This original article was featured in the August 2022 issue The American Chiropractor. 

Rethinking Retention 

If patients knew what I knew, they would do what I do. No doubt you know that saying. We’ve all been taught that patient education is essential regarding retention. It’s so ingrained in us that we assume it’s the truth.

I believed it was the truth and spent years educating my patients. New patient workshops. Weekly handouts. Table talk. TV’s throughout the office show educational content. You name it; we did it.

Yet, despite all that education, we still had patients who would drop out of care. It floored me when a patient I knew got the big idea about chiropractic suddenly stopped coming in for care.

And even more confusing was the patient I knew didn’t understand the actual benefits of chiropractic, yet they were sticking to care. Why? Why did some stick and some didn’t? And why were my patient education efforts not causing my patient to “do what I do.”

Can you relate? Do you find yourself banging your head against the wall? Why won’t patients just get it?

Me too. I set myself on a mission to figure this out. If it wasn’t patient education alone, I wanted to know what makes some people stick to care while others don’t. So I turned my practice into a laboratory and started interviewing my patients on camera. 

 I’d ask them questions like:

“You’ve been coming here for over two years and have over 100 visits; why are you still coming?”

“You left your prior chiropractor to come to see me. Why?”

“When you first came in, you made it clear you did not want to be told you need to keep coming back, yet you still signed up for care and are still here. Why?”

I asked lots and lots of questions from a large group of patients to learn all I could. I wanted to know what made them tick.

Guess what I didn’t hear them say. Not a single one mentioned anything about patient education or my care. Shocker!

I share my expertise on what drives our patients’ behavior to follow through because patient retention is the most important thing you need to master as a chiropractor. Why?

If there was an adjustment I could teach you, and you would always get better clinical results, would you want to know it? Of course, you would.

Would you agree that the reason you may not get the best clinical results for a particular patient is not that you don’t know that magical adjustment. It’s simply because your patient failed to follow your care recommendations. They prematurely dropped out.

And if you’re willing to learn that magical adjustment to get better clinical results, wouldn’t it make sense to master what it takes to help patients follow through with your care recommendations better?

Don’t make the mistake of thinking retention is all about making more money. Granted, high retention practices do make a lot of money. But that is not the reason to focus on retention. We focus on retention to help our patients do better. And yes, as a result, you generally make more money.

I know many doctors who focus on retention and whose practices grow year after year—in a decade, growing from a few $100k per year to well over $1M to $2M per year in cash collections.

Retention is something that a lot of practices struggle with. It can be overly complicated to create a high retention practice, or sometimes people just miss the mark entirely. We all know how important it is to have a patient stay for the recommended treatment plan to improve their outcomes. For a practice to succeed, it must have a high retention rate. So why is it so hard sometimes?

While patient education does play a role, there’s a bit more to the equation. Do you know at what point your patients are dropping out? Taking the time to identify this will help you diagnose where to make improvements that can make HUGE changes to your retention rate. 

You may be AWESOME at getting patients to say “yes” to care but then lose them two months later. Or, you may struggle just to get that shopper call to show up for their first appointment. Others may lose patients as soon as the insurance benefits have been exhausted, but the patient comes right back at the beginning of the following year. 

We want to look at the whole picture to make sure that the entire journey for the patient is complete and doesn’t have any points that the patient drops out. 

When working on improving retention, it’s essential to think of the most common scenarios in which a patient may drop out of care so that we can adequately neutralize those. I’ve identified eight of the most common situations where a patient may fall out of care. I refer to these as “Dangers,” and they take place at different touchpoints throughout the patient journey in your office. 

Let’s dive into what these dangers are. In this scenario, Dr. John and his CA, Liz, have a patient by the name of Scott, and we will review where these dangers can take place and what causes them. More importantly, we review the solution to avoid these. 

Danger #1: Scott No-Shows For His First Visit
Cause: When Scott got off the phone with Liz, he wasn’t sure this was the right place for him. Whether that was due to Liz’s tone of voice, her inability to focus on Scott, or simply not connecting with him, he decided to shop around for another doctor.

Solution: Liz answers the phone with a smile and eagerly assists Scott, putting all other jobs aside to give him 100% of her focus. To avoid the danger of Scott not showing up for his first visit, Liz will email him a warm welcome message with a brief explanation of what to expect on the first visit. This email helps put Scott’s mind at ease and build even more rapport, making it easy for him to show up.

Danger #2: Scott No Shows For His Report of Findings
Cause: Dr. John and Liz failed to build rapport, giving Scott hope that Dr. John would be able to help him.

Solution: When appropriate, patients should leave the first visit with a feeling of “I sure hope, when I come back for the report of findings, Dr. John tells me he can accept me for care.” Liz will send Scott an email after he leaves stating what he should expect when he returns for the Report of Findings. It states explicitly Dr. John will let him know if he can accept him as a patient, motivating Scott to return.

