what every patient needs when it comes to a care plan?

Mm-hmm. , I, I think, I think we're kind of, Stepping outside of our bounds of being a good doctor by doing that, you, you, I can't look at a patient. I'm, maybe I'm just not that good, but I can't look at a patient and say, well, that patient needs 18 visits. I've gotta do all this other crazy stuff, like do a history.

I've gotta ask a bunch of questions. I've gotta let my orthopedic, neuro, and neurological testing guide me. If I'm taking x-rays. I gotta let the radiology films guide my decision making process. I can't just look at a patient and say, well, there's what they need. It doesn't work that, and you can't have this preconceived notion when the patient walks, when every patient walks into the door that everybody gets the same thing.

That's what we mean by cookie cutter, that predetermined treatment protocol. Yeah. I think when you look at it, you, you have to say to yourself from that standpoint, I have prior history with, with this type of. Once I get done with, you know, a very, and, and I really like a detailed interview with the patient, especially when you get into PI and that sort of thing, um, information is king.

The more that you can find out about what happened, what the patient's feeling, and really document that, well, that's number one. Number two, you get into the ortho neuro testing, um, range of motion testing. Kinda look and see, you know, where is the dysfunction because it's not all about their pain. We already know that.

And then when we start getting into treatment, Here's a really easy way to to to look at it. Look at it in, in, in six visit chunks or two week chunks, especially when you, when you're dealing with an acute injury, you're probably gonna see 'em two or three times a week. So after a couple of weeks, you should be doing a reeva, you should be finding out where they're at, and that's reevaluations are so important.

And I think that gets you away from what we call the cookie cutter approach. Mm-hmm. , why would I recommend three times a week for six weeks with a patient when I have no idea at that point? Now that very well may be exactly what it takes. It very well may be from my prior experience about what it's gonna take to get that patient to where they need to be.

Yep. But, If I'm not documenting and supporting that, why would I start with that? Now, I may tell the patient, in my prior experience with your type of injury, you had a car accident on ice. We all know that the ones on ice are worse, right? And why? Because the, the, the opposing forces, um, I, I went through a really nice.

PI seminar where we talked about, uh, collisions on ice. Mm-hmm.  or slippery surfaces. And it, it's amazing how much worse people get injured. So let's say a person's, you know, ha has a slip and fall on ice, or they have a car accident on ice. In my experience with patients that have had this type of trauma, it, it's gonna take 18 visits for you to get where you need to go.

Just so I preface it for the patient. Sure. What am I gonna do so far as a treatment schedule with that patient? I may. Here's what we're gonna do. We're gonna start with two weeks of care and then reevaluate you. Yep. And then we'll progress from there. So I don't need to put down a cookie cutter treatment.

See now it looks like cookie cutter, even though I'm really trying to use my knowledge. So in some cases, as chiropractors, you're trying to forecast ahead and doing a really good job, but you're forecasting and we don't wanna forecast. What we wanna do is make recommendations that are then followed up with objective findings.


Exactly. So there's where a re-exam is really important. Yeah. They, they are. And you've really gotta pay attention to history, mechanism of injury, especially on a PI case, you know, and you brought up mm-hmm.  the, uh, added impact that the patient absorbs when they're on a slippery surface, because the mm-hmm.


the ground isn't absorbing part of that, but, right. You've also gotta think about, so here, here, I'll just make an example. You got a family of four, they're in a. . Okay. Mom, dad, uh, and, and two kids. Mm-hmm.  one is 15 and one is 10. Mm-hmm.  are the injuries, even though they're all all in the same accident in the same car, are the injuries to all four of them gonna be the same?


No. The answer is no. Is the recovery time for all four of them gonna be the same? The answer is no. Age predisposition, uh, con commitment, uh, I can't ever say that word. Uh, issues going on, you know, general health, direction of impact, general health status, airbags, I mean, it, it, all this stuff plays into it, you know, is that, is that 15 year old, 16 year old, whatever I said are, are they gonna be what I always call the hyper healer because their body's.


So dynamically changing and growing, that they're just gonna heal that much faster, right? Is that 15 year old gonna heal faster than, um, 55 year old mom? Yeah. Yeah, certainly. So how can you put both of 'em on an 18 visit treatment plan? Here's the thing that I don't think we realize sometimes. Especially in the PI world, all these insurance companies are interconnected.

Mm-hmm. , it's called the Cardnal System. Mm-hmm. , they've been interconnected for years. They're all sharing this huge database of information, including how often you treat them, how many times you treated them, what the schedule looked like, what the diagnosis was. When, when they see you doing the same thing over and over and over again, how easy is it to throw up a red flag?

