The Practice Nirvana Blueprint: A Step-by-Step Guide to Building a Million-Dollar Practice

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. Welcome everybody to the Practice Builders Podcast. Uh, my name is Dr. Vince Leone.

And I'm Dr. Kyle Pankinen.

And Dr. Kyle, what is our topic today?

We're going to talk about, I think, something that'll be really interesting to any doctor that's listening to this. We're going to talk about a Something called Practice Nirvana. And this is something Dr. Leone has worked on for the last couple of years, trying to flush out what that exactly means and what that would look like in clinical practice for a doctor that's focusing on niches and really maybe has taken their practice to a fairly high level. And, and now wants to evolve their practice into this model that we at Specialized Practice call Practice Nirvana. So without any further ado, I'm going to let Dr. Leone introduce this and what his concept of Practice Nirvana is.

Yeah, and I think, you know, who is this for? And I would probably say if you're between say $50K and $100K a month, then this is, this is really ideal for you. Now, you may or may not have an associate at this point. If you do, that's great. If you don't, it's going to be valuable and necessary to bring one on. And there's a specific reason for that, and we'll talk about that in a second. But this has been getting a lot of attention. We introduced this at the Decompression Summit last month in September, which was a Rousing success, another sold-out summit. It was so fun. So if you didn't make it to the summit this year in 2024, highly recommend you join us in 2025. So it'll be September 2025. I think it's going to still be that same weekend, 13th, 14th, something around there. But regardless, now, why, why did I develop the concept of Practice Nirvana? And it's because there are some very significant In my opinion, flaws or problems with the current chiropractic model. So see if any of these resonate with you. One, insurance payments are going to continue to dwindle. And while insurance is not going to go away completely, because that means they would be out of business and they don't want to be out of business, right? They're making too much money and they want to be in business, but they just— they're going to continue to make it more and more difficult. You see that with preauthorization. Like, 10 years ago, did you ever think that, Dr. Kyle, that you would have to ask the insurance company and get preauthorization to treat a patient?

No. And what's happening, actually, for a while, when I first got into practice, we had to do it a lot, and then it kind of went away for the last few years. And now I've just been informed by my staff that one of our insurance companies, it's coming back again. And I've been in practice for 25 years, and now it's like, all right, I have a good track record, and now you want me to do prior authorizations again? It's ridiculous, and it's a bit demeaning and insulting, really.

It really is, right? It's essentially insurance companies dictating care, which is a bunch of baloney. So, because they're not the one treating— they're not doing the consultation, the examination, and treating the patient and having the interactions and Everything associated with patient care. It's crazy. So anyways, so insurance payments, in my opinion, and that's just a trend, right? And it's my opinion, but it's also what the research is showing. I mean, we are getting paid less today than we did 10, 15, 20 years ago, and it will most likely continue to go in that direction. I mean, if you think insurance payment— insurance companies are going to start paying you more. In the future, then I have I have a bridge to sell you. So point being is that's I think that's a real problem moving forward in the in the if if you want to make money, right? If you want to like you know actually be paid what you're worth with the current chiropractic model where we're doing adjustments only, we trade time for money. It's a very low leverage and one to one, right? I adjust a patient. I get paid for that that particular Piece of my time. There's continued wear and tear on the body. So chiropractic is is by by its nature typically a very physical treatment right option for the doctor, and it's and it it wears on the on the doctor's body. I mean, if you've been in practice for fifteen, twenty, thirty years, how does your wrist feel? How does your knees, hips, back, shoulder? Like you know, we only have so many adjustments in us. So there's continued wear and tear on the body, which is a negative-sum game. It does not maximize our scope of practice, right? We are able to treat foot pain, knee pain, shoulder pain, and we typically only treat spinal pain. In the typical chiropractic model, doctors are the head chef, the waiter, the dishwasher, the office manager. You're doing everything. But if you do take a vacation, you're out of the office for a week or so, you pay for it twice, right? Because you pay for the vacation itself, and then you pay for the lost revenue, which is not fun. And essentially what you're creating is a glorified job. I even had one recent client say, hey, I feel like I've kind of built a prison. He literally used that term, which is pretty sad, right? And this is a very successful doctor. And so, so it's essentially a glorified job. In other words, if you don't show up, you don't get paid, right? Where a business, a true asset, it will pay you whether you show up or not. And then low value placed on the core product service, which is our adjustments. Now, this— look, I'm a second-gen chiropractor, was adjusted coming out of the womb, and that— I value the adjustment. I think it's tremendous. I get adjusted every 2 weeks, roughly. But that doesn't mean that society at large values the adjustment. And right now we have The Joint, which is a NASDAQ-listed company, a billion-dollar company. They have over 950 locations. And you know what they charge for an adjustment, Dr. Kyle?

