Can a Small Clinic Survive Big Insurance? A Chiropractor at a Crossroads | with Chris Anselmi, BOAC #68

0:00So I got in a cab with her and we were going down 9th Avenue and we watched the first tower fall in the cab. We come out, the second tower's down. We walked back home that day, literally with people who were covered in the dust. And it was a harrowing experience. He was very honest with me. He said, I left not on the best of terms and so on and so forth. And I called his previous employer and his previous employer tore into him. He said, he's a bad guy and you shouldn't hire this guy. If you call their previous employer and they tell you don't hire that person, usually listen to them. But if there was something in my gut that told me not, I don't believe what he has to say.

0:36And I noticed immediately people's willingness to spend thousands of dollars on these care plans without blinking an eye. Why? Because they perceive value and benefit in this machine and in this service. And they either read about it or understand it. And it helped them on their first visit. I had a woman yesterday tell me, my husband and I are now talking about going out to dinner at restaurants. Can you imagine not being able to go out, having the reluctance to go out to dinner in New York City? And they're in their mid to late 60s, but they experienced so much pain for such a long period of time, they stopped going out to dinner.

1:21Before we get started, this episode of The Business of a Clinic is sponsored by Virillo. Virillo is the trusted marketplace for clinic owners looking to sell and groups and clinic buyers looking to acquire high-performing clinics. There are very few specialized marketplaces in the UK that focus on this transition for clinic operators. Virillo is one of them. Learn more at virillo.co.uk. Now on to the episode. Hey, everyone. I'm back. I'm Sally as part of the Coherent Healthcare team with the next episode of Business of a Clinic. Today, I am in New York with our guest, Dr. Ansalmi, who is a very long relationship of mine.

1:59He is a phenomenal chiropractor, has had a top clinic in the Flatiron District of New York for, I can't remember how long I've been seeing you. It's a long time. and I would love you to say a few words introduce yourself thank you very much always good to see you in terms of a little bit of my history like you said I graduated from chiropractic college guess you were probably a baby in 1997 it was just a few years ago and then I worked on Park Avenue not far from where your parents live for three years actually right around the corner and and then I ventured out onto my own in 2000 which was an interesting time to venture out I'm trying to think.

2:39I was January of 2000 and I think September of 2001 is when it was 9-11. So it was a pretty interesting time. And I wasn't too far actually from the Twin Towers. My first practice actually, I rented space and my office would look down the window to the towers, which was pretty interesting. Went out on my own. I did that for a year. I got my bearings, started the process. And then in 2001, that's right, in 2001, I took up a space on 915 Broadway, which is where I met you. And I stayed there up until 2021 or 2022. So I was there for a long time. My original associateship, I worked in a facility where there were a confluence of modalities.

3:24So you had physical therapy, you had chiropractic, and you had massage therapy. So I learned the value of that model pretty early on. And I appreciated that model just for the mere fact that different, although we all work within the umbrella of musculoskeletal medicine, different, each discipline has different tools in their toolbox. So it was nice that I didn't have to do everything, that we had other practitioners there to facilitate what they do better than what I could do. I took that model. I always kept it in the back of my head. And then when I went out on my own, I started that process.

3:53First with a massage therapist. And then quickly, once I established myself a little bit, I brought in my first physical therapist. And then the rest is kind of history. I think you and I met probably around 2003, 4, 5, something like that. You were like a wee little baby. I think, I don't know who, your brother might have been my first patient or maybe your father. I'm not quite sure. But it's a long history there. And then we spoke about this a little bit preliminarily. And then when I was on Park Avenue, I met a woman who was the head nurse in the pain management department at the Hospital for Special Surgery.

4:27She followed me when I went out on my own. And then she reached out to me one day and said, hey, listen, Hospital for Special Surgery is looking for a chiropractor. There's an endowment and there's somebody who left some money and they're interviewing. And this is the person you should talk to if that's something you'd be interested in. So I started that process. It was a huge opportunity. I spent about a year interviewing. I interviewed with about 10 or 11 different people, which was exciting and stressful and anxiety provoking. After that, they asked me to write my own delineation of privileges, which was a unique situation because it was unique both to them and myself.

5:01They've never had a chiropractor on staff. What you just said, a delineation of privileges. Could you just explain that for a second? I'm going to try not to butcher it because I only wrote one and I don't do it often. But I believe it's a working document that a hospital needs in order to create a scope of practice. So they'll say, all right, what are the things you do? What are the things you don't do? What is the premise behind your discipline and your specialty? And I, gosh, it was so long ago, but I think I reached out to some of my peers and some people that I knew helped me along in this process, but I didn't know anybody else who had an affiliation with a hospital.

5:33So it was really uncharted territory. It was great. And it was a lovely experience. I became credentialed with HSS and then I did that for 15 years. So I was at HSS on Tuesdays and Thursdays. And then the rest of the week I was downtown. And then there came a time where it just ran its course. It was a lovely opportunity and a lovely situation. And I thought it was appropriate for me to just focus back on my office, my main office. It makes so much sense. So working at a hospital for pain management, and I guess it's actually becoming more of a theme. We were just discussing it before the podcast, actually, of these kind of different syndromes and pain management and things that are correlated that might not seem at first glance correlated.

6:12So let's say immunity and back pain, something that actually is highly correlated, or that's been my understanding recently. Do you think you, what did you learn at the hospital or being around that interdisciplinary setting that you brought back into clinic? Yeah, that's a good question. I think it's primarily an orthopedic hospital. And when I joined them, I think, like I said, 2002, 2003, orthopedics, it's funny, the orthopedics has had, I don't want to say a resurgence or a rebirth, but it's become, I think as your population ages, it's become more predominant and more prevalent in people's lives.

6:48People are living longer. They're much more active than they ever were. If you think about your aunt or your uncle at 50 or 60 years old, or I should say me, I'm much older than you, as opposed to your average 50 or 60 year old now, 50 and 60 year olds are running marathons. They're biking, golfing, swimming, they're doing, I have kite surfers who are in their sixties and tremendously active lives. And because of that, orthopedics plays a more predominant role in their lives because they want to stay healthy and they want to stay fit. So I learned the value of good musculoskeletal medicine. I was lucky to be surrounded by essentially best in class, right?

7:24HSS is world renowned for their orthopedics. So you literally had the best of the best in each department. And because of that, I was able to do things like go to grand rounds and be literally a fly on the walls. They discuss cases, do things like meet with the radiology department and review films and MRIs and things of that nature. And it also, being a chiropractor, humbly, it helped me in terms of my, maybe the, I don't know if the right word is reputation, but when people looked me up as a chiropractor, sometimes people have trepidation. They said, this gentleman's affiliated with the Hospital for Special Surgery.

