300 patient visits a week in an all-cash practice with 90% of your new patients coming from referral. Is that still about where the practice is?
First of all can you share why you first decided to go all-cash with your practice?
Some doctors are thinking about going all-cash what would you say to them?
What are some the best ways you found to generate referrals?
Have that you integrated referral generation into your culture?
Especially with your team?
Have you emphasized this in your staff meetings?
Tell me about your Wednesday wellness workshops?
Also what is your opinion about re-activations?
Is this something that you actively pursue?
Dr. Davis: Hey everybody! I'm here with Dr. Terry McCoskey from Fairborn Ohio, and Dr. Terry for those of you who don't know Dr. Terry, he's been an emcee at the Upper Cervical Experience and NUCCA events, and been around a long time over 25 years in practice, 27 years in practice, but Dr. Terry for those of our audience who haven't heard of you or haven't meet you personally, can you give just a little background on you and introduce yourself to our audience.
Dr. McCoskey: Absolutely! Thanks Dr. Bill. I appreciate the opportunity to reach out and share with your people. Yeah, like you said like this is my 27th year. I graduated from Palmer College in Davenport in December of 1989, way back in the 1900s some of your kids don't even know that. This was before Google and the internet and texting and so forth. So yeah, way back in 89 we got out of school. My wife and I moved to Fairborn because I had met a fellow who’s been in practice for about 40 years and he and I had connected and he was looking to take us somebody who could purchase his practice over time, and so he and I worked together and for about five years, and then at that time I purchased that practice and eventually also the real estate that came with it, and since then that was again 27 years ago. We had now have a different clinic building. We built nine years ago. So, we've got our own freestanding space now. Helping a lot of people town and it's just been a wild ride but we're having lots of fun and served lots of people and just enjoying our time on the planet.
Dr. Davis: Awesome, and I know when we talked before that you've always had an all cash practice. Is that right?
Dr. McCoskey: Well, when I bought that practice, actually when I joined him is again he was ready to slow down. I was back in the late 80s early 90s and that's when managed care was just hit the ground and people were just taking a beating. In fact my doc probably retired five years earlier than he would have otherwise just because of the stress of managed care.
So, my witnessing his stress was a large influence on changing the practice to a cash practice. So, I bought the practice in 1995 on the 100th anniversary of chiropractic. And that year, we purchased it in September of that year and then in the following year 96, we pulled all the plugs to any insurance connections, and just went to a fee for service or direct pay office. So, we've been all cash or all credit or all checks or all whatever since 1996, yes.
Dr. Davis: Alright, and you're seeing around 300 patient visits a week. I think from what I remember hearing right?
Dr. McCoskey: Yeah. We're right at 300. We're kind of bumping that number up now. We've got a new young associate that kind of make up a number a little bigger over time, but we work three full days and two half days and right around 300 patient visits a week. What else do you want to know?
Dr. Davis: Well, so when you switched over to going all cash in 96, tell me about that transition and I know there's some doctors out there might be thinking about going to an fee-for-service type practice, maybe want to get out of insurance, and well just talk about that transition.
Dr. McCoskey: It was a stressful time. I mean I was young in practice and but the thing was the managed care thing just didn't feel like the insurance, the third party interference in your relationship with people just didn't feel right in my heart. You've got other people making decisions based on what the coverage is and you've got people who've never met your patients before who are working in a big glass building somewhere along the interstate, and they're influencing the way people receive care and it was wrong for me. It didn't feel good to me.
So, I knew that when I purchased that practice we were going to make the change, and I won't say it was stress-free. I mean, we did a lot of praying. We had a lot of sleepless nights, and we got some advice from other people and they said, ‘you'll never make it,’ and of course I was buying the practice at that time. Dr. Mood was financing it because I didn't go to the bank. He was financing the practice buyout and his friends were very nervous about that transition that we were going to close and you couldn't make it, and so but I will say we sent him a letter to all of our existing patients, and we did it in January.