I would guess around $20.

You are right on. $20. $20. And it's no insurance, right? So it's $20. And if I had to guess So we have Coke and we have Pepsi, right? We got McDonald's and we got Burger King. We have Home Depot and we got Lowe's. If an enthusiastic and entrepreneurial individual sees the joint doing so well in such a short amount of time, don't you think someone else is going to try to compete with them? And my guess is yes, right? And again, is this going to happen this year or next? Probably not. But don't you think in the next 10 years something else is going to pop up and be a competitor to the joint? And, you know, hey, we can do it just a little better, maybe a little bit less, whatever. But the point being is it's driving the value of the adjustments down, down, down, down, down, down. So if you are a single practitioner and you have a small clinic, 1 or 2 staff, and you're charging $50 or $60 an adjustment, right? And Maybe your systems aren't that great. Maybe your staff's not trained that great. Maybe you're really good at adjusting, but they can— someone can go and pay less than half and probably get a really good service experience. They're in and out. Who, who are they going to choose, right? So I, I'm just the messenger here. I, I don't believe that this is a good thing. I'm just saying this— I believe this is the reality, and these are the problems with the current chiropractic model, which is what inspired me to Go into niches in the first place and then create the model of practice nirvana. So, Dr. Kyle, any thoughts on any of that stuff?

They did a study of HMOs when HMOs came into being in the late '90s, I think in the late '90s, early 2000s, especially in Minnesota as the HMO state, managed care. They did studies on this and they found that some doctors said, ah, These are medical doctors too. I'm not going to get signed up to be in-network for these HMOs. My patients are loyal to me. They like me. They'll never leave me. And they've— and they found in the study that for a copay difference of as little as $3 to $5 difference, patients will leave a doctor that where they were with to stay in-network. to go to a different provider because they can pay $3 to $5 less. So what you're talking about is another joint coming along and now their adjustment is $17 or $16 or $15. That will be reality. In Minnesota, we have an organization of cities that's called ChiroWay, and they're doing the same thing. What is it?

ChiroWay?

ChiroWay. Yeah.

There's also Chiro One, and I don't think that their model is quite the same as The Joint. Um, but so, you know, ChiroWay, I mean, I think that's a terrible title. I think that's— I don't like the name at all, but that doesn't mean they're not going to be successful. Um, but, you know, unfortunately, I just, I feel like this is the reality and the future that is going to honestly probably wipe out the whole middle class of chiropractic.

Yeah, you're, you're going to have a whole group of doctors that are just making minimal amounts. They're making enough to get by. And then you're going to have just a handful of really elite doctors that are just killing it. Like, but there's not going to be much in between.