7:58He must at least be somewhat okay because the hospital has invited him on and he has the credentials. So it made a difference in the practice. It's really interesting. It's very hard, I guess, to differentiate yourself these days, especially now. And I guess really your practice grew with the rise and rise of the Internet and of reviews and of all of these things of marketing, reputation, all of these different attributes. So even though maybe it was unintentional to have that affiliation be ringing you up in the ring, What other things did you do or think about in terms of that? Like how are patients finding you now?

8:34How were they finding you before? That's a good question. So it's funny as I remember this vividly. I remember a woman came into my office who was referred to me from the hospital and she said, listen, there's this, what did she say? She's like, there's this thing called blogging. She's like, you should do this thing called blogging. I was like, why? What's a blog? She's like, it's incredible. And she worked in publishing, I believe it was, or PR, one of those disciplines. So she said, you know, you should really start doing this. It's a wonderful way to get your information out there for people to know who you are and what you do.

9:07So I think when I left HSS, social media and marketing your practice on a global scale from an internet and social media perspective wasn't really catching on or hadn't really caught on at that point. You had a website, you had an Edward campaign, a Google Edward campaign, but it's nowhere near the juggernaut that it is today. I look back at it at times and I say to myself, maybe I should have stuck around for the ride. Again, just for the mere fact of allowing me to keep that feather in my cap being affiliated with the hospital. But things seem to work out. Totally. And you were saying about people getting older and doing more as they age.

9:50And I know I can say for myself, I've seen you for maybe 20 years, 25 years now, and my family similarly, and your clients seem to always come back to see you. Correct. How would you say, could you speak a little bit about your service and how you're able to retain that relationship with them? Sure. How you bring them into practice, how you maintain and have that kind of program within it? Yeah, that's a good question. Let me think about that. So I think first and foremost, I treat all my patients as if they were family members or if they were someone I hold with highest regard. So someone comes into the office and we put together a care plan for them or if they have an issue.

10:30We try to be effective and efficient with their time, their effort and their energy, try to get them better as quickly as possible and then guide and lead them with regards to education in terms of some of the things they can do to maintain the health and wellness we're trying to achieve. I think that's super important. I think it's important to give them the things that they need in order to get them better. And I think it's also important to give them some space as well. We maintain, we work in a care plan, we bring someone through a course of care, we get them better, we integrate some services.

11:01Once they've reached a certain level of health and wellness, we send them home with exercises, we tell them come back in a month, come back in a quarter, whatever the case may be. depending on their level of activity and what they're looking to gain out of my service. Some people, I have some people who are very active who come and see me once a week for years because they're playing multiple sports and raising a family and have a full-time job. And the service that I provide helps them do that in a healthy manner. So I guess to answer your question, it's about honesty. It's about giving them the best service possible and giving them the service that they need.

11:41Completely agree. It's interesting. I keep hearing with especially this idea of discharge patients, and I'm always really jealous of them because I feel that I'm hypermobile. I have all my hip problems, all these different things. I'm an athlete. So I am in constant versions of acute care. And if I'm not, then I'm in super acute care. What's your take on that in terms of nudging a patient towards or checking in with them, let's say, like seeing how they are, checking in with them. I think you mentioned like, oh, we just charged them, but it'd be great to see them every month or once a quarter as maintenance.

12:12Like, how do you see that kind of duty of care towards the patient to not have them in to try and treat and make them better, but to also make sure that they don't fall behind? Of course. What I'll say is the nature of my business and the nature of what I do as a chiropractor. There's a premise behind my service where a chiropractic adjustment is something that we could all use in some way, shape or form. just to keep things super simple. You have your brain and your spinal cord, your nervous system. Your nervous system sits within your skull and the vertebra of your spine. Any person, an active person, a sedentary person, you have the ability and you have the opportunity to shift these things and to compress these things and to move these things slightly out of position.

12:58What does that do? It causes compression on a nerve or irritation on a nerve or misalignment within a structure, whether it's your lower back, your neck, those things through time have the opportunity to decrease your ability to move like on a global level, like for yourself, we were talking about your athletic endeavors. It also has the ability to decrease the nerve pathways to things like your heart or your lungs or your kidneys. It's not a stretch to talk about things like allergies or something like headaches or something like bowel or bladder issues. All of those things lead back to your nervous system, which flows through your musculoskeletal system.

13:37So to have the opportunity to have someone who doesn't prescribe a pill or doesn't give you an injection and has your global musculoskeletal health in mind and has the tools in order to keep you functioning optimally is really a wonderful thing. But you have to, you know, you have to understand the process as a patient and you have to commit to it and you have to believe in those things for lack of a better term. You just mentioned something again very I guess on a deeply personal level very interesting to me is this idea that MSK can actually help impact things like allergies or things outside of that.

14:19Sure. I know that you've expanded you have we can go back into it because I would love to hear kind of that journey of being the sole practitioner. I can't imagine within your first year having 9-11 happen we can I really want to get into that too and especially given the time it's been quite a heavy journey but how you've grown the team to even include things like acupuncture as part of it within that I know I just said a bunch of different questions or points maybe we can go just taking us back to the origins as the way to work through it sure being in someone else's practice making that decision what was going through your mind it was yeah it was I I think there's like a cliche or a term of sorts that's used jestfully.

15:00But when you're young and dumb, for lack of a better term, you don't have fear. So I've always been a, even when I was in high school, I started a business with my friend. I was 15 years old. He was 16. We started a landscaping business. I had one lawn. He had one lawn. So we combined our lawns. And then we threw our lawnmowers in the back of his Jeep. And we did our lawns. And then we sent out some flyers. And then before you know it, we had this monster business. through high school. So I think I've always had an entrepreneurial spirit. That business is still alive today, which is incredible.

15:31And actually in high school, I was able to sell my entity to somebody else and proceed along on my path. So I think part of it is entrepreneurial. Part of it is when you're young, you don't have children, you're not married, you have nothing really holding you back. I have incredibly supportive family and parents, which helped me along with the journey, which made a huge difference. So some of the fiscal weight was, I wouldn't say relieved, but it was just spread out. It helped me manage those things. So those things are hugely important. And then I think it's individualistic a little bit as well.

16:02I think you have to be really driven. I think you have to be really purposeful, eye on the prize, and you have to be in it for the right reasons. So I hope that answers your question. And then in terms of slowly bringing other people on board, I think it's just like anything else, like a natural evolution in terms of, like I said, I started with massage therapy because it was an easy integration to my service. and then what I did was I had one space on 21st Street where we met and then I literally moved across the hall to a slightly bigger space then I brought in physical therapy and then let me think about this then I moved upstairs a few years later and then I brought in acupuncture and I brought in another physical therapist and I slowly as as the business progressed I slowly built the model into essentially what it is today.