So, it was the first of the year. We just said, the good news is our fees are not going up this coming year. However, we are going to be pulling the plug on some of your insurance things that if you if you have coverage, we will still provide you with receipts that help you maximize whatever that relationship is, but we're not going to be in that relationship anymore. So, we work for you. You'll pay their bills. We'll provide you with a receipt if you would like, but we're not going to be connected to that third party experience anymore, and to my surprise probably we saw probably a 10% impact as far as people who left the practice for that reason, but I've always been at a mindset and you mentioned this earlier when we’re talking. We want to be able to provide value to people.
Dr. Davis: Right!
Dr. McCoskey: So I can provide them a value that they can appreciate and charge a fee for them that's reasonable, but we'll be fine and we'll pay our bills and then someone will be fine and we've been blessed to have that life. I mean it was back in 96 and we haven't looked back since.
Dr. Davis: Yeah and today I think doctors I talked to there's less and less doctors that are even involved with insurance at all, and so I think I especially within upper cervical, there's a large majority of doctors who are all cash and I think that there's been a lot of very successful doctors with that kind of model.
Dr. McCoskey: Well and when you go back to what they're learning in the colleges, they're being taught that a cash practice is not the way to go. I have a new associate. He’s still with me for now two years and I was very involved in his education while he was at Life University, and they're not being led to believe that a cash practice or a direct paid practice is a good idea, and so it's nice when docs like you and I and people in the field, lots of upper cervical people especially can not only survive that side of third party pay, but you can thrive outside a third party pay, and it really does. Just come back to providing value to people. Nothing is about cost in my mind. Never about what I'm charged.
Dr. Davis: Yes.
Dr. McCoskey: It’s always about the values you've been delivering to that person, and can you paint a picture for them and let them see a long-term relationship, and then discharge a therapy and watch things get better. It's not that hard.
Dr. Davis: Yes, because the biggest thing is, people are going to pay for things that they value. Right?
Dr. McCoskey: Yes.
Dr. Davis: People pay for vacations. They pay for braces for their kids teeth. They pay for all sorts of things that they have to pay cash for, and so…
Dr. McCoskey: Health care is the only place where we don't do that.
Dr. Davis: Yeah.
Dr. McCoskey: I've been led to believe that your health isn't your responsibility, and oh by the way when your body breaks do you take it to these people and they'll fix it for you, and then oh by the way somebody else is going to pay the bill and cover the bill, and it's just really very unfortunate but health care is the only place that somebody else is expected to do the buying.
Dr. Davis: Right. Absolutely. So, shifting gears a bit, I know from our past conversations you talked about how you're about 90% referral. Right? About 90 percent of your new patients are coming from referrals?
Dr. McCoskey: Yes, for a variety of reasons, but you know it's one of those things where after you’ve been in practice for a little while. It took probably five years for me to figure out that not everybody is a fit for my practice. Initially we would take all comers, and initially they were may be connected to third party pay, maybe not, but it took me a little while to understand that not everybody is a fit for what we do, and I can't be all things to all people.
So, we really have done a better job of tailoring our message to, here's where we are, here's what we do, and here’s we fit, and this is a weird thing too, but like not everybody likes me.
Dr. Davis: Right!
Dr. McCoskey: Because… and I don't like everybody. So, it's really important to me that we have a good connection and a good doctor-patient relationship, and if we're not the right office for them and I'm the guy who's going to help them find a better connection, but now the overwhelming majority of the people that come to me now our buddy referral.
My new associate doctor is not as choosy as that. He's out doing different events, and he's finding his way in the world, and how to connect to people. So, we've got the majority by referral, but some of them now, he's out just send us a message and tell them the story, and attracted in his own tribe.
Dr. Davis: Right, and talk more about this the idea that not all patients are the right patients for your practice, right? Talk more about that, and I know that that's sometimes that's a foreign concept for doctors and that there's actually a niche or a target market or a group of people that you really want to serve and you want to attract more of those. So can you talk more about that?
