Editor's note: Part I of this three-part series ran in DC October 7; Part III will be published in the 12-2 issue.
Chiropractors who were in practice in the 1980s probably remember that time as the decade of "milk and honey" for insurance reimbursement for our treatment. Public demand and a handful of cost-effectiveness studies had finally won our profession inclusion in most comprehensive health insurance policies. Doctors were able to determine their own treatment plans and were usually reimbursed 80 percent of usual and customary charges. Chester Wilk was exposing the AMA's campaign of greed-based public deception, and 97260 was emerging as a viable billing code to describe what chiropractors do. At long last, things were looking up for our profession. So what happened?
The easiest answer may be to point the finger at managed care and say, "That's what ruined it for us." Blaming something or someone may ease the pain by allowing us to vent some righteous steam and indignation at how the insurance industry is victimizing us once again. But blaming accomplishes very little. It focuses us on the past and keeps us from the critical self-examination that must be done to help us shape our future. We cannot hope to solve present-day problems unless we learn from mistakes of our past.
Learning the lessons of managed care may be the most important challenge facing chiropractic today. The wave of managed care is sweeping across America. A recent article in Chiropractic Economics notes: "HMOs cover 3,000,000 people in New York City, 1/3 of all Los Angeles residents and 2/3 of Portland, Oregon. It is estimated that by the year 2000, 3/4 of Americans will be members of managed care organizations.1 Don't think that you are going to escape the grasp of managed care by practicing in rural America. Small-town USA is being targeted by managed care organizations.1 Managed care has even begun to expand into the arenas of workers' compensation and auto liability.
Managed care is not just a team in the health care choice line-up. It is rapidly becoming the only game in town. The remaining question is: "Who will be chosen as the players?"
Cost-effectiveness studies have become the best antidote to the pain of watching our authority, autonomy and actual livelihood as chiropractors being compromised by changes in the insurance industry. With all of the positive statistics that have been presented about the effectiveness of our care, why hasn't our market share increased over the past decade? And why are insurance carriers becoming less chiropractic user-friendly? Even though study after study has demonstrated the high level of patient satisfaction and the efficacy of chiropractic treatment in managing many of the ailments that commonly are seen in doctors' offices, we are still viewed with suspicion by much of the third party payment system. Practice management systems that encourage maximizing the utilization of chiropractic services have even begun to undermine our credibility with current or would-be patients. Something is wrong with this picture.
We believe that at least part of the problem may be that the actual utilization patterns that are seen in the real world too often exceed the number of treatments that are documented in the research setting. Analyses of sophisticated databases suggest that too many chiropractors are simply not practicing up to (or perhaps, more accurately, down to) our potential in getting our patients well as quickly as possible. And too frequently, even when we are doing a good job of fulfilling our potential, we are not documenting the results adequately.
Clearly, the time has come for us to demonstrate our capacity to treat neuromusculoskeletal disorders successfully in a variety of clinical settings. This must be demonstrated not only in our research projects and teaching institutions, but also in the individual doctor's office. This is a critical choice that each of us must make if we are to establish collectively our rightful place in the managed care marketplace of the 21st century. Accomplishing this goal will require a paradigm shift. We must be willing to distinguish between acute injury care and lifetime/maintenance care. We must understand the meaning of "reasonable and medically necessary" and how to explain our treatment in light of such standards. We must learn how to document our treatment and patient care in ways that communicate our focus and measure our effectiveness. Most importantly, we must articulate a method of accomplishing all of this without compromising the legitimate needs and concerns of the most important element in this health care equation -- our patient.
This is a huge task, but it can be done if we remember what is special about our system of care. Chiropractic, with its unique understanding of the relationship between structure and function, recognizes the self-healing capacity of the body, and our hands-on approach touches a place of cellular wisdom within ourselves and our patients that is deeper than insurance codes and ICD-9s. Still, we must accept that insurance coverage has been a "foot-in-the-door" that has enabled many patients to discover chiropractic care. Without that access, can we realistically expect that our market share will increase?
Maintaining, and hopefully increasing, our accessibility in the insurance arena is the best way to guarantee that those patients who know about chiropractic care can continue to seek our assistance. It also is the best way to promote ourselves to the more than 85 percent of the health care consumer population that is not currently taking advantage of the excellent care that we have to offer them.
The responsibility of producing the clinical outcomes that research has shown to be possible in the controlled clinical setting rests with each and every doctor of chiropractic. If we make cost-effectiveness the cornerstone of our care, then the patient education process should naturally produce the flow of referrals that will keep our practices flourishing. If we strive to do the best possible job in treating those conditions that we are best suited to treat, we will build an unimpeachable case for full inclusion in the third party payment system. When we have learned to "manage" our care better, managed care organizations may be less inclined to feel the need to manage it for us.
Reference
1. Dr. Ty Talcott, "24 Ways to Get Your Share of Managed Care!"," Chiropractic Economics Vol.38, No.5 (March-April, 1996): Pg. 38.
Eileen Hearn, DC
Dean Goodman, DC
Santa Monica, California
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While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