Middle. No. So the days, the $50, $60, $70 adjustments, I think, are limited. And so that Again, that's why we're preaching this, right? With high-ticket niches and the Practice Nirvana model. So what does this model look like? It is going to be a blend of insurance and cash-based services with more emphasis on cash, right? So now, why do we keep the insurance? Because I get this question a lot, Doc, is like, hey, do you recommend your clients go all cash? And the answer is no, I really don't, because there are still some good insurances, like here in Washington State, like Premiera. Premiere is great. You know, Amazon, like Microsoft, they all have Premier and they still pay really well. But that's not even what I care about, right? I don't care about they're paying $40 instead of $20 for an adjustment. What I care about is they were going to cover exams and X-rays because patients want to use— like, I mean, I don't want to tell you what I pay for insurance as a private business owner. Small business owner, it's a lot, right? So, people want to use their insurance, right, if they can. And so, in our model, they can. It's not going to cover the core services, right? Decompression, laser, shockwave, etc. But it will cover the introductory portion to get them over the threshold and that they can be evaluated for the doctor and determine if they're a good candidate for care.

I agree 100%. That going exclusively cash, we have some doctors in our group that are doing that and it can be done, but it's a hard, hard road to, to go. And doing about a blend of it. So in my practice, we are literally right at about a 50/50 blend of insurance cash. If you still offer or you take insurance, it's an entryway. It's a way to get people in the door. Like you said, their, their exam and their x-rays and maybe their adjustments are covered, but that then you have opportunity to get them under the care of your cash-based services. And that's where the other half of our practice comes in. And before we introduce cash-based services and niches, we were seeing a lot of patients And it was all under traditional insurance model, and we were, we were making ends meet. We were getting by. We were paying our bills. We were making a living, but there was nothing left over until we added niches and cash-based services. And then all of our growth over the last several years has been in that realm, and we've been effectively been able to double our practice. Since that time, just by adding in the cash-based services, and patients are willing to pay cash for services that are valuable, and that's— that is going to help them. So that is a strategic part of what we're talking about, and I'll let Dr. Vince go into the next layer of this.

Yeah, yeah. And it's important because, um, the next layer is you are positioned as a premium service and experience. So, I saw a study recently that 51% of patients change their healthcare provider based on the customer service. And so, we— our doctors, like, if you look at the offices in our, in our stable of doctors, I mean, they're all premium offices by and large. They're, you know, some are not quite so much, but the vast majority of them— I mean, we have one doctor, he just dumped $80K into renovations. We have Dr.— another doc, you know, I think maybe $70K. So, You don't need to do that right away, but you do need to, you know, over the long term, you need to be positioned as a premium service. And this is doing focus on, you know, presentation in the office, staff training, you know, obviously the customer or the patient experience. So we are the specialists in the community, right? Because we, we're specializing in a condition, whether it's Disc, knee, or neuropathy. But the office needs to be representative of that. You know, you can't, you know, charge a premium price and look like McDonald's. That's just that it does not match up. So we're focused on lower volume and high cash fees, right? So we don't need 100 new patients a month, you know, in this model. So that's that, you know, we're it's not a it's not like we're not seeing five new patients a month, but we're probably in that thirty twenty to thirty new patients a month. But we don't need seventy-five new patients a month. To reach the numbers that we're going to talk about. You have an associate that does the bulk of the, um, well, all of the really the chiropractic exams and adjusting. The owner focuses on really leadership, right? Building the proper team, strategically growing the practice, being the true CEO, um, and then being a true expert in his particular niches. Um, staff handles, uh, patient care, right? So you're going to have techs, we call them techs, they're going to put patients on The various equipment, and then a a really robust marketing strategy. So that is the basics. We're going to get into some more of the the nitty gritty. But any thoughts on that, Dr. Kyle?

Well, the key is is as you implement this this model, the doctor that's been in practice ten and twenty and thirty years and starting to get beat up a little bit. They can start to hand lower the amount of adjustments they're doing while that that associate doctor comes in handles either all or the bulk of that. So you're you're going to be able to extend your career hopefully longer if that's what you want to do. And then with the technology that we have with laser, well, we can get a robotic laser. Instead of a handheld laser. A decompression table only takes a minute to set somebody up on that. And so some of these high-end therapies we can do, we can have staff do those. And they can handle a good volume because it's so quick with modern technology to set people up and get these therapies going. And so you can have a really efficient running office. With just that associate and the right techs in place. And you as a doctor can just focus on, you know, the marketing component, mentoring, leading that associate doctor, making sure your staff is well trained. And it cuts down on your physical stress and hopefully your mental, emotional stress as well.

