Space, Pace, and Budget: A Guide to Choosing the Perfect Niche

Welcome to the Practice Builders Podcast hosted by Dr. Vince Leone and Dr. Kyle Pankinen, your source for building cash services. Let's dive in. Hello and welcome everybody to the Practice Builders Podcast. My name is Dr. Vince Leone.

And I'm Dr. Kyle Pankinen.

And, uh, welcome back for another episode where we kind of dive into how to add and grow high-value cash services in your practice, or what we call a high-ticket niche. Dr. Pankinen, how are you, sir?

I am great. Excited for this episode and good to be, good to be with you with this.

Awesome, awesome. So today's topic, how to choose the best first niche or second niche for your practice, right? So some doctors may have a niche and they're wondering, well, what's the best second niche to add? Or some doctors Um, they don't have any niches and they're like, what's the best first niche to add? And I've found like when, you know, when doctors, um, when we jump on prospective client calls, right, they kind of fall into 3 buckets. They either have no— they have a successful practice, right, um, and, uh, chiro practice, and they see the value of adding a high-value cash service because they're gonna, you know, diversify their revenue streams, you know, less reliant on insurance, make more, work less, the whole thing. Um, or they have a niche and maybe they— but they can't seem to get it going right. They're, they're kind of stuck. It's not really working. It's not making the money that they anticipated when they invested in the equipment. And, um, so they're looking for a proven model. So that's like the second, second gentleman or lady who is, uh, wanting to grow these services or Finally, the bucket, last bucket is a doctor. Hey, they're doing really, really well with this particular niche and they're wondering, well, what's the next niche I should add? Um, thoughts on that, Dr. Kao?

Yeah, there's doctors that come into this with various degrees of experience. The bottom line is though, these are all niches that we're gonna talk about that can add significant revenue to your practice that don't require, uh, some, there's some investment, but there's not a ton of investment and you can fairly quickly get a good return on your investment. So whether you have one niche or 2 niches, this, this will be an applicable discussion for you. If you're looking to add in even that 3rd niche, it's, it all is relevant here. And there's some really exciting niches that we can choose from in our profession. So I think with that, we'll let Dr. Vince introduce what we think is Probably the, the best niche to add that makes most sense for us as chiropractors.

Yeah, 100%. And I always default to decompression because it's the best first niche, right? So when— and the reason why I choose decompression is it's actually one of the most affordable, right? Because if you get into— and we'll get— we're going to talk about, you know, the, the options, right? What are the niches available to us in just a second. But I always typically lean towards decompression because it's, it's so perfectly aligned with our current scope of practice, right? Our specialty is the spine. Now, a lot of doctors aren't really specialists in the disc, and that's something that we help them with as well in the program. But, you know, patients totally expect, hey, if I have a spinal issue, it's a chiropractor. Right now, if I have a knee issue or a foot issue, that's not so much that they're going to say, hey, I should go to the chiropractor, right? And so what I've found, and I would love to hear kind of your thoughts on this because you're in active practice, I am not. I went into full-time consulting in 2018, but I found about 15%, right? 10 to 20%, call it 15% of just regular neck and back pain patients coming into your office, just your new patient flow. referrals, advertising stuff are disc patients, right? So you can invest in a table, and if you know how to evaluate, qualify, and enroll, you can immediately generate more revenue, serve these patients at a higher level, right? Treating the disc with decompression, which is the best nonsurgical therapy for disc. Um, and boom, you're like off to the races.

Every doctor has these cases in their office already, even without doing advertising. Dr. Leone is right. Somewhere in that 10 to 20% range of people that are coming in that have radicular component, neck and arm, low back and leg. These are— most of these are disc conditions. And chiropractic is powerful. Chiropractic can help a lot of conditions: facet syndrome, SI joint problems, subluxation, a lot of the common biomechanical-related back and neck conditions we treat. But a lot of chiropractors struggle in handling these more challenging cases where there's a disc bulge, a herniation, spinal stenosis, and things of that nature. And to have these higher-end therapies, namely here decompression, can really set you apart from your competition down the road that doesn't have this. Or even if they do, it doesn't really matter because this patient base is already coming into your clinic anyway. So Every chiropractor could have a decompression table, and there's plenty, plenty, plenty of these cases to go around.