Dr. McCoskey: Sure! Our ideal patient-relationship is usually going to be somebody who is a, they're interested in getting the primary reason of their condition is existing.
So, this is somebody who's already probably been other places or to other kinds of doctors, and they've already experienced something that was less than ideal for them, and so our job is to paint a picture of here's what we do. As far as spinal corrective care, here's what we do, here's what we don't do by the way. We don't do any therapy in our office. We don't do any rehab-type things. Not of those are bad things, it's just not what we do. So, I really like to be upfront and say, ‘here's what you can expect out us, and here's what we can expect out of you, and if that makes sense, then we can create a relationship that should be mutually beneficial for as long as they believe that to be true.’
But I don't want everything, people are coming here looking for traditional chiropractic adjustments without any x-rays and without any measurements and without any, that's not us. So, everybody's going to be evaluated individually. Everybody's going to be x-rayed. We are, I'm not a very good guesser. So, I like to see things, and x-ray them, and measure them. If that's not appealing to people and we don't get each other about that. We just help them find a better connection.
Dr. Davis: Exactly. I think at a certain point your patients understand that, and when they refer others in, they give them that expectation, correct?
Dr. McCoskey: Well, yes. They referred patient as somebody who's already the ways behaved and at that point, I only think of that like have you ever had a cat?
Dr. Davis: Cat?
Dr. McCoskey: Yeah, cat. They will bring you treats. They might bring you a dead mouse or they might bring you something from the wilderness, but what they're doing is rewarding you. They're offering something to you because of what you've done for them, and I think that's what patient referrals are. The only reason that they would refer to you or to me is because we've done something for them that they could appreciate, and they're going out on a limb by sharing it with other people. So, we always work really hard to honor that. If you're the person who sent me a new patient, I'm going to make sure you get a card in the mail. I'm going to make sure I will reward you for it when we talk together in the next visit. I'm also going to make sure the referred patient knows how important you are in my practice. They brought you a gift, why would you do anything other than shower them with thanks and adoration.
Dr. Davis: That's a great point. So, I want to talk more about this creating a referral culture and generating these referrals on a consistent basis for your practice. You already touched on one thing you do, which is making sure that's when someone does refer, that you show them appreciation and make that a big thing, talk about some other ways that you found to generate referrals or how that's become such an important part of the practice.
McCoskey: Well one of the things that we did just recently and this is brand new. I've not done this before but my associate doc and I, and we now have a community relations director employee at our office. So, she set us up a lunch and learn with medical practice in the community next to ours, and I take care of this medical doctor, but he's created kind of an empire. He's got five other on these and some therapy people in a rehab joint, and anyway. So, they built this big new clinic building. It's beautiful. So, we decided to set up a lunch and learn with them, which I thought was wonderful. I mean we got a catering company, this gourmet luncheon is going to be fabulous. It's early in December, and what I learned when I got there was they have somebody do that for them twice a week. There's always pharmaceutical reps. Pharmaceutical reps bring them lunch and pitch them twice every week and their next available time for that was in July.
Dr. Davis: Wow!
Dr. McCoskey: I mean, just really what I thought was this fabulous thing just to say, ‘Hey! Congratulations on your new office, your new people.’ They do it twice a week. Now, we were even better because we brought in gourmet food, no junk. That kind of thing, but just reaching out to them and saying, ‘you know what, how can we help you connect to new people in the community?’ I didn't go in there pitching them, say we need you to send us patients. It was just a communication strategy that was mutually beneficial. How can I help you? Now that you got this big new facility and these new docs in your place, and they sent three people in the last two weeks that I would never have probably seen otherwise.
So, just making yourself known in your community and reaching out to other people who are interested in doing the right thing is turning into a wonderful opportunity for everybody connected to it.
Dr. Davis: Absolutely, and you also mentioned that you also do workshops in the office, right? Your Wednesday wellness workshops, can you talk more about those?