Of course, they're throwing up the red flag, they. And you're, you're not saying doing the same thing over again. In other words, if I come in and let's say I'm doing an adjustment cold laser and maybe, I don't know, some ice or whatever, may, or maybe I'm doing some ESTIM or something. Mm-hmm. , as we get farther along.

we may be doing a lot of the same things with each one of these cases. What you're talking about is from case to case to case to case over the years. Yeah. Every person that walks through your door gets the exact same treatment schedule. Yep. Which doesn't make sense. Um, you're not gonna treat, you know, if I've got a, a, a lady that's 83 years old that's in a minor fender bender, she might require as much.

as a patient that had a 50 or 60 mile an hour crash when they're 16 years old. Right? So you, you never, you know, and, and that's where you go back to your re-exams. I think those are golden because you can really start showing at that point if you're doing a really good exam to begin with. Now we're looking at.

how did range of motion improve? How did ADLs improve? Because those are important, even though we're not working with a Medicare patient, because we've all, we, we've all seen how that works. Mm-hmm. , you're trying to improve ADLs, but we're trying to improve ADLs in every patient. So those are very good indicators with, with even our PI cases or work comp Absolutely.

Cases. What's going on with that patient using, absolutely using oswestry scales, you know, uh, those are good things to do. Anything where you can objectively look at the patient and you can say range of motions improved on the oswestry scale. They're this, um, orthopedics, you know, this was negative and this was negative.

Or maybe they're all negative at that point, but you've still got pain in range of motion. You've still got, you know, some loss of range of motion. Mm-hmm. . Those are all important factors to look at and document. So I think as we look at this, documentation is king. It's king, and, and, and yes, we need to derive all that from a good patient interview and a good exam.

So it all, it all hinges. There's your found. . Right? And you've heard me say this a million times when you do your evaluation, your history. So let's just walk through a soap note. Mm-hmm. , you get your subjective and you've really flushed it out and asked a lot of questions. You do your objective. Take those two things and connect the dots in your assessment.

Mm-hmm. , and then on into your plan. You know, don't just talk about finding right si pain. Why is it painful? What about it is painful? How does it affect function? Tie it back, tie all those loose ends back to help flesh out your treatment plan. I'm telling you, it's not hard to build a fairly elongated chiropractic treatment plan if that's what you, if that's what the patient needs.

Mm-hmm. , you just gotta take the steps to get there, you know, and this, I, I pulled the newsletter up here real. , and again, I'm not gonna mention names or where I got this or anything, it's just something I get. I, they send these out like twice a month. In this news letter you talked about, every patient receives the exact same treatment schedule daily for a week, four times for four times a week, for two weeks, three times a week, for three weeks, four times a week for.

one time a week for four weeks, and on and on and on. Okay. Right. Some patients probably need that. Does every patient, no. And then here's a couple other things. He talked about what you just said. Not using outcome assessment questionnaires. Mm-hmm. . So you've got no basis for how the patient's care or how the patient's condition affects their activities of daily living.

And then here's the. Providing D M E like tens units. Mm-hmm. For a ridiculous price. Like a thousand dollars for a $40 tens unit. Actually probably $29 tens unit. Yeah. You know, while that's tempting, maybe to some be, just be reasonable. You can build in a little bit of your time as long as you dispensed it.

You can't have staff dispense these things if you're billing insurance. Right. But if you dispensed. , okay. Charge 85 to a hundred dollars. It doesn't take that long to show the patient how to use it, why they want to use it. And here's another thing that he talked about in this newsletter. You don't give D M E on day one.

Mm-hmm. , just like we're supposed to do with chiropractic care. We need to do a trial of chiropractic care to see what's gonna work. Right. Do your trial of chiropractic care and then see if the patient needs. Especially if you're seeing them pretty repetitively in the beginning. They're not gonna have time to use the D M E probably at home.

Also document why you gave them a TENS unit. Right. What are they supposed to do with it? How are they supposed to use it, and why are they supposed to use it? You talked about the fact that we're not putting that in our notes. Mm-hmm. , you know what's great about all. When you play by their rules, which I don't think are unreasonable, no.

They're just saying, Hey, we'd kinda like to know why you're treating them. We'd like to know what your rationale was for that treatment plan. Um, and, and if your rationale is supported by outcomes, assessments, follow up exams, you're in good shape. Here's what I think's beautiful about this. This will bleed over into your regular practice in your regular notes.

Yes.  Because you are used to denoting things that way. Will that be beneficial for you in the long run? Well, if you ever had an issue where you ended up having your notes, uh, you know, pulled and somebody looked at 'em for one reason or another, yep. Absolutely. It's beneficial. There is nothing worse than an error of omission.

Yep. In other words, you knowing what you did with the patient and why and it's absolutely 100%. , but it's not in the notes. Yep, yep. Guess what? It it, it, you can say all day long, this is why I did it. Well, doctor, it's not in your notes.  Exactly. I, I and you. That's just not a battle you can even win. No.