Dr. Pankinen, you know what the funniest question I get is? Decompression dead? Yeah. And I'm like, dead? Well, are there patients that no longer have disc issues? Because I'll tell you what, I have a good buddy, and he is Uh, in the ER with the spinal surgeons for spinal surgeries every single day because he's the rep for the company that makes the pins, the screws, all that type of stuff. By the way, one pin is a grand. That's what they charge for a grand. So, and these costs are going through the roof since COVID Anesthesia alone can be $100 grand, he said, which is just bizarre to me. So these, these surgeries are going up to $250,000 for a spinal surgery. Okay. Now, Um, so is decompression dead? No, guys, not even close. Just like Dr. Pankinen said, it doesn't matter if there's 10 doctors down the street and they all have a decompression table. If you have new patient flow, you're gonna get disc patients and then you can treat them. And our average case is anywhere from like, say, $3,000 to $6,000 depending on what services that you include in addition to decompression or just Maybe some doctors just do decompression, and you can add revenue quickly and easily by just adding a table and bringing up your skill sets so that you can properly evaluate, qualify, and enroll.

Couldn't agree with that more, docs. If you don't have decompression, add it to your practice. It's an easy niche. You can polish up a little bit on your exams, get a little higher end so you can identify those disc cases. Get— if you don't have x-ray, you're probably going to have to have somebody that can do that for you. A lot of these people come in, have already had MRIs that show disc, but also develop a relationship with a local MRI facility or a local medical facility that's willing to do these for you, and you're off to the races.

Let's talk about some other niches that are available to us, Dr. Pankinen. What are your, say, top What do you think the top 4 or 5 niches are for chiropractors?

Yeah, if I was gonna go into order of them, I would probably list— like I said, we've talked about decompression first. I think chronic knee pain is a beautiful addition to most chiropractic practices.

I think you could love the knee pain niche.

Love the knee pain niche. And we'll talk in a future episode about the equipment you need for that. But as Americans are aging, we have an aging population. We have an overweight population, and osteoarthritis is one of the more— in the knee is one of the most common causes of disability in older Americans, and the rates of that are rising. So if you did nothing else but targeted osteoarthritic knee patients, say 60 and older, you have a whole big niche group of patients. that are looking for help because medically they really only have 3 tools in their toolbox for almost all pain. This is a true statement. Either they're gonna give pills, shots, or surgery. Well, pills don't fix it. Shots only give temporary relief and they actually destroy cartilage and bone. We know that from studies. And surgery is always the last resort. So if we have a protocol that we can use to treat these things non-surgically, You're going to have a big demand for that. So knee is a beautiful niche to go into next, and it's fairly easy.

It's—

most chiropractors know how to do at least a basic knee exam, and if you polish up on your skills a little bit with that, you can develop a high-end exam with a little bit of practice and training and be off to the races with that niche as well.

And there's a lot of correlation with knee and back, right? So if they have a disc, Or a chronic back issue, a lot of times the knee, or it'll be one or the other, right? They may come in with a knee and then they need the back worked on after, or vice versa. So it's a beautiful opportunity to continue to serve the patient because once you say, say a patient comes in with a disc issue and you treat them with spinal decompression, they get excellent results and they're they're like, oh doc, by the way, I didn't tell you because my back is so painful, but my right knee. Is really an issue as well. It's probably related, right? And so then they're like, you know, is there anything that you can do to help with my knee? Or even better, you tell these people, hey, we also offer this service, right? Through signage in the office, regular communication via email, etc. And they're like, hey, can we do an evaluation on my knee? You did such a good job on my back. Do you have a non-surgical, drug-free protocol? For my knee as well.