Dr. McCoskey: Right, every Wednesday night we do our Wednesday. It's kind of an introduction to spinal care. We just call it getting started, and then the third Wednesday night each month is always a special topic. It might be women's health issues. It might be nutrition. It might be exercise, stress management whatever, but every Wednesday night at the office we've got something going where if people want to share. That's a great referral tool because they'll say, ‘I've tried to get my husband to come but he just doesn't want to.’ So, I always just say, ‘bring him to the workshop. Every Wednesday night we do that, 6:30. It doesn't cost you anything to bring in. He’s welcome anytime.’ So, that's a safe way for people to introduce people to our practice. They get to meet the people, then the team. They get to see the building and feel the vibe, and it's also a bit of a question and answer session for them at the end. So, they can get comfortable saying, ‘yeah, this is a place I want to explore,’ not so much for me. So, the Wednesday wellness workshops are huge, that I will say through the holidays, we kind of curtail that because everybody's busy, but we're looking forward here and be back up again in January.
Dr. Davis: Sure! And it’s a great time of year for it, right?
Dr. McCoskey: Yeah, our January program is a new year, new thing. We'll look at seven different aspects of health from your finances to your physical health, to your emotional health and spiritual things, that community things, family thing. So, we've got a workshop that we do every January, that’s about goal setting and planning your life instead of letting your life plan you. So, yeah we're looking forward to that next month as well.
Dr. Davis: Definitely, and you talked about your team, your associate and so forth, can talk more about how you have helped your team catch the vision of the practice and also just your team being involved in that referral generation because so frequently our CA's and the other parts of our practice can really help and generate referrals?
Dr. McCoskey: Well, I think some of your listeners, if you've been in practice more than five years, you understand that nobody's going to be has invested or nobody's going to care as much about your practice as you do, and finding good employees I think is a challenge especially in the times we're living currently. My primary staff person, Paige, has been with me now 19. This will be her 20th year with me.
Dr. Davis: Wow!
Dr. McCoskey: And I stole her. Frankly, I took her from another position that was stressing her out. She had small kids at the time and she had come into our practice for care and did very, very well but she was working 60 hours a week in a job she did really feel very powerful, and she said, ‘if you ever need somebody to work here, I want to know.’ And in a very short time, I said, ‘hey! I need somebody to work here,’ but she knew what spinal care was all about. She knew what upper cervical is all about and so long story short, she's been with me for 19 years.
We just hired a new staff person who's been with us for less than 90 days, and she's like the Energizer Bunny. She came from Florida. She was working in a PI based practice down there. She never understood the concept of corrective spinal care or wellness kind of chiropractic care and she had contacted me before they moved back up. Long story short there, it's a match made in heaven and she's our community relations person. She goes out, takes back packets of cookies or our local items, she takes those to do businesses and she's been our connector in the community with the Chamber of Commerce and so on. So, she's kind of our new patient ambassador or community ambassador, and then I've got another staff that's been with me for four years now. Courtney's been with us for four years and again she came in completely accidentally if you believe it anything accidental, but she had come in with her niece. It was a three-year-old at that time with chronic ear infection and she did really, really well and Courtney said, ‘hey! if you ever need somebody to work here…’
So, we've been really blessed that the people who we surround ourselves with are as committed to serving as we are. None of ever going to care about it as much as I do, but the reality is I've got a really good team of people around me. My daughters have all worked in their practice well enough. My wife has been involved in her practice. So, we just really focused on surrounding ourselves with service-oriented people and we've just been really fortunate over the years just to be happy with it.
Dr. Davis: And this is something that, do you have weekly staff meetings?
Dr. McCoskey: We have a Monday morning meeting every week as in the second and third Wednesday mornings, we do a little more detail-oriented like where it's going to be training or goal-focused or whatever. So, yeah we do our review of the week from last week of Monday. We set the pace for the coming week that day as well and then twice a week or I mean twice a month we'll meet on Wednesday morning and we'll spend two hours getting into the more nuts and bolts of how do we stay connected, what cases are going well, what do we need to revamp on our procedures, what's our community calendar look like. So, yeah we do. We spend a lot of time laying some groundwork that keeps us focused on getting things done.
