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How Registered Dieticians Are Reimbursed For Their MNT Services?

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THE ENTREPRENEURIAL

NUTRITIONIST Fourth Edition

■ KATHY KING, RD, LD Owner, Helm Publishing

Lake Dallas, Texas

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Acquisitions Editor: David Troy Product Manager: Linda G. Francis Design Coordinator: Teresa Mallon Production Service: Maryland Composition Inc.

Copyright © 2010 Lippincott Williams & Wilkins, a Wolters Kluwer business

351 West Camden Street 530 Walnut Street Baltimore, MD 21201 Philadelphia, PA 19106

All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner.

The publisher is not responsible (as a matter of product liability, negligence, or other- wise) for any injury resulting from any material contained herein. This publication contains information relating to general principles of medical care that should not be construed as specific instructions for individual patients. Manufacturers’ product in- formation and package inserts should be reviewed for current information, including contraindications, dosages, and precautions.

Printed in China

First edition Copyright 1987, Harper & Row Second edition Copyright 1991, Kathy King Helm Third edition Copyright 2002, Kathy King

Library of Congress Cataloging-in-Publication Data

King, Kathy, RD. The entreprenuerial nutritionist / Kathy King. — 4th ed.

p. ; cm. Includes bibliographical references and index. ISBN 978-0-7817-9369-8

1. Dietetics—Practice. I. Title. [DNLM: 1. Dietetics—organization & administration. 2. Dietary Services—organiza-

tion & administration. 3. Entrepreneurship. 4. Professional Practice—organization & administration. WB 400 K53e 2009]

RM218.5.K56 2009 613.2068—dc22

2009007496

The information in this book is for general use only; it is a starting point; it should not be considered legal or medical advice. Readers are referred to the appropriate professionals for more individualized information.

All rights reserved.

No part of this book may be used or reproduced in any manner whatsoever without written permission, except in the case of brief quotations embodied in articles and reviews.

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This book is dedicated to the dietitians and diet techs who have shared their

wisdom and life’s lessons; also, to Savannah, Cherokee, Laura, Chris, and

Kate, grandkids, Grace and Grant, and my husband, Dr. Larry Gilbert, the

flowers in my garden, for their never-ending love and support.

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Becky Dorner, RD Owner, Becky Dorner & Associates, Inc. Nutrition Consulting Services, Inc. Akron, Ohio

Mary Abbott Hess, LHD, MS, RD, LD, FADA Partner, Culinary Nutrition

Associates, LLC Past President, The American Dietetic

Association Chicago, Illinois

Mary Ann Hodorowicz, RD, LDN, MBA, CDE, CEC Owner, Mary Ann Hodorowicz

Consulting, LLC Palos Heights, Illinois

Susan Magrann, MS, RD Nutrition Education Consultant California Department of Public Health

Program Sacramento, California

Teresa Pangan, RD, PhD Owner, Webnoxious Co-owner, Feed Your Career Flower Mound, Texas

Jane Grant Tougas Owner, JGT Ideas Cincinnati, Ohio

CONTRIBUTORS

CASE STUDY CONTRIBUTORS

Chere Bork Grace Cadayona Amanda Clark Mitzi Dulan Karen Fynan Donna Israel Jill Jayne Sheela Krishnaswamy

Linda McDonald Diana Noland Teresa Pangan Elyse Resch Mia Sadler Bonnie Taub-Dix Mandi Wong

v

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ACKNOWLEDGMENTS

vii

I want to thank the dietitians and other professionals who contributed chapters to the first or second editions of this book: Alanna Dittoe, Karen Dolins, Marianne Franz, Cecilia Helton, Paulette Lambert, Susan Tornetta Magrann, Becky McCully- Varner, Wendy Perkins, Olga Satterwhite, Marilyn Schorin, and Jan Thayer. And a big note of appreciation goes to the new authors of chapters in this edition and the

last: Mary Abbott Hess, Jane Tougas, Becky Dorner, and Mary Ann Hodorowitz. My special gratitude goes to Teresa Pangan for her three wise and detailed chapters on the Web. Also, to Dollie Parsons and Savannah Helm for their editing and suggestions.