Danger #3: Liz Is Unable To Prepare A Care Plan Properly
Cause: Dr. John doesn’t take the time to Forecast Care and build a comprehensive treatment plan based on clearly defined objective findings or with a clear patient goal in mind. This failure to Forecast Care makes it nearly impossible for Liz to build a care plan. How can Liz be expected to go over payment options for Scott if she can’t create the care plan?

Solution: First, Dr. John needs to know the goal of care for Scott. Second, this goal will allow Dr. John to forecast how long and how often Scott will need care and precisely what that will involve. Knowing this information is vital for Liz to build a care plan.

Danger #4: Scott Will Likely Say “No” To Care
Cause: Liz failed to build a comprehensive and compliant care plan in advance of Scott’s report of findings. For Scott to say “Yes” to care, affordable payment options must be forecasted.

Solution: Liz took the treatment plan Dr. John forecasted for Scott and built it into his care plan. Because Scott can see the end goal and has payment options that fit into his existing budget, he will feel more comfortable enrolling & committing to care. This gives Liz the confidence she needs to go over finances.

Danger # 5: Scott Says “No” To Enrolling In Care
Cause: There can be several reasons why Scott says “No” to care. It could be that Dr. John has poor communication skills, isn’t prepared with a forecasted plan, didn’t demonstrate the need for care in an easy-to-understand format, didn’t show Scott the expected results, or failed to make a good case presentation.

Solution: Dr. John is prepared to present his clinical justification using The Wellness Score to accept Scott as a patient. Once Scott says “yes” to the forecasted treatment plan, Liz will present the prepared care plan and allow Scott to select a payment option. Scott loves seeing what to expect while under care, with no hidden surprises, both clinically and financially.

Danger #6: Scott Drops Out Of Care Early
Cause: Scott may drop out of care when his symptoms and pain go away or when his insurance benefits are exhausted. Patients often lose motivation once their symptoms are gone, leading to missed visits and the risk of dropping out of care. Those solely using their insurance typically fall out of care when their insurance stops covering care, and their out-of-pocket cost goes up.

Solution: When Scott enrolls in a well-forecasted care plan, he knows what he’s committing to in advance. Simply having that agreement upfront significantly reduces the likelihood of Scott dropping out early. Since Scott’s insurance was already incorporated into the care plan right from the beginning, Scott never needs to have his out-of-pocket cost go up, even when the insurance ends, or his symptoms go away. Scott enrolling in a care plan neutralized both of these common causes of premature drop-out.

Danger #7: Scott Misses Visits And Drops Out Of Care
Cause: By the time Scott arrives at this point, he’s committed to a forecasted care plan, is making automated monthly frictionless payments, and is frequently contacted with emails. The most likely reason Scott would start missing visits is that Dr. John fails to do regular progress exams and gives Scott feedback that’s intuitive. Scott not knowing the progress he’s making towards the goal of care makes it easy for him to lose motivation and drop out early.

Solution: Throughout care, Dr. John performs regular progress exams and reports to Scott the progress he’s making. This feedback is essential once Scott’s initial symptoms no longer motivate him to stay under care. This feedback reinforces to Scott that he benefits from the care and alleviates Dr. John from the awkwardness in convincing Scott to keep up the course.

Danger #8: Scott Says “No” To Wellness Care
Cause: Scott will likely drop out of care at this point if there are any considerable financial hurdles. For example, Scott had prepaid instead of making automated, frictionless monthly payments. He will now have to decide if he wants to make another big purchase for care. If Scott were on anything other than the monthly payments, he would likely have to think about the new program. This new “purchase decision” is the most significant reason patients drop out during the transition to wellness care.

Solution: Knowing the great clinical news Dr. John gave Scott when completing the corrective care plan, Liz confidently delivers the good financial news that Scott’s payment will go down. Since Scott’s monthly payment was already part of his monthly budget, the fact that the new payment is less makes it a no-brainer for him to continue.

If you find yourself losing patients at one or more of these dangers, give it a shot at implementing the solution provided and see how quickly it neutralizes the danger and thus increases your retention rate. 

As you can see, there are very predictable causes of patient drop-out. When you know the reason, you can find the solution. Those doctors who make it a focus on using systems that provide a solution to these dangers are the ones building the high-retention, profitable practices.

About the Author:

For nearly two decades, Dr. Miles Bodzin ran a successful, high-retention wellness practice in San Diego, CA. He retired from practice in 2011 to focus solely on helping chiropractors increase their patient retention. As Founder and CEO of Cash Practice Systems, Chiropractic’s #1 Technology Platform for Creating Loyal Patients, his leadership resulted in serving over 6,000 chiropractors, being listed on the Inc 5000, and being named one of San Diego Business Journal’s Most Admired CEOs. Dr. Bodzin may be booked for interviews and speaking engagements at bookings@cashpractice.com or reached directly at drbodzin@cashpractice.com or 877-343-8950 x200.