Toward a Better Understanding of the GPC System

The topic of this chapter, the famous or infamous box-on-the-wall system of practice, is really not part of the philosophy of chiropractic. While a fee system might reflect the philosophy, the philosophy actually transcends fee systems. Anyone interested in the history of the GPC, or God-Patient-Chiropractor fee system as it was originally called, would benefit from reading my essay published in the Journal of Straight Chiropractic, Volume I. The history of this fee system is really not important to its practice today as it currently bears little resemblance to the concepts first presented by its founder Dr. George Shears. Shears’ thought chiropractic should be practiced closer to the model of a church than to that of a healing art, including the use of both the term “God” in the description of the system and of “offering” or donation with respect to the means by which people paid the practitioner. Shears’ also thought that licensing laws might be circumvented under the freedom of religion clause of the Constitution. The idea obviously never caught on. It is not easy to explain this system for a number of reasons. First, it has so many variations that there is no consistent approach. Second, it has changed considerably over the years. Not only has the system changed but society, economics and the profession have also changed considerably. For example, prior to the acceptance of insurance in chiropractic there were many more chiropractors using the box. The vast majority of these abandoned the box when they realized they could work less and make more with insurance. Now, with the ever-present threat of insurance cutbacks, interest in the system has once again bloomed. Third, the system involves something very personal, an individual’s income. Asking a chiropractor what he averages in the box is essentially asking him how much money he makes. Most practitioners of the system will not share that figure even if they know it. So the chiropractor wanting to learn about the system never has an important aspect of it (how much you can make) explained to him. Lastly, the most successful practitioners of the box on the wall system have been in practice for many years. Newer practitioners have simply not had sufficient time to become successful. It is impossible to tell whether the success of practitioners like myself is due to the time period in which we started or whether a chiropractor starting a practice today could be just as successful. For example, the average fee when I started was only four dollars a visit, while the average fee today is ? I can tell you, people have not put in the box proportionate increases over the years. Overhead was lower in the 60’s, way lower, and there were not as many chiropractors to compete with. Nor did we did have student loans to pay back when I started in practice. Most chiropractic college graduates today have a student loan nearly three times what my present office cost to build in 1971. For all of these reasons this chapter is not meant to be a recruitment program for the fee system. I hope to present the pros and cons in a logical and objective manner and allow the reader to decide whether this system is worth trying.