At Lippincott Williams & Wilkins, I want to thank David Troy for his enthusiasm and support, and my editor, Linda Francis, for her cheerleading.

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TABLE OF CONTENTS

ix

Contributors v Acknowledgments vii Preface xi Introduction xiii

PART I The Beginning 1 1 The Entrepreneurial Spirit 3 2 Is Self-Employment for You? 13

PART II Building a Strong Foundation 27 3 Business Strategies and Management 29 4 What Can We Learn from the “Masters”? 44 5 Nurturing Creativity 49 6 Building Your Credibility 54 7 Ethics and Malpractice 59 8 Creating a Good Business Image 67 9 Counseling Expertise 73

PART III Managing Your Business 91 10 Business Plan 93 11 Marketing Decisions 100 12 Legal Forms of Business Ownership 113 13 Protecting Your Ideas and Interests 124 14 Choosing Your Business Advisors 133 15 Money and Finance 138 16 Start-Up Decisions and Costs 155 17 Prices and Fees 166 18 Reimbursement 177 19 Negotiation, Selling, and Contracts 190 20 Office Policy and Dealing with Clients 200

PART IV Taking Your Ideas to Market 207 21 Promoting Your Venture 209 22 Using the Internet in Your Business 227

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x CONTENTS

23 Website Basics 235 24 Promoting Your Website 259

PART V Developing Your Professional Practice 273 25 Consulting in Long-Term Care 275 26 Tapping the Food and Culinary Markets 281 27 The “Write” Way to Get Published 299 28 Media Savvy 312 29 Sports and Cardiovascular Nutrition 322 30 The Wellness Movement 330 31 Continued Competency 338

Index 341

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what kind of time investment is involved? We have the results!

This fourth edition is totally updated with new chapters on Reimbursement by Mary Ann Hodorowitz, MBA, RD, and What Can We Learn from the “Masters”? (those making more than $100,000 net in their own business). We have new information about marketing on the Internet, uses of the Web, tapping food and culinary markets, and consulting in long-term care. We have numerous practical examples to illustrate points, and answers to questions commonly asked by new and seasoned entrepreneurs. The term “entrepreneur” will be used to identify both self-employed people and em- ployed intrapreneurs who try things in new ways. The opinions are obviously those of the authors. They should provide you with a starting point for your own research and personal growth.

Hundreds of dietitians have told me that the first three editions of this book helped them start and maintain successful businesses. For thousands of others, it taught skills and strategies that were used daily in their employment setting. Many say they referred to this book many times over the years as new decisions and hassles arose. I hope you find this book helpful and interesting!

Wow! It has taken over 30 years but we have many wonderfully successful entre- preneurial nutritionists in the U.S. and around the world. In my 2008 World-wide Entrepreneurial Dietitian Survey, 30 dieti- tians were netting over $200,000 per year and 60 were netting $100,000 to $200,000 per year. Do you want to know how they did it? Read our new fourth edition of The Entrepreneurial Nutritionist!

This book is written for nutrition profes- sionals who want to start their own busi- ness. It offers them practical successful guidelines and business knowledge, skills, and insider tips. I have included interviews and case studies from successful practition- ers who may act as role models for you while others will show you what you don’t want to do.

Our most exciting newcomer to this edi- tion is the results of the first and largest worldwide entrepreneurial survey ever con- ducted, with over 1335 dietitians who com- pleted the 88 survey questions. Do you want to know how much dietitians charge or what products sell the best? How much it costs to start a business, or how many years it takes most dietitians to break even on their initial investment? What market- ing ideas work best and which ones don’t work at all? Do you really want to hear

PREFACE

xi

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INTRODUCTION TO ENTREPRENEURSHIP

Entrepreneurship can be one of the most challenging, difficult projects you ever un- dertake. It may also be one of the most satisfying and exciting. Trial and error, ad- justing to market changes, and trusting your gut instincts are part of every new venture. Passion for your projects is a must. Becom- ing skilled requires study, action, money, assessment, more action, more time, and more money.