Sure do.

And then you do the evaluation, and now they're like, yeah, this guy already helped me once. They don't want to go anywhere else. This is positioning, right? So when you start to position yourself as an expert in these tough chronic conditions, and and we focus on chronic back, knee, and foot, then patients will stay with you and continue to invest with you because once they see. It's, it's a trust issue, right? So once you get them over the hump, prove that you can help them. No one wants to go to surgery if they don't have to, right? They're in rehab for like 6 months for a knee, right? Who wants that? Or for back, probably the same. So, um, love the knee niche. Uh, what's next, Doc?

We'll talk about a couple of foot niches. So a nice easy one for doctors to implement in their practice would be plantar fasciitis. Huge group of patients I have out there. Some of the same reasons we see knee overweight population. We see a lot of people into running sports and things like that too that that have that condition, and that this one affects a larger demographic. I mean, you see from all the way from 20-year-old runners up to 70, 80-year-old patients that have this condition, and with a couple of good basic therapy things that we'll talk about on future podcasts. That is an easy niche to add. And probably the, the final 2 niches I would mention would be peripheral neuropathy. Again, a foot condition mainly. Granted, it can affect the hands, but most cases are gonna be the feet. And then weight loss.

Mm-hmm.

Now you have to look at order of complexity. Spine fits most chiropractors, easiest to implement. Knee would probably be second, followed by plantar neuropathy cases. They can put a few gray hairs on your head. And those are— some of those are challenging. That was the first niche that Dr. Vince added to his practice.

Probably not the best idea, but I just made it work.

He just made it work. But some neuropathy cases can be very challenging, and there's multiple layers and multiple potential causes. But If you take these cases on, you get the training, you get the protocol honed in. These can be some beautiful, beautiful cases where you will make a tremendous difference in these people's quality of life, and they they will love you. They'll buy you cookies and candy and rolls and donuts, and come in with a smile. I've seen it many times. So tell us a little bit more about your neuropathy niche, Dr. Vince, and what you saw in your own practice with that.

Yeah, I mean, I just didn't know any better, you know. I was struggling. This was 2009. I had just started my own practice. I was an associate for 2 years for my father, and of course I knew more than him, you know. He'd been in practice for 35 years at that point, and I had been in practice for 2 years and knew way better than him. So I decided to start my own practice, promptly struggled And my coach at the time, Dr. Brighton Moser, he's like, Dr. Veens, you got— you're, you're dying. And I'm like, you're right, I am. You're my coach.

What the heck should I do?

And, uh, I always credit him for saving my career. And that's why I went into coaching. Um, because, you know, I, I think we need coaching. I know we need coaching. But point being is he said, I have a friend, Dr. Joe DiDuro. He's teaching neuropathy. Go train with him. And I did. And that's— and I just You know, I just didn't know any better. In other words, in terms of like, well, what's the best niche to go into? Because neuropathy, as Dr. Pankinen just, you know, um, kind of stated, it's complex. And so where you're talking about like, you know, disc, knee, um, and plantar is musculoskeletal, you know, or soft tissue. Well, neuropathy is obviously neurological. So there's— you have, you have multiple layers to that condition. Um, you know, thankfully we had a good protocol and I just kind of, um, just, you know, kind of went into it blind, but just, uh, I didn't really have any other choice. Point being, I was going to make it work come heck or high water. Um, so, uh, these patients are in dire need. Now with us and at a specialized practice, we do an in-office protocol. I know that there's, um, coaching programs out there that do a home-based protocol, right? You send them home with some lights and Rebuilder and that type of stuff. In my experience, and Dr. Panknin, um, I would be curious to hear your thoughts on this, I just think they need more help than that, man. They just— these people are sick, and they've, you know, 70% of all neuropathy patients are diabetic-induced, so they're not very healthy. Um, I like using super high-quality equipment in the office, um, that we can really address the multi kind of factorial issue with this condition. I don't know, what are your thoughts on that?

