On "Lucrative" Acupuncture Practices and Free Labor

another small business case study

Art by A. Cohen

Recently an alert subscriber sent me a link to a practice for sale and suggested I might like to unpack it in a POCA Tech class. I definitely will, and I thought it would be useful to unpack it here also. (Note that this practice isn’t a community acupuncture clinic¹, it’s an example of the conventional one-on-one model.) So this post is a reality check about acupuncturist compensation, with a short detour into the acupocalypse, all by way of a case study.

Okay, let’s take a look at “a unique opportunity to own a lucrative acupuncture and Chinese medicine practice in the gorgeous Portland suburb of Sandy, Oregon”.

But before we get into the numbers, I want to remind everyone that any practice that’s for sale almost always represents a best-case scenario. Getting your practice to the place where it can be formally valued as a business (instead of a hobby) is an achievement that not many acupuncturists can claim. So kudos to the acupuncturist who did! In this post I’m not going to talk about the pros and cons of buying a practice, or whether this particular practice is worth buying at the listed price; I’m only going to talk about what the numbers reveal about acupuncturist compensation in general. Okay, here goes:

Imagine working only 20 hours per week while grossing about $100,000 yearly. No additional marketing is necessary—the reputation of this practice keeps a steady flow of new patients streaming in via word of mouth from other patients, insurance company listings, referrals from other health care providers, and the internet.

The following income and expense summaries are derived from an average of income and adjusted* expenses from 2021-2023. Note that the current owner has office hours about 20 hours per week and takes up to three weeks off per year.

Income: Average gross yearly revenue (three years): $102,738 ($8,562/month)

Expenses: Average adjusted* expenses: $50,079 yearly ($4,173/month)

*Adjusted expenses are the net expenses that a new owner would have to take on in order to run the business at the same level of revenue as the current owner.

Net Profit: Average $52,659 per year ($4,388/month)

There’s a lot to unpack here but let’s start with the way that the advertisement plays fast and loose with the concept of “profit” — and (in my opinion) takes advantage of people’s lack of understanding of small business. When people hear the words “profitable business” it’s easy for them to assume that means “passive income” — because isn’t that what business is all about in a capitalist society, making money off other people’s labor?

Maybe — but not if it’s small business, especially a sole proprietorship. In this scenario, I wouldn’t call that $52,659 per year ($4,388/month) “net profit” — I’d call it wages. The owner of the practice grosses $100K yearly, but just about half of that income goes to overhead. What’s left over is what the owner gets as compensation for their direct labor.

That’s still pretty lucrative, right? $52,659 per year for only 20 hours a week of work? Ooh, let’s play my favorite game, “Spot the Invisible Labor”! (It’s like Where’s Waldo, but for sketchy capitalism.)

First, remember that this $52,659 per year is not a W-2 position for an acupuncturist created and administered by somebody else, and $4,388/month is not the take home pay. If the business is the basic sole proprietor kind, the owner of the business will be paying about 30% of that in taxes and FICA, which they have to remember to take out themselves — which suggests actual take home pay of closer to $3100 per month. That’s a lot more taxes than most people are expecting — and also, a lot more work. This isn’t a position where you can clock in and clock out.

According to the ad, “The clinic currently has one 1099 employee who works part time for a total of one day a week doing bookkeeping, checking patients in and out, and answering the phone during the office’s busiest times. She may be willing to stay on with a new owner or help in the transition by mutual agreement.” Don’t mistake this employee for a business manager; this employee is someone who has to be managed as part of the owner’s responsibilities. The owner is the business manager. In fact it would be best to think of the $52,659 per year as wages for not one job but two — acupuncturist plus business manager — filled by a single person.²

In addition to treating patients, the owner has to take care of the business itself, which means being on-call 24/7 (if a pipe breaks, for example) and being the back up for any actual employees. If the 1099 bookkeeper doesn’t do the bookkeeping for some reason, the owner either has to do it themselves or find someone who will. All of that caretaking almost certainly doesn’t fit neatly into the suggested 20 hours a week. Owning a small business, even an established one, is not unlike having a child. Not only is there an open-ended amount of required labor, you’re never really off-duty.

Maybe you could bring in more than $52,659 a year, though, if you worked more? The ad helpfully provides a list of ways to work more: sell more supplements, hire other practitioners or sublet space, do more marketing, do your own insurance billing instead of outsourcing it³, do some email marketing, start a blog (lol). All of these options require an unknown amount of effort and no guaranteed additional income. Small business means risk. You can work a lot and not know for sure whether you will get paid for it: That’s a feature, not a bug.

The ad suggests also that you could see more patients if you put in more clinical hours, but there’s no guarantee of that, either. Just because the current owner is only working 20 hours a week doesn’t mean she only wants to work 20 hours a week, though that’s implied; maybe she isn’t able to attract more patients. The practice averages 77 visits per month; it doesn’t say there’s a waiting list. Maybe 77 patient visits per month is the ceiling. You could interpret “consistent patient volume” a number of ways — including as evidence that after 17 years, the practice has maxed out its growth.