The mere idea of starting a business ven- ture of some sort was embraced by only a few maverick dietitians in the 1960s and 1970s. Self-employment became more pop- ular in the 1980s and 1990s. Today, entre- preneurship is in the mainstream of dietetics and world-wide business. Dieti- tians are choosing self-employment to make more money per hour, to have more flexible hours, to try new ideas, and to work with new client populations or food in a different way.

EARLY ENTREPRENEURS

The dietitians who founded our profession were innovative, risk taking individuals. Many were consultants, authors, or inno- vators who created their hospitals’ and uni- versities’ first dietary departments.

Eloise Treasher began the earliest known clinical private practice in 1949 in Balti- more, Maryland. As Eloise retired from work at The Johns Hopkins Hospital, many physicians wanted to continue sending their patients to her, and her consulting business began. Treasher stated, “Private

practice is not for everyone, and not every- one will be good at it. But, if you offer qual- ity counseling and service, you will be in demand.”

In 1953, Norma MacRae began her coun- seling business in Seattle, Washington. Her practice included writing cookbooks. When asked about her success, MacRae stated, “I knew I had ‘arrived’ when physi- cians started coming to see me as patients.”

Other pioneers include Virginia Bayles, RD, a consulting nutritionist in Houston, Texas, and author, Dorothy Revel, RD, from Fargo, North Dakota. Carol Hunerlach, RD, of Maryland, is credited with spearheading the movement to organize the Nutrition Entrepreneurs (formerly Consulting Nutri- tionists) Dietetic Practice Group of The American Dietetic Association.

Today, there are creative, extremely suc- cessful dietitians who are best-selling au- thors; others own multimillion dollar companies, restaurants, health food stores, vineyards, publishing houses, home health agencies, large long-term care consulting firms, and computer companies. Others offer services on a smaller scale where they consult to cruise lines, act as a chef or per- sonal trainer, or counsel private clients. A growing number of highly skilled clinical practitioners are practicing biochemical- based functional nutrition therapy, which will become the practice of the future as medicine turns to functional medicine practice for chronic care therapy. Entrepre- neurial nutritionists also write newspaper columns, host television and radio pro- grams, author books, invent products, de- velop websites, consult to top athletes, speak professionally, and act as media spokespersons for food companies.

INTRODUCTION

xiii

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perwork, marketing, or other nutrition projects with no guarantee of income.

Before one year was up, I knew the con- cept worked. I decided to borrow $1000 from my grandparents and open a 10- by 13-foot office in the new medical complex being built next to the suburban hospital where I had last worked. I loved it. Patients came to me and I didn’t have to counsel them over the stirrups on an exam table. I furnished my office with antiques and plants. I raised my fees slightly ($10 for the initial and $3 for revisits) to cover the in- creased overhead, and I looked like a legit- imate business.

During my third year, I decided to sub- lease the office 2 days per week to a speech therapist. That freed me to take consultant positions at Head Start and retirement homes, and start a Master of Science course in exercise physiology to broaden my ex- pertise. It also gave me a change of pace from full time counseling.

To promote my business, I gave several free speeches each week. I appeared weekly on NBC TV’s “NoonDay” and monthly on KMGH TV’s “Blinky’s Fun Club,” for a total of 8 years. I volunteered for the Col- orado Dietetic Association so that other di- etitians would get to know me and I them. After 3 years, over half of my new consul- tant accounts were from referrals from other dietitians.

I learned more about sports nutrition by volunteering for 3 years for the exercise physiology staff at the University of Den- ver. I was their “on call” nutritionist for speaking at sports conferences and counsel- ing athletes. I invented a natural sports drink with the aid of the Herty-Peck Com- pany in Indianapolis which 7–11 Stores wanted to buy, but that is another book.

