Some recent events would make it appear that the value of an adjustment is based not on the quality of care delivered or the level of a practitioner's experience, but on the lowest reimbursement fee the worst chiropractor will accept from the cheapest managed care company.
You may not realize it, but health maintenance organizations (HMOs) and other managed care companies are watching as American Specialty Health Plans (ASHP) negotiates and renegotiates their reimbursement rates with doctors of chiropractic in California.1,2,3 They understand all too clearly that the value of something is the lowest price you can buy it for, regardless of the benefit.
The DCs in California are now down to $26 for an office visit, which includes "a brief re-evaluation, manipulation and adjunctive therapeutic modalities and procedures." This is the current rate, down from $38 last year: a whopping 30% decrease. And while the owners at ASHP are insisting that this decrease is absolutely necessary, a much larger issue has emerged.
How Low Will You Go?
In doing our homework on this issue, I've had a chance to talk to other people with different managed care organizations. Off the record, they are not shy to admit that these new rates could set off a string of "adjustments" in reimbursement rates across the country (not to mention Medicare, worker's comp, etc.).
Some have suggested that an oversupply of DCs in California is in part responsible for the current situation. In reviewing the reimbursement rates offered to acupuncturists by ASHP, one discovers that an acupuncturist is reimbursed at a much higher rate ($40 per visit) than a doctor of chiropractic. For those DCs fortunate enough to belong to both professions, the choice is obvious: give acupuncture to all of your ASHP patients.
The solutions to this situation have taken various forms. Some less-informed DCs have called for a boycott. Not only is this activity illegal, but there always seems to be at least one DC willing to join the panel for every DC who resigns.
Another possibility involves creating a "chiropractic union." This potential solution has been embraced by the acupuncture profession, but it is still too early to judge its success.4
Short of unionization, the laws in some states have been modified to allow "collective bargaining" for some health care professions, but when given the opportunity to support and be included in these initiatives, several state chiropractic associations have declined.
There are many in our profession who hope to retire before the managed care steamroller gets to them. While this may work on a personal basis, it does little to aid the profession. The final solution may include a number of strategies. It will likely involve legislation, negotiation and lawsuits before we can finally stop running from managed care.
Whatever the solution may ultimately be, the answer is never to do nothing. Managed care issues must be at the top of our agenda and stay there until a solution is enacted. And while state and national associations must be careful about acting in concert so as not to be in possible violation of existing state and federal laws, this doesn't keep them from holding conferences and think-tanks (with their attorneys present) to assess the current situation and how it is affecting their members.
The associations could also use these conferences to better communicate the facts about managed care, and equip DCs with the skills needed to evaluate the contracts they are being offered (math skills surprisingly many DCs don't seem to be able to do) and assess their business plans accordingly. (The California Chiropractic Association has developed a "calculator" that allows DCs to determine their cost per patient. It can be found online at: http://www.calchiroassn.org by selecting "Calculator" from the menu on the left-hand side of the CCA page.)
It may be that after further assessing the plight of their members, our state associations will decide that additional legislation is in order. If so, they will no doubt discover a host of other health care provider associations already working toward the same solutions.
This is not a case of chiropractic versus managed care (or anyone else for that matter). Managed care is just a business model created in reaction to the obscene medical spending that has become almost cultural over the past five decades. (After managed care is gone, there will be some other model under which we'll have to function.)
This is about chiropractic becoming more aware of its own value. This is a time when DCs have to gain an even greater respect for what they do and how there efforts contribute to wellness.
The responsibility for solving managed care issues rests squarely on the shoulders of the providers. You must make it work (or fix it if it doesn't).
The insurance companies aren't really interested in health: they're much more interested in profit. They are faced with as much as 20% attrition each year. This means they have little reason to think about the long-term health benefits of their insureds, because most of them will be someone else's insureds in three years. Their motivation is profit, not wellness. If wellness happens for their customers, that's fine, but if it doesn't - and there aren't any lawsuits - that's just as good for them.
It is up to us to decide how much we'll put up. It always has been. As the reimbursement rates continue to drop, we must constantly ask ourselves: How low will we go?
- Interview with the CEO of American Specialty Health Plans. Dynamic Chiropractic March 6, 2000. http://www.chiroweb.com/archives/18/06/01.html
- ASHP drops reimbursement to $30 global fee - 1999 withholds will not be returned. Dynamic Chiropractic August 6, 2000. http://www.chiroweb.com/archives/18/17/02.html
- ASHP - even smaller fees, but not "global". Dynamic Chiropractic September 4, 2000. http://www.chiroweb.com/archives/18/19/03.html
- Acupuncturists vote to unionize. Acupuncture Today July, 2000. http://www.acupuncturetoday.com/archives/2000/jul/07guild.html
Click here for more information about Donald M. Petersen Jr., BS, HCD(hc), FICC(h), Publisher.