A few months back I was asked by Lisa to give a “guest lecture” for the CA class at OCOM. Recently, in forums Tatyana brought up the fact that she was going to start teaching a class, asking for experiences/advice from people who had done it. I was going to just post there, but I feel like there could be a lot of input from the Bloggosphere, so I’m making this my post.
Also, a lot of this stuff has relavence not just for students, but fresh out acupunks and people who still might be curious as to “what’s this CA stuff all about anyway?”. In lots of ways these are some fundamental issues that we all have to deal with in the “deprogramming” from school’s standard “Private Practice” model to the Commmunity Acupuncture model.
I’m being lazy, so this will be in the same outline form that I used as the basis of my talk. Many examples were specific to the Portland area, so bear that in mind. Of course, not everyone will agree with these points, I welcome any discussion.
Hybrids? Herbs? And Private Practice?
1. Tons of ideological reasons not to do it, probably covered already
a. divides loyalty
i. patients don’t often understand the differences in treatment or cost
ii. Class issues
b. very different modes of practice
i. CA and PP are totally different approaches
2. I am no zealot–even with CA–I’d love to be able to have a hybrid, but here’s the practical reasons that I can’t:
a. You do not have the energy to practice full-time
i. currently in clinic? How do you feel after a shift? Could you take that 5 days a week? 8 hours a day? Imagine pulling double shifts everyday all week long. . .
ii. Acu demands so much energy, you can really only do it “part-time”
A. This Demands that you choose
B. You have to make as much as you can within 20 treatment hours
D. All this isn’t to say that you can’t have a Private Practice, but you can’t have both
b. You probably don’t have the resources to make it work
i. square footage is your largest expense, and the two types of clinic are, in fact, mutually exclusive as far as physical set-up.
ii. you’re second largest expense is payroll–ie reception, essential, in some form for CA, arguably you could do with-out it in a PP
c. I’ve tried it, I have to tell you, bottom line was I made more on CA than I ever did on PP, when you’re no longer in school rent and food money are serious concerns
i. Market reasons
ii. cash flow reasons
iii. you will prefer one to the other
Learn how to do acupuncture, learn it very well
1. people will not come to you for herbs
a. they know what acupuncture “is”, they come in for that
b. a few very motivated people have probably already done herbs with someone else, to them you doing herbs is a “bonus” not the impetus
c. trying to “push” herbs on patient’s new to them is a sure-fire way to make them uncomfortable, and maybe drive them away
2. Acupuncture can treat 90% of what you see
a. given enough time, acupuncture will take care of it
b. acupuncture is cheaper
c. of the remaining 10% that would find herbs very helpful
i. ~5% are fairly easily dealt with
ii. ~5% are extremely difficult cases that you will find frustratingly difficult, not fun challenges, often they are cases that have confounded many different practitioners of many different modalities
3. Community Herbs are still an experiment
a. doing it at WCA for ~3 months
b. so far only a small fraction, actually around 5%, of 350-400 total pt’s
i. that’s ~3 people a week, not sustainable
ii. double that to my original 10% projections and it’s still not sustainable
4. Herbs are a very dodgy source of income
a. inventory = tons of overhead
b. reasonable mark-up’s aim for break-even
i. you make pennies on the dollar for herbal medicine
ii. the charge for your time is the money-maker
iii. Herbs take longer, so for the same amount of time you’re loosing potential income.
5. If you still want to do herbs, building a very strong acupuncture practice, CA or PP, is a prerequisite.
a. It is so unprofitable
i. the goal with herbs are to break even
ii. it is a service to your patients, but providing this service requires you are taken care of
iii. this requires a Practice or JOB that can PAY the BILLS
b. Naturopaths do use supplements to boost cash flow
i. this model is profitable for a number of reasons I personally find offensive, and professionally are incongruent with the practice of Chinese Herbal Medicine
A. often multiple supplements are given, thus the accumulated profit margins increase VS find the Formula for the patient, maybe with some modifications
B. Often they are given continuously, ie no real plan to stop them, again consistent flow of inventory = more consistent cash flow VS very few Formulas are meant to be taken for weeks on end, let alone months
C. Standard mark-up’s are 100%, that means, often patients are charged TWICE what the practitioner pays for the product, VS at WCA we do it with ~60% mark-up, and we have just started to turn a profit on inventory
c. Real-life examples of herb practitioners:
i. Hiener Freuhoff–has a teaching/admin gig, and charges extremely high rates for his time
ii. Guiho Liu–does acupuncture on most of his patients even if they’re there for herbs
iii. Both have OTHER sources of income
Making it Work as a PP
1. Make sure you have enough in savings to pay your total cost of living for at the VERY LEAST 6 months, more like a year
a. all small businesses grow very slowly, 3 yr window
b. many small businesses rely on loans to make it through the 3 yr window
i. for a loan you need a business plan
A. Market research, financial analysis, bank willing to listen
B. A back-ground in business will help, but it will still take ~6 mo’s to get it done
c. 2 out of 3 small businesses fail
2. Find an untapped upper class market, move there
a. any left?
b. do you want to be there?
3. Take-on the insurance beast
a. in the Portland area, even insurance gig’s are super competative
b. the future of insurance coverage is shaky at best
i. most people don’t have acupuncture covered
ii. many plans will happily cut acupuncture from their benifits if they hit a rough patch
iii. the possibility of a national health system will perforce exclude acupuncture
c. This costs you money
i. doing it yourself is such a waste of time=money, you might as well pack up and go home
ii. paying some one to do it will increase your over head
iii. getting a billing person will decrease your profit margin, usually ~5%
4. bottom line, it can be done, but you’ll have to have the stuff to make a small business work, all the acupuncture skills in the world will make no difference in the face of that.
5. Find someone to hire you.
a. you might as well try to start a cash only private practice on NW 23rd (arguably the most “posh” of Portland’s commercial streets).