The Basis For The System

Today the box-on-the-wall fee system is based upon a number of factors. The first is the idea that chiropractic care is such an important prerequisite to life and health that every human being should be able to avail himself or herself of it. It is based upon the idea that nobody should be denied chiropractic care for financial reasons. The second idea is that the need for chiropractic care is so frequent that it necessitates a flexible fee system and the box seems to be the most flexible of all fee systems. Further, everyone in the family should have this care on a regular basis. Lastly, and this is an important aspect of the system, it moves the practitioner away from the fee for service system that is associated with the practice of medicine. Fee for service gives the impression that an individual is being taken care of for a specific ailment or condition and when the condition has been satisfactorily treated/cured, and the fee is paid, the contract and relationship between the doctor and the patient is ended. It is easy to see that this idea is not what the straight chiropractor is trying to convey to the patient or the public. This is not to suggest that there are not other ways to make the point about the uniqueness of chiropractic care. A yearly fee system is certainly another way of doing it. It is also possible to explain the uniqueness of chiropractic care with a fee for service system. It just makes it easier to get the idea across that chiropractic is not an alternative or substitution for medicine if one moves himself and his practice as far from the medical model as possible. The box fee system helps in that removal. Before continuing on and as a follow up to our brief discussion on fee for service, it may be a good time to deal with what seems to be the greatest criticism of the patient-set-fee system. It has been suggested by Markson, Nikitow and others, that allowing the patient to set a fee or not having a fee comparable to medicine demeans and belittles the practice of chiropractic and ultimately making it less valuable in the eyes of the public. That may be true for those chiropractors because they see chiropractic, and probably everything else in life, as being valuable in terms of dollars and cents. It is simply not true, even if many people believe it. Those that believe “you get what you pay for” do not themselves apply that principle to everything. I have no idea what it costs today to have a baby in an expensive hospital. But would having that baby in the back of a New York City taxicab make it any less valuable to the parent? If people do put a value on things based upon the price then we as chiropractors should work toward changing that attitude rather than helping to perpetuate it. How much is love worth? How much is a life worth? How much is an air conditioner worth to an Eskimo? How about to a native in Equatorial Africa. Obviously, value is directly dependent upon an individual’s perception of an object. So we can either change peoples’ perception or find people who have the same perception as us. But we surely do not feed into the wrong perception. The fact is that you cannot put a price on a chiropractic adjustment. I have heard chiropractors say an adjustment is worth more than open-heart surgery. That may be true if you do not need open-heart surgery. However, if you are dying, open-heart surgery may save your life and a chiropractic adjustment makes no such promises. Suddenly, open-heart surgery is much more valuable. Recently, I was discussing this issue with the wife of a chiropractor who had once used the box but had abandoned it. She told me about another chiropractor who had had a box but also gave it up, partly because he found loose change in the bottom of the box. His feeling was that this indicated that the patient or patients did not value his care because they were paying very little for it. It occurred to me that how much someone values chiropractic may have nothing to do with what they give. I began to think of possible scenarios that would cause someone to drop change into the box. The first that came to mind was a single mother with three children, all of when come the office weekly for an adjustment. She knows the value of chiropractic care to for her family, but all she has in her purse is eighty-five cents so that is what she drops into the box. She gives everything she has in her purse. After her, a businessman comes in who usually has no less than $500 in his pocket. He says to himself, “I get a one-hour massage each month for $50. This chiropractor only spends two minutes with me but he is a doctor so I think $20 is a good fee. Bet that is more than most people drop in the box.” Now, my question is, which patient has a better understanding of chiropractic and places more value on it? I think the woman does. Would you rather have 200 patients each day like the businessman who leaves his family at home and gives you $20 for each adjustment because, like the massage, it makes him feel good? Or would you want 200 single mothers who see the benefit of care for herself and her children? I would want the single mothers. Well, I would prefer 150 single mothers and 50 businessmen. This way I could pay my bills but still be giving care that was appreciated to 75% of my patients. The point of all this is that how much one pays for care is not a criteria for determining how much our patients appreciate and value chiropractic. Because a person drops a large bill in the box does not mean they understand the Big Idea of chiropractic. If you do not understand it, then you cannot value it unless you value it as a therapeutic measure on a par with medicine. In doing that, you have in my opinion, demeaned the value of chiropractic to as great a degree as one possibly could.

Various Approaches to a Box-on-the-Wall Fee System.