Dr. Davis: It's so important isn't it that you have that connection with your team and that you're regularly meeting and then like you said regularly training too – right?
Dr. McCoskey: Right, yeah. Whether it's rehearsing, here's what we say when and here's what we do, what this happens, how do we want to attract new people in this arena. So, you know and I would love to say that I am like the key to organization, I am not. In fact, I am that I'm like a kite. Sometimes they've got to warn me back down to the earth, but oh! I'm surrounded myself with people who are better at that. So, how are they? We need to have a weekly staff meeting and if it's a staff meeting, who should run it?
Dr. Davis: Right.
Dr. McCoskey: Yeah. It's their meeting, but it's their way of being able to contribute to the productivity and get things done. So, I don't run these meetings. I just say, ‘here's some agenda items I'd like to cover,’ and then 75% of that, that's their baby. I don't do that. That's their gig. So, what I've discovered is if I just surround myself with people who are smarter than me, I don't have to do as much.
Well, yeah that's especially what we want to do. Right? When we're building a group of people, a team to serve a mission in a vision. If you put everybody on that team that's just like you, you're not going to get much progress.
Amen, yeah you've got to be able to get a mix of personalities in there to get a lot of different things accomplished. So, like I said it's not always perfect moment. We're just doing the best we can like everybody else, but I don't very fortunate for the people we've got in our team right now. We're doing good things that having fun doing it.
Dr. Davis: Awesome! So, I wanted also just talking about another subject that I'll hear questions about or all picked questions emailed to me sometimes and that's on reactivations and being in practice as long as you have, sure there’s people that have dropped off and is that something that you actively pursue or what's your opinion about reactivating people who never been in practice for a while?
Dr. McCoskey: My opinion is, if they left, they left for a reason and I cannot always want to know what that reason is. So, when somebody drops off the schedule, we'll send them a postcard saying, ‘Hey! Can you fire this back to us? It has a few options on it. Here's why you might have dropped out.’
The other thing we do is every 90 days. We’ll send that reactivation letters or postcards to say, ‘Hey! We haven't seen you for a while. We know here was your problem last time. If we can help in the future, don't hesitate to reconnect, and then I always do a big push for that, and in December, right with the years ends, because we're going to either clean out our files and put your stuff in the storage unit or we're going to reactivate you whichever you would prefer.’
So, we always do a reactivation letter at the end of the year and you'd be surprised, a lot of people leave but I don't think they leave our practices because they're dissatisfied. They just got what they want, and they'll call us again when they perceive that need, and I'll meet people out of the community and I know your other listeners do this too. You'll see people that you haven't seen for a while. They're like, ‘Hey! You know.’ It's not that they're not happy except that they're doing well, and they somehow let this get off of the radar.
So, yeah we do try to stay connected to people. We do a monthly postcard. So, all of our active people get monthly postcard anyway. So, we try to stay in front of them. We do a birthday card. People get a birthday card for their birthday every year. So, just keep your name in front of people is kind of visit-focus to that, but there's some people who leave and quite frankly, you're glad they left. Right?
Dr. Davis: Right.
Dr. McCoskey: I don't put that person back. It wasn’t a good marriage. It wasn't a good match and why would I try to save something and I don't want saving.
Dr. Davis: Right.
Dr. McCoskey: So, important doesn't know who's who in that arena.
Dr. Davis: Absolutely! Yeah and in doing those things that you've talked about, have you found that you'll get some consistently coming back every few months or on a consistent basis?
Dr. McCoskey: Oh, all the time. Yeah.
Dr. Davis: Yes.
Dr. McCoskey: All the time. Like I said it's not that they're unhappy. They just let it get off their radar.
Dr. Davis: Yes.
Dr. McCoskey: Their concerns were addressed and if our line of work, you know this. The question is never, ‘Will your misalignment come back?’ The question is always when? Into what degree? …and so in some ways it’s job security, because we always know that no matter how good to get that spine corrected stabilized, periodically life happens, and the things are going to come in boon. So, if we can teach people that along the way, and I think that goes a long way to retention. One of the things I really enjoy doing is helping people make the connection between their spine, their nervous system and how well they live their life.