Sports consulting with the Denver Bronco Football Team, Denver Avalanche Soccer Team, paid media work, media spokesperson jobs, lecturing, and writing started to come my way as my expertise and reputation grew. My approach to nutrition was from a wellness point of view, so when the trend finally hit Denver, I was ready to grow with it. I taught wellness nutrition to

MY STORY

I graduated in Food Science and Nutrition from Colorado State University, which gave me a good, solid academic back- ground. My internship was at Beth Israel Hospital in Boston, a Harvard teaching hos- pital, where I discovered my love for clini- cal nutrition intervention and outpatient counseling.

After practicing 2 years as a hospital clinical dietitian, I began my business in 1972 in Denver, Colorado. The lack of pre- vention and outpatient counseling in the hospital setting frustrated me. I decided to go into the outpatient setting and start my private practice. I wanted to see if I could make a difference by keeping clients healthier when their symptoms or abnor- mal clinical values first appeared instead of waiting until they progressed and hos- pitalization was necessary.

My business strategy was easy: Keep my overhead low, work day and night for a year, and then reevaluate. This decision was not hard to make, since I was single and had nothing of value to borrow against—but I had the time and dedication.

My business started at one physician’s of- fice 2 days per week for $5 per hour. I lived on that income while I developed my busi- ness, working out of six other physicians’ of- fices. I spent a lot of time in transit, waiting for patients to arrive, and marketing to physicians so they would remember to refer clients. After expenses were paid, I lived on $8 a week for food.

I went to a lawyer friend of mine in order to pursue incorporation. He said, “I won’t do it.” I wanted to know why. He said, “Because you aren’t worth suing. Why waste your money?” I have never forgotten that philosophy: Weigh costs against the benefits or risks before investing.

The first year I charged $7 for the initial visit and $2 for revisits—and some people still complained about my fees! I supported myself from the start, supplementing my income with cleaning houses and sewing. For every hour I generated income in the business, I usually worked 3 hours on pa-

xiv INTRODUCTION

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INTRODUCTION xv

online testing (see our website at http:// www.helmpublishing.com).

In 1997, after looking for an asset to in- vest in, I purchased a rundown feed store to hold my publishing company and a “healthy” gift store less than a mile from my home on Main Street in Lake Dallas, Texas. I had it renovated into a beautiful peach-colored store with a white front porch, surrounded by an herb garden. As the publishing company grew, it made it very difficult to run two businesses, and we had to close the store or hire another per- son—it was a financial decision that had to be made. Retail antiques were great fun, but not especially profitable in a small town after 9/11.

From my 37 years of experience, I have learned that when the tough decisions have to be made, no one can do it better than I. I have stopped looking for that ex- pert on a white horse. I try to learn from each experience and person I meet who knows something I don’t. I have learned skills I never wanted to know. I find it still takes time and patience to break into new business arenas where I am unknown. I, and other entrepreneurs I know, continue in business because we love the chance to be creative, to create high-quality output, to work with people, and the freedom. The difficulty of the challenge makes us appre- ciate the rewards even more.

Innovative practitioners will continue to lead our profession into new, nontradi- tional job markets. We, as a profession, need to identify these trailblazers and let them teach us how to find these new career avenues. We should be willing to learn about new areas of practice and then act as mentors to our younger members. Or, rec- ognize when someone is willing to take the risk and support that individual with our goodwill and enthusiasm—not the Tall Poppy Syndrome where an innovator is punished by their peers. We need this type of growth and experimentation to take place worldwide in dietetics.

Kathy King, RD, LD Owner, Helm Publishing

Lake Dallas, Texas

physicians, nurses, and hospital administra- tors, as well as the public. I was always curi- ous and open-minded about alternative therapies. Being involved with media meant that I had to explore things the Denver pub- lic was interested in knowing.

My commitment to the profession grew as I was elected President of the Colorado Dietetic Association, and spent 5 years in the leadership of the Council on Practice, and 2 years on the American Dietetic Asso- ciation’s Board of Directors and House of Delegates.