1. GPC. This is the approach to the box system in its purest form. In using the word “purest,” I am not inferring that it is the best or even the method everyone should employ. Each person has to develop a method that they are comfortable with. This method seems to be the one that Shears originally had in mind. The chiropractor does not set a fee nor does he suggest a fee. He even refuses to tell the patient what is the average fee in the area. The fact is, that the average chiropractor in the area is probably practicing therapeutic chiropractic and charging accordingly. The box or receptacle is placed in an area or location where what is placed into it can be a totally private matter. That is, it is not in the adjusting room nor is it visible to any of the staff or other patients. There are no requirements placed upon the patient such as coming regularly or attending a lay lecture, health talk, or workshop. They are not required to bring in other members of the family or to refer other people. It is not that these activities are not encouraged, they are just not a prerequisite to using the fee system. Basically the use of this system has nothing to do with the character, the honesty, or the commitment of the patient. It depends upon the character and the love for humanity of the chiropractor.
2. Cooperative. This system was first effectively presented by Reggie Gold. He developed this alternative system partly because of his desire to take away the spiritual or religious connotation of the term GPC, but for other reasons as well. Reggie believed that if the chiropractor was going to make the commitment to give the patient care with no assurance of reward, then the patient, in order to follow the system, had to cooperate by following certain requirements laid down by the doctor. Some chiropractors actually have a higher published fee which they inform the patient they must pay if they choose not to follow the system. It is usually comparable to an average physician’s fee. The requirements can vary but generally they include: coming regularly, bringing the family for care, referring others, and coming to at least one health talk which usually includes bringing a prospective patient with you. This variation of GPC is about 20-25 years old. At any time during care, if the chiropractor determines that the patient is not “cooperating,” the patient is so informed and told that he must begin to pay the published fee. I have found that rarely do chiropractors follow through with the threat. Most of the chiropractors who use the threat of having to pay a fee have been in practice for many years and actually take the stronger stand of simply dismissing the patient. The thought behind this that if a person is willing to pay a medical fee then he likely only wants symptomatic relief and is not wanted as a patient. Of course, a chiropractor in practice a long time can usually afford to dismiss a few patients now and then. For a new practitioner with heavy debt and high overhead, it may be difficult to dismiss patients.
3. Mixed. In this system the chiropractor has some patients “on the box” and others pay a fee. The most common way by which they are differentiated is whether they have insurance or not. It should be noted, that it is technically not legal to have a dual fee system. Insurance companies will only pay a “legally collectible fee,” a fee you charge and bill the patient for. Consequently, if your fee is voluntary for patients, you cannot be charging an insurance company. Some chiropractors have gotten around this by saying that the box is for maintenance care since insurance does not ordinarily pay for maintenance care. This seems like a fairly good argument, although I am not sure anyone has yet been challenged by an insurance company. A number of chiropractors have used this system in an attempt to wean themselves off of insurance. I am not sure how many have been successful. Insurance, in my estimation, is like an addiction in that it is very hard to break especially if you are not willing to give it up completely. Many readers may be contemplating the box system because they want to get away from the insurance game. You should know that it will probably be difficult to do with a mixed system, especially when you see your income decrease despite an increase in your patient volume. Remember, patients will not and do not pay what insurance companies do. Anyone contemplating a switch should be prepared to have at least a temporary drop in their income until they attain sufficient new patients and an overall increase in volume to offset the financial differential. If you continue to use insurance rather than go “cold turkey,” it is probably because you cannot afford such a financial drop. If this is the case, you may want to reconsider whether or not the box is a feasible notion for you at this time.
The box on the wall is clearly the most liberating way to practice chiropractic. You are free to invite everyone into your office. You are free to have them come as often as you want to see them. You are free to tell them up front to come weekly for life and be confident that they know there is no hidden agenda. I have even told patients that I believe weekly care for them and their family is so important that I would pay them to get my care if I could afford it. It is so important that at the very least I would give my care away for free. But I can afford to do neither. The box on the wall is the next best thing. Being even partially chained to the insurance dollar will never let you truly experience this freedom. In the end, the mixed system builds two practices. One that is lifetime-care oriented and another that is condition-treating and symptom oriented. It is a function of insurance not of the practitioner.
4. Suggested Payment Schedule. This is actually a variation of the cooperative approach. There are variations among chiropractors.
In the “pure system” nothing is ever mentioned about when to pay. It is totally left up to the patient. In this variation the chiropractor suggests that the patient pay something on each visit, which is not an unreasonable request. However, for some patients the amount of money in their pocket and the amount that can be placed in the box varies according to the day of the week. They may have more after payday than they do a couple days before they are paid. I would not want to put a patient in the position of having to skip their adjustment in the middle of the week because they would not be paid until the end of the week. It seems to me that that would be defeating the principle of the box. Some chiropractors have the box in the adjusting room or a box in each adjusting room as the case may be. In this way the doctor is able to see if the patient is paying on each visit.