16:49Makes complete sense I think that we've spoken a little bit about setbacks in these journeys. And I didn't realize that September 11th was so closely after and that you were actually even closer than 21st Street and Broadway to the Twin Towers and the site and Ground Zero. How did you experience that moment and being such a young business and being so young yourself and getting through kind of the heart-wrenching and reeling moment of the city. Sure. Plus, where exactly were you at? So yeah, I'll give you the short notes. So was it, I think it was a Tuesday morning, I believe. So when I first went into practice, I only worked Monday, Wednesday, I think Monday, Wednesday, Friday, or Monday, Wednesday, Thursday, Friday, I don't remember.

17:32So I was off on Tuesday morning. I believe it was a Tuesday. And then just like everyone else, I got a phone call. That's something that happened. I turned the TV on. And there it was. My wife, who was my girlfriend at the time, she worked down on Mercer Street in Soho. She was going to work that morning and everything unfolded, a little studio apartment, house kitchen, everything unfolded on the TV. At least the second plane hit on the television. I watched it on the television. Incredible. Right. So we actually, we, she had to go to work, but I didn't want her to go by herself because it was so close to the twin towers.

18:05So I got in a cab with her and we were going down ninth Avenue and we watched the first tower fall in the cab. We saw it from an angle as we got further downtown, which was insane. And then, again, we're on Mercer Street, and you can see the second tower at the south end of Mercer Street. And it was billowing and all that other stuff. We go into her place of business, and we hear a bunch of screams a few minutes later. We come out. The second tower's down. We made our way back home. We walked back home that day, literally with people who were covered in the dust, the cement dust and things like that.

18:39And it was a harrowing experience, incredibly challenging and difficult. One of many, actually, since then in New York City, from a city slash business perspective. And I'll never forget, I think I had that Wednesday or Thursday, I had my first like busy day in 11 months or whatever it was. I remember I had almost a full schedule. And I think I had a secretary at the time. I'm pretty sure I did. Or a friend guest person. We, it's just, you have empathy, of course, and you just work your way through it and build back up. What was interesting about that situation, and you hear it over and over again, is so many people came together after that.

19:19So it was very unifying, even for New York. If you recall, I believe the subway series was that fall. So you had this real New York kind of strength and unity. So people bounced back as best they could and as quickly as they could here in New York. But it was interesting, to say the least. Do you think that it affected the practice at all in terms of it? Was it still? I can't believe. First of all, I can't believe that your wife went to work, seeing the towers on fire. I think you also went down there. Second of all, was it business as usual? Did people come back? Like what happened? It was the Wednesday after, the Thursday after.

19:53It was supposed to be so busy. What I'll say is that I don't remember it significantly affecting the practice. I remember it most likely affected the practice temporarily. temporarily. Again, I'll circle back to young and dumb. I was so driven and so focused and I had so many things going on that maybe I didn't realize it, but I don't remember it having a significant impact on the bottom line. Let's put it that way. When that early in practice, like I would clean the office, I would order the supplies, I would do the QuickBooks, all those things. So I was super busy with all the other stuff going on as well, but I don't remember it having a tremendous this impact.

20:31So at that time, you were doing everything under the sun and you had and but you had one day off is that to do the admin to be the scheduler to do all of these types of maybe I think part of the business model in the beginning is they tell you like, fill up one day, then two days and three days, I think it was more kind of just logistics, like, I think I was like I said, Monday, Wednesday, Friday, or Monday, Wednesday, Thursday. And once those hours became busy, then I went to a full time schedule. So it was more just allowing people to schedule care plans and to schedule consistent treatment.

21:04But I think I was only going three days a week. And how has that changed that mentality from today? Are you still, do you own or lease the site that you're in now? I lease the site. And you told me you recently are subleasing. Correct. Actually about that. And when you were starting off, were you subletting from? So no, when I started off, I signed a lease. It was three treatment rooms and a little reception area. It's quite big. Yeah, it was actually, it wasn't big and it wasn't small. A couple of the rooms were like too big and then one room was small. But it was nice because they all had windows, which was lovely.

21:39And then we had, I'll never forget. So it had windowed air conditioners. So when all the rooms were busy and the doors were shut, the waiting room would get stifling hot. It was ridiculous. These are the fun things in the beginning. But so yeah, so then during COVID, again, another much more, I feel like, significant impact on the practice. during COVID, my lease in my 915 Broadway space came up and it just seemed like a good opportunity to make a move. So we found a similar space. I looked at a bunch of spaces, literally two blocks away, more square footage, but roughly the same price point. So we took advantage of that.

22:14And that's what allowed me to get the more square footage. And then I didn't particularly need all the square footage. So I embarked on the endeavor of subletting some of the space to, I have a spinal orthopedist, orthopedic surgeon. And I have like a woman who does cosmetic stuff. And that's helped out a little bit too. It's amazing. So I guess going back to COVID, you said it was a very hard time and I guess more recent memory and it seems had bigger, a bigger impact on the practice. Could you speak a little bit about kind of the challenges of that time? So COVID was so different because the city shut down, right?

22:48Everyone left New York. That was insanely challenging. So there were like almost eight weeks where my practice was closed. So the tricky thing about that is like landlords don't really care if the world shuts down. They still want their rent. And there's all sorts of other responsibilities that you have, fiscal responsibilities. So it got very dicey very quickly. And then when we did come back to New York, we started at three days a week. And then we slowly ramped back up to five days a week. But it's interesting. I feel like, and you might be able to expand on this a little bit yourself, is I feel like it was a litmus test for a lot of companies to determine whether the work-from-home environment was sustainable.

23:32and I think it passed. I think people, I think a lot of companies realize that we can have people be just as productive, get just as much work done and decrease our footprint, whether it's the high rent per square foot in New York City, allows them to, instead of having 20 ,000 square feet, they can go to 5 ,000 square feet and have people share desks and come in a couple times a week or a couple of times a month. So it changed the dynamics of the city quite a bit. So let's say as an example, prior to COVID, 50 % of my patient population were people who commuted. Now it's 20 or 25%. You have to change and adopt to these things in order to maintain a certain level of success, but it was very challenging.

24:17And I don't know if that ever really came back. They say it's back, but I don't really know if it's back. What type, it's interesting, and it did really grind to a halt. It really changed how businesses function and kind of concepts. I was wondering what types of things when you were gearing back up or even during the eight weeks off, did you spend that time reassessing, reevaluating what you're doing, anything along those lines? Yeah. What happened so quickly, so I had a full team that I had to make sure I had to file all this paperwork in order for them to get like short-term disability, or I'm sure I'm not using the right word, but allow them to receive some type of financial stipend.