Especially if you have to go to court. You know? And, and I think that's something else that maybe we don't think about. You know, we get, I think sometimes we get starry-eyed when a PI patient walks in the door and we think, oh wow, this is gonna be a great case. And there are great cases. Not saying they're not, but we can't put our eagerness to have a high revenue case in front of, I'm gonna use your word in front of our rationale.

Mm-hmm. , it's a perfect word. We have to be rationale about the whole process. Right. And make sure that we document well. With the assumption that we're gonna have to go sit in a courtroom and in front of a jury answer questions about the case. I mean, mm-hmm. , I, I don't know how many times I did that. I would get called in as an expert witness on other doctor's notes, and it was, mm-hmm.

horrifying to me sometimes to see what some of the doctors had had or didn't have in their notes. Just be 10 feet tall and bulletproof with your document. And they may have been really great doctors and given really great care to the patient, but notes and care are two different things. And I think we get frustrated sometimes as chiropractors cuz we're like, well I don't know how much I should document, how much I shouldn't there.

There are plenty of really good classes out there. There are also opportunities with cats, consultants. Mm-hmm. . So from a standpoint of what we. , we can take a look at your notes. We're more than happy to take a look at your notes and yes, we're gonna pick 'em apart, but wouldn't you rather have us pick your notes apart than someone else?

Yeah. We're not gonna take money back from you. Yeah. So we are there to help and I have concerns about our profession on, on, on a daily basis of.  providing cookie cutter care. And the other end, and we kind of talked a little bit the about this in the last podcast, was sometimes about not making any kind of future recommendation for care, not giving the patient a roadmap for the future.

Mm-hmm. . And neither one of those is great. You, you don't want to be on either, either side of that fence, you know, before we. Jumped into the studio here. You were talking about somebody you know mm-hmm. , who was progressing along with their care. They weren't, yeah. They, they, they weren't over their symptoms.

They weren't back to full function. But you said right in the middle of the care, the doctor turned to 'em and said, well, I guess come back whenever you feel like you need to. Yeah. What kind of a treatment plan is.  and that was like, it, it was sort of like having a car halfway fixed. It's like, okay, you go to a body shop and they took all the dents out of the car.

It still doesn't look great. It needs some paint and that sort of thing. And then they paint like one door and put it back on there and go, call us later if you want us to paint the rest of the car. . I mean, honestly, the, so the patient had numbness in their, in their arms and the PA and the numbness was getting better, but.

They just said, call us when you need us. And I was like, man, I was, I was struggling to understand that. Now, there may be more behind that story than we know, but if that's truly how it happened, I, I'm just, I'm at a loss to understand that kind of. So care schedules are important and patients want you to direct them, but they don't want you to cookie cutter and neither does the insurance company.

They want you to use objective outcome. Assessments, objective exam findings. They wanna know what's going on with their client that they're gonna pay for well. And if I was that patient and I was still having issues, but I was getting better, and the doctor said, come back when you need to. I'd have gone call me when you need to.

I'd gone straight out to my car and I'd have picked up my cell phone and I called the office and said, Hey, I need another appointment.  or you find another chiropractor and that's actually what happens. I'm, I'm doing what you told me to do. Yeah, that's exactly right. That's how you lose patients. So, yeah, because that's exactly what's gonna happen here.

This, this, this patient is gonna end up going to another chiropractor because I've already made a recommendation for them to go see somebody that, that I trust will do a great job with them and well, you know, it just is how it is. Unfortunately. So everybody just, just don't, don't do cookie cutter treatment plans.

Don't, don't think what's easiest for you. Think what's right for the patient and use your rational thinking skills to create a rational treatment plan. Yes. And, uh, treat patients on their level, not yours. How's that? And treat 'em and treat 'em ethically, like you said, with the DMEs. I mean, that's absolutely, that's just you, you've got to, at the end of the.

Be proud of what you do when you do the right thing, when you create a win-win situation. Here's something else I always say, if it's good for the patient and it's good for the doctor, that's the win-win. So that's your litmus test. Yes. So just do it. Do what's right. Do what's right, and you won't make an amazing living in this profession.

You'll have fun and most of all, you'll sleep. Yeah, exactly. I like to sleep at night. Yes, so no more cookie cutter treatment plans. All right, everybody. We appreciate you listening. As always, if you haven't done so yet, go to the Kats Consultants' website, check us out. We've got all kinds of downloads, and you can listen to other podcasts.

Be sure to subscribe to the podcast so you catch us every week. And from all of us here at Kats Consultants, thanks for tuning in to the KC CHIROpulse podcast and we'll see you next time.