A Tale of Two Sliding Scales (abridged)

This post started out to be an update about our new clinic, but it’s turned into something else that is more about the sliding scale. The sliding scale isn’t something community acupuncture invented, but our use of it in very specific ways is actually quite different than how it gets used in many other places.  This is a key factor, I believe, to the success of our clinics and therefore their ability to uphold POCA’s mission.  Since 2008 when the recession struck RI and we expanded our $20 to $40 sliding scale to $15 to $35, we haven’t really given it much thought.  After we made that change our volume jumped, we (finally) moved a couple of years later, and we’ve been growing solidly since then in many ways.  Last month we opened a second location.

Our new clinic at Thundermist Health Center (THC) is not the typical CA set-up.  It’s a foray into new territory of working with (and within) a larger organization, with which we share several core values, foremost, patient centered care.  In the medical world this term probably means something different than how I understand it.  Basically I take it to mean: patient care comes first.  That probably seems like an obvious thing for a health care providers to think about.  But the reality is in the US this ideal has been trampled by the managed care system and the medical industrial complex.  Capitalism and its demand for unending growth, it turns out, isn’t good for health care.  It’s too much like cancer.

Our new gig at THC has gotten off to a good start.  At one of their 3 locations, THC is giving us the use of a large room, with a reception area, ADA bathroom, easy access from outside, and ample parking.  The location we are in serves about 10,300 patients annually.  In 2012 THC had over 100 thousand patient visits to their medical and dental facilities at locations combined.  They are an organization designed to see lots of people, many for whom they are the only health resource.  THC has a 365 day a year “QuickCare” program to give access to non-emergency medical help for people who might otherwise use an hospital ER for this.  THC’s services are  mainly utilized by people from low-income households, with a small segment of this care focused on serving homeless people.  Their reach extends into communities that PCA would never have reached on our own.  This is in part why we are partnering with them.

But THC is working to change the image of community health centers to include primary care for more people, not just the poor or indigent, because adding in other segments of the population into their user stream will help them to be more stable and because there is a need across the country for more primary care services and providers.  PCA on the other hand is working to change the image of acupuncture as something not just for the rich, but for everyone.  We have seen, like the other clinics of the community acupuncture movement, that making acupuncture more affordable also stabilizes our ability to provide our services too.   Neatly- PCA and THC meet each other in that middle ground of trying to create more access, contain costs, and build communities that cut across the markers and lines that often separate and isolate different segments of society.  None of this looks like conventional capitalism which is part of why it is working.

One reason we had to say yes when this opportunity landed in our laps was that we are beginning this new clinic with virtually no economic risk.  THC approached us with the idea of providing acupuncture onsite so that it would be convenient for their large patient population, many of who struggle with issues of poverty, transportation, chronic pain, and often times prescription and/or illicit drug abuse. Woonsockett, RI where THC was born 40 years ago as a volunteer run family planning center- in a city with several seminaries and nunneries, is currently the epicenter of a prescription drug overdose epidemic that puts RI at one of the highest rankings for this problem nationwide.  THC knows that in order to give acupuncture a chance to help their patients, they need to bring acupuncture to their patient communities, and they need to make it affordable.  They were willing and able to provide us with a resources that would make it possible for us to set up a clinic: namely very low overhead.  So they’ve invited us into their space at no cost to us, they continue to help smooth out our systems by giving us access to some of their staff resources for PR, marketing, and basic operations, and their providers refer lots of patients to us, and in general everyone there seems very happy to have us around- even though we keep hanging signs up about being quiet or not cutting through the community room during clinic hours.

THC doesn’t have tons of money, despite what looks like to us to be a big budget.  In 2012 their revenue from all sources was $27million, which they used to provide over 110,000 treatments, while they continue to grow their reach by adding services, programs, jobs, and facilities.  Compare this to the non-profit hospital my brother works for that had a surplus equal to 2 years of operating costs to spend down at the end of this fiscal year.  The new CEO was redoing their office in marble.  THC could use some of that money.