Presenting the System

One of the most important aspects of the box on the wall system is its presentation. Any explanation of the system must include the philosophy of straight chiropractic. The more you integrate the philosophy and the better you present it, the more effective the system will be. There is synergy between the philosophy and the fee system. The philosophy explains the fee system; chiropractic is for everyone so everyone should be able to afford it. The fee system validates the philosophy. Having a fee system like the box says how important the philosophy is and that you really believe it, enough to give it away to those who cannot afford it. Without the philosophy, the box-on-the wall fee system will not work. It necessitates a volume practice to be successful. You need the philosophy to get people excited enough to come regularly, bring their families, and refer enough people to build a significant volume practice.
While the explanation must include the philosophy, how it is actually done is up to the individual. I believe that the uniqueness and the benefits of the fee system should really be emphasized. Being basically a low-key person, I have not presented the box as enthusiastically in the past as I should. After I had been in practice for a number of years and word of the system had spread around town, I was almost nonchalant about it. I guess I wanted people to think it was such an integral part of my practice and philosophy that I hardly even thought about it. I have come to realize through that such presentation hurts the system. It should be presented with enthusiasm and excitement, like you are giving the patient the greatest offer they could ever possibly receive from any chiropractor. If chiropractic should be presented as a great and wonderful thing, and it should, then so should the fee system. It is a unique selling proposition (USP – see Practice Building for Straight Chiropractors) in your office and it should be actively and enthusiastically promoted. Keep in mind that excitement about the system will not replace a good understanding of the philosophy. Patients still have to get the Big Idea to want to come regularly for the rest of their lives. Paying an affordable fee may enable some to utilize chiropractic who ordinarily would not, but it will not be an incentive for lifetime care.
In our office we use a video program to introduce the new patient to the office and to chiropractic. Within that video is a two-minute segment about the fee system. However when I meet with them, explain chiropractic and my finding, as far as vertebral subluxation is concerned and then I reiterate the fee system and give my emotional pitch ( as emotional as I can get). Generally I will tell them how their being under chiropractic care is so important not only to them but also to us that it necessitates a very special fee system–one which allows each and every person to avail themselves of such care.

The Box as an Advertising Tool

I believe that the box on the wall fee system is one of the most important and effective concepts that a straight chiropractor can advertise. The purpose of advertising is to get people in the office and as straight chiropractors we want to stimulate them in a way that is consistent with our philosophy (i.e., cannot claim to cure cancer or any other disease). The fee system is attractive to people and is surely consistent with the philosophy of lifetime care.
The chiropractor may want to and could use the fee system as the body or the basis for the ads. But even if the thrust of the ad is something else (e.g., how great the body is, the importance of having a good nerve supply, optimum performance or increased human potential), the fee system should be prominently displayed on every ad that goes out of the office.

Can the System Work Today?

This is a most critical question and since I started using the system 30 years ago, I may not be the right person to answer it. Two types of chiropractors ask the question: the young person just starting out and the chiropractor who wants to convert his practice. I believe the system can work today, but not for everybody. Some people have the mistaken impression that the fee system builds the practice and nothing could not be further from the truth. My own practice was a failure for 18 months with the box on the wall (See Practice Building for Straight Chiropractors for my personal story). If a chiropractor, either new or in practice for years, expects the fee system to build the practice, he or she is going to be sadly disappointed and will inevitably abandon it. Hopefully, they will give it up before they have to abandon practice altogether. People need to be educated about chiropractic to build a practice. The fee system may help but it is not the total answer. Further, the practice has to be built bigger and faster with the box system because of the differential between what patients and insurance companies pay. The system necessitates a volume practice.
It would seem easier for the practitioner who wants to change from a fee or an insurance practice because already has a base of patients but there are problems. The patients may not be oriented to lifetime, maintenance care and changing them over is often difficult. Further, the chiropractor who has had a relatively successful fee for service practice may see a temporary drop in practice volume. Some patients are so accustomed to insurance or so proud of their job benefits or so just plain old dumb that if you stop accepting insurance, they stop coming to you for care. Others may leave if you begin to stress lifetime care. This will clearly be a problem for the chiropractor who lives at his means and has no cushion or no ability to reduce his income. The drop in income may not be significant or long term but the chiropractor should be prepared and able to handle it in the event that it is.
The key to the success of this system is to see a volume of patients. If you can not or choose not to see a volume, then you should not expect to be successful with the box. Herein lies the difficulty for the new practitioner. Too few chiropractors coming out of school today are choosing to build volume practices and many of those who would like to build a volume practice are not able to do it. Although this inability is unrelated to the fee system, it creates significant problems if you have chosen this fee system. There is no question that the financial demands upon the chiropractor today are greater than those in the past. Student loans were nonexistent thirty years ago while today they often soar to well over $100,000. The assumed need to have a luxurious office only adds to that problem. As chiropractic assumed the medical model, it also assumed the look of the medical doctor including the luxuriously appointed office. The chiropractor who wants to compete with the medical doctor should realize that the physician has a part-time job to help pay for his office. Generally speaking, medical doctors are paid for doing rounds in an affiliated hospital. The chiropractors just beginning in practice must be willing to work very hard and to do many things, some possibly outside their comfort zone if they want to build a practice quickly. Those who cannot or choose not to build quickly, had better have a substantial financial cushion or a part-time job, or a love for hot dogs. Working a part-time job while you build they type of practice is a reasonable alternative you may want to consider. I have much more respect for a chiropractor who works nights at a 7-11 to build the right type of practice, than one who simply disregards the philosophy for the sake of the almighty dollar.
A chiropractor starting a practice with the box on the wall fee system must be careful to keep his overhead low. I know of a number of box practitioners that practice without so much as a chiropractic assistant. It is always easy to expand your office, buy more adjusting tables or hire staff. It is much more difficult to rattle around in too big an office, sell off unneeded equipment or lay off staff. Of course, this is sound advice for any new practitioner but it is crucial for those who want to practice with the box. Decide what the absolute minimum will be that you will need to begin your practice and then try to reduce that by half!

