The Notre Dame Principle: What Cash-Pay Chiropractors Can Learn from College Football's Only Independent Program
- Dr. Lucas Marchand
- 5 days ago
- 7 min read
There's a peculiar fact about Notre Dame football that most people accept without really examining: they're the only major program in America that doesn't belong to a conference.
Everyone else joined up decades ago. The Big Ten, the SEC, the ACC - these aren't just athletic associations, they're economic alliances. They guarantee revenue, schedule opponents, negotiate television deals, and provide a clear pathway to championship consideration. Conference membership is the default position in college football because it makes sense. It spreads risk across institutions. It creates stability. It means that even in a down year, you're still part of something larger than yourself.
Notre Dame looked at this entire arrangement and said no.
They schedule their own opponents. They negotiate their own broadcasting contracts. They assume the full operational risk of running a major football program without the institutional safety net that every other school relies on. And somehow, improbably, they've made it work for generations.
I kept thinking about this while talking to chiropractors who've left insurance networks to build cash-pay practices. The parallel isn't perfect - no comparison ever is - but the underlying tension is identical. They're making the same calculation Notre Dame made: trading institutional protection for operational control. And in both cases, the choice reveals something fundamental about how excellence compounds differently under different structures.
The Conference Model
A conference provides what economists call "risk pooling." When Ohio State has a losing season, they're still part of the Big Ten. Their revenue barely dips. Their recruiting stays strong. Their brand remains associated with a prestigious collective. The conference absorbs individual volatility.
In healthcare, joining an insurance network functions the same way. You get immediate access to a patient population. You get predictable reimbursement schedules. You get administrative support for billing, compliance, and credentialing. If you're part of a hospital system or multidisciplinary group, you get shared overhead, referral pipelines, HR departments, and marketing budgets that no solo practitioner could justify.
Most importantly, you get institutional credibility. Patients trust "someone at the Cleveland Clinic" more readily than they trust "a chiropractor I found online." The institution vouches for you. It gives you borrowed authority before you've earned your own.
For most practitioners, most of the time, this is the rational choice. It lets you focus on clinical care rather than business operations. It means that if you're merely competent - not exceptional, not differentiated, just solid - you can still build a stable career. The system protects you from the full force of market competition.
But there's a cost. You don't control your pricing. You don't control your schedule. You don't control which patients you see or how long you spend with them. You don't control your brand or your clinical philosophy. Every decision gets filtered through institutional priorities that may or may not align with your own judgment.
And critically, you don't capture the full economic value you create. Insurance reimbursement rates are set externally. Group practices take their percentage. Hospital systems prioritize utilization metrics over patient outcomes. You're compensated, but you're compensated as a component of a larger system, not as the primary driver of value.
The Independent Path
Cash-pay chiropractors opt out of this entire apparatus. They don't accept insurance. They don't join hospital affiliates. They build solo practices or small partnerships where they control everything: pricing, scheduling, clinical approach, patient experience, brand identity.
This is the Notre Dame model. Total autonomy. Total risk.
What you gain is obvious. You set your own prices based on the value you provide, not what an insurance actuary decided ten years ago. You design your own patient experience without institutional constraints. You build your own brand that can become genuinely differentiated rather than generically professional. You keep the full economic value of every relationship you build. But what you lose is less visible until you actually try it.
You lose the referral pipeline. In a hospital system, patients come to you because the system directs them to you. In a cash-pay practice, every patient is someone you had to find, attract, and convince. There's no institutional momentum carrying you forward.
You lose the safety net. If you have a slow month in a group practice, your paycheck stays relatively stable. In a cash-pay practice, a slow month means you might not cover rent. The variance is yours to absorb.
You lose the borrowed credibility. When you're not affiliated with a recognizable institution, you're starting from zero with every new patient. You have to prove yourself every time, not just once during your credentialing interview.
Most significantly, you lose the permission to be merely good. In a conference, an 8-4 season is acceptable. You played your schedule, you contributed to the collective, you didn't embarrass anyone. In independence, an 8-4 season might mean you're out of business. There's no cushion. Excellence isn't a goal - it's the baseline requirement for survival.
Why Notre Dame Works
Notre Dame has survived as an independent because Notre Dame is Notre Dame. They have one of the most recognizable brands in American sports. They have a national alumni network. They have a television contract that most conferences would envy. They have recruiting pipelines built over a century.