Before I get much further (or more off track) with this story, let me speculate on a much in the future possible ending for my update:  THC opens and runs its own community acupuncture clinics.  A lot would need to happen for this to be a happy ending to this tale, including discovering that it is possible to run a community acupuncture clinic with a sliding scale of $5 to $25 dollars.  We plan to discover this ourselves, and then use that information to help THC open more clinics if they want to.  A sliding scale of $5 to $25 is what we have agreed to offer to THC patients, and also their employees.  For everyone else our usual sliding scale of $15 to $35 remains.  The number crunching we did prior to agreeing to this project looks like operating at 60% capacity with a 40/60 split of people paying on the $5/25 versus the $15/35 scale would put the clinic at break even- assuming that the majority of operating costs are already covered elsewhere in the budget.  THC’s facility operations costs are pretty fixed.  If we weren’t using the community room 12 hours a week it would be used as a auxiliary break room.

The operational logistics are like a finite math problem that can be worked out by making small adjustments to an existing budget.  What is going to be more challenging to work out is how we operate with 2 sliding scales.  The challenge isn’t just in meeting payroll, and supply budgets, but more in how comfortable we are knowing that the treatment volume needs to be consistently high in order to make the lower sliding scale work.  High volume low cost.  Lower cost, higher volume.  That’s basically how it can and needs to work, but we have to be careful about how we drive things toward a higher volume.   Acupuncture is after all, still very weird.

Sliding scales work in different ways in different organizations.  THC has their own sliding scale that requires income qualification, although they will offer care on their sliding scale that also starts at $5 for at least 30 days prior to the completion of their sliding scale qualification process.  As recipients of state and federal grants, THC can turn no one away for lack of funds.  They really want to provide care and do an amazing job at this, but they have a different culture and language around their sliding scale that will probably make it challenging for us to use the sliding scale in the way we do.  We have a well developed culture and language around our sliding scale which is based around a desire not to shame or guilt anyone into paying more.
A key discussion happens in every CA 101 class that I've ever been to, which basically goes something like this:
Q- “How do I deal with patients who are paying me less than I know they can afford?”
A-“How do you know what your patients can afford?”
The conversation has a few more turns from there but the gist of it is: If you are not comfortable letting your patients choose what they would like to pay on the sliding scale you offer you either need to charge to a flat fee, or make sure your sliding scale is such that your average payment falls within the confines of what you are comfortable with.  Without this piece in place your clinic's sliding scale will serve to alienate some of the people you might otherwise attract.  This won't be true for all your potential patients, but it will be true for those for whom community acupuncture was designed to serve.  One could argue that we each set up our clinics to serve our own communities and those communities differ demographically, geographically, economically, etc.  But if in order to keep your clinic open you need the community of your community to try your services and spread the word about them, then it seems wise to keep an open mind about how the high volume low cost thing really works.  You don’t need to make it work- you just need to keep your costs low enough that it does work.  The product- affordable acupuncture- it seems is something almost everyone seems to need.  If they can access it.  And if alienating people with how you talk about your sliding scale creates a barrier to them getting care that will have its own impact.

As I mentioned above the community acupuncture movement did not devise the use of sliding scales, but the use of sliding scale fees has been crucial to our success.  First there is the straight forward fact of more affordability; some one who can’t afford $35 can pay $15.  Simple.  There are other subtleties tied up in the use of the sliding scale as used by CAN and now POCA clinics.   Over time, we’ve formalized these subtleties into guidelines because they are so key and fundamental to making a tool like the sliding scale work.  Another way POCA clinics use sliding scales that is different than most organizations using a sliding scale is that the user gets to decide for themselves what they want to pay.  Having this choice empowers people to control their finances, rather than to have us dictate arbitrarily what they should pay based on income.  I understand why an organization like THC would need to use a qualification system, and I know that some of these systems do take into account household expenses as well as income, but non-the-less very few of us like having someone else tell us how to spend our money.

Money is a loaded issue for everyone I know.  Seriously.  I cannot tell you that I know a single person for whom this is not true.  People have issues about having enough money, too much money, what things cost, how the government is spending it, personal debt, national debt, minimum wage, corporate greed, etc.  POCA clinics must use a non-qualifying sliding scale, and the POCA Locate A Clinic guidelines spell out: The use of Income Guideline charts is strongly discouraged, as is any language intended to drive patients to the top end of the sliding scale, either on the clinic’s website or explained in person.   Money, specifically what patients pay to receive our services, is the issue here.  The guidelines are set up to allow for the most possible choice for the patients.  It’s a way of focusing the services we provide on them.