When I married and moved to Texas in 1983, I didn’t want to start over again by building a group of clinical offices. Instead, I helped develop a hospital-based wellness program, consulted at The Greenhouse Spa, wrote or edited several books, acted as a media spokesperson, hosted my own na- tionally syndicated radio talk show for a year, and traveled giving lectures and semi- nars. When I wasn’t traveling, I worked from a home office so I could be home with my two daughters. Through meeting inno- vative dietitians from around the world, I have been fortunate to speak in six foreign countries. Individual patient counseling was a special high for me and I have counseled over 6,000 people, including three who lost over 125 pounds through diet, exercise, and cognitive-behavioral counseling.

This book has been translated into Japa- nese by Reiko Hashimoto, an outstanding private practitioner in Tokyo who also counsels sumo wrestlers. I self-published the second and third editions of this book when the publisher let it go out of print, and I asked for the copyright. That experi- ence opened doors to more writing and publishing other dietitians’ material. Helm Publishing is now a publisher of continuing education for Registered Dietitians (RD), Di- etetic Technicians (DTR), Registered Nurses (RN), Certified Diabetes Educators (CDE), and Certified Dietary Managers (CDM). We are a mail-order and online cataloger with over 75 products that are more outpatient, nontraditional, functional medicine, and prevention oriented. We adopted marketing on the Web over 12 years ago for sales and

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I

WORDS OF WISDOM

Do not follow where the path may lead. Go, instead, where there is no path and leave a trail.

Ralph Waldo Emerson

Many of life’s failures are men who did not realize how close they were to success when they gave up.

Thomas Edison

It’s choice—not chance—that determines your destiny. Jean Nidetch

1

THE BEGINNING

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Individual dietitians, worldwide, have be- come very successful, self-employed busi- ness owners over the past 25 years. Their ingenuity, creative verve, aggressiveness, and willingness to handle fear of failure are leading them and the dietetic profession around the world into new markets and fields of experience.

Starting a business is a lot of work. It can take over your life. But for 97.3% of the 1581 dietitians who answered this question on the 2008 World-wide Entrepreneurial Dietitian Survey, they said they would choose entre- preneurship again if they had their lives to live over (1). There aren’t many jobs that can boast that high of a satisfaction rate.

Many new graduates see nutrition’s po- tential in the marketplace and want to try something different. They eagerly watch and listen to the role models who are blaz- ing new trails, or they see markets that no one has tapped. This wonderful enthusi- asm must be tempered with reality—their business skills may be limited, networking contacts take time to establish, and start-up funds have to be available. Will waiting 5 to 10 years before starting a business guar- antee success? Of course not; it depends on your personality, your decisions, and what you do while you wait. While employed, you should try new ideas, save money, and meet people.

How much experience did our most suc- cessful entrepreneurs have before they started their businesses? Of the 90 surveyed dietitians who made over $100,000 net (profit), it is very interesting to note that 13.6% had no employed dietetic experience before becoming self-employed, 38.6% had 1–5 years experience, and 26.1% had 6–10

years experience (1). In the full survey, of the 1589 respondents who answered this question, 75% had, at most, 10 years of ex- perience (Fig. 1.1) (1).

EXPERIENCED PRACTITIONERS

As many dietitians and dietetic technicians reach the top of their professional career lad- ders, they look for new ways to grow. They want to be successful, recognized, and well paid for their expertise. Jean Yancey, a for- mer small business consultant from Denver, called this their “X-Point,” or crossroads. At this X-point, they arrive at a decisive point where they feel they must do something dif- ferent. These successful practitioners feel like so many things they used to do need to be left behind (a case of “been there, done that”). It feels similar to starting over again to pursue new career avenues, but this time, it is on a much higher level of expertise.

For some, the answer is entrepreneurship. This is the chance to be their own boss, schedule their own time, and create new services or products to make a personal profit. It streamlines decision-making, mak- ing it more effective. Entrepreneurship stim- ulates productivity and relieves boredom. It capitalizes on the personal and professional relationships the person has nurtured over the years.