Yeah, that's a really good point there, Dr. Kyle, is, is, uh, it is, it's physically tiring to adjust 50 patients a day. It's, it's also emotionally stressful, right? Um, and if you're not having a whole lot of fun in practice, it's going to be really tough for you to grow, right? When we're having fun, like, I love working on my business, but if you don't love working on your practice and working in your practice, that's pro— and you're not growing, that's probably one of the key reasons why. And so, you know, taking steps to minimize that stress and create more joy in the practice and doing something innovative and fun, that's again another reason why we're introducing this model. So let's look at the team. It's a pretty lean team, right? So you have obviously the owner/lead doctor, you have your associate doctor, you have what we call patient success manager. And this is a blend between— they're gonna, they're gonna manage The team in the office, and they are going to close. Right? So they're going to be the financial individual that talks all finances with the patients. So we separate doctor and finances. We have four techs. Right? So it's one tech for two tables, and sorry, two techs, two tables. Well, we'll go into the equipment a second. Four techs.

4 techs.

Because you really kind of have 1 swing, right? So 1 tech can do 2 tables. That's no big deal. But you need to— you typically need a tech per laser, even if they're robotic, because they're kind of moving around and helping other patients. And then you have 1 swing. So if we have 4 techs, because we'd rather have a little bit more than a little bit less. And then 1 ambassador, what we call an ambassador. This is your receptionist, but we call it an ambassador in this model because This individual is so important to first impressions, and first impressions drive patient experience. And so, in other words, when someone walks in the door to your office, what do they see? What do they hear? And what do they smell? Right? And so the ambassador is really, really important to be highly trained, and they have to have great energy. And it's all about attitude and energy for this position. We can train the skill sets on the phones and the greetings and the scripts and all that type of stuff, but they have to have attitude. And energy, and that's it. You know, that's your team. If you really, really grow, maybe you need a second closer or PSM. But it—I think to get to the numbers that we're going to talk about in just a second, I think you're fine. So this is what our equipment looks like. We have two decompression tables, two class four lasers, two knee decompression chairs, two shockwaves, an orthotic station, a supplementation line, and then your chiropractic tables. And that's going to, you know, provide, you know, in other words, it's going to eliminate any bottlenecks in terms of patient care so that they can, you know, shuffle around in terms of the sequencing of their protocols. And, you know, give you the basically the leanest amount of equipment. So if I had to guess in terms of the total investment on equipment, Let's call that 80. Let's call that 60. So we're at 140, 160, you know, like $200,000 in equipment. I'd probably say something like that. Thoughts on that?

Well, that's a small price to pay for the— because you're going to be generating enough revenue From these high-end—

Oh yeah.

Therapies and services that to have return on investment. So the doctor listening like that, wow, that's $200,000. But your return on investment on that equipment is gonna come around really quickly if you do this the right way and you focus on delivering high-end exams, quality consultations, and you get patients sign up under these programs. Even if you only have a 50% conversion rate, you're going to do really well and help a lot of people, and your return on investment will come much quicker than you anticipate. I mean, I tell doctors all the time to buy a laser, like one of the, the MLS robotic lasers that we recommend. They're right around $50,000, and they're just like, what? And if you use that laser right, I tell them, you will easily have that paid off in 1 year or less.

Oh yeah.

And, uh, So every one of those pieces of equipment you need, you can get them paid off in 1 year or less if you do the model right. So don't be afraid to spend the money, docs. You got to have a little faith in your— you're in pulling the trigger on the high-end equipment so that you can take on these more challenging cases but get reimbursed at a higher level as well.