Should You Do It?

Every practitioner who wants to try the system wants to know if they should or not. Unfortunately, it is an individual thing. The practitioner contemplating the system should keep in mind that the decision is not irreversible. There are many great chiropractors with successful practices, seeing a high volume of patients, who have tried the system and found it did not work for them for one reason or another. So you have nothing to lose by trying. However before trying it, you really should examine your motives. If they are not correct, then it is likely that you will not be successful.
I would question whether chiropractors who want to use the box to get out of the insurance rat-race can be successful. It is possible I suppose but the odds are against it. In fact, using the system because you believe it will draw a volume of patients is probably the wrong motivation as well. You have to have a burning desire to make chiropractic available to everyone regardless of their financial situation to be successful with the box. You must be convinced that if necessary you will take a vow of poverty to get chiropractic to the masses. (You probably will not have to live in poverty but you should be willing to). In other words, chiropractic for the world should be uppermost in you mind, above financial rewards. In fear of sounding almost melodramatic, to optimize your chance for success practicing with a box should be a calling to you.

My Personal Philosophy

There are a number of reasons why the box on the wall fee system has been successful for me, not the least of which is the fact that my family and I are comfortable with a relatively modest lifestyle. We do not take expensive vacations. We do not have homes at the shore or the mountains. And we do not buy new cars every other year. I enjoy my practice and I enjoy being there on a day-to-day basis. Some may consider me a workaholic. I am seeing patients 50 hours a week (Monday through Saturday). I often write or travel to speaking engagements on my off times. I enjoy sitting by my pool or on my deck during the late spring, summer and early fall months and writing. This lifestyle coupled with my love for practice enables me to see a high volume of patients and to spend little money over and above the necessities of life.
Patients and chiropractors often say to me, “You must have a lot of faith in mankind to have such a fee system”. Actually, that could not be further from the truth. My confidence is not in man but in God. I think too many chiropractors think people are generally good and generous and will not take advantage of you. However, if you have lived any number of years, you find the opposite is true. There are people who come in the office who do take advantage and they are flat out deadbeats. This type of practice will attract patients like that. There are others who will not purposely try to take advantage of you but will anyway. There are those who will in their minds “catch up with the box on the next visit” but then forget. There are others who have no idea what an adjustment is worth or what your time is worth as a professional. I am not saying anybody really knows, but it is likely that people will underestimate rather than overestimate. There are also many generous, gracious, and honest people who come into the office. However, my success or my income does not depend upon people. I do not worry about what my average fee is and could not tell you it if I had to.
I have the philosophy that I have a job and I have a calling. My calling is to give people chiropractic care. My job is to come to the office every day and at the end of that day empty the box. The box pays me, sometimes a lot and sometimes not so much. But I get paid by the box and I take care of peoples’ subluxations because that is my life’s work. God puts the money in the box and He will continue to do so as long as I serve Him by taking care of people. I do not know how He puts it in there, although occasionally I see a patient’s hand going up to the slot so I assume that is one way, maybe even the only way. All I know is that I have faith in Him that every day enough will be there and He has not let me down in over 30 years.
People say that is fine and good but what do you average? I usually say if you are worried about average then you are probably not yet ready for the box on the wall fee system. I believe practicing this way is one of the most rewarding aspects of chiropractic practice. I have been doing it for so long and it is such a part of my life and practice that I am not sure I can separate it from the practice or me. I hope that if the reader decides that the system is for him or her that you will experience all the joy and reward from it that I have experienced.