Forget the Ford - Check Out This Chevy
By Wayne M. Whalen, DC, FIACN, FICC
It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change. — Charles Darwin
As a profession, we stand at a crossroads more than ever before. The following are some observations and recommendations based on 25 years of practice and involvement in the political life of chiropractic.
What Do Most Doctors Want Help With, When Asked?
How to bring in new patients. It's understandable: New patients are the lifeblood of any practice. And it isn't like there aren't plenty of ways to bring in new patients. The most effective and least expensive is to simply ask for referrals. However, many doctors still won't institute simple steps to ask for referrals. Instead, many look to elaborate, frequently expensive schemes, often with dubious ethics.
A simple truth is that while new patients are great, if there is a giant hole in your practice bucket, all the new patients in the world won't ultimately make a difference; they'll simply flow out the bottom. Instead, you should focus on your office systems, how new patients are greeted, processed and their choices respected.
When your office is professional, respects patient preferences and is based on scientific evidence, patients will naturally stay, pay and refer. If not, the holes in your bucket will almost always be bigger than the input of new patients. Multiple measures can address this problem: a coordinated and consistent internal and external marketing program; systematic approaches to every aspect of your practice; and reproducible and supportable treatment strategies.
Are You Teaching or Selling?
There was a time when a doctor's "orders" were gospel and patients did as they were told. Of course, that was a long time ago, and certainly before the Internet. Today, patients have access to huge amounts of information – some accurate, much of it not. But the point is, many are trying to do their own research. However, they need your help.
Being able to cite current research, evidence from neutral third parties and national guidelines will usually trump your personal opinion and the confusion of the Net. For example, an evidence-based report of findings using current research and national guidelines to suggest treatment frequency, procedures and alternatives will be perceived by a patient as "education," as opposed to "selling." Which do you think will result in better compliance?
For That Matter, Research Still Matters
I occasionally hear that we (the chiropractic profession, presumably) have already "proven" that "chiropractic works." I wish it were true, but my conversations with researchers and chiropractic leaders who interface with policymakers suggest something else.
Is there good evidence for chiropractic treatment (particularly manipulation) for certain conditions, such as back pain, neck pain and headache? Yes! There are also some studies that suggest efficacy for other conditions, but they are by no means definitive, and not agreed upon by other researchers, including chiropractic researchers. One need only review national guidelines like ODG, ACOEM, Cochrane and others to see where we really stand.
Complicating the whole issue is that we tend to rely on research regarding manipulation from other types of providers, such a PTs and osteopaths, but want to claim their results as our own.
Frankly, there is a great deal of work to do. Nowhere is this more true than with respect to non-NMS issues, such as asthma, otitis, colic and other conditions. We have interesting preliminary studies, which some of our colleagues use as definitive evidence of efficacy. It isn't. It could be and I hope it will be, but the proof isn't there yet. We need funding!
The reality is that the PTs are moving aggressively to fill the void of conservative care for musculoskeletal conditions; are providing resources to accomplish their goals; are fighting legislative battles around the country to be able to do manipulation and treat without referral; and are publishing extensively on these issues in the peer-reviewed literature. They already have institutional authority and excellent positioning in the broader health care system. We ignore them as competitors at our own risk.
Doctors of Chiropractic Want to Be Paid Better
It's no surprise that reimbursement rates for DCs in many jurisdictions are half of what they were 20 years ago, and most doctors believe a managed care practice alone is unsustainable. There are many factors affecting this reality. Many doctors are still willing to join and stay in plans that pay less than their cost of providing the service, giving plans little incentive to raise reimbursement rates. The belief seems to be that some patients, no matter how poorly compensated, is a better scenario than no patients. Adding insult to injury, some plans discriminate against DCs by limiting which services they reimburse for, regardless of what their state scope of practice might be.
Unfortunately, federal law precludes doctors and particularly state associations from colluding to raise reimbursement rates. The reality is that regulators, legislators and juries want to see more affordable rates for consumers, not higher fees for doctors. Ultimately, it is likely that reimbursement rates will rise based on only a few scenarios:
Integration Can Be Successful
Clem Bezold and the Institute for Alternative Futures has once again outlined likely alternatives for the profession over the next 10 years.1 One scenario includes increased integration of the profession into mainstream health care, including insurance coverage. Some in the profession will welcome this, while many others will lament and fight it.