THE ENTREPRENEURIAL EXPLOSION

Entrepreneurism is thriving in America. Being an entrepreneur has moved from cult status in the early 1980s to become de

1

3

THE ENTREPRENEURIAL SPIRIT

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4 THE ENTREPRENEURIAL NUTRITIONIST

businesses in the U.S. returned the follow- ing impressive statistics (6):

■ There were an estimated 10.4 million privately-held firms.

■ This accounted for every two out of five (40.2%) businesses in the country.

■ These firms generated $1.9 trillion in annual sales and employed 12.8 mil- lion people nationwide.

In a survey of influential Americans com- pleted for Ernst & Young, results showed 78% believed entrepreneurship would be the defining trend of the 21st century (8). People who completed the survey felt the major factors that would contribute to this rise in entrepreneurship were (8):

■ New technology (helps small busi- nesses compete), 76%

■ Economic conditions (low inflation), 53%

■ Social conditions (two incomes, return to family), 45%

■ Global economy, 33%

THE ENTREPRENEURIAL MINDSET

Thomas Petzinger, a Wall Street Journal columnist and author of The New Pioneers, believes, “Everyone will have to be an

rigueur at the turn of the century. In 2006, there were more than 26.8 million small businesses in the U.S., and more than 12.3 million Americans were self-employed (2). In 2004, there were approximately 17,000 large businesses in the U.S. (3). According to the Small Business Administration (SBA), small businesses represent (4):

■ 99.7% of all employers ■ 60%–80% of the new net jobs ■ 50% of the private sector output ■ 97% of all exported goods

According to Dun and Bradstreet, the aver- age small business owner has three employ- ees, 1.3 locations of business, and is not a part of a franchise organization. They found owners typically work about 50 hours a week at businesses that generate average revenues of $50,000 to $200,000 (5).

Between 1997 and 2006, businesses that were fully women-owned, or majority- owned by women, grew at nearly twice the rate of all U.S. firms (42.3% vs. 23.3%) (6). During this same time period, employment among women-owned firms grew 0.4%, and annual sales grew 4.4% (6). Women start their own businesses at twice the rate of men (7). In 2006, reports on women- owned (or majority owned by women)

FIGURE 1.1 ■ Number of years of dietetic employment before begin- ning self-employment (1589 respon- dents) (1).

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CHAPTER 1 ■ The Entrepreneurial Spirit 5

entrepreneur in the future” (9). This state- ment comes from the awareness that jobs have changed drastically in the past two decades and entrepreneurship is more mainstream. “Entrepreneurship was really an immigrant activity for many genera- tions” (9). Business life helped immigrants learn English and slowly assimilate into so- ciety. Petzinger sees people of all ages be- coming entrepreneurs and bringing new ideas on social goodwill, creative solutions, and more holistic views on merging their home and business lives (9).

In his classic book, Innovation and Entre- preneurship, Peter Drucker, veteran business consultant and management philosopher, says “the entrepreneurial spirit is based on the premise that change is normal, healthy, and desirable, that it sees the major task in society, and especially in the economy, as doing something different rather than doing better what is already being done” (10). Entrepreneurship is a way of thinking where you see the possibilities of an idea before you dwell on its limitations.

Rosabeth Moss Kanter, former editor of the Harvard Business Review and author of Change Masters, a book based on her study of 50 corporations, concluded that those companies on a downward slope were there because of “the quiet suffocation of the entrepreneurial spirit” (11). There is a close relationship between entrepreneur- ship and innovation in meeting new cus- tomers’ needs, increasing job satisfaction, devising new work methods, and improv- ing quality (12). New ideas are essential.

In The Atlantic Monthly, authors Stephen Pollan and Mark Levine made observations about small business (13):

■ The current tax situation makes it clear to Americans that owning one’s own business is one of the few oppor- tunities people have to create wealth.

■ Government at all levels realizes that small businesses are the primary cre- ators of jobs and is offering incentives encouraging entrepreneurs into their communities.

■ Technology—in particular computeri- zation and information processing—is lowering the start-up costs associated with small businesses and helping them seize chances.