So, I think the better we can connect those things for that person, the more likely they are to stick around long enough to not only get the right results that they came in for initially, but they'll also stick around long enough to just participate in a wellness oriented lifestyle, and learn about what is actually chiropractic not just condition-based management.
So, the reactivation is only necessary where the retention falls short.
Dr. Davis: Right.
Dr. McCoskey: That's a big deal for me. I like how long do you plan on getting adjusted?
Dr. Davis: Yeah.
Dr. McCoskey: So, why would other people not want that opportunity? If they understood it the way we understand it, they would all understand the value in investing for their future for the rest of their life.
So, if we can connect that dot to some of other things that they already do and already know about like what are you going to stop brushing your teeth? Well, I'm probably not, and I don't wait until they heard. I brush them because it's a smart choice.
So, if we can help understand the value in doing that, then suddenly your reactivation list goes way down…
Dr. Davis: Exactly.
Dr. McCoskey: …because you're retention reading is going the way up.
Dr. Davis: Yeah, and you said one of the things you really enjoy is helping them to make that connection, right? Between their spine and their nervous system and how that affects their life and their health, and so talk about some ways that you use that.
Dr. McCoskey: Yeah.
Dr. Davis: As you first start developing that relationship, what are some ways that you really can emphasize that and try to lay that framework in their life?
Dr. McCoskey: Well, like I said, anytime we're going to teach people something new and let's face it, chiropractic for most of those people is going to be something new. Upper cervical model of chiropractic certainly is going to be different than what they're used to, and I think the trick to that is just helping them understand this new thing that they want to learn about. It‘s just like this old thing that they already know about, and this new thing called chiropractic and taking care of your spine is like this old thing that you already know about called taking care of your teeth or taking care of your car or taking care of your roof on your house. So, whatever thing you want to keep for a long, long time in your life is usually going to need some kind of care, and some kind of maintenance, and some kind of restoration at some point, and your body and your spine are no different.
So, it's a matter of kind of picking the lock for them and saying, ‘what matters to you and how can I help you attract what matters or connect what matters into how you would take care of your spinal care.’
So, I mean it's not rocket science. There's tons of information that's just basic communication. I guess once we can understand the value of it. Now, if you've got chiropractors or if you're the chiropractor who's not getting adjusted, it's going to be very difficult for you to convince me that I should.
Dr. Davis: Right.
Dr. McCoskey: Right?
Dr. Davis: Right.
Dr. McCoskey: If you want several ways, it's going to be very difficult for you to tell me how I could be eating.
Dr. Davis: Right.
Dr. McCoskey: So, my theory is always been my patients will never be healthier than me, and they will never do things that I'm not doing. So, I need to be authentic in the way I deliver that information.
Dr. Davis: Absolutely. Well, I think this has been awesome, lots of great information, lots of value for our audience, and before I wrap up for today, is there anything else that you'd like to share or any encouragement that you'd like to bring to doctors and students that are listening?
Dr. McCoskey: Well, I think we need to encourage all the time. I don't know anybody that doesn't need encouragement at least occasionally, and so to those guys and gals that I would say, that could be hard and you're swimming upstream a lot of the time. Just know that you're working in a practice that has a vision bigger than you.
And then people need the service that you provide. They don't maybe know that they need it but your job is to get out and share what you know because there’s a lot of people that are literally dying because they don't know what we know, and so you got to get out of your comfort zone a little bit. You've got to take it to the streets a little bit. You got to learn how to tell the story a little bit, because good things come to those who are willing to do the hard work and good things done.
So, I guess that's how I would close that up.
Dr. Davis: Awesome. Well, thank you so much for being with us today Dr. Terry and we'll talk again soon.
Dr. McCoskey: Bill, again thanks. As the year winds down, have a blessed New Year and looking forward to see you the next show.