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Dynamic Chiropractic – November 20, 1995, Vol. 13, Issue 24

Is Cash Practice One Answer?

By Rob Sherman, Esq. and C. Jacob Ladenheim
"Managed care" is a term that evokes fear and resentment in many health care providers, especially those who are on the outside looking in. Even those who have gained access to managed care organizations (MCOs) are faced with a myriad of burdensome requirements, such as pre-certification and utilization review often conducted by MDs and nurses. Reimbursement requirements are frequently different for each plan and a doctor may have to fill out a four page form just to receive a $30 payment.

Is it any wonder that the purveyors of "the cash practice" are doing a landmark business? Doctors are asking, "If I can make a decent living without having to subject myself to the drudgeries of managed care, why not consider a cash practice?" It is a good question. And in those "mature" markets where managed care has an established foothold -- such as most parts of California and major metropolitan areas such as Minneapolis -- new doctors and doctors "out of network" are finding that a cash practice is the only viable business business option.

An Industry in Transition

It is little solace to the struggling practitioner that managed care is "in transition" and there is light at the end of the proverbial tunnel. Many managed care organizations are bowing to the demands of consumers and including doctors of chiropractic within their networks. Dynamic Chiropractic noted in a recent issue that even MCOs with long-standing policies against chiropractic conclusion, such as Kaiser Permanente, have recently begun to open their doors to chiropractors (see the 10/9/95 issue of "DC").

Employers are also beginning to recognize that MD gatekeepers who restrict access to chiropractic treatment. For instance, Insurance Risk magazine reports that the initiation of practice guidelines within USAir's managed care plan has allowed greater access to chiropractic treatment. Prior to the implementation of the guidelines, "[I]t was virtually impossible to access chiropractic care, because of the bias in the medical community," explained Jim Davis, senior director of employee benefits for USAir.

Clearly, the managed care community is responding to the demands of chiropractic's greatest advocates -- its patients. But for many doctors, these changes are not coming fast enough. Hard hit by managed care, doctors and their state and national associations are searching for effective strategies to maintain and build viable practices.

Provider Coalitions Are Formed

Pro-chiropractic legislation is one avenue that many state associations are pursuing. Economic hard times are forging unlikely provider coalitions as past differences are set aside. The allopathic, osteopathic, chiropractic, pharmaceutical, and even physical therapy associations are joining forces with other nonmedical groups and introducing legislation under "any willing provider" and "managed care fairness" banners. Common interest in bringing "fairness" to managed care outweighs past differences. The ACA has even met with the AMA.

Legislation may take years to pass however, and is always vulnerable to repeal and "loopholes." The current ineffectiveness of "insurance equality laws" aptly demonstrates how easily an adversary can find enough holes in a statute to make it look like Swiss cheese.

Building Relationships: the Long-Term Solution

Cultivating relationships is also imperative. It is a more complex alternative, but one that will build the foundation needed for chiropractic.

Consider your own life. Who do you trust? Most likely, you trust only those people with whom you've built a sound relationship. It is proven that people donate money to people first, causes second. If you were to call your closest chiropractic friend and ask for a contribution to a chiropractic cause, your friend would readily contribute. The cause is secondary.

Data + Trust = Believability

"Data" works the same way. Repeated preaching about cost effectiveness to decision-makers will not bring this profession within the mainstream of health care unless the data is presented to those with whom you have a relationship. Simply stated, data + trust = believability.

Policymakers know that manipulation of data is an art form. Data is often used by policymakers simply to justify a decision that they already have made probably based upon information provided by someone they trust. Trust comes from the relationship, not from data.

While all this is essentially common sense, it is amazing how few people in any profession consciously build relationships. Instead, many seek a quick-fix answer to their problems. There are none. Even law suits take years to resolve: ask Dr. Wilk, et al. Although we make our living as litigators, we understand the limitations of a law suit.

Where Do You Begin?

