In the first two parts of this three-part series on the sliding scale, we've looked at the why (part 1) and the how (part 2) of using a sliding scale. In part 3, we'll consider the who. Specifically, who benefits from acupuncturists using a sliding scale? Who are the patients attracted to sliding scale practices?
Two weeks ago, my clinic finally reached our goal of providing more than 200 treatments in a week. Our 206 patients, all of whom used our $15-to-$35-per-treatment sliding scale, included 5 waitresses, 6 baristas, 2 warehouse workers, an actor, a machinist, 3 college professors, a medical doctor, 4 bartenders, 5 jazz musicians, an exotic dancer, an ironworker, 3 florists, 2 carpenters, 2 executives, 4 small-business owners, a painter, a textile artist, 4 administrators, a seamstress, 2 bike mechanics, a realtor, a welder, 3 mental health therapists, 2 high-school teachers, 3 preschool teachers, 5 grocery workers, a cab driver, a bus driver, 2 nurses, a computer programmer, 2 social workers, 2 massage therapists, 3 delivery drivers, 2 construction workers, a stone mason, a professional stuntman, an organic farmer, 2 librarians, 3 bookkeepers, a photographer, 3 acupuncturists, a welder, a couple of little kids, and a midwife, as well as a whole bunch of retired folks and students. They were white, black, Asian, Native American, Hispanic and Pacific Islander. Our youngest patient was 5 and the oldest was 80. One of the pleasures of having a sliding scale is the fascinating range of people you get to meet.
Some of the people who came to our clinic that week have good incomes; some of them better than ours, in fact. In theory, they might have been able to pay $65, $85 or $100 per treatment. What are they doing with their money? Some of them are raising their grandchildren, some are sending funds to sick relatives and some are paying huge medical bills that they thought their insurance would cover but didn't.
I believe, however, that it's not only the people who come into our clinic for treatment that benefit from the existence of our sliding scale. I think most acupuncturists who've been in practice awhile realize there is a subtle but potent connection between health and self-esteem. People tend to take better care of themselves when they believe they are worth it. The source of self-esteem is, without a doubt, inside each person, but the surrounding environment can either reinforce or erode self-esteem.
Classism, like other "-isms," derives some of its power from the way it affects people's self-esteem. Here's an example: Imagine you suffer from arthritis. You've never ventured outside of conventional medicine; you control your symptoms with over-the-counter prescriptions because you've heard scary things about prescription arthritis drugs like Vioxx. Basically, you feel uncomfortable with taking any pills at all. In a magazine, you read an article about how popular acupuncture is becoming and how all over the country people are using it to treat their arthritis without drugs. This sounds like exactly what you need. Finally, you have a choice about your health care. The whole idea of Chinese medicine makes sense to you. Excited, you look up an acupuncturist in the phone book and call for an appointment. The acupuncturist explains that it will require a series of treatments, at least 10; this too makes sense to you. Your joints didn't get this bad over night; of course, it will take time to reverse the process. You're so enthused and hopeful that you almost forget to ask how much it will cost, and then you nearly drop the phone. There's no way you can afford even one treatment, let alone 10. Imagine what you might feel: disappointment, anger, even a sense of shame. You got excited about something that is apparently for other people (lots of other people, according to that magazine) but not for you.
The awareness of having choices creates a sense of freedom, a sense of personal power, and a foundation for self-esteem. The awareness of not having the kinds of choices other people have creates the opposite: feelings of confinement, helplessness, and a nagging suspicion that maybe you don't deserve any more than you have. If you don't deserve what other people have, it's reasonable to assume you're not worth as much as they are, maybe not worth much at all. Now imagine you are the friend, neighbor or the sister of the person above, who tells you about not being able to make an acupuncture appointment. You're not interested in acupuncture, but when you hear this story, you feel depressed as well when you realize you couldn't try it even if you wanted to. A sliding scale is good for the self-esteem of the whole community - no matter how many individuals actually use it - because it restores choice to people. And what's good for community self-esteem is good for community health.
Sliding scales also help acupuncturists who don't use them in their own practices. Although many acupuncturists worry about professional competition, the reality is that the ratio of acupuncturists to the total U.S. population is minuscule. At last count, there were around 16,000 of us LAcs - that's a drop in the bucket, relatively speaking. The most significant marketing problem we have as a profession is that most people really have no idea what we do. In my own informal marketing research, I've found that the single biggest reason a new patient comes to acupuncture is that they know someone whom it helped; often that someone lives in another state, or across town, and is seeing an acupuncturist I'll never meet. Nonetheless, that acupuncturist helped grow my business. Because there are so few of us, we are all, always, doing each other's marketing, no matter what our fee structures are. By exponentially increasing the number of people who have the opportunity to try acupuncture, sliding scales benefit the entire acupuncture profession.
There will always be people, acupuncturists and patients, who value anything, including acupuncture, precisely because it is expensive and exclusive. The fact that most people can't afford it somehow elevates it, reinforcing that acupuncture is unusual, refined, and special - most definitely not for everyone. Won't these people feel a little deflated by the proliferation of sliding-scale clinics, by acupuncture becoming accessible to the masses and the riff-raff? Actually, no. As noted in part 2 of this series, using a truly accessible sliding scale essentially requires very simple, streamlined treatments and modest treatment settings. People who like their acupuncture to be upscale can easily differentiate themselves from those of us who choose to do simple treatments in community settings. In fact, they benefit, too. The existence of us riff-raff makes them even more elite and special by comparison, which is a way for them to boost their self-esteem.Hey, fine with me, whatever works.
In fact, the only ones who may not benefit from the growing number of sliding-scale clinics are the insurance companies, as more and more acupuncturists, discovering an alternative, choose not to do business with them. But I'm not too worried about them; they seem to be able to take care of themselves. They can keep doing that while we start taking care of our communities.
