I just read the Manga report, the Canadian study on treatment of low back pain where chiropractic was a big winner.It made me think about health care reform in the United States. Service will be delivered by whoever can do the best job for the least amount of money. That is our challenge, making short-term sacrifices (release patients when they feel well) to reap unbelievable long-term rewards (become portal-of-entry physicians for all low back patients, or better still, all neuromusculoskeletal complaints).
Let's imagine what would happen if chiropractors were portal-of-entry providers for all neuromusculoskeletal complaints. If this were true, you would never see another chiropractor in a shopping mall, at a swap meet, or advertising for free examinations, x-rays, and treatment. Even the bottom of the barrel would be so busy they wouldn't have time to go over police accident logs and chase ambulances. We would no longer do medical-legal work to eat, we would do it as a favor to an old patient or the community. The scum that make a living brainwashing hungry doctors and new graduates on how to treat a patient longer would have to find some other profession to pollute. We wouldn't hear stories of patients who say they feel wonderful but whose chiropractor tells them they must come in for 20 more treatments because (choose one): a) your legs are uneven; b) your muscles aren't balanced; c) your x-rays aren't straight.
I believe if chiropractors were portal-of-entry providers for all neuromusculoskeletal complaints, our health care system would save a lot of money. For example, I just finished treating a lady who had been suffering from headaches and neck pain for nine months. She initially saw a general practitioner who gave her medicine that did not work. Subsequently, she was referred to an orthopedic surgeon, a neurologist, and a physical therapist. She had every test, scan, and study in the book. She also had tried all kinds of medicine and physical therapy, but to no avail. She entered my office frustrated and depressed. Upon taking her history she stated that her medical bills for this problem had totalled in excess of $20,000. It took me 12 visits ($500) to eliminate her muscle tension headaches. If she would have been referred to a chiropractor by her general practitioner when her complaints originated, the cost of her care could have been reduced even greater (two or three visits at $100-150).
Every doctor I know has stories like this one. Chiropractors could potentially save our country hundreds of thousands, and maybe even millions of dollars in health care costs each year. This would only happen of course if we'd release patients when they feel well. Keeping people on endless maintenance plans is our profession's biggest enemy. Instead of cost effective, we become cost prohibitive. Instead of being included in plans or reform, we become excluded, or utilized as therapists working by prescription (if we are unable to release patients when they are better, then someone will do it for us). Instead of potentially treating 100 percent of the population, we would probably see fewer and fewer people as more and more plans eliminate us. Maintenance plans also make it unattractive for other professionals to refer us patients. Let's turn the table a minute. Would you refer your patients to a general practitioner who would have them return every three or four weeks for maintenance medicine for the rest of their lives, no matter how well they were feeling?
The reason the authors of the Manga report came out so strongly in favor of chiropractic was the fact that chiropractors in Canada were cost effective. They got results and they stopped treating, or if they didn't get results, they promptly referred. In this study, the chiropractors were allowed to see each patient up to 17 times a year. When the researchers calculated how many times a year chiropractic patients went to their chiropractors, the number was only 11. Obviously there aren't as many practice management people in Canada. The folks down here would have those doctors seeing every patient for as many times as the insurance would authorize. It's too bad all our "dynamic practice-building people" simply do not realize that the way for every chiropractor to have more work is to treat each patient less.
As primary care physicians for neuromusculoskeletal complaints, we would encounter more patients who require soft tissue work, such as trigger point therapy, myofascial release, cross friction, or mobilization. Our profession would have to decide whether to train our students in all types of hands-on treatment or just manipulation. I believe we should establish ourselves as the masters of physical medicine, not just manipulation.
Speaking of students, it is interesting to imagine how our schools and students would be affected if we got the job of portal-of-entry physicians for neuromusculoskeletal complaints. With close to 100 percent of the population utilizing chiropractic, field doctors' schedules would be so full they would not be able to adequately supply the demands of the public. Many people would turn to our school clinics for care. Instead of treating classmates, family, friends, and school staff, our interns would be exposed to reality while in clinic. Schools could double their clinic requirements without a single intern graduating late. Because our field doctors would be so busy, the demand for quality new doctors would be high. The days of young chiropractors compromising their ethics to get a job would be history.
Healthy competition for new graduates would lead to starting salaries that would no longer be embarrassing for a professional with eight years of education, while helping reduce our high student load default rate. There would be an increased interest in becoming a chiropractor. Our schools would have many more applicants than they could admit. We could take advantage of the situation by demanding bachelor degrees and entrance examinations for every applicant. With brighter people entering chiropractic schools, it is likely that brighter, more talented graduates would emerge: a benefit to everyone.
Of course there would be some casualties. Those doctors who work for insurance companies reviewing cases like 87 visits for a thoracic sprain-strain with no second opinion or referral would be out of work. All tough cases would have a multidisciplinary approach that would help the patient and create a check and balance system to insure no provider is overzealous.
The above scenario would benefit us more than just financially, it would force a working relationship and a second look from our detractors. I believe our profession would gain respect from the allopathic and insurance communities. Chiropractors would have more clout to demand funding for studies to determine how effective chiropractic care and soft tissue therapy could be for a host of other nonneuromusculoskeletal conditions that, up until now, have had anecdotal results and have given our detractors ammunition to assault our profession. If we want to expand our patient base, improve our practices, and generate more personal and research income, we must continue to show health care providers, the insurance industry, and the general public that chiropractors can treat neuromusculoskeletal conditions better, safer, faster, -- cheaper.
G. Douglas Andersen, DC
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