When Stéphane Provencher, DC, graduated from chiropractic college in 2007, he had plans of being a “doctor.”
Not only did he want to work on subluxations but he planned to help patients improve their nutrition, cognition and overall health. To that end, he embarked on studies in functional medicine and energy work, homeopathy and nutrition. For a while, he treated patients in every way his scope allowed. But his move to a high-volume practice in Virginia increased his patient load from two visits per hour to 10. Provencher quickly realized he couldn’t do it all, but he still wanted to provide these services to his patients.
So, he left that office and opened Gainesville Holistic Health Center in Virginia, where he began incorporating other practitioners to provide the services he was too busy to offer patients. One of these was a naturopathic doctor.
“Eventually, everyone needs to choose their battles,” Provencher says. “By bringing a naturopath on board they can identify another vector of health that a chiropractor either doesn’t have the time or knowledge to treat. They are looking at the body, mind, emotions, nutrition and lifestyle, and take a diagnostic approach to better serve the patient.”
For people seeking medical treatment from a doctor who isn’t an MD, naturopaths are an increasingly popular alternative. If this is something you have considered incorporating into your practice, it can help you attract new patients and increase income—if you do it right.
Naturopathic physicians are providers who often work as primary care doctors treating a range of conditions from allergies to chronic pain, from obesity to menopause. They can perform minor surgeries like stitches and prescribe certain medications, although their scope of practice varies by state.
The core work of a naturopath, however, is a focus on wellness and disease prevention, and treating patients with nontoxic therapies. They receive a medical curriculum much like an MD does, and they also have a strong focus on holistic care, including nutrition, homeopathy, botanicals, acupuncture and counseling.
Naturopathy is a small but growing modality with about 6,000 licensed practitioners in the country, according to the American Association of Naturopathic Physicians (AANP). Currently, 20 states and the District of Columbia license these doctors who graduate from a four-year residential naturopathic program and are required to pass a board examination to gain licensure.
Though not all states license naturopaths, these doctors are working everywhere. The important thing to understand is they can only practice according to each state’s guidelines. Their scope of practice is going to vary in every state where they are licensed, says Amy Rothenberg, ND, past president of the Massachusetts Society of Naturopathic Doctors.
In states where naturopaths aren’t licensed, some have dual degrees and work under an acupuncture or chiropractic license. Others work as health counselors or act as physician extenders, working under another licensed provider. In these particular states, it is especially important to determine the training a naturopath has, Rothenberg says. “In states where they aren’t licensed, anyone can call themselves a naturopath,” she says. “I’m sure they are nice and have studied very hard, but they didn’t go to medical school.”
Naturopaths are a sound option to take over primary-care services for practices like Provencher’s, thanks to the time they are able to dedicate to patients. When a new patient arrives, a naturopath will often do blood work, an exam and may sit down for an hour—or more—going over a person’s diet, nutrition and lifestyle factors.
“A naturopath can bring in a broad spectrum of armamentarium therapeutically,” says Frank King, ND, DC. “They can order lab tests that can be utilized to discern how to balance hormones or body chemistry. They are well-schooled in the latest and greatest of all of those arenas of natural care.”
King said bringing in a naturopath instantly makes a chiropractic practice “more green, holistic and eclectic.”
While some naturopaths can prescribe medications, many opt not to even if their scope allows it, Rothenberg says. This jibes with the natural tendencies many chiropractors ascribe to in their practice. Naturopaths can help patients who are seeking noninvasive approaches to pain for maladies like chronic disease, back pain and headaches.
Naturopaths can use their training to augment adjustments by doing things like recommending magnesium for chronic pain and other herbs with anti-inflammatory properties to nourish soft tissues and joints. Naturopaths can also help reduce a major instigating factor of pain: stress. Stress management and reduction is typically a part of their training.
The first step to take before bringing in a naturopath is to verify they have been trained with a clinical background at one of the eight accredited schools in the U.S. and Canada, says Scott Muzinski, DC, NMD.
Next, it’s vital to understand the practitioner’s goals and how they foresee working with a chiropractor.
“Some work great together and share information well,” Muzinski says. “And there are some providers who think theirs is the only profession with the right answers.”
It’s also important to ensure a naturopath has an acceptance of the general philosophy behind chiropractic medicine, according to Jaclyn Chasse, ND, vice president of scientific and regulatory affairs at Emerson Ecologics. This helps ensure that referrals from the naturopath and chiropractors aren’t forced and the two sides are working on the same page.
When you are considering bringing anyone into your practice, it’s crucial to understand if they share your philosophy and practice goals. The best way to do this is to have clarity about your core beliefs.
“You need to have a practice philosophy that is well-articulated and documented.” Rothenberg says. “And they (the naturopath) should know theirs. Most people have this written down.”