The middle of the story with how PCA’s clinic at THC will be dependent on how well we do in bringing in our culture around the sliding scale, or changing our culture if need be so that we don’t alienate the people we hope will use our services and tell their friends and family.  If we cannot bring how we talk about it, write about it, think about it, and feel about it to a neutral ground where patients can truly feel free to pay what they choose on our sliding scale we will just make a mess of it.  This will be harder to do well with 2 sliding scales, but PCA is fortunate to have a community with which to sort bits of this out with.

One of the “land mines” is distinguishing PCA as a business solely supported by patient fees without un-necessarily burdening patients with an education about how our business runs.  I’m not against sharing that information, especially if someone wants to know it, but it seems unnecessary to share it in any detail unless asked.  In fact, I’d say that it would probably influence people to pay more if I did disclose to them these details.  For example: we have a lot more no show appointments at THC- at least thus far.  It’s annoying as hell, and there are probably reasons for it that we cannot even comprehend yet.  And really this is a small detail, one of many, that will dictate whether or not we succeed.  But rather than seeking to eradicate this piece- maybe we need to work with it in order to really make the clinic work there.  Our ability to engage with the community, to spread the word, and to build trust enough the process of getting acupuncture- assuming that folks can access it and that we are stable enough to provide this access- these are what will make or break the new clinic.

Our projections about the new clinic becoming self-sustaining are in part dependent on attracting a percentage of patients who will pay on our non-THC sliding scale.  We’re banking on the huge popularity of our clinic in Providence which operates at between 65 and 95% capacity on any given week over the past 14 months.  We’re flush there, even with our average payment having slowly dropped over the past 7 years. We’ve widened the door in Providence so that our average payment- and our average patient- show us that we’re succeeding  at reaching people who otherwise could not afford to get acupuncture.   Reaching further and further, geographically, economically, is only of value if our systems help people to feel like they belong and that this resource is for them.  We need to be sure that people paying on the lower sliding scale don’t feel like the other folks are subsidizing their treatments.  Or vice versa.  That would have disastrous potential.

If and when THC takes over doing community acupuncture (and this part of the story has many other paths that could lead to POCA Tech training their staff, POCA Tech East Coast being housed in one of several large THC facilities, THC providing clinic sites for POCA Tech students, etc.) I want to be damn sure that they are doing so in adherence of the POCA Clinic guidelines- which perhaps may be more formalized policy by then.  I hope.  THC could probably subsidize someone to do acupuncture in their facilities.  Hospitals have had acupuncturists as independent contractors in their pain clinics for at least a decade (though not widespread.)  THC has nothing close to a hospital’s budget, but still, they could simply pay someone to provide this treatment.  The success of that type of set up would be based solely on a reliable funding stream (hah!) and the ability of providers to drive referrals to the clinic. 

THC is wiser than that.  They don’t know us well yet, but they understand that we are part of a growing movement.  They understand that we have systems and structures that work, which is why our clinics and our movement keep growing.   We are facing the challenges of meeting and combining cultures-PCA’s and THC’s- especially around the sliding scale.  This requires us to consider how we balance clinic financials under new circumstances whilst maintaining the integrity of the sliding scale.  Fucking up how we talk to our patients, anywhere, would be one of the worst things we could do.  Why and how we use the sliding scale has been discussed a lot over the years in the CAN and POCA forums.  When core systems work well they often dissolve a bit into the background, but it’s never a bad time to drag them out and remember why they are there and how they work.

Author: crismonteiro

I've always thought that I would live to be 100 years old and now that I have an actual idea of what it might be like to inhabit this body for a century I want to be damn sure that Community Acupuncture is around to help me through my days and in the end, on my way. In the meantime, I am passionate about getting shit done, and also having fun.

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  1. Cris, thanks for writing this; I’ve been wondering how the Thundermist clinic is going! What a fascinating, massive, complex project you folks have taken on. I look forward to further updates.

    Especially, thank you for this: “alienating people with how you talk about your sliding scale creates a barrier to them getting care that will have its own impact” and this: “We need to be sure that people paying on the lower sliding scale don’t feel like the other folks are subsidizing their treatments. Or vice versa. That would have disastrous potential.” No kidding!