You begin building long-term relationships with decision-makers through your patients, community groups, friends and relatives. Everyone knows someone who can introduce you to someone who knows someone. Some have postulated that we are only a few people away from knowing everyone in the world. Someone you know knows someone else you should talk to.

And what do you say? Probably very little at first. Ask questions about the other person. Use the phrase, "Tell me about it," to get the other person to open up. Open ended questions work well. Try this technique at any occasion: it works.

This process takes time. It's not easy. It's frustrating, and it's especially trying when you develop good relationships with an MCO, but still can't get in because the panel is "filled." Nonetheless, it is essential that doctors continue building long- term relationships even in "closed" markets. Panels will open due to the demands of those patients seeking chiropractic care.

How Do I Make a Chiropractic Presentation?

As relationships build, you will have ample opportunity to discuss chiropractic access in MCOs through one on one conversations or through group presentations. To be effective in this environment, you must have some command of chiropractic effectiveness data and an understanding of the wealth of persuasive arguments for chiropractic inclusion in managed care organizations.

This is not a difficult task considering the wealth of material offered by state and national organizations. For instance, the ACA offers a complete packet of material on the AHCPR guidelines that you can send to legislators, attorneys, patients, or literally anyone with an interest in health care. This federal study rated manipulation in the forefront of treatment alternatives for low back pain, yet only a few within the profession have taken full advantage of this document. You can obtain this information packet by contacting the ACA at (800) 986-4636.

The Foundation for Chiropractic Education and Research (FCER) also has outstanding presentation materials including an 11-minute video endorsed by the Congress of Chiropractic State Associations (COCSA). Contact FCER at (800) 637-6244 for a description of the video and a catalogue of available materials.

The Ohio State Chiropractic Association (OSCA) has developed a complete presentation packet for use in making presentations to service groups, legislators, managed care organizations, or others. The packet contains overheads, slides, and a "flipchart" of various studies showing chiropractic cost effectiveness. A script on the use of the material is also included. For further information on the presentation packet, contact the OSCA at (800) 837-6721.

OSCA President Dr. Ron Farabaugh developed the presentation flipchart and has used it extensively in educating policymakers and patients. "Individual doctors and OSCA district officers have used the flipchart before MCOs, legislators, hospitals and employers," Dr. Farabaugh explained. "Columbus Community Hospital was greatly influenced by the presentation and incorporated chiropractic within the hospital."

"The presentation packet combines all of the scientific data in one format with a clear visual display," Dr. Farabaugh stated. "For instance, the difference in education between medical and the chiropractic practice is visually explained. It also shows how chiropractic can be integrated into a multidisciplinary setting.

"Once you learn the material presented in the flipchart, it is much easier to have a personal conversation with a decision-maker. You are armed with the data.

"Out patients also love the presentation. I keep a flipchart in my reception area, and use pages as handouts for patients."

The Kansas Chiropractic Association produces an educational video on chiropractic education and cost effectiveness studies that was distributed to many legislators and insurance representatives. You can reach the KCA by calling (913) 233-0697. The Alabama Chiropractic Association developed a cost effectiveness brochure that is used throughout the nation. Contact ASCA at (205) 262-2228 for further information.

So What's the Answer?

Managed care is not inherently good or bad. In five years, the managed care landscape will drastically change. How chiropractic fares under this environment will depend upon a combination of strategies, including:

  • the passage of legislation that breaks down artificial barriers to patient access;


  • the success of law suits that challenge arbitrary MCO policies;


  • the development of relationships with policymakers;


  • the education of patients and others through the use of materials developed by state and national associations;


  • the continuation of research projects that demonstrate cost effectiveness;


  • and most significantly, the advocacy of our patients.

All of these components are crucial to the progress of this profession. None can be ignored.

Rob Sherman, Esq.
Columbus, Ohio

Jacob Ladenheim, Esq.
Fincastle, Virginia

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