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Dynamic Chiropractic – January 29, 2007, Vol. 25, Issue 03

Reducing the Side Effects of Managed Care

By Steven Kraus, DC, DIBCN, CCSP, FASA, FICC

Authorization of care. Every six visits. If you read those words out loud, it might leave a bitter taste in your mouth. You know what those words have meant and will continue to mean: more work and less income for many chiropractors.

My question is, "What comes next, Doctor?" Can we find something to wash away the bitter, or do we shrug our shoulders and say, "I guess that's the way it is"? Unless you want to join that 1 percent of chiropractors who have opted out of Medicare and managed care, authorization-of-care forms still need to be filled out and turned in from now until doomsday. That's the preferred-provider network contract you signed and, in one sense, that's the way it is.

Those aspects of authorization of care that leave a bitter taste in our mouths include the lost time and lost patient care, the stress it places on our workflow and the intrusion it brings to the doctor-patient relationship. Is that the way it has to be? What if we could fulfill our contractual obligations while efficiently using our time, increasing patient care and regaining control in the doctor-patient relationship? If you're thinking, I'd need some extra staff to do something like that, then I say look no further than the intelligent application of technology and forget hiring anyone. Electronic health records are what we need to take away that bitter and bring sweetness back to our practices. Pen and paper just aren't strong enough to empower chiropractors over issues such as authorization of care.

Efficiency So Far

Until now, trying to find ways to condense paperwork and increase the efficiency of workflow has been the response of most chiropractors to increasing documentation requirements. Frankly, this response has offered the best shot for individual doctors to reduce the negative side effects of managed care's management. Other chiropractors have left practice and some have fought at their state capital, but most of us are struggling through. Struggling, because even with the changes we've made, there's a very flat and wide plateau that we've come to inhabit when it comes to our clinic efficiency.

Desktop computers, three-in-one printers, billing and scheduling software; when these tools became widespread in most chiropractic offices, they were a benefit to clinic workflow. What keeps them as sub-efficient tools is their continued reliance on paper as the final media of record-keeping. It ultimately comes down to pen touching paper. The instinct to struggle through by cutting losses and running a more efficient ship is a good one. But for the doctors who will continue to rely on a paper model to meet such needs as authorization of care, it's an instinct with limited positive returns in the future.

The Limits of Paper

Why will a paper record model of clinic efficiency inevitably keep you struggling rather than overcoming the side effects of required documentation? Mostly because of physics; because you're limited by the fact that one piece of paper can only occupy one place in space and time. This limitation forces multiple interactions within your clinic that directly affect your ability to maximally deliver patient care and earn the wage you deserve. And in the end, we get those side effects, such as stress, lost time with our patients and their intrusion on the doctor-patient relationship. A decade ago, we had no other option than to work within the limits of physics. Pen and paper were it. The advancements in digital documentation have made that struggle unnecessary. Of course, we also should understand that not all digital documentation is created equally.

A Case Study in the Doctor-Patient Relationship

For the sake of example, let me describe one scenario in which pen and paper physics worsen the side effects of authorization of care. Let's look particularly at the doctor-patient relationship. Your patient, Mrs. A, has been receiving your care for the past four weeks for minor traumas she experienced in a fall. At this point in time, she already has made 11 visits, and you're ready to seek authorization for further care. Mrs. A, however, is feeling better. In fact, she started feeling well after the first three weeks, but you see some chronic symptoms that existed prior to her accident, and some functional deficits that still bother you.

It's now up to you to upgrade your plan of care, make changes based on Mrs. A's progress, and complete duplicate forms for ACN, ASHN or whatever PPO-required forms need to be sent off, including the functional-rating index. Mrs. A's information, although it already exists in her patient record, must be transferred to a new form, where you also add in your latest notation from your SOAP notes. This includes your desire to change the goals of her progress to also address her chronic condition. At this point, you or one of your staff already has invested 10 to 15 minutes into the process, and now comes your interaction with Mrs. A. This is where the intrusion of the doctor-patient relationship becomes most apparent.

For the second time, you're required to place paperwork in front of Mrs. A that requires her time and authorization. It's a moment when Mrs. A reflects on the care she's received and the progress so far, and judges whether it's worthy of two more weeks. After all, if you've invested all of this work into asking managed care's permission to treat her; doesn't her opinion matter, too?

The Fork in the Road

Essentially, authorization of care has placed an unavoidable fork in the road for of all your patients. But your clinic inefficiency has cost them some time as well. It's given Mrs. A a new opportunity to reconsider her commitment to your plan of care. It would be a great opportunity to recount the patient's progress, explain her improved range of motion, show the subjective and objective changes she's experienced and help her understand what other benefits can be expected. Instead, she's waiting while you throw paperwork together, and then asked to sign when you're in another room catching up with another patient.

Rather than helping her through this process, you've given her an obstacle to receiving care. The next episode she has in the future, she'll remember the inconveniences of your clinic and will think twice about whether it's worth coming in, especially if she thinks she can "wait the pain out." Rather than steer your patients with the evidence, the benefit of technology and efficient clinical processes, you're forced to ask them to re-evaluate their progress alone, because you've already spent too much time on this task.

Remove the Intrusion

Digital documentation cannot completely remove the intrusion of authorization of care, but it can help you turn this requirement into an opportunity for growth. Without pen touching paper, you're no longer limited by paper physics. Rather than gathering data from three places to create a single form, you simply can create company-specific authorization forms with a push of a button. Patient data, clinic data, SOAP notes, functional-rating index, PPO-specific forms for ACN/ASHN etc., are all digital and can exist in as many places as you need simultaneously. Lost time can be found. Stress can be reduced. Lost patient care can be restored, not only with the more time you have, but also with the fewer clerical errors that are made in filing for authorization - the kind of mistakes that can cost you weeks.

And as far as the patient-doctor relationship is concerned, a painless digital process gives you the opportunity to help your patient through that fork in the road with your opinion, your expertise, and an actual review of their progress; not only because you've invested only seconds in the paperwork, but also because digital has kept you current with every aspect of your patient's care, including your development of a viable plan of care and any cooperation you've had with other providers.

Mrs. A will get the idea that your opinion actually supercedes managed care, because she'll be blissfully unaware that you're even concerned about it. After all, if you think authorization is in the bag, then why would she even reconsider her confidence in you?

It's Already Happening

Believe it or not, that kind of clinic technology is already here. And the side effects we feel as a result of managed care need not be as powerful as they are. We can wash away that bitter taste. All it really takes for us to experience this reality is to take that instinct we have to run a tighter ship and realize paper is holding us back. Then we can discover that the old plateau of clinic efficiency could be placed far below us, as we ascend to greater opportunities in the digital clinic of the future.

Click here for previous articles by Steven Kraus, DC, DIBCN, CCSP, FASA, FICC.

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