1. Get patients involved. We have no time to waste. There are still many huge decisions to be made regarding chiropractic's inclusion in national health care. Those decisions will be made by President Clinton, the National Health Board, the National Health Advisory Board (which will be established to interpret the general plan of the National Health Board), and your U.S. Congressmen.
Early in the campaign for chiropractic's inclusion in national health care, there was a lot of excitement in the chiropractic community. Hundreds of doctors were getting thousands of patients to send letters to the president and members of Congress. In the last month there appears to have been a decrease in that activity. We cannot drop our guard now. The best type of letter is an individual letter from patients; second best is a simple form letter individually signed and mailed. Don't forget to have each of your staff and family members write a personal letter too.
2. Create a normal claim's history. The era of overutilization and NOOPE practice is drawing to a close. There is no better reason than national health insurance and no better time than now for overutilizers in the profession to correct their procedures and establish a normal claim's history with insurance companies. If the AHPs decide to be selective of which doctors will be included in national health care, overutilizers in each profession will certainly be excluded. Currently, a vast majority of insurance companies keep a two-year claim's profile on each doctor. If you create a more normal claim's history starting now you may avoid being excluded based on your previous insurance profile. If you refuse to change your profile, you run a high risk of being excluded from national health care coverage and national health care will have been successful in reducing the cost of care to its patients.
3. Ready your patient base for managed care. In the event chiropractic is excluded in some way from national health care or if the coverage is less than adequate, your patients will need to pay for chiropractic care personally. To do this they must see the value of chiropractic care. You must start educating your patients at this time. Quality reports of findings, spinal care classes, and education during the series of treatments is imperative.
Some practices have a large percentage of maintenance patients who pay for the service personally. These practices will be much more immune to the effects of national health care than those NOOPE practitioners or other practices which rely heavily on insurance. If a patient is in the habit of paying cash for occasional maintenance care, it is unlikely that they would discontinue care in the event chiropractic is not well-represented in the new national health plan.
4. Contact all area HMOs. Chiropractors have been notoriously negligent in working with HMOs, because of the general trend of HMOs to exclude chiropractic, but also because chiropractors never actively pursued coverage in HMOs. As a management consultant I know of chiropractors who are now covered in HMO plans. In most instances, these doctors were included simply because of their constant contact with the HMOs. You should maintain constant contact with the HMOs in your area. In the event these HMOs become the area providers in our future health care plan and chiropractic is to be included, they will be much more likely to work with you because of all the previous contact they have had with you. Remember, as a management consultant it has been my experience that in a vast majority of cases our clients' inclusion in HMOs was not because of insurance profile but because of constant contact with the decision-makers in the HMO.
5. Inform employers regarding the area health plan they should join. Employers will be obligated to provide coverage of their employees in the national health insurance plan if they have fewer than 1,000 employees. If they have more than 1,000 employees they can be self-insured. Your patient base includes many employers. They will need to make a decision on which AHP they will join. One of the concepts in national health insurance is to provide "managed competition" between AHPs. It is possible that some area health plans will have better chiropractic coverage than others. Be sure to inform all your patients who are employers as to the best area health plan in your region.
6. Have credential readiness. It is possible that the AHPs will accept doctors only if they have certain credentials. This is currently true in HMOs and PPOs throughout the country. The most basic of credentials that you will need is a state license and malpractice insurance. The amount of malpractice insurance required by HMOs and PPOs at this time ranges anywhere from $100,000 to $3,000,000. Suffice it to say that at least some malpractice insurance may be needed and a history of malpractice insurance would be a good idea. Other credentialing may include certification in postgraduate courses such as CCSP or CCRP, or diplomate courses such as DABCO or DACBR.
7. Structure your practice towards high volume. Most socialized medicine and national health care plan throughout the world limit the number of procedures paid for, the number of times these procedures are paid for, and the amount paid for these procedures. Doctors are rarely limited as to the number of new patients and, as a result, the total number of visits provided by the practitioner. As a result, it is likely that practice growth in the future will be a function of high volume as opposed to high fees, and you may want to structure your practice in that way.
8. Become a cost-efficient office. According to the Association Research Group which compiles statistics for the American Chiropractic Association, both the median net income and mean net income of chiropractors were approximately seven percent less in 1990 than in 1989. It is possible that with national health insurance, the income of chiropractors will again be decreased. Obviously one way to avoid this is by lowering overhead. Usually a plan to lower overhead must be phased in over several months. Now would be a good time to become more overhead-conscious in your practice, but be careful; this does not mean putting off important business decisions that are necessary for growth.
9. Adopt a positive approach to national health care. As with any other major era in chiropractic, the national health care era will have negative effects on some practices and positive effects on others. Much of the effect will be controlled by the attitude and action of the individual doctor. National health insurance could create many positive outcomes. Overutilizers in the profession will be reduced, the undesirable effect of no out-of-pocket-expense practitioners will be eliminated, advertising may become less necessary, we may move closer into the mainstream of health care and public acceptance, and when health care in the United States is run by big business, those treatments that are most effective will gain in popularity. That puts chiropractic in a very good position. Chiropractors who have been in practice over 20 years practiced in an era where chiropractic care was not covered by a vast majority of insurance companies. Those colleagues will be the first to tell you that chiropractic does well because it gets results and not because it is covered by insurance. Should we lose all of our insurance coverage, chiropractic would still survive and do well, especially for those doctors who are willing to look at national health care reform for the positive effects that it can have and who are willing to adapt to the changing times ahead.
David J. Kats, DC