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Dynamic Chiropractic – February 12, 1996, Vol. 14, Issue 04

The Side Effects of Managed Care

By R. James Gregg
Managed care is the issue of the day for chiropractic. I sincerely wish it were not, but I don't make the rules for the contemporary health care marketplace. Whether or not we would be better off if I had that power is an open question, but one we need not brood over. In my last column I presented some basic thoughts about managed care and the impact this phenomenon is having on our profession. I was surprised by the feedback and gratified to know that many of you share my concerns as well as my frustration over the bite such plans are taking out of too many chiropractic practices. There are so many implications and considerations in this area that demand our attention that I thought it would be worthwhile to focus once again on this issue and provide a little more commentary on this problem from my perspective, both as a practitioner and as a state and national association officer.

There are a number of serious problems that do not get the attention they deserve when managed care is discussed in a chiropractic context, and I believe that this is an appropriate forum in which to begin such discussion. The more we share information on managed care amongst ourselves, the better equipped we will be as individual practitioners to meet the challenges of managed care. The problems I would like to address here might be called the side effects of managed care. These issues ripple through our practice experience and threaten to fundamentally change some of the greatest strengths and rewards of chiropractic practice. They do not always strike at the immediate bottom line but impact us severely nonetheless.

The first of these debilitating side effects is a psychological and emotional one. This is the erosion of faith and confidence that is brought about between us and managed care patients by the approval, utilization review, and justification processes that seem to accompany most cases under managed care. As a private practitioner, part of the deepest satisfaction of practice I have enjoyed over the years is that unique relationship of trust and confidence that develops between doctor and patient. I believe that this deep trust is a vitally important part of the healing equation. Because the patient feels that their problem is being thoroughly addressed through proper diagnostic activities, that proper care is being administered by someone who truly cares about their health, fear is removed from the patient's emotional mix and they can focus on getting better, not on being sick or injured. How many times have you seen a wave of relief come across a patient's face when you begin to explain their problem and how chiropractic can help? What a tremendous feeling and validation accompanies the ability to ease people's most profound fears by a presentation of the chiropractic solution to their special problem. Enter the managed care procedures. It is no longer a matter of trust between doctor and patient. It is a matter of something far different and I feel almost sinister in its implication.

Managed care plans approach individual health episodes from a very negative perspective. Prior approval, as is required by many plans before chiropractic care can be undertaken, implies that the patient might not know what is valid and appropriate, and too many plans work on these fears and use the approval process to talk patients out of chiropractic care, literally forcing patients on to more expensive care that they never really wanted in the first place.

Next come the utilization limitations that reflect not the optimal care of the patient but what the plan is willing to spend per case to protect profitability. Most people in our society respect and are quite willingly led by what they perceive to be authority and supposed expertise. Now we have someone else standing in judgment over access to chiropractic services; every negative action represents a step in an educational process designed to teach people that chiropractic might not be what they thought it was, is suspect, or that there are other more powerful alternatives that they should be utilizing. I believe that this is often a part of the managed care strategy. This is a tragedy, it is unfair and it is bad health care policy. Such procedures strip the individual of a sense of control over their own health care decisions. It adds anxiety to a usually already tense situation, and when care is approved, brings a patient into the chiropractic office with a whole new set of questions and concerns about the appropriateness, utility, and even safety of chiropractic care. It makes us look suspect, and robs us of that critical chance in too many cases to speed the healing process through trust and a strong sense of confidence on the part of the patient.

Whenever any factor comes between the doctor and the patient, there is a danger that the healing process will be interfered with. Sometimes this interference is subtle and hard to define or quantify; sometimes it is blunt and immediate. What do we doctors do when our care for a particular patient is limited to a level grossly below what we in our hearts feel is the minimum needed to meet the patient's basic need for care? This is the saddest of situations but one that many of us see every day. How can we feel about the three or four visit plans? How deflating and depressing it is to the DC and patient to have to face each other and discuss the economic and health consequences of such limitations. It is cruel and I think unforgivable for a system to offer such shabby window dressing in care where a patient is allowed to start down a proper road of care and then told that if they wish to continue, it will be at their own expense. I believe that many plans employ those limitations as a carefully considered strategy to kill a patient's inclination to seek chiropractic care for good. This is a likely consequence of this type of experience.

Perhaps the most worrisome side effect of managed care is the medicolegal by-product of care limitations. What are your legal responsibilities and what is your potential exposure in malpractice terms when someone else decides to terminate care, even though you may feel, based on the compelling clinical facts, that care must continue. Do managed care plans assume such liability for you when you face such situations? No. I believe that this is a point on which all national chiropractic associations should immediately combine forces to lobby for legislation requiring such an assumption of liability. As if the legal confusion isn't enough, what about the moral and ethical confusion? It literally hurts me to have to stop care before the maximum benefit to the patient is reached, and doubly so when care is stopped by a managed care decision.

The final issue I wish to raise in this brief discussion is that of patient confidentiality. For my entire professional life, my relationship with my patients was surrounded with a sacred sense of strict confidentiality. This trust adds to the doctor/patient relationship in a very significant way and provides for a setting in which the patient can feel completely free to share all that is bothering them. Sharing is a deeply personal endeavor that crosses the physical line and includes emotional and sensitive matters. With managed care plan administrators demanding full access to all records and an ongoing series of detailed reports about the patient, this strict sense of confidentiality is threatened. How can I as a professional promise confidentiality when I know that plan utilization personnel are likely to be pouring over my patient files? This is a potentially dangerous issue, not only for its personal and emotional consequences on the patient, but also because of possible liability questions. How can I protect patient records and details of care I provided, including possible diagnostic findings that might be embarrassing or otherwise hurtful to the patient, when those records are not my sole or exclusive responsibility? I can't.

Managed care is not the answer to our nation's health care crisis. At best, it is a short-term vehicle that hard pressed private insurers and government administrators can utilize for a while to hustle people into settling for second-rate care. We must all think very carefully about the implications of the basic tenets of managed care, considering all the side effects and spin-off consequences. We must find the resolve we need as a profession to stand up and fight for the rights and the dignity of our patients.

R. James Gregg, DC
Garden City, Michigan

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