For the more challenging conditions, you need a, you need a robust in-office protocol, in my opinion. You— there are some tools that you just can't send home with a patient, like a Class 4 laser or some type of electroanalgesia. And the home therapies that are used can be good adjuncts, to an in-office neuropathy program. But I think in the long run, you're gonna get better results by having a hybrid model where you're having them come in the office for the bulk of their treatment, but they also at the same time have some type of therapy that they're doing home on a daily basis. The home care model, I think, can get results. So, so some of the more mild or mild to moderate cases. But the moderate to moderate to severe cases, it's going to take a robust in-office program to tackle that monster. That's no doubt about it, in my opinion.

And here's the problem is if you're thinking about going one way or another and you start charging patients $6,000, $7,000, $8,000— our protocols aren't typically that expensive. We like to, we like to basically, you know, under-promise and over-deliver. So we're usually around that $4,000 to $6,000 depending on the kind of the market. Other programs, they're charging like $8,000 to $10,000, partially because they're— they have about $2,000 roughly in hard costs, right, with the rebuild or the lights, etc. So they're trying to make up for it, right? But I'll tell you what, if you take too many people's money that don't get results, your confidence sinks like the Titanic, and, uh, you're not going to be offering these niches much longer.

100%. And that's what it all— that in order to get conversion, to get people to say, yes, I'll do your protocol, you got to be Very confident in your protocol and in your opportunity to get them results. You kind of got to know what your batting average is, what your percentage of success is, and be able to then confidently look them in the eye and tell them, these are your— this is your odds, Mrs. Jones, of getting this— these results. You know, last year in clinical in my practice, we were able to help 84%. of my neuropathy cases. I keep track every year, year to year, what my percent success rate is. So when I have a prospective patient come in, I— and as part of their report of findings, I tell them things like this. So, Mrs. Jones, you have an 84% chance of getting a good to excellent clinical outcome, meaning 50% or greater relief of this chronic condition you have.

And that is, you know, so Dr. Pankinen is obviously— he's our dedicated clinical coach at Specialized Practice, and that is just such a fantastic benefit that he brings to the table for our members because he's been tracking our protocols for the last, what, 3 years, Doc? Something like that?

Yep. Well, more than that on my own, but as I've been with you for the last— actually, this is the 4th year of doing it now, and consistently with Our decompression protocol, knee protocol, neuropathy protocol, and plantar protocol, we are right always in that 80 to 90% range. I did have one year with decompression, we're at 94.6%. But bottom line is, I tell docs when I consult with them, if you have a protocol that can help 80% of your cases to get at least 50% or greater relief, You got a pretty good protocol. If you can't get 80% of them better, then you gotta tweak your protocol and enhance it in some way, shape, or form. So bottom line is, that's how you develop that clinical confidence, though, is track some of your results. So doctors that are adding a niche to their practice, I always coach them to track your results at least your first year or 2 so you know what you're doing. What kind of success rate you're getting. And then you can tell patients, this is— there's some studies out there that show this and this and this, but this is what I'm accomplishing in my own clinical practice. And you'll build a lot of confidence doing that.