In theory I suppose you could get another job, or pick up a side hustle, but in reality that’s challenging. Owning a business takes up a lot of headspace, and even 20 hours a week working one-on-one with people can feel like a lot — so you shouldn’t expect to have huge amounts of energy left over in this scenario.

Art by A. Cohen

The take home message? You have to work pretty hard as an acupuncturist — and/or shoulder significant amounts of risk and responsibility — to earn a heavily-taxed $52,659 annually. That’s what success in this industry looks like. I wouldn’t call it lucrative.

Most acupuncturists aren’t expecting to have to work this hard, or navigate this much uncertainty. Small business requires creativity and commitment; it asks you to give yourself to it. It reminds me of the quote about writing that’s attributed (probably inaccurately) to Ernest Hemingway: “Writing is easy. All you do is sit down at a typewriter and open a vein.”

To make WCA and POCA Tech, I had to open a vein, more than once. Other people did too. If we hadn’t, these organizations wouldn’t exist. I had my reasons; some of them are grim; but I don’t have any regrets. Small business — with all its challenges, uncertainties and demands — has been one of the most healing things I’ve done for myself.

In my experience, if you want to build anything lasting, if you want to bring something over the border from non-existence into existence, at least some of the time you’ll be working for free. If you’re building something really weird (like an acupuncture practice) you’ll be working for free much of the time because hardly anybody’s going to understand what you’re doing. (I’m not saying that’s how things should be; it’s how they are. I don’t really do shoulds.) Not only that, your heart’s blood is a required ingredient in the mortar of whatever you’re building. Ask me how I know!

The acupuncturist who established the practice that’s for sale, who got it to the point that we’re looking at her financials right now — she opened a vein. The idea behind buying an established practice is that you won’t have to. The $69,500 price tag on this practice is the cost of not opening a vein.

A lot of acupuncturists and would-be acupuncturists approach work as if there were no meaningful differences between big corporations and small business. They don’t want to offer “free labor”; they don’t want to give themselves to their work without knowing for sure that they’ll get paid. They might see this refusal as a form of anti-capitalist resistance. I get the reasoning — and the desire to not be eaten alive by capitalism — but in my experience, if you apply this lens to acupuncture, you might end up not working at all. Unless there are investors involved (which is a whole other thing) no small business gets off the ground without copious amounts of “free labor”; most of them need ongoing infusions to grow — or just to keep going.

Which gets us to the acupocalypse.

The acupuncture establishment has been trying for the last four decades to sell the idea that really, acupuncture isn’t weird and acupuncturists are entitled to “normal” jobs with decent professional-middle-class wages and good benefits, where nobody has to do any free labor. Respectability, in other words. Respectability means never having to (visibly) open a vein. (So messy, so rude.) Although America claims to love small business, it really doesn’t, and it looks down on people who have to bleed to work.

Not only that, the infrastructure in the acupuncture profession presumes the existence of professional-middle-class wages for acupuncturists. An education that costs upwards of $150K isn’t such a big problem if there are plenty of W-2 jobs with “normal” salaries of $100K or more for graduates to slide into. Ditto for spending $2000+ on the NCCAOM certification process. Unfortunately those “normal” jobs are rare as unicorns. Success as an acupuncturist is more likely to look like pouring everything you have into a $40K position in a hospital or netting $50K as a sole proprietor.

In an earlier post about the acupuncture profession trying to become part of the Medical Industrial Complex, I wrote:

being part of big systems, in our capitalist society, isn’t free. It isn’t a reward that society bestows on you if you’re deserving enough and you jump through enough hoops. It always comes down to somebody paying actual money somehow — and it’s usually way more expensive than it looks. Generally there’s a brutally extractive element somewhere out of sight, like a strip mine leaving wreckage in its wake, that makes it possible to fund the shiny, visible parts. What the OPB articles reveal is the acupuncture profession’s hidden strip mine. All those graduates with hundreds of thousands of dollars in debt that keeps growing due to compound interest — that’s how we’ve been funding the project of becoming part of the system.

The cost of whatever respectability acupuncture appeared to have was thousands of graduates carrying debt they’ll never repay. That particular jig might be up. If so, we’re headed for an era where the only structures in the acupuncture profession (including the infrastructure itself) will probably be made the way small businesses are made: out of free labor and heart’s blood.

1. If you want to look at a post that unpacks a community acupuncture practice for sale, see The Road Not Taken: a Small Business Case Study.

2. Or as my friend Jade (who is also the Board President of POCA Tech) put it, “The part of practice that’s running a small business isn't really comfortably middle class at all — it’s the really up and down and risky part and there's so much that can go wrong. Even a great business plan won't save you. Acupuncturists used to come visit my clinic and I told them to stop when they're like, omg you're like a machine I thought this would be so calm to run. You're not a rich investor that doesn't work there. You work there!”

3. Insurance billing isn’t easy, which is why WCA doesn’t take insurance (see part one and part two).