However, there are many examples of successful integration, including various medical plans, the VA system and other paradigms. Accountable Care Organizations under President Obama's Affordable Care Act ("Obamacare") present further options for chiropractic doctors to shine in terms of our efficacy and cost-effectiveness. When the skills of the DC are respected and utilized, everyone benefits.
But It Requires More Responsibility
The fact is that increasingly, treatment options, physician opinions and patient choices are subject to evidence-based care paradigms. There are limits, flaws and prejudices, to be sure. But ultimately, when all providers are held to the same standards, we as a profession have a chance to shine, based on our merits; and after all, isn't that all we have ever asked for?
We Need to Stop Practicing in Isolation
Most DCs are in solo practice (although that is changing). A diminishing number participate in their local, state or national organizations based on a variety of factors. Many doctors feel isolated, or that their respective organizations are ineffective, irrelevant, or do not reflect their values or goals. Unfortunately, those attitudes and the resulting drain on membership at all levels result in fewer members, more concentration of narrow frames of reference and opinion, and fewer and fewer resources to actually accomplish their goals.
At a time when collectively, we as a profession need each other the most, we move further apart and rely less on our collective wisdom, joint efforts, goals and vision. We attend fewer conferences and less local meetings, and talk to each other less. That cannot be good.
As a profession, we need to find more ways to share our challenges and especially our successes. We need to share and collaborate more, keep each other out of trouble, call out the outliers, and celebrate our diversity as well as our shared goals. We should be sharing our triumphs, ideas and solutions, rather than our dirty laundry.
Whatever You Call Them, We Need Guidelines
Many in the profession have railed against any limitations whatsoever on care. That may have worked 15 or 20 years ago, but it is no longer practical in an era in which all other professions have established treatment guidelines, and where all third-party payers apply them.
Our profession's unwillingness to address this issue has resulted in guidelines developed by other professions or third parties being used to determine what appropriate chiropractic care is, rather than what chiropractic doctors believe. The fact is that when we develop our own definitions of reasonable practice, most of us agree. Rather than avoid developing our own guidelines, we should embrace the process and ensure they are broadly representative and meet our needs – and more importantly, the needs of our patients.
As a Profession, We Need to Decide Who We Are
The evidence shows that we continue to see a tiny percentage of the population (which may actually be shrinking), despite the reported increase in acceptance of "alternative care." Many in the profession espouse an expanded (or "principled") role as "wellness doctors" based on some reported effects of adjustments on subluxations. Others see our role as more specific, defined at least initially as the "spinal care experts," or as experts in musculoskeletal care.
Ironically, nearly $950 billion is spent annually on the treatment of musculoskeletal disorders,2 though our profession receives only a tiny percentage of that. It could be much larger if we as a profession had a clearer market position. Instead, we are like a box of chocolates: Patients never know what they're going to get. Are treatment recommendations consistent with published guidelines, or is the patient given a treatment plan of 60 or more visits out of the gate? Is it any wonder patients are confused?
As any businessman will tell you, to be successful (either as a business or more broadly, a profession), you must provide a service that matches as closely as possible what large numbers of consumers perceive as their needs at that time. The service must solve the consumer's problem more effectively, more safely, less expensively or in some other way they will perceive as better than a competitor's approach.
Forward-looking businesses will try to determine what needs or issues their potential customers (read "patients") have, and then develop an approach to fill that need. Most surveys of chiropractic patients or potential patients indicate they see us principally as having expertise in neck pain, back pain and headaches. That is what they are likely to buy from us.
Unfortunately, we often try to sell them something else. It is a lot like deciding you want to buy a Ford. You like Fords. You've done some research or you've owned a Ford before. You go to a Ford dealer you've not been to before, walk in the door and ask to buy a Ford, only to be told what you really need is a Chevy.
Even though you repeatedly argue that you are simply there for a Ford, you are repeatedly advised that it's really a Chevy you need. Is it any wonder our potential patients are confused?
How Can We Come Together to Solve This?
Dr. Wayne Whalen, is a 1986 graduate of Palmer College of Chiropractic West. He is a past president of the California Chiropractic Association and past chairman of the Council on Chiropractic Guidelines and Practice Parameters. He is board certified in chiropractic neurology and was named a Fellow of the International College of Chiropractors.