The doctorate-level physical therapists are arriving, primed and ready to fill a market niche that was once ripe for the picking: seamless, integrated manual medicine care within the existing health care delivery framework, entirely focused on an NMS perspective.Yes, they manipulate. And yes, they do good research. In fact, they may be catching up with our good work of recent years. They are university-based, and their professional membership base is some 80,000-90,000 strong.
They did this all in full view of the public, and of course, our own pundits, like the Haldemans, Krantz' and the Keatings, have been pointing it out to us for decades. When they approached our institutions about collaborating with them three decades ago, we besmirched them, so they went off to do it on their own. Wait, it's worse: The latest assessment of the use of chiropractic in the U.S. shows that in the past five years or so, we've dropped from caring for about 10 percent of the population to about 7.5 percent, while the use of other CAM providers has continued to increase.1
So, are you worried yet? What's the solution? Another lawsuit against another medical or allied-health trade organization? Get some more laws passed to protect the chiropractic status quo? Maybe another PR campaign lauding how fabulous chiropractic is? How about some celebrity endorsements to just educate the public about us? I know - let's sue some more insurance companies and bring them to their bloody anti-chiropractic knees! Maybe we should publicize more about how spinal adjusting adds years to life and life to years. Or maybe better yet, let's get prescription privileges! Wait, I've got it! Let's work to make our internal political and philosophical squabbles more pronounced and public! That should get us more patients, eh? And certainly the respect and admiration of health care leaders and government officials. Perhaps we should more loudly proclaim our victimization and ostracism at the hands of organized medicine, to get more sympathy from the public!
Oh, I know! All we really need is to get more educational literature in the hands of patients to persuade them of the need for lifetime care and convince them to refer more friends and family members to us. And we need better, more expensive (and billable) technology to justify the need for this ongoing care. We should also try and stop the proliferation of those wretched practice guidelines that obviously are developed by greedy insurance companies solely to challenge our patients' rights to the care we want to give them! And let's not forget to disparage anything medical, especially anything that one of our own patients is receiving that doesn't seem to be working.
Geez, what am I thinking? What we really need are more clever practice-management strategies that can get patient compliance for more frequent and longer treatment! We need to assure that each and every patient is educated about how bad his or her spine will become without chiropractic care, and we need to show pictures of how bad things look on X-rays! Scare 'em into using us! If we can ensure that they get lots of care for months and months (regardless of their condition or how they feel), surely that is in their best interest! No doubt, these strategies are just on the cusp of getting us the breakthrough into the mainstream we deserve. We've only been using them for 100 years, so maybe just a bit longer and...
OK, just in case the point of my cynical comments isn't obvious, all of the "solutions" in the preceding three paragraphs have something in common. They are very shortsighted, doctor-centered approaches to our care of patients. All of them aim to preserve business as usual, and to get other folks to adapt and change to our way of thinking; they also don't require us to do anything we don't like. We frequently get so focused on chiropractic that we can be in denial that the public only wants what we offer if it helps them in a meaningful way. No amount of hype or marketing to build individual practices will help us gain cultural authority. In fact, many of the approaches that brought us success in the past, and may still have some perceived immediate benefit for a few individuals, can have unintended negative, long-term consequences for the profession as a whole.
So, what should we do? The bad news is that we have to try something new. And I'm afraid change is the hardest thing in the world to do. It is also uncomfortable. The good news is that, were we to offer a seamless way for the health care system to work with us, it might not be too late.
I recommend that everyone who reads this column take a look at the following Web site: www.bridgestoexcellence.org. Read through the various Web pages to get a flavor of what is happening in the health-care think tanks and quality assurance programs. Download the free 51-page white paper on Measuring Provider Efficiency and read it. There is a health care "quality revolution" underway today that is taking the health care system at large - providers, institutions, payers, and purchasers - to task for the low-quality, disorganized, and costly care that characterizes much of the health care system. "Bridges to Excellence" (BTE) reflects an effort to operationalize recommendations made in 2001 by the Institute of Medicine in their report, Crossing the Quality Chasm.2 They identified the six areas in which the health care system needs to be redesigned to make it safer, more timely, more effective, efficient, equitable, and patient-centered. Everyone is charged with making improvements. They emphasize that the task is not an easy one, and that it encompasses all levels within the health care system which must be engaged, including:
- insurers, purchasers and regulators;
- hospitals and medical groups;
- office practices and hospital units;
- individual clinicians; and
You don't need me to tell you that doctors are being squeezed by paperwork and accountability demands, often to the detriment of time spent with patients. Even more frustrating is that while direct patient care is reimbursable, time spent responding to adjudication paperwork usually is not. Not to mention the economic challenges involved in the cutthroat business of managed provider networks. But you do need me to tell you that on top of all this, the competition is figuring out ways to not only survive, but also to flourish in the emerging health care environment.
To the extent that chiropractors can provide a high-quality, high-value service that meets the needs of the public and can seamlessly serve the needs of the health care system, we too will survive and even flourish. To the extent that we continue to be in denial and remain doctor-centered, we will increasingly find ourselves outcompeted, outnumbered, and out of business. The old days of putting only our interests first, and believing that all we have to do is "educate them about chiropractic," are gone forever.
Our services and the role we play need to be understandable within the context of evidence-based health care, including the thresholds for care of covered conditions versus noncovered elective care. Our documentation and correspondence have to be decipherable and our care recommendations have to be reasonable. Our ability to seamlessly interface with other providers, meet the accountability needs of our customers, (yes, that means our patients and whomever buys their health insurance coverage, be it a taxpayer or employer, and whomever they hire - like an insurance company - to administer the health benefits) will determine their willingness to buy services from us.
The more we can do it better, faster, and cheaper than the competition, the more likely we are to increase our share of the market. However, the harder we make it for the health care system to work with us...
- "No, claim manager, you have to learn our lingo to be able to pay us."
- "No, concurrent care provider, we're going to "dis" you and all your medical treatment with our mutual patient because it's not within my chiropractic belief system."
- "No, regulator, we're going to fight you, sue you and pass laws to force you to keep our interests above your other constituents' interests."
It is also more likely they will turn to someone else to get the benefits we could offer. After a couple decades of growth, it looks like about 20 percent of our customers have done just that.
Visit that Web site, folks. Do it this week. The opportunity to be a partner in building solutions is at hand. Get together with your colleagues and brainstorm ways to discuss that white paper, how to do a better job in your offices, how to improve your patient outcomes and be more efficient, and how to make yourselves a resource to your community. And encourage your alma maters to do the same.
- Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use of complementary and alternative medicine by US adults: 1997-2002. Altern Ther Health Med. 2005 JanFeb;11(1):42-9.
- Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.
Robert Mootz, DC
Associate Medical Director for Chiropractic,
State of Washington Department of Labor and Industries
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