Yeah. And one thing, you know, when clients come on, uh, if they haven't been in the high-ticket niche world, they get a little, you know, they're a little nervous, right? Hey, you know, is this gonna work? And, and should I charge this, you know, this much money, all this type of stuff. But What I always tell them is like, hey, you have not treated thousands of patients with these protocols, but this protocol has, and you get to use this protocol. So lean on the protocol and you don't have to lie to a patient. You don't have to say, hey, oh, I've been doing this forever. No, no, no. We— I trained with a coach. We have proven protocols. It's helped thousands of patients around the country, and it will work for you if I can qualify you for care. So that's made a big difference for a lot of doctors just starting out. From that confidence factor, because I'll tell you what, Doc, and you you nailed it with that confidence in the report of findings. A lot of doctors like oh gosh, I don't know if I can sell. If you're confident that you can help the patient, the patient senses that, and money is is way less of a factor, right? If you're trying to talk them into care or that type of BS, no bueno, right? You you you speak to them, you know, obviously respectfully. We have a whole report of findings. training on how to do it properly. But when you have that confidence that you can help somebody, they sense that, and, you know, then it's just a matter of figuring out the finances. Now, really quick, I have a 3 kind of pronged approach of how to choose the best niche for you, best first or second niche. I like space, pace, and budget. Okay, so really quick, how much space do you have in your clinic? Now, like knee niche or neuropathy doesn't take up a lot of space. But decompression, you know, those tables can be fairly large. The Hill's not that big, but if you get like a DRX 9000 or Accuspina, those are quite large, right? So you have to think, okay, space. How much space do I have for my clinic? Next one is pace. Now, if you offer neuropathy, that is a different pace, right? These are the average age of neuropathy, 62 years old. So If you have like a kind of a young, more vibrant patient base, like they're in their 30s, 40s, 50s, um, bringing in neuropathy probably won't make a lot of sense. I mean, it's just, it's going to be kind of like a little contradictory. Um, what are your thoughts on that, Doc?

Yeah, neuropathy patients, I mean, they're obviously, they're older, they move slower. If you do an in-office protocol with them, they're going to be in the office 45 minutes.

Yeah.

To an hour. And so unless you have some dedicated space where you can, you don't have to have that space for something else, it's gonna tie up a room or 2 for quite some time. So those are some considerations that you need to think about with neuropathy, even though the machines itself doesn't take up a lot of space, but they'd have to be on these therapies for a, a pretty good chunk of time. So something to consider. The knee niche, that one doesn't take quite as long as a neuropathy case does. And decompression, you're probably looking at 30 to 40 minutes. They're gonna be in the office, but neuropathy can be close to an hour in some instances. So those are things that come into play. Plantar is pretty quick. You don't need much space for that.

Mm-hmm.

So good point. Those are some things to keep in mind and consideration when choosing your next niche.

Yeah, yeah. And then finally, budget, right? So we have space, pace, budget. By the way, back on pace, if you're an older doctor, been in practice for 30 years, and you really— and you have quite a bit of Medicare patients. By the way, I love Medicare patients. Um, if— and you have like a high Medicare kind of contingent in your patient base, and you like complex cases, like you, you, you get excited by the clinical side of things, neuropathy may be a phenomenal niche for you. Because you can spend more time with these patients, you can get excellent results, you can connect with them because you're probably close to their age range or getting there. And that's like my father, you know, he's, he's, he's Medicare age and he works with a lot of these patients. So, so, so something to keep in mind for you docs that have been in longer, and if you like, really like the complex clinical cases. But then finally, budget, right? What is your budget? Because interestingly, decompression is probably the least expensive one to get into, right? Because you really just need the table and you can, you know, there's a wide range of tables. I mean, you can buy a Chattanooga table, not that I would recommend it, but you could, and for like $5,000, $6,000 on eBay, right? So you could get in super cheap on decompression. I don't know that I— I don't, I don't want to say I don't recommend the Chattanooga. I, I know doctors that have it and get good results and, and, and, you know, have been cranking them out. Um, I just, you know, I like a little, a little more robust table personally. Um, but, you know, that's all you have to buy. Whereas with, like, you know, neuropathy, knee pain, you're going to have, um, a couple different therapies, you know, Class 4 laser, shockwave, etc., NeonTrack. And, you know, they start to add up.