24:57I forget the terminology they used during that time. I had to take out disaster relief loans in order to keep things moving and rolling and go through some of my savings and things of that nature. It was so fast and so furious. And it was almost like, it was like a tidal wave. It was like every day the mountain grew larger and larger And you just, I just went back into my practice and licked my wounds and pulled out my bootstraps and got back to doing what we do. But again, I don't know in terms of, it was a different landscape at that point. It's interesting because I think that you have such a personable relationship with each and every one of your clients.

25:36It's a practice that is such. Have you ever done any type of not newsletter outreach, but actually one-to-one engagement or reaching out to people individually, having your front of house team calling up or messaging your kind of Rolodex? I think we estimated maybe 48 ,000, 50 ,000 patients who you've seen throughout the 30 years of practice. Anything to read? So we do a monthly newsletter. We look at the click-through rate and the open rate. Throughout the decades, people unsubscribe and opt out of it and things of that nature. but we have a decent newsletter. We have a texting system for texting reminders for appointments, which is automated, which is nice.

26:16And then we don't have our staff reach out to them one-on-one directly. During COVID, I did reach out to a handful of patients who I was in the middle of care plans with just to take the temperature and see where they were at and kind of get a feel for what their headspace was. But what's interesting, and I think Jared, correct, in doing my research, I spent some time watching some of his YouTube stuff. And I listened to some of his business model things. And it's funny, we every once in a while, we'll email a patient with regard if they've fallen off their care plan or if they don't, if they don't, if they've disappeared, whatever the case may be.

26:49And and just as he said, you rarely get a response. It's it's hard. It's hard. And it's and what is the reasoning? Is it because technology has moved on and that is no longer the point of contact or the way to reach out to these people? Obviously, snail mail is no longer really an option. What is the best way to interact? WhatsApp is cumbersome. These are interesting things. If I was to engage with them more, would I have a better retention rate? Possibly. Yeah, maybe. What we often find is that sending one email, you don't get a response. But sending a series of messages and being right hot to trot when you come back and making sure that the exact right mood and emotion, that it's reaching out as care.

27:34Or, hey, I'm checking in. How are you feeling, Sally? It's been a long time. In my case, I've been living in London. I'd probably respond, it's great to hear from you. I'm living in London right now. I'll message you when I'm back in town, as I'd certainly love to see you. But it's very nice to actually have that. Sometimes people get so busy with life that they don't even think about their bodies. And it's only when it's screaming in agony that they actually come in. A lot of our clinics are in England. I'm very American. I'm very New York. I probably am the loudest patient in the room. But it's very moving to see people say, oh, it's funny you mentioned or you reached out to me.

28:09It's funny you messaged me. I have been having this pain in my shoulder, my neck and my back that's been bothering me for months, but I just haven't come in. I haven't thought about it. I haven't. And now you're right. I could do with an appointment. I could do this. So it's about that kind of consistency and not being bombarding, but to just check in with them, see how they're doing all of these things. You mentioned that after COVID, you started taking a bit of insurance patient balance shifted. And I was wondering if you could speak a little bit about that. We have a lot of people who are debating or working through insurance first.

28:46Yeah, coming back into the fray and coming back from COVID, prior to COVID, we were primarily an out-of-network facility or fee-for-service facility. So what that meant was if you had out-of-network benefits, we would accept those benefits and you would have some financial responsibility while you were meeting your deductible and so on and so forth. And that did a couple things, right? It allowed us to, first and foremost, get higher reimbursements for our services. And then it allowed us to treat the patients ultimately the way we wanted to treat them, the way we felt was appropriate. you know, trying times being what they were, we decided to accept a couple of health insurances in order to just bump up the numbers a little bit and just to keep everyone busy as we cycled back into the mix.

29:29That was four years ago, maybe a little bit more at this point. And now, as we spoke about, the problem with doing something like that is insurance companies are not built for your healthcare needs, right? They're built for quick fixes. They're, at least from a musculoskeletal perspective, they're very limited in terms of their scope and what they allow us to do and not do. And they reimburse at a very low rate. So it changes the model of your practice. Instead of you have to work, you have to play the quantity game as opposed to the quality game. And we never wanted to do that. And we never really liked that.

30:05We did what we needed to do. But as we spoke about preliminarily, we're at a crossroads of sorts. We're trying to figure out what is the right, what is the next appropriate step in order to get back to the way we want to practice, the way we like to practice, and then to the outcomes, making the outcomes better. So what do you think that is? Like, where do you think you're going? Or what are the two options of how the practice might go? The problem is it's a scary thing of sorts. So if I were just to turn around and cut off all insurances and just go cold turkey, I think we would find ourselves twiddling our thumbs a lot and not seeing a lot of people.

30:44And I could see that having a significant impact on the practice. So what we're trying to do is find a way to soft land this a little bit, maybe get out of one of the insurances or have people let them know that we're no longer participating in this insurance. If you want to come in for the service, there's a fee involved. And I think also it's a relief to my practitioners because now they don't feel like they need to rush through these visits. They can spend a little more time with these people. They can generate a little bit better outcomes and do the things that they've been trained to do. One of the things I've always done is I've always surrounded myself with really good practitioners.

31:21And then I'm a little bit of a hands-off kind of, I don't know if I want to use the word boss or director or whatever the case may be. But if you just get really good people and then let them do what they've been trained to do, guide and lead them a little bit, I feel like a lot of things take care of themselves. So I've surrounded myself with these really good practitioners. I'm trying to figure out the middle ground or the way that I can have the general public understand the value and benefit of that and be willing to pay for it. Now a quick break to tell you a little bit about Coherent Healthcare, the company behind the business of a clinic.

31:56Coherent helps fast-growing healthcare providers engage, support, retain, and nurture their patients from intake to discharge. As you get bigger, your patient body grows enormously, and it becomes much more than just another hire, just another front office team member. It's no longer a people problem. You need technology that can scale with you. Coherent helps you do that by keeping every patient on track. In short, we're the agentic CRM and patient support platform for outpatient hands-on healthcare. To learn more, visit us at CoherentHQ.com. Now back to the episode. It's very hard to find talent in general.

32:32And it seems like your talent has stayed for forever. Knock on wood, right? Can you walk me through some of the stories of how you've actually found these practitioners and other parts of MSK and brought them, coaxed them into your clinic and your world? I think I remember I had a practice consultant once and she said, what is it, hire slow and fire fast. I think that was the term that she used. it's a lot of you break a lot of eggs to make an omelet so i think as you progress through the process you get better and better at it for me it's a lot of it is gut i don't i look at credentials before they walk in my office they have to have their credentials they have to have something on the resume that's that stands out a little bit but then it's a lot of it personality driven i spend more time with these people than i do my family i'll give you a quick story which is a good one.