Yeah, yeah, absolutely. I mean, I kind of, you know, if you're gonna play at this level, this is the big leagues, right? So I kind of look at like, kind of, if you think of like baseball, you have the big leagues and then you have minor leagues. Like the kind of traditional chiropractic office doing $10,000 to $20,000 a month, I mean, no offense, but that's kind of to me the minors. Um, when you're at our level in the big leagues, you, you got to pay to play. I mean, there's just no two ways around it because you are positioning yourself as a premium premium experience, you're positioning yourself as an expert. You can't run out rinky-dink equipment or no equipment, right? And call yourself an expert or a specialist. It's like it just doesn't compute, right? So you've got to make the investment. But here's the key. You don't need to make that investment like on day 1. I mean, you grow into it, you sequence into it. I'd probably say over the course of, say, 2 years. So Now let's, let's talk about what the, what probably everyone's interested in is, well, how much money am I gonna make? It's like, you know, is this gonna be worth it? So from a revenue standpoint, we're, we're gonna have Cairo because we're not gonna toss Cairo. Like, we still want Cairo because that feeds the other niches. So we have Cairo and 2 niches. So essentially, we're gonna have our total revenue is gonna be $150,000 a month. We're gonna have $50K in Cairo, $50K in niche one, which is probably gonna be decompression, $50K in niche two, which is probably gonna be knee. So $150 a month, $1.8 million a year. Your overhead, if we look at overhead, you're gonna pay yourself $10K, you're gonna pay your associate $10K, and you're gonna pay your closer $10K. Now again, I can just see minds being blown and jaws dropping and oh my God, what are we gonna pay? It's like, guys. We're building the Avengers of chiropractic. Okay, so you don't pay peanuts if you want pros. You do not pay peanuts if you want pros. So you got 4 techs at $4K each. That's $16K. Your receptionist, your ambassadors around $4K. And again, you're probably not even paying your guys $4K now. That's okay. But, but if you want someone to stay and look at your business as a career, not a job, you got to pay well. And marketing is going to be about $15K a month, right? So, you know, from it— and again, I'm sure people are like, oh my God, $15,000 in marketing. It's like, hey, if you want to, if you want to, you know, hit that $150,000 a month, you need to saturate your community on multiple channels, internal and external, and you got to pay to do it. And you got to get the flow coming into your office. And then miscellaneous around $15,000 a month. So that's rent, you know, all that crap. Total overhead, that's $80,000, right? So you're netting $70,000 a month, right? $20,000, maybe $20,000 of that net goes to Uncle Sam. So you net $50,000 a month. Now, how beautiful is that, right? $50,000 a month. I mean, think of your retirement. If you're going to net $600,000 a year. Now, does that make more sense when it comes to investing in your equipment and your team? I mean, when I presented that at the summit, Dr. Cowell, I mean, people were hooting and hollering. They're excited.

Oh, 100%. I mean, because very, very, very few doctors in our profession are hitting those kind of numbers. And when you present a model like that, And you put those numbers down and you people start to think and starts rolling in their head like you know what? This is possible. This is doable, and and it really is. Now, does everything in life work out perfectly like you put on paper? Well, you and I know that that's not right. But this is this is this is a model. This is something that we can strive for and shoot for. You gotta have a goal. If you aim at nothing, you'll hit it every time, as the old cliché goes. And so we gotta have a, a practice model where we're working and striving towards something, even if it takes us a period of some years to get to that and to, to build from a, a, a $10K practice up to $100,000 or $150,000. That's a process. But a doctor that's in the already in that, like you said, the $50,000 to $100,000 K a month, that doctor can transition to this model or work towards this Practice Nirvana model and likely get there potentially in a 2, 3, 4-year timeframe. I think 3 years, very achievable.

I think 3 years. So Dr. Bergtold's a great example. You know, he started with us, he was doing like— and I think he's okay us sharing this— 45— I hope he's okay.

I think he is. I think he is.

