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Dynamic Chiropractic – July 13, 1998, Vol. 16, Issue 15

Helping Gatekeepers Refer to Doctors of Chiropractic

By Arnold Cianciulli, BS,DC,MS,FICC,FACC
In today's health care environment doctors are bearing more and more financial risk for the care they give their patients. To reign in costs MCOs have implemented economic controls, such as caps on chiropractic care of $200 per year per patient, or $1000 for a lifetime of chiropractic care. Is it any wonder that more than 1,000 bills regarding MCOs have been introduced throughout the U.S.?

MCOs call this a backlash that we the consumers don't understand. What is so difficult about understanding bias against chiropractic services? Isn't it time for the doctors of chiropractic to come together to fight these arbitrary caps? The purpose of gatekeepers was designed to regulate high risk and high cost clinical decisions. These primary care physicians (PCPs) were encouraged to limit access to costly care. The public has grown increasingly mistrustful of managed care. Patients' access to chiropractic care has become a carrier concern. Consumers know that the PCP's desire to refer is influenced by financial pressure. Patients realize these pressures result in delay of care and denial of treatment, which results in personal risk to the patient. DCs are victims of MCO greed and misdirection from their allopathic directors. Let's face it, the amount of unnecessary surgery and related spinal care by MDs continues with only slight abatement.

Quality of Care

Quality of care has emerged as a key issue. State legislatures are passing laws to force MCOs to reconsider some of their protocols. Direct access for chiropractic care is not cost prohibitive. As usual, MCOs claim rising costs for direct access, but this is not supported by actuarial data.

However, the fear of increased costs to employers scares off other MCOs from offering direct access. Their solution is to charge patients more for the privilege of a POS (point of service) product. Unfortunately, lumping DCs and other specialists under POS allows them to charge more. So, the MCO's financial incentives for utilizing neurologists, orthopedists and the expensive specialists are imputed to chiropractic care! Thus, our services are under the umbrella of higher costs.

A Western Pennsylvania Blue Shield product has lumped us with fertilization services, thereby applying a 1-2 percent increase to the employer. What is the logic of this lumping by Blue Shield? How is this clinically justified? Perhaps the clinical perspective was not even considered. In spite of significant proof of chiropractic effectiveness for lower spine problems, the policies of MCOs are restrictive. As long as an economic smokescreen is used to exclude chiropractic services, the poison of the AMA quackery propaganda will continue to frustrate patient access to our services.


There are two major steps that our profession must take today if we want growth and equity in managed health care. First, in spite of present research proof and a willingness to commit to greater exploration for chiropractic care in the future, we must recognize the importance of politics. Like it or not, between proof and policy, there is good old-fashioned politics. We need massive grass-roots political action.

Second, we must agree upon criteria for referral. We must develop the tools to enable referral decisions to be made based on appropriate criteria. We must make the clinical guidelines for referral to DCs available to PCPs and other MDs. They need to know when referral to a DC is good evidenced-based medicine. We must supplement them with information which is solid (evidenced-based) and assure them that we are not supplanting their judgments.

Actuarial guidelines are based on national averages, but patients are not average. They have different presenting conditions and past medical histories. We must intelligently inform PCPs, et al., that it is wise to refer to a DC under patient specific guidelines. The appropriateness for chiropractic interaction must be developed and shared with PCPs.

In summation, I would urge all state associations to get up to speed politically, because the consumer backlash offers us an opportunity to rework managed care. I would suggest to college presidents that they give top priority to the development of clinical criteria to be used by PCPs for their use in referring to chiropractic physicians. If we fail to develop appropriate referral guidelines for PCPs, et al., then ask yourself: from what source will they get chiropractic guidance? The AMA? The American College of Orthopedic Surgeons?

I prefer the chiropractic profession. What's your opinion?

Arnold Cianciulli, DC
Bayonne, New Jersey

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