In other words, Notre Dame proves that independence works when you're exceptional at the things independence demands. If you're merely average at negotiating television deals, at building a national brand, at recruiting against conference-affiliated competitors - independence kills you. The structure amplifies whatever you already are.
The same dynamic plays out in cash-pay practices. The ones that thrive aren't just good clinicians - that's table stakes. They're good at customer experience design. They're good at communication and expectation-setting. They're good at building referral networks without institutional backing. They're good at branding in ways that make them memorable in a crowded market.
These aren't skills taught in chiropractic school or medical school. They're business operator skills. Marketing skills. Relationship architecture skills. The system protects most practitioners from needing them. Independence exposes you immediately if you don't have them.
What This Reveals
I spent time examining what separates successful cash-pay practices from struggling ones, and the pattern was consistent. It wasn't clinical skill - everyone was clinically competent. It was operational discipline.
The successful ones treated patient experience like a product to be engineered, not a service to be delivered. They thought about touchpoints, communication cadence, and perceived value at every interaction. They understood that in a cash-pay model, you're not competing with other chiropractors - you're competing with everything else the patient could spend money on. The comparison isn't "you vs. the chiropractor down the street." It's "you vs. a weekend trip, a new piece of furniture, a nice dinner out."
They also understood something structural about independence: it forces you to specialize. In a conference or insurance network, you can be a generalist because the system provides volume. Independence demands that you be known for something specific. The cash-pay chiropractors who struggled were trying to be everything to everyone. The ones who thrived picked a niche - sports injuries, pregnancy care, chronic pain management - and became undeniably excellent at that specific thing.
This is why the Notre Dame comparison matters. Notre Dame can't just be "a good football program." They have to be Notre Dame - historically significant, nationally recognizable, worth watching regardless of conference affiliation. Similarly, a cash-pay chiropractor can't just be "a good chiropractor." They have to be something distinct enough that patients will pay out-of-pocket when insurance alternatives exist.
The Amplifier Principle
Independence doesn't make you better or worse. It amplifies what you already are.
If you're excellent at building relationships, independence lets you capture the full value of those relationships without institutional middlemen extracting their percentage. If you're mediocre at building relationships, independence exposes you to market competition without institutional protection.
If you're disciplined about operations and patient experience, independence gives you the control to optimize everything. If you're sloppy about operations, independence means there's no administrative team cleaning up after you.
If you have a clear clinical philosophy and can articulate it compellingly, independence lets you build a brand around that philosophy. If your clinical approach is generic, independence leaves you indistinguishable in a crowded market.
The conference model - insurance networks, group practices, hospital systems - allows for variance in these capabilities. You can be strong in some areas and weak in others, and the collective structure compensates. Independence demands strength in all of them simultaneously.
The Question Worth Asking
The real insight isn't that one path is better than the other. It's that they select for different things.
Joining the system selects for clinical competence and professional reliability. Being independent selects for operational excellence and market differentiation.
Most practitioners aren't trained for the second set of skills. Medical education and chiropractic education focus almost entirely on clinical knowledge and diagnostic reasoning. They don't teach you how to build a referral network from scratch. They don't teach you how to communicate value to patients who are comparing you to their vacation budget. They don't teach you how to design a patient experience that generates word-of-mouth growth.
The ones who figure this out - either through instinct, training, or painful trial and error - create something the system can't replicate. They build practices that are genuinely differentiated. They develop reputations that transcend their immediate geography. They capture economic value that would be impossible within institutional constraints.
But this only works if you're capable of becoming that. Independence doesn't magically make you excellent. It just removes the structures that allow you to be anything less.
The Choice
Notre Dame's independence is strategic, not ideological. They're not independent because they hate conferences. They're independent because their specific advantages - brand recognition, national reach, television appeal - create more value outside a conference structure than inside one.
The same logic applies to cash-pay chiropractors. Going cash-pay isn't a philosophical statement about insurance or healthcare policy. It's a business structure that works when your specific capabilities create more value in a direct-pay model than in an insurance-mediated one.
Which path demands more of you? Independence, unquestionably.
Which path gives you more control? Also independence. The question isn't which is better. The question is what you're capable of becoming, and which structure amplifies that potential rather than constraining it. Notre Dame proves that exceptional independence beats comfortable membership. But it also proves that comfortable membership beats mediocre independence.
The choice isn't between two paths. It's between two versions of yourself - and which one the structure will allow to emerge.
Have a wonderful week,
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