33:19So I have an associate chiropractor who's almost a partner at this point. And I remember it was like 2006, 2007, his resume came across my desk. I was looking for a chiropractor and I brought him in to interview him and he went pretty well. And I just happened to have my practice consultant there that day. She was there working with our team and she thought he was pretty good as well. And I drove back and forth to the city then. I take the train now because I wanted to get home and see my kids. My kids were young, so I wanted to get home at least for bath time. And on the way home, I'm on the West Side Highway.

33:55I called his previous employer, and he was very honest with me. He said, I left not on the best of terms and so on and so forth. And I called his previous employer, and his previous employer tore into him. He said, he's a bad guy, and you shouldn't hire this guy. And I can tell pretty quickly in the conversation, I didn't love his energy. the guy on the phone who was telling me about this employer. I didn't like the way he was speaking about him. And it just, something was off about it. And I remember hanging up the phone with that gentleman and saying to myself, I'm going to hire this kid. So it actually had the opposite effect, which is an anomaly of sorts when you're going out trying to hire someone.

34:35If you call their previous employer and they tell you don't hire that person, usually listen to them. But if there was something in my gut that told me, not this guy, I'm not, I don't believe what he has to say. And he's still with me today. And he's an all star. It's amazing. Do you work on you? Of course. And judge that? What are you looking for when you're like, other than personality, time spent? Like, what are you looking for with what would you say would be a great chiropractor, a great physio? What are the signs that you're looking out for the yeses and nos? Sure. So yeah, I have people work on me sometimes.

35:06Physical therapy, it's a little different because it's usually a process and it takes time. But massage therapy, chiropractors, acupuncture sometimes. I look for, believe it or not, I look for athletics. A lot of the people who are in my office come from an athletic background, whether it's college athletics or consistently athletic after graduation. I think it's important because if we're working with athletes, I want them to understand and be athletic themselves. I also, I think someone who's able to carry a course load at a collegiate level and also play athletics or be a part of an athletic endeavor, those people have their stuff together.

35:45Those are people who understand the importance of discipline and who are structured and who are organized. So those things are feathers in their cap. And a lot of it's personality-driven. Like I said, I want to find someone who has a good personality. I want to find someone who will work well with others. It just takes one bad apple. My practice is it's not big, but it's not small. One or two bad seeds can become a problem. So I could not agree more with that. You're speaking about athletics. I seem to recall that you've seen quite a few star athletes over the years. Yeah. How they came across.

36:16Sure. You know, what the plans, what levels and how they came across your chair. What do you even call a chiropractor bed? Is it a bed? That was my HSS affiliation. Not too long after I became affiliated with HSS, I got a call from the surgeon in chief for the New York Knicks. And she said, listen, I have a player who has a back issue. Could you come up to our training facility, which is just in Westchester, and take a look at them? And I went over the moon. I was so excited. So I said, of course, absolutely. And that started that relationship. You probably can't tell me sitting down, but I'm 6 '6".

36:52So I think that those gentlemen appreciated the fact that I was tall and I work on them a little bit and move them around a little bit. But that was a huge opportunity. It was so much fun. I had I've had the good fortune of treating a lot of people like the movie industry and celebrities and people that my daughters go crazy for. And they're lovely people. I really and I'm not just saying this. I've had maybe one or two. I wouldn't even call them bad experiences, but it just wasn't tremendous. But most of the people, those people are lovely, but I really get excited when I work with the athletes.

37:26It's super fun. And so it allowed me that opportunity to to work with a bunch of those people. And then because of that, I have this accreditation called active release technique, which is a soft tissue rehabilitation technique, which I'm master certified in as well as Dr. Sherman, the other chiropractor. And so that helped us because that's big within the athletic community. But it ebbs and flows. We'll see a bunch of athletes and then we won't see them for a little while. Then we'll see them again. And I got a text message from my ex-Michigan football player who I happened to become friendly with.

37:57He's like, hey, I'm in New York for the week. Can I get some work done? And I said, absolutely. Just call the office and set it up. Those are fun. I enjoy that. Those are fun patients. They're all fun patients. But for me, those are challenging patients. Those are people who have invested almost an entire life in health, wellness, physical fitness, athletic endeavor. So to help them out and to get them better, I enjoy that. It's amazing. You must have been really happy this year then with the Knicks. Incredible. I just wish I was still their chiropractor, but I was still happy for them. It's a great group.

38:29You mentioned about this as well, going on a course, actually, about kind of marketing, about bringing people back in, about doing things. And I was curious about walking me through, you said why you came, what came about it, what kind of pulled you to do this as an offsite and just around the themes that you were thinking about after it seemed like you were really engaged with it. Yeah, you caught me at that moment. I was really kind of knee deep in it. So I have a mentor. I have a friend who's a chiropractor who's probably about 10 years older than me. I consider him a dear friend, him and his family actually at this point.

39:01And I've always looked to him for advice and we've always been good with each other. And he said, listen, I've embarked on this program, which helps you just learn the ABCs in terms of value and benefit for our services. And how to talk to patients with regards to not so much the clinical aspect of what we do, but the finances of what we do. And how to have that conversation with a patient with regards to value and benefit and the fees and the cost of my service. And this is what we're going to do. And this is why we're going to do it. And let's get started. So it's a program that I embarked on.

39:34It was a seven-week program. And then it was like an immersive in Chicago for a weekend. It was awesome. I met some incredible people. The team that runs the program, they're incredible. What was great about it was very different types of chiropractors. So if you know anything about my profession, they're all different types of chiropractors. Some of them do this and some of them do that, but it didn't really make a difference. We all came together and the tools and the processes can be applied to anybody or any type of chiropractor. One of the things I've never really had to do was have that conversation with patients, right?

40:08For all these years, it's just, this is your issue. This is what we need to do and let's get to work. but what the course taught me was listen these patients have the best relationship with you not your office manager not your front desk person they trust you you've created the relationship with him you're the person who should be having this conversation if there's a financial responsibility or what the financial responsibility is and why it is what it is and and let's get to work so it's been a work in progress i've had some success with it which is incredible for someone like myself, because again, I'm not used to doing these things.

40:44But the more I do it, and the more I flex that muscle or exercise that muscle, I think the better I'm becoming at it, and it becomes empowering. So what exactly is it? If I come in, let's say, to see you, and I come into your clinic, and I haven't been in a long time, what would be different this time that we interact than last time? So let's pretend it's not you. Let's pretend you have a significant lower back issue, right? And you come into my office and - Which is true, by the way. I do have a significant lower back issue. Okay. And I perform a case history and I perform an exam and I have you come back in a day or two.