  2. Cris wrote:

    ” Fucking up how we talk to our patients, anywhere, would be one of the worst things we could do. ”

    Yeah that’s the crux of the problem. An issue that all CA clinics face upon opening is what exactly they are gonna charge and how to communicate that to their patients. The first decision to make is deciding to go with a sliding scale or a flat rate. So far the great majority of clinics have chosen a sliding scale ($15-40, $20-40, 15-45, etc.) but by no means are the clinic owners happy with that decision because the question then comes up of how to explain to patients that they can pay what they like along the scale. They see confusion on the faces of their patients and are not sure how to react.

    One way some clinics have reacted is to change to a flat rate. Beach CA in San Diego did this and they are very happy they did. Their flat rate is $20. Their clinic finances work out nicely, patients can easily see what to pay: win-win. That Beach is one of the more successful clinics going suggests that more clinic owners think about adopting a low flat rate if they continue to feel uncomfortable with a sliding scale.

    Most CA clinics however stay with a sliding scale and so have to communicate it to potentially confused patients. Working Class Acupuncture (WCA), the first CA clinic, also faced this problem in its early years. At the time WCA was experimenting with how to hire acupuncturists and one of them that we sublet to suggested that we write up a chart that had income guidelines. Since we were in the middle of just figuring out what we were doing we said okay. We devised this chart that we gave to patients who said they weren’t sure what to pay plus we posted it on our website. We still said pay what you can afford but in addition the guidelines looked something like this:
    – If your income was less than $25K/year pay $15
    – If your income is between $25K and $35K, pay $20

    Etc. up to the top of the sliding scale of $35.

    Interestingly these guidelines were adopted to a few dozen other CA clinics when they started up-and they still exist today on many CA clinic websites. But WCA dropped these guidelines before we even founded CAN back in 2006. Why did we drop them? Because the income guideline chart goes a bit against telling patients to “pay what you can afford”. I think that is kinda obvious, right? And the income guidelines fail to take into account what expenses a patient has in their lives. They may make say $50K/year but their expenses leave them with precious little extra cash and so they need to pay at the low end of the sliding scale. The guidelines don’t work for them. The truth is the guidelines don’t work for most people. That’s a problem.

    But wait! There’s more! See, one of the great things about doing CA is that it recognizes that Acupuncture works best if done frequently-like every day or a few times a week for acute problems. This is the problem that Boutique Acupuncture clinics can’t solve easily because they charge so much that most people can’t afford frequent treatments. And for CA clinics, the income guideline chart also works against frequent treatments because it tends to get people to pay per treatment an amount that they can’t sustain if they are coming often.

    In the long run, the income guideline chart quietly fails CA clinics. It quietly keeps many patients from getting enough treatment for their conditions. And that slows down a clinic’s growth since a fully satisfied patient is by far the most effective means of advertising.

    For years I’ve supported the option for CA clinics to use the income guideline chart. It is after all is said, not a a big impediment toward allowing patients to pay on the low end of the sliding scale if they want. Most if not all clinics that have the chart still say, “pay what you can afford”. And for a lot of them they mean just that: they don’t make a big deal out of what a patient pays and they more than anything want their patients to get well and will do what they can to have that happen-including going below the sliding scale if the patient’s needs require that.

    But I dunno. What then is the point of having the income guideline chart? I’m thinking we should probably get rid of allowing it in the Locate A Clinic (LOC) guidelines. The tricky thing about not allowing them is two things that continue on the next comment:

  3. 1) A bunch of clinics have had it for years now. Good upstanding CA clinics on LOC. Why tell them now that they need to get rid of their guidelines? It does seem somewhat intrusive for us to tell them 5,6,7 years later to remove their guidelines, especially since for most of them the guidelines just sit there in their website and they have developed a comfortable way of telling their patients “pay what you can afford” on their sliding scale. I guess I am a little shy of irritating these long standing clinics. Newer clinics that use the guidelines is another story though. I definitely think that going forward new clinics shouldn’t be allowed to use them. It might be better to discuss in the forums this issue of getting rid of income guidelines but I am now at least partially on board for getting rid of them.