Finding a good match in integrative clinics isn’t always easy. On paper, a provider can look great, but might not work out in practice. You don’t have to align on every point— sometimes different skill sets can make things work better —but your “broad-stroke philosophies” should be similar, Rothenberg says. For instance, some naturopaths are more likely to prescribe medications; others won’t at all. You would want a point like this to align with your practice philosophy.
It may also be beneficial to bring in someone who has a similar clinical interest as your practice. Naturopaths are trained to treat most aspects of primary care, but some may focus in narrower areas. If your patient population trends toward men over 50, you might want to work with someone who is interested in cardiovascular medicine. If you have a younger female population, a person with training in women’s health may be a good fit. Rothenberg knows a naturopath who only works with patients with kidney disease.
“Some people do specialize, mainly because of their personal interests and development of their expertise,” she says.
Making it work
Integrating any new provider into a practice can be a challenge, but there are some items to consider that can make the transition a lot smoother.
Rothenberg suggests talking to your existing patients to make sure there is an interest in naturopathic medicine. If any have been treated by a naturopath, they may be able to direct you to ones with whom they have had good experiences.
“You need to make sure they were a good listener and compassionate and capable of fielding patients you will send their way,” she says. She also says it’s imperative to ask for —and contact—a person’s references before bringing them into your clinic. Hiring on a three-month trial basis is also something Rothenberg highly recommends.
There are various business arrangements that can be made with a naturopath, and which one works best is going to depend on how the providers work and your state regulations determining their licensure and scope of practice.
Some naturopaths will work on salary, and some on salary plus a bonus for patients they bring into the practice. Some may prefer hourly rates and some a percentage of fees. They can be hired as staff members or as independent contractors renting space in the practice. The last option works well for a chiropractor who wants to have a tight referral network, but not want to deal with having an employee to pay and oversee, Chasse says.
Provencher says having an independent contractor relationship with his naturopath has worked beautifully for six years. It has provided them with an internal referral network and each person gets their percentage of the bill when they collect.
With this scenario, it’s good to set up boundaries, Rothenberg says.
“It’s simply shared space with clear expectations of each other’s expertise and how referrals will be shared,” she says. “The most important key to success is an understanding of who is treating what and how. To have a successful collaboration, there needs to be clarity around each provider’s interests and strengths so you are not stepping on toes.”
Muzinski stresses the importance of understanding that bringing in a new doctor will be part of a building phase. It may be part time or on a contractor basis initially until demand grows. Naturopaths may be able to bring their own clientele to the practice. If not, you may be bringing someone in to build a business around through both internal and external marketing.
“Most people do stuff through the web today and it’s pretty easy to change your website and start sending emails saying, ‘We are now capable of doing this,’” Muzinski says. “It may build up pretty quickly depending upon where you are at.”
King cautions that, whatever arrangement is made, it’s wise for chiropractors to have some kind of contract with a naturopath they bring into the office—particularly if the chiropractor is bringing in a young practitioner and building up a business. You will need to put something in place that keeps them from going down the street after a year and raising their own shingle to see your patients.
The business model
There appears to be little downside to bringing in a naturopath and the financial case for having one in a practice is relatively strong.
Muzinski wanted to focus on primary care with his patients from the time he was in chiropractic school. Patients in his office get blood pressure and pulse readings, physical exams, urinalysis and regular blood work from a naturopath. Bringing in this provider enables you to have a full primary care practice without extra training or sacrificing time spent on adjustments.
“Having a naturopath has been a huge financial support,” he said. “There are a lot of patients who come specifically for that particular piece.”
Chasse agrees. It can bring people into the clinic who wouldn’t think of a chiropractor as part of their normal care team, she says. Someone may come in to get herbs for a digestive issue and be introduced to chiropractic for that or other health issues.
“It can be a practice builder for those kinds of patients,” she says.
Naturopaths can also change the flow of income. Depending on your state, some naturopaths can take insurance. And if they don’t take insurance, they can add a cash element to a practice that may not already be there.
“The option to have cash running through a practice, paid at the time of service, can be a big draw,” Chasse says.
And while many chiropractors have dipped their toes into offering supplements, Chasse says they account for as much as 40 percent of practice revenue for a naturopath.
“That is pretty substantial revenue that often is shared if the naturopath doesn’t own the business,” she says.
Other strong revenue drivers are blood draws, nutritional IV and pain injections, homeopathy and therapies like platelet-rich plasma injections. Some naturopaths, Chasse says, have even moved into doing cosmetic work. This is an area ripe for growth, considering in 2017 there were nearly 16 million minimally invasive aesthetic procedures performed in the U.S., according to the American Society of Plastic Surgeons.
“Working with a naturopath can bring revenue that can augment and compliment any primary care a chiropractor is doing,” Chasse says.
Tammy Worth, a freelance writer based in Kansas City, Missouri, specializes in business and healthcare subjects. She can be contacted at firstname.lastname@example.org.
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