41:21I might take some x-rays depending on when the last time you had x-rays or depending on your signs and symptoms and clinical features. You'll come back within a day or two. We'll go over your x-rays. We'll go over your clinical findings and I'll present a care plan to you, which I feel is most appropriate for you to get you better. And it most likely will consist of not only my service, but a combination or an integration of physical therapy or acupuncture or massage. So it might consist of three or four months of a care plan, which consists of gradations of these services. And there's a reason and there's a system behind it.

41:58And ultimately it's what's best for Sally in order to get her better and to get her back to riding horses or living an active lifestyle or doing whatever it is you want to do that you can't do because of this issue they in the seminar they called it a life effect right so it's incredible i i asked these things in the past but i never asked them in the way i was taught during this the seminar so you talk to patients about their life effect and you say tell me is there anything that you need to do want to do or like to do that you can't do even if it's just partially. And when you ask these questions in a certain way, in a certain manner, it's incredible the answers that you'll get because people don't correlate their inability to play with their kids on the floor with their lower back issue.

42:45They're not coming to me because they have a lower back problem. They're coming to me because they want to play with their kids and they can't. So if I take my model and say, this isn't an insurance model, this isn't what UnitedHealthcare or Cigna wants for you. This is what you need in order to get better. And you need, it might require not only time, effort, and energy, but there's an expense to that as well. It's not, listen, it's not, you're not buying a car, but there's expense. There's expense about it. If you want the Columbia Physical Therapy School graduate to work on you, and if you want the Division I soccer player, chiropractor to work on you who spent the last 25 years honing his skill and taking continuing education.

43:27And if you want these incredible practitioners in an incredible office with incredible equipment that's centrally located in the middle of the Flatiron District, there's a fee for that. And if that's something that I've been able to educate you in terms of the value and the benefit of that, then it's going to be fine. And if you don't see the value and benefit in that, then I have to keep your file on file, keep your clinicals on file, and allow you to go somewhere else. And that's what I'm struggling with as well. I'm learning that as well. I'm by nature, I'm empathetic, and I'm a little bit of a softy, but I got to get over that because, again, if you want this level of service, there's a cost to it.

44:11And at the end of the day, it's in their benefit. That's the thing. I actually just said to my partner the other day, I said, God, I think health is going to be my number one expense because for many different reasons. But it just is. If I didn't have these different comorbidities and issues, then I'd be fine. But I am choosing to want to live and act. As you said, I want to do these things or I want to play polo. I want to whatever it might be. And or to be able to just even sit at dinner and have my back not go out and be in excruciating pain. your health comes at a cost, unfortunately. And I think what's great about it is that these care plans are meant to actually sustain the health and make them better, right?

44:54You're saying with your clinical expertise, this is what I think you need to get better. I'm curious, though, because when I've seen you before, you have made a version of a care plan for me, let's say. I have seen the acupuncturist, the physio, and it was fabulous, and it was all encompassing. What do you think changed from, let's say, how you were doing it before and thinking about it to the more professionalized version that you're doing now? So I don't think it changed that much per se. What I will say is it might be a little bit more structured now. And I think maybe what changed more than anything is the dynamic nature of insurance has changed, right?

45:31So in the past, it would just be like, okay, this is your care plan. Let's get to work. And this is who I want you to see. And this is when I want you to come in. Now I have to have that additional conversation and this is what it's going to cost and how would you like to pay for it? And then, again, people have to be willing to pay for that service. None of my care has changed per se. My care plans are still roughly the same. Yeah, I would say those things are essentially everybody's different. So there's no two care plans that are the same. But what might be different now is the addition of having that financial conversation.

46:08And with that, are you looking to get them to pay upfront? Are you getting a card on file? Like, how are you committing them to that care plan? Yeah, the program talks about having them either pay upfront or having them break it up into a couple of payments. There's an interesting psychology in that as well, which I'm learning, is that if people perceive value and benefit and they pay for it upfront, it's a funny thing that happens. They never miss their appointments. They're never late. They don't no show because they've given their hard earned money to you and bought into your process in order to get better.

46:46So there's a psychology to it, which I'm learning as well, which I never had to take into consideration. So, yeah, it's new to me as well, but I'm understanding it and it's making sense. It seems like it would be a good time then to actually go through your patients, your historical patients and call them in, say, I haven't seen you in a while. would love to give you a free consult to see what you might be needing physically. Like, how are you feeling? How's your back? Because it is this opportune moment, you're changing the strategy going forward. And so you could actually drum up a lot of business from your existing patient body.

47:21Of course, some have moved away, some what have you. But where else do patients come in from? Are they mostly coming in from word of mouth? Or are you still spending? Are you seeing anything change on Google Ads? Sure. Yeah. So I ran a robust Google AdWords campaign for well over 10 years. I would say that was the lion's share of my new patient acquisition for a long time. But, and I think we spoke about this a little bit, so the algorithms and the way Google Ads work is, especially in the musculoskeletal space, and especially within the confines of Manhattan, you can whittle it down to literally block radiuses.

47:58you can whittle it down to times of day, days of the week, things of that nature. It is in an incredibly competitive space. So if you think about your standard, just saying neck pain or lower back pain, physical therapists, acupuncturists, hospitals, physiatrists, orthopedists, yoga. I'm sure I'm leading a bunch of other people out. So all those people are vying for the same patient, right? So what will occur is that cost per click to grab their attention becomes higher and higher. And there's a tipping point moment where I cannot, it's almost costing me money to have these people come into the office.

48:35When you talk, we talked a little bit about it, what it costs me to see a patient and combine that with your AdWord campaign spend. And I'm not able to recoup those funds. It becomes super duper challenging. So we've cut back the AdWord campaign a little bit. A lot of it is word of mouth. It's a lot of it is other patient referrals. and that seems to be where we are these days. It's so right about the, it's getting more and more competitive online for everyone and not to mention with AI, but I think actually you'd be in a great position with AI because of how many years of traction of sending people your way.

49:10But it's something we also see quite a bit with Coherent. It's like, okay, there was a cost to acquire the client to come in, then you saw them. So usually the first, sometimes even the first session is a loss maker, especially if you factor in if you have other physios you're paying or whatever and then you give them a consultation you give them a care package and then no one follows up to convert them and so all of that money has just gone down the drain we're considered a leafy bucket correct in a lot of ways and after people come in for the first session what's your next step what happens after that yeah so again not to beat a dead horse but But at this conference that I went to, they talked about a person will not come back after day two if you don't educate them on value and benefit on day one.

49:58So it all happens on day one, essentially. What happens in those situations? Listen, there's only so much you can do, right? If someone doesn't want to come back, it's usually for a couple of reasons, right? Either they're feeling worse and you haven't educated them enough to tell them, listen, you might feel worse for a little while. This is a process. Cost. Cost is probably one of the primary reasons. If you say to a person, you need a significant amount of care and there's a cost involved in this care, and if they can't afford it, they're not going to come back. Or some other kind of extraneous reasons, but I would say those are probably the primary reasons.