    2) The second thing is much more insidious and it relates directly to the quote that I have from Cris: ” Fucking up how we talk to our patients, anywhere, would be one of the worst things we could do. ”
    How clinics talk to their patients is not regulated on LOC because how can we know other than though second hand anecdotes from our patients? The problem is pretty real though as I am aware of some CA clinics that pressure/manipulate their patients into paying more than they feel comfortable with. I am aware of this because I’ve had patients complain about clinics they’ve gone to when traveling on vacation. I’ve heard of these complaints enough that I’ve told some of my patients to not go to certain clinics.

    I don’t know why some clinics try to manipulate their patients into paying more though I suspect it has to do with their bottom line and they think they need to make more per patient. This hard sell seems more likely to happen in more affluent areas. I don’t know what to do about these clinics if the issue is just verbal-as opposed to posting things on their website. Clearly they don’t get an important aspect of CA.

    One more thing. The employee who recommended that WCA adopt income guidelines? He quite a few months later but before that WCA dropped the guidelines and never looked back as we saw that they were slowing out growth. That employee never understood WCA and didn’t want to treat a lot of people. And maybe that’s the core of the issue for some clinics.

  4. Indeed, money is a loaded issue, no matter what. Personally, I’m so thankful that PCA doesn’t use a chart. Community acupuncture, PCA, and POCA have all had such positive impacts on me, and I KNOW that if there were an income guidelines chart, none of this would be true. Why? Well, I know that on “paper,” I can afford more than I usually pay; and, I am a rule follower and guilt-ridden ex-Catholic, so no way would I have paid less than what the chart says! This means that I simply would not have gone to acupuncture very often, whereas now I go almost once a week. And if I didn’t go very often, would I really see much of a benefit, and would I continue to be a patient? I certainly would not have told the many, many people who now ask me to please, shut up about acupuncture already! (many of whom now go to PCA regularly too 🙂

    Being able to decide – in fact, *having* to decide – how much to pay is empowering for me. Uncomfortable at first, yes, as many truly worthwhile things are. To me, initial discomfort or confusion is good; it means that people have to stop and really think, rather than just do what someone or something else tells them to do. That is radical.

    The patient-determined sliding scale is an example of the beauty of Community Acupuncture. What is right and just and radical turns out to be good for business. Everyone wins!

  5. If you are having problems with a higher-than-other-location no-shows, perhaps it’s worth accepting a higher-than-other-location amount of walk-ins? I can see the possibility of people not being quite as able to commit to a “hard” schedule if they are combining CA appointments with other THC appointments. If you are expecting/pressuring people to make an appointment, might you be encountering some passive resistance to it? Just a thought.

  6. Good call MM-

    We’ve been wondering if part of our acculturation to THC will be to be more flexible around people keeping appointments- whether specific times, or coming at all. We’ve had a number of patients out there who we haven’t been able to contact via the phone number they gave us when they were originally scheduled. Turns out their phone minutes were used up for the month so they couldn’t have called us, nor could they receive a call from us.

    I’d say overall THC serves more people whose lives may be chaotic enough that we cannot reasonably expect them to call us if they can’t come. If we had a more robust walk-in thing going, that would help balance this piece out.

    First we’ve got to get some volume flowing through though. Our focus should be more on turning up the flow in every way we can before figuring out how to fine tune the no-show/ missed appt. thing.

  7. LOVE this blog post…and it’d abridged! I’ve been thinking about this for days.

    And congrats on the partnership. This could turn out to be a beautiful story. It makes me wants to pack up and punk for y’all.

    A few things: I am strongly against income guidelines (like you, Cris). Money, shame, guilt, money, guilt, shame… pay what you can works better.

    I wanted to add my thoughts, as one of few clinics using the flat rate. I have my own shit about the sliding scale, (https://pocacoop.com/forums/viewthread/5369/)
    and am curious, given the TCH culture, if you’ve considered a flat rate for acu tx. $10? $12? It’s new yet, but I personally found that we had fewer no-shows after instituting the flat rate. Again, though, that may be my own shit.

    One last plug though–it’s harder to fuck up what you say to patients when there’s no gray area.

  8. Also, as a clinic owner, I would *drive myself crazy* if I cared what each individual patient paid and the ins and outs of what they could afford. My sanity is way more important to me.