Yeah, that's exactly right. So you can, you can get in the decompression niche fairly cheap. If you're gonna get into the world of Class 4 laser, which we recommend for a lot of these niches, and we'll talk a little bit more about our next episode, those can get up there in expense. But we will also have an episode coming up where we'll talk about how to really do well with your Class 4 laser. For laser shockwaves can be a little expensive too. So that decompression niche, I think it still comes back to that. If you're looking to add a niche, that's a great place to start. Or if you have one of these other niches but you don't have the decompression niche, that would be the next one to add. And I think that's a great place to, to leave it here, Doc, is to just— we, we did, I think we did a good job of covering the niches that are available. We could touch on weight loss too, but We can save that for another day. But neuropathy, as Doc— like Dr. Vince said, is not dead, docs.

None of them are dead. And one reason why we chose these niches, because this is what we specialize in, right? We specialize in decompression, knee pain. So chronic back pain, knee pain, foot pain, whether it's plantar or neuropathy. So we chose these for a couple reasons. One, they're all weight-bearing, right? So in other words, Versus like a shoulder or a wrist or an elbow, it's it's going to be really impactful to someone's life. So in other words, they want to get it fixed. So that's number one. Two, there's large audiences: chronic back pain, chronic knee pain. These are massive. The the number, the the patient audience, right? The number of people that have these conditions, they're huge versus like say shoulder, elbow, wrist. You want to go where the fish are swimming, right? So we want to address. you know, conditions that are really affecting someone's life so that we can positively change their life in a big way. And we want a lot of people to be able to choose and help, um, in that particular niche. That— so there was, you know, a lot of thought put into why we chose these particular niches. Again, weight loss is a great niche if— but, you know, for me, I didn't really love working with weight loss patients personally. It was kind of outside the scope of practice. I think that it can be a really good niche. It just— you need to dial in the staff-driven side of things so that it can really be a true passive income. But if you do that and you have the right protocol, I think that it's a nice thing to add. I don't think you're going to make a million bucks, but, you know, if you can, you could probably add $10,000, $20,000 pretty easily.

Agreed. Yeah, I'm not crazy about the weight loss niche as far as I just— it's not quite, I would say, in the wheelhouse of most chiropractors. I mean, it's kind of diverging away from what we maybe would— people would traditionally think of us for. Not that there's anything wrong with it, and I think doctors can be very successful with it, but it— the weight loss niche, you got to have dedicated room for it. You got to have staff trained specifically for that. And, uh, some of those can be pretty challenging people, especially if you have— if you're relying on patients to change their lifestyle, which most Weight loss. Good luck. Success entails— if you're just relying on lasers and things to shrink some inches and they're unwilling to do their lifestyle changes, you're going to have short-term success. That's about it with a lot of these programs. So, uh, you got to have a strong lifestyle component to really get long-term success.

Yeah, that's a great point. Okay, so I think that's a great place to stop. Any last words there, Doc, on the best first or second niche to choose for chiropractors?

Bottom line is these niches are all exciting. You gotta find what resonates with you best clinically. And the bottom line is with these niches, you don't need to reinvent the wheel. There are doctors out there that are successfully doing these niches. And so if you have interest in getting into these niches, places like what we have, specialized practice, can really take the guesswork out of it, teach you a proven protocol that you can follow, and you don't have to struggle. You can just hit the ground running in a few, couple, 3 months. You can hit the ground running and start seeing success in many cases and build these niches up to make these cash-based high-end ticket niches a big part of your practice. And, uh, it's a lot of fun.

Yeah, 90 days or less and doctors are rocking and rolling. So, um, all right, so that's it, uh, it for this episode for the Practice Builders Podcast, how to choose the best first or second niche for your practice. So hope this was valuable for you. Um, if you— if it was, please like, subscribe, Give us a review.

Would love a review.

Love a five-star review. If you got a one-star review, you can hold on to that one. But but and share this with the doctor friend of yours. If you have a colleague that that you feel like this would be valuable for them, hey, share the love. Like let's all grow together and help one another out because by doing that, we grow and we help more patients in the process. So that's it for this episode. We'll see y'all on the next episode. Take care.