50:34So just from the data we see, a lot of times it's a matter of following up with that, that it's not pressing where there's something that they're on the verge of committing. It is a cost. They have to think about it. maybe the plan that you're presenting them will be a couple of thousand dollars of care plan or even if it's a couple of hundred dollars a month probably more than that we're in new york but let's say a couple thousand dollars a month of care plan it's a big thing they have to think about it they have to sleep on it and there's not that proactive checking in how are you feeling what's happening why didn't you convert even understanding how many people are saying this is too expensive or how many people are saying i had a bad experience or how many people are saying oh, I'm so sorry, this is New York.

51:14People are working 24-7, getting them to find a time, schedule it, and have front of mind. It's something that we like to do, which is lead follow-up and accounting for that and accounting where your dollars and time are going. Yeah, listen, I think similar to what I heard from Jared recently, if there's a professional, pragmatic way to keep yourself top of mind with these people with regards to the touches, getting back in front of them. Again, even if they're done with their care plan and they're out of pain and you just that gentle reminder that somewhat consistent gentle reminder in terms of who you are and where you are, I can see how that could help.

51:51I can see how that can make a difference. There's I've talked to patients that say I used to go to a chiropractor all the time and now I'm here to see you. I'm like, why didn't you go back to that other chiropractor? They're like, oh, I don't know. I just kind of lost touch. And you were you came up on my Google feed or whatever, which I'm just, okay. But often I think, especially in healthcare, if people have a good experience with a practitioner, it's hard to find. So they'll circle back or they'll at least make an attempt to try to find them. Okay. Completely. That gentle, not just a marketing email, but hey, how are you?

52:20We just thought like, how was your first, how are you feeling after our session yesterday? Like, how are you feeling after we did this? It's that idea that as if you are the person reaching out to every patient every time and how can you get there? Because it's so difficult to do. It's an unscalable and unteasable thing. But as you said, that's a crazy example. Someone was seeing their chiropractor, had a long relationship with them, and then for whatever reason that day decided to search and come into you. That happens all the time. It shouldn't. And I agree with you when you have someone like yourself or other really fabulous practitioners that I have.

52:55I only, I'm a very snooty practitioner snob because it's such a difference between excellent and not. And that loyalty is there no matter what. But for patients who are less, let's say, doggish or New Yorkie about it than I am, I think there's a whole range of forgetting memory is hard to remember. Oh, maybe they were busy that day or maybe when it's only when it's so bad that they can't possibly go on, do they call a chiropractor. Correct. And so how can you catch that before also to give them a better treatment plan or a better way of preserving it. I think it's really an interesting point. And I'm glad to hear that you're, I think what's nice is this is the care plan for you.

53:38This is, we're doing this for you. It's what the same thing that the conference was saying, which is you're doing them a service and therefore it should cost money. Correct. And it's, it's like people have to believe in the value and benefit of the service, In the world of musculoskeletal medicine, there's a plethora of options. I had a woman in my office last week. She had two microdiscectomy surgeries in the past 10 years. She's in her mid-40s. She was an absolute mess. She could barely stand. She was really bad. Within two visits, she felt 30%, 40 % better. She walked in. You can see it in her face.

54:16She was straighter. She was moving a little better. I talked to her about a care plan. She balked. She was not interested in the service. there's only so much I can do. If she's decided to explore other options or go in a different direction, all I can do is present the facts and give her an opportunity to take the journey, the health journey that I've prescribed for her. And if she decides not to do that, that's on her. And I have to let that go and move on. When she bought, did she give any reason? Was it a price? Was it too much? She didn't. She said, I will think about it. She came back for a third visit for treatment and we talked a little bit about the care plan and she said i'll let you know i'll reach back out to you and i don't think she's coming back there's usually i don't we'll see what happens but maybe she's a difficult person or maybe she has her own people i'm not quite sure but these things happen all i can do is yeah all i can do is present what i feel is best for that person once people have gone down that road once those soft tissue elements have been cut into too surgically, once they've been altered, once things like disc material has been shaved away and things of nature, it becomes much more challenging in those cases.

55:26And those are cases there's, I have a lot of tools in my toolbox, but there's also, there's a threshold with some of them. I think I thought I could help her, but she has to think that as well. Clearly you could, because she came back for three sessions and is feeling better. She wasn't able to walk, she's able to walk. And sometimes that perception in reality, some people just need to do it at their own pace. We also, people can say, oh, I'll reach back out to you when I'm ready. That's cool. At least they know you're there thinking of them and such. So I think that's great. That's happening and super necessary.

55:59You mentioned earlier, actually, with part of these care plans that right at the first when you see them for a consultation, maybe you do a little work on them and you sometimes recommend an x-ray at that time. Is that in office or is that out? Yeah, we have digital x-ray in office, which is nice. We brought it from the other location to this location. It's an excellent tool to have another good tooling box. It's funny, harking back to that original patient, she was reluctant to get an x-ray. And I said, listen, I'm not willing to put hands on you until I've seen what your spine looks like. You've had two spine surgeries.

56:34I can't, I don't feel comfortable as your practitioner doing what I need to do in order to make an appreciable difference without taking a look at your skeletal system. So it's an excellent tool to have in the office. And we use it intermittently, but we use it effectively, I'll say. It's a wonderful educational tool. When you're able to put up a digital image of someone's neck or their lower back and explain to them, Mrs. Jones, the headaches that you're having, the inability to look at your computer screen for more than 30 minutes, look at your spine, look at your neck, look at the bones of your spine, look at the way this bone has shifted forward or this bone has shifted backwards.

57:10In other words, look at the inability of your neck to move through certain ranges of motion. We'll do flexion and extension films to show the lack of movement in certain segments and the opportunity which lies there in order to free up those areas and in order to get them to move properly. We use the term subluxation. It's used a little differently in the medical world, but that's a term chiropractors use to explain misalignments and aberrant flow within a musculoskeletal region, more specifically the spine. and we use that as well in order to educate our patients in terms of what's working and what's not working.

57:45And so is that a machine you guys fully own and then charge for the service of? So this is a digital X-ray machine. It's just a standard machine that we have in our office as a, again, a clinical diagnostic tool. We did recently purchase a soft wave machine, which is a form of shock wave therapy. I think we spoke about this a little bit as well. So we, the other chiropractor myself, about a little more than a year ago, started researching what's another tool that we can bring into our practice, which will help patients from a musculoskeletal perspective. And we're hearing more and more noise about these shockwave therapy machines.

