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Dynamic Chiropractic – May 6, 1996, Vol. 14, Issue 10

Is the Face of Managed Care Changing?

By Stephen R. Seater
At the Foundation for Chiropractic Education and Research (FCER)'s Staying Well division, our employees talk to between 40 and 50 doctors of chiropractic every day. Many are crying the blues about what is happening to their practices because of what they see as total indifference to chiropractic, or even an outright shutout of chiropractors by managed care companies. And, indeed, this often seems to be the case. Many doctors say they have no idea how to get into a managed care plan. Others say that even if they are able to be included, the number of treatments are so restricted that it doesn't make economic sense for them.

According to Arthur C. White, MD, medical director of the San Francisco Spine Institute, the first round of managed care is over. It lasted from 1990 to 1995 and was characterized by an almost complete loss of patient choice and the tightening of the "economic screws," as Dr. White put it. The American people however are becoming increasingly disenchanted with this kind of health care, as has been detected by numerous studies. These studies demonstrate that patient satisfaction is becoming increasingly important in determining the success of managed care companies. CareData, Inc., of New York City, has pioneered the study of HMO patient satisfaction. In 1994 CareData completed a series of regional surveys that involved 22 employers and 3,397 employees in the New York metropolitan area. Oxford Health Plans, based in Norwalk, CT, ranked highest in overall satisfaction and experienced an inflow of more than 250,000 new members based on the survey results. The CareData surveys focused on primary care physicians, specialists, pharmacy benefits, hospitals, and customer service.

Patient satisfaction is just now beginning to be a major driving force in the health care marketplace. It has become so important that a recent Roper-Starch poll placed patient satisfaction ahead of outcomes. And, in a recent conversation with CareData's president, Todd Cooperman, MD, I was told that patient satisfaction was at least the equivalent of outcomes in determining the direction in which health care will move in the years immediately ahead.

Why is this good news for chiropractic? The answer is simple: chiropractic enjoys an extraordinarily high degree of patient satisfaction. A recent article appearing in Spine found that of those patients seeking care from MDs and DCs, the chiropractic patients were more likely to feel that treatment was helpful (99% vs. 80%). They were also more likely to be satisfied with their care (96% vs. 84%) and less likely to have sought care from another provider for the same episode of back pain (14% vs. 27%).

The high rate of chiropractic patient satisfaction documented in the Spine article correlates well with a study done for FCER by Research Dimensions, Inc., called "The Chiropractic Patient in Rural, Health Professional Shortage Areas of the United States." And these studies corroborate Cherkin's findings that chiropractic patients are three times more satisfied with their care than patients of family practice MDs. Furthermore, a Louis Harris poll revealed that 70% of the American public believes that chiropractic care should be a basic benefit of their health plan.

The desires of the patients, along with cost effectiveness, are now becoming a major force to contend with in the health care arena. Patients are more than a little unhappy with the old version of managed care: huge, unwieldy organizations that ration care and stifle patient choice. The growing dissatisfaction on the part of many Americans has caused the situation to begin turning around. New managed care organizations are emerging that want to provide high quality care for their enrollees. As the health care market becomes more saturated with managed care plans, as is now the case, those that concentrate on providing high quality care and more patient choice are enjoying a competitive advantage over the other plans, as was seen with Oxford Health Plans. These enlightened companies are the ones most likely to use low cost chiropractors, who also happen to enjoy high patient satisfaction. We are just beginning to see this change taking place, and not surprisingly, Oxford Health Plans is among the pioneers in providing a chiropractic benefit to its enrollees.

There is some disagreement as to the percentage of Americans who visited chiropractors prior to the first stage of explosive managed care growth. I am comfortable with 10 percent. It turns out that 10 percent of anything in a highly competitive marketplace is significant. Why else would Oxford and others want to include chiropractors all of a sudden? Here is what Mary Hanley, president of Health Care Networks, says: "Chiropractors in the network are critical for us. We feel that they are low cost providers and we'd like to see a lot more of the low-back and musculoskeletal problems being treated by quality chiropractic physicians as opposed to going to an orthopedist of neurologist. The other issue is that chiropractic services are definitely becoming a marketing issue. There are many patients whose provider of choice is a chiropractic physician. From a pure marketing standpoint, I know that we have received numerous clients because we include chiropractic services."

According to Dr. White, "These new managed care organizations, therefore, are using triage organizations to get patients to the most appropriate level of care as rapidly as possible. The chiropractor is a very appropriate subspecialist for early referral for many conditions." He also believes that chiropractors who want to practice as primary care providers will be increasingly invited into managed care groups and that "those who practice most efficiently and successfully will remain in the game."

The newly emerging managed care organizations will invite chiropractors to join multidisciplinary teams that screen, diagnose, and treat spinal conditions. Dr. White believes that in most instances the "chiropractor will make the decision for diagnostic testing, surgery, work status and disability."

Although it is still very early in the second phase of managed care growth, it can already be seen that the patient satisfaction and cost effectiveness enjoyed by chiropractic will work to insure the inclusion of chiropractic services in many managed care plans.

I believe that research, clinical, economic, public opinion surveys, etc., are responsible for the progress chiropractic has made over the last five or six years. This will continue to be true in the foreseeable future, as we enter the age of evidence-based practice. Research can be used to not only influence change on the part of large corporations, but also as a factor in passing legislation and informing government bureaucrats. It is an investment every chiropractor should make for the future of our profession.

Stephen Seater, CAE
Arlington, Virginia

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