Chiropractic's Involvement in Managed Care

A Runaway Train Going the Wrong Way

By Donald M. Petersen Jr., BS, HCD(hc), FICC(h), Publisher

Not since the late 1980s when the profession was responding to the questionable actions of a couple of practice management companies have chiropractors been so focused on a particular issue. More DCs have contacted us regarding managed care than all other topics combined. Interestingly, the vast majority of those complaints have been against "chiropractic" managed care companies: situations where DCs seem to be taking advantage of other DCs.

To understand how we got to managed care, one must understand how health care has evolved. Perhaps the best way to fully grasp the situation is to use this analogy:

Imagine you have a 10-year-old son that you send to the local store every few days for needed groceries. You send young Billy to get a dozen eggs, but when he returns, he not only has the dozen eggs, but all sorts of other food, including snacks, candy and toys. Upon questioning Billy, you discover that the "kindly" grocer encouraged Billy to buy the extra goods because they were important to have. When Billy explained he didn't have enough money, the kindly grocer explained, "That's OK, I'll just bill it to your Dad."

Upon hearing this, you explain to Billy the issues of cost vs. benefit. Billy tells you he's glad he got the extra goods. You respond by informing Billy that he will have to pay for the toys, snacks and candy out of next week's allowance. Billy agrees and the matter appears settled.

But the pattern continues, and soon, Billy has used up his entire allowance for the next six months. Billy has grown accustomed to having everything the kindly grocer sells him, and so he rebels loudly to your efforts to trim his spending. What are you going to do?

This is where the situation medicine has left us. They have "kindly" sold the public all of the pills, surgery and technology that they wanted, forcing the third-party payers (you) to recognize that someone has to draw a line on spending somewhere. Managed care is really managed spending.

No health care provider likes managed care. Unless you are a PPO owner, reviewer or administrator, you don't like managed care.

Nevertheless, chiropractic has a very important role to play in the delivery of health care under managed care. And while not every DC will want to be involved, chiropractic must be implemented appropriately into the managed care environment to be effective for all concerned. From what we are hearing, this is not happening in many cases.

The appropriate application of chiropractic must take into consideration the important attributes of managed care and chiropractic care:

Chiropractic

• most effective when caring for initial problems before medical treatment or surgery;

   

• cost effectiveness comes in the form of decreases in medical/surgical expenses;

   

• Chiropractic enjoys three times greater patient satisfaction than medical care.¹

Managed Care

• recognizes need to organize care so that the most cost-effective care is applied soonest;

   

• must motivate health care providers to only provide the care needed;

   

• currently has a serious image problem with public.

It seems like a perfect match: Allow DCs to see patients first and treat them sufficiently to greatly reduce the need for more severe (and costly) interventions.

But the current models have one fatal flaw: motivation.

In most organizations, the owners make money not by reducing medical/surgical costs, but by controlling and reducing chiropractic care. Instead of utilizing chiropractic care to eliminate surgery, chiropractic is being rationed to the point that it is substantially less effective. Thus, by the decision of those who don't ever see the patient, the patient is given only enough care to delay the need for surgery. This leaves many chiropractic managed care patients to become surgical time bombs which will inaccurately suggest that chiropractic care is ineffective.

As long as the owners of these PPOs, IPAs and HMOs are motivated to cut chiropractic care in their effort to make money, chiropractic will never be appropriately positioned to be effective in managed care. Other health care professionals and administrators don't understand how chiropractic should be implemented. We have to show them.

Only the members of this profession, you and every DC in the US, can stand up and require chiropractic managed care organizations to correctly position us as an integral part of the changing health care arena. Can you do it? Can you stop the train and turn it around?

Reference

1. Cherkin DC, MacCornack PA: Patient evaluations of low back pain care from family physicians and chiropractors. West J Med 1989 Mar; 150:351-355.

DMP Jr., BS, HCD(hc)

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