58:18We started doing some research. We took a pretty deep dive and we came across, ultimately landed on this software machine. And what I did was I actually rented it from a gentleman here in New Jersey, and he would bring it to my house and I would bring it to my office once a week. I would drive it in like a vacuum salesman. And it comes in a huge case. But what we did do was we did enough research and found the best machine on the market. It's an incredible machine. It was originated a couple of decades ago out of Germany. And it was used originally to break up kidney stones and gallbladder stones and things of that nature.

58:55And then the technology through trial and error, they realized the technology was there in order to heal musculoskeletal issues. We brought it on board and it's been just short of a miracle in terms of what it's done for musculoskeletal pain we use it on a whole host of things tremendous results with knees shoulders ankles there's some white papers with regards to its effects on plantar fasciitis and we incorporate that into our care plan when necessary when appropriate so if someone comes in with one of these musculoskeletal tenderness issues, tendon-related issues, will use this machine and possibly incorporate acupuncture or corporate physical therapy throughout a course of care.

59:37And like I said, Sally, it's been incredible. It's been incredible. And you see, like the results seem to be fabulous for patients. I feel like I've had very good results with it myself. How do you get the word out? Like, how do you bring that into the care plan or in terms of the monetization if someone hasn't yet used it? Is it been beneficial in terms of when you're looking at the finances of renting the machine and then thereafter profit after that? That's a great question. And I'll give you a little insight into the tipping point moment for me. So the interesting thing about this service is it's not covered by insurance, right?

1:00:12This is the same machine that the hospital for special surgery has at their facility. So right off the bat, your mindset is completely different. Look, this is the service that we provide. This is the technology that we offer. This is the cost of the technology. We offer a reduction for the first visit. So come in, feel what it's like. Let's take a history. Let's try it. You can try it. We'll try it on you. See if it makes any bit of a difference. So we give people an opportunity to come in at a discounted rate. If they respond appropriately to the care or if they find value and benefit in it, we have different care plans based on their needs.

1:00:48And then, again, if during my history and exam, if I feel like they can also benefit from additional services, I'll incorporate those services into the care plan as well. But what it did was it helped me strengthen my fee-for-service muscle, right? Again, to circle back to our original conversation, this is the machine, this is the cost of the machine, and this is the care plan I'm prescribing. If you pay for it all up at once, we give a small discount, but nothing really. It still falls within the confines of being equitable. And I noticed immediately people's willingness to spend thousands of dollars on these care plans without blinking an eye.

1:01:28Why? Because they perceive value and benefit in this machine and in this service. And they either read about it or understand it. And it helped them on their first visit. So it was a bit of a light bulb moment for me in terms of if they can, if they're willing to pay for this, they're willing to pay for my other services as well. Especially when they're all together. I think it is that thing where you're like, OK, especially when it's manual work, right? Sometimes the first you feel somewhat better after the first episode, even first appointment. But when you're going to something like acupuncture, which seems the first time you're going, it's crazy.

1:02:04You're like, oh, I'm going to have needles stuck in me. And somehow this is going to make my back pain go away. And it's amazing. It like it works magically. It feels like magic. But I think that being able to show people or have them try it, I think it can be if they're unfamiliar with a service. and they're concerned about it. Especially, as you said, there are many different types of chiropractors. Chiropractor, being a chiropractor, you can see a lot of bad chiropractors. It can have a bad rep. Same with acupuncture. Same with all of these things. Whereas massage seems less risky, let's say.

1:02:35Station, not everyone has the excellent background you do. But to then have that perceived service or see the value, you need to actually try before you buy. So is there a discount at all coming in? or do you just have it be more like a one-off? Yeah, so there's a 50 % discount for the first visit. So it's pretty robust. And what it does is it takes that financial barrier of entry out of the equation. It's not quite a loss leader, but it's essentially a loss leader. But again, this is an unknown service for a lot of these patients. They've never had it before. There's some reluctance. Again, it's called shock wave.

1:03:08They don't want to be shocked. But this one's called soft wave. But once they've received the service, most of them quickly realized the benefit involved and the way they feel. And are you bringing, you started off with the machine coming down once a week. Has it since changed? So we started it once a week. And then I said, listen, it's too popular. I need it two days a week. And I did that for almost 10 months. And then I finally purchased a machine about three and a half months ago. So it's there in my office seven days a week now. I finance the machine because it's extraordinarily expensive.

1:03:39I can imagine. But again, as a tool in our toolbox, and again, to offer these patients an opportunity, to receive relief. I've had patients that say I've been dealing with this pain for eight years, 10 years. Nothing has helped. The combination of this service with some of the other things that we've done, I'm able to... I had a woman yesterday tell me, my husband and I are now talking about going out to dinner at restaurants. Can you imagine not being able to go out, having the reluctance to go out to dinner in New York City as a... And they're in their mid to late 60s, but they experienced so much pain for such a long period of time, they stopped going out to dinner.

1:04:15That's, again, a life effect, right? It's terrible. I can imagine it. When my back fully went out and I couldn't walk, it was like three months, four months where I'd be like, yeah, I can't go over to a friend's house because I couldn't sit on. For instance, the chair, no way I could be sitting on. Or everything would be with fear about what could happen. And sure. And God forbid you're back in square one and you're back in that place where you can't walk. And all the progress you've made has come collapsing down and you're in agonizing pain. I think people don't who have not experienced intense back pain don't really understand that it is paralyzing.

1:04:52You can't do anything. There's not one whether you're sitting, standing, lying down. You cannot find a comfortable position to be in. And it's excruciating when it's happening. So I can actually, sadly, I can imagine what it's like to be like, yeah, I can't go out to dinner because my back hurts. You've walked a mile in her shoes. Yeah. But it's amazing to hear that's the effect that people are having. It's incredible. With it. Yeah. It's been a really nice addition to the practice. And yeah, we're looking forward to incorporating it more into our treatment programs. And with the x-rays, is that a complimentary service or do you charge for the x-ray?

1:05:25We usually charge for the x-ray. There's several things involved. And on your initial visit, we incorporated it into the initial visit. But if you came into my office and you're under care and you say, I fell on my shoulder, I think I broke something, you charge for that x-ray. It's nominal. It's not a too many amount of money. Because imaging is becoming, as I said, people are finding a real lucrative monetization route within imaging too. Probably a lost leader of sorts, but it's an excellent tool to have in your toolbox. Yeah, again, for the purposes of clinical relevance. It makes complete sense.

1:05:59It's fabulous. It's been a really fun conversation. Thank you so much for coming. Yeah, my pleasure. This was really fun. Yeah, this is great. Thank you. Thank you so much for joining us on this episode of The Business of a Clinic. We hope you had a good time. We hope it was helpful. If you can think of anyone who should join the conversation, feel free to nominate them, send them our way. We'd love to invite them to participate. If you like what you saw, give us a like, share, comment. We hope we'll see you again next time. Thanks so much.