Anyway, so he was doing like $45,000 when he started with us. At the end of year 1, you know, he's around $90,000, $100,000, something like that. And he's— he'll probably hit nirvana probably at the end of year 2. Now, he's a master implementer, he takes massive action, and he's, you know, just all over this. But when, you know, when we finished year 1 and moved into year 2 together, he's like, I think I can do this in about a year. And I said, I think, I think you're right. So I think, you know, if you're a rock star like Dr. Berg told, I think you can do it in 2 years if you're around that kind of $40,000 to $50,000 a month. If you want to take a little bit more time, I think 3 years is totally doable, you know, to get there. But it's, it's all possible. Kyle's well on his way. And, and it's, it's just, you know, If you think about your practice in, you know, what do you want life to be like in 3 to 5 years? It's like, do you want to continue to do the same old, same old and then be fighting everything that's going on with the economy and just the trends that's happening in the insurance industry? Or do you want to have something, a more exciting vision, right? Because I'll tell you what, when you start laying out this type of vision for your team, You know, if you want people to work with you long term, you really need to have a big enough vision that they can fit their vision within your vision. In other words, that they can see an exciting life serving at a high level, being paid well, and doing something that very few other people are doing, right? And so it— but it starts, starts with you. It starts with the owner.

100%. You gotta have— for your team to have the vision, you gotta get the vision in your own head. And if you can present that to them with some gusto, some enthusiasm, some—

Gusto, I love that.

You're serious about this. Yeah, gusto, I like that word. This is— it's infectious to them. And the key with staff, and I've, I've said this other occasions, is What Dr. Vince said, they need to look at their, their job with you as not just a job, it's a career, it's a calling. And if it's a career and a calling and they treat that way, they should be paid that way as well. I think a lot of times in chiropractic we hire these, our techs or our assistants, and we just, well, what's the least amount I can pay?

That's true.

To, to keep them around for a while. And, and, and we just hope, oh, I just hope they don't find a better job or get, you know, and we're just kind of desperately holding on to them. And it's ridiculous. And you pay them like they're a professional and treat them like they're professional and, and, and show them the vision of their job as being a career, not just a—

Hourly job. Yeah. And Kyle's a master team builder. I mean, he has had team members that's with him for years and years and years. And that's where I got that, that, you know, they look at their position in your company as a career versus a job. I got that from Dr. Kyle. And he's really mastered that. And look, from my perspective, it's like, if we're going to grow and do big things in life, I heard this, I can't remember who I heard this from, but it's like, Like bringing other people up with you, right? Sharing the wealth, sharing, you know, the, the, the good life with, with those people in your orbit. Like, that's to me is just as rewarding as the actual, you know, rewards that we get personally. So when you can provide someone with a career and a and a good paycheck so that they can, you know, have a great life and take care of their family and take care of their kids and provide opportunities. I mean, that's, that's when things get really exciting, and that's when no one's going to leave you, because very few owners and, uh, you know, doctors are willing to do that.

Couldn't have said it better, Dr. Vince. I, I think this was a very— I think this will be an eye-opener episode for a lot of docs that listen to this. It's going to get the balls rolling in their head that, like, wow, Practice nirvana. What do I need to do to get there? What do I need to implement? And that's what Dr. Vince and I do. We help doctors along the path. And it's it's so fun when you get that doctor like Dr. Burke told that just gets it and they go after it. It's fun. It's fun to see it. It's it's the growth and their enthusiasm and they just they just get it and they take off and it's. It's just, I love seeing it.

Absolutely. And I think that's a great place to wrap this one up. So, um, I, I hope this has been valuable for you. I, I do also think this will, you know, can, could be a, a big episode and, and hopefully move the needle with a lot of doctors. Um, and, uh, I, I fervently believe this is the future of, uh, chiropractic, and at least in thriving So, any last words of wisdom there, Dr. Kyle?

Well, I just say let's focus on that word thrive and not just survive as a profession. We've worked hard, we went through a lot of years of education and building a practice. We don't want to just survive. Let's move our profession forward and see a whole bunch of doctors thriving. Absolutely.

100%. Okay. Well, that's gonna wrap it up for this episode on Practice Nirvana with the Practice Builders Podcast. Thank you all for joining. We'll see you all on the next episode. Take care.