- There is increased awareness and utilization of CAM services, with chiropractic among the most utilized and developed.
- A chiropractic program is being established within a major, publicly funded research university.
- Chiropractic has been incorporated within Department of Defense benefits, including the establishment of services at Bethesda Naval Hospital, where Dr. Bill Morgan facilitates first-class chiropractic residency training and provides chiropractic services for the U.S. Congress and other officials.
- A federally funded research center has been established at Palmer College of Chiropractic.
- Even though all health-care benefits, including chiropractic, are under increased scrutiny, health plans and networks increasingly address the issue of providing some kind of chiropractic benefit.
- Clinical and scientific contributions from chiropractors populate the health-care and scientific literature.
- "Best-practices" guidelines and care pathways increasingly acknowledge value for chiropractic care.
- Disparaging attacks on chiropractors from the mainstream health-care community are the exception, rather than the rule, these days.
All of this points to the mainstreaming of chiropractic services, at least within the American health-care landscape. However, there is still much work to do. Cost-containment efforts sometimes still single out chiropractic services for exclusion or reduction, and interdisciplinary doors aren't entirely open. What is it going to take to achieve full mainstreaming and integration of chiropractic into health care?
Although we grow day by day, many idiosyncrasies of the chiropractic profession continue to make it difficult for others to embrace us, even as they increasingly find resonance with what we offer. At the top of my list in this regard are unity and professional maturity. From my vantage point, there is no good reason for the elimination of differences in opinion, methods or philosophy. However, such diversity need not result in disunity. Issues of power and ego will exist wherever human beings gather, but the nature of professional debate in our midst too frequently harnesses personal attacks over reasoned discussions of issues.
Another growth area is our professional training. I know I shall injure some sacred cows with this one, but the way we build chiropractors relies all too heavily on didactic exposure and regurgitation, and too little on apprenticing and competence. Great things are happening at some of our educational institutions, mind you, but much chiropractic training remains lecture, multiple-choice tests, and numbers hoops. A full-throttle shift from minimal criteria toward optimal competencies is still needed.
Chiropractic remains in an identity crisis. Are we a health-care service or some kind of immutable law? As a health-care service, we can propose bold (tested or untested) theory, speculations and innovations. We just can't claim such theory to be absolute, indisputable fact. As a health-care service, we would be patient-centered and health-outcomes-oriented, rather than obsessed with physical findings or symptoms. I remain amazed at how some DCs (much like surgeons and other allopaths) act when they get all wrapped up in some model, set of findings or doctor-centered issue. Instead of the medical adage, "The surgery was a success: The heart was repaired, but the patient died," a chiropractic corollary might be, "The adjustments were a success and the subluxations are improved, but the patient still can't work, still has to be seen three times a week, and still is in pain." As a service, we have to get the job done for the patient.
Desired Future State
|Chiropractic interests are represented and perceived as a "special interest."||Chiropractic interests are represented so we are perceived as a community resource.|
|Chiropractic education and credentialling is minimum-qualification driven.||Chiropractic education and credentialling is maximum competency and benchmark-driven.|
|Other providers are competition.||Other providers are resources.|
|Use of scientific evidence is a defensive "prove" mentality.||Use of scientific evidence is an offensive "improve" mentality.|
Addressing the External World
The reality of increasing demand for shrinking resources has never been more pointed in health care than it is today. Some of the most successful "businesses" in the health-care marketplace are responding with more efficient care; better patient selection for specific services and procedures; extensive quality improvement strategies; and continual assessment of health-care consumers' and customers' needs. These days, the consumer and payer are not necessarily the same person, and may have quite different needs.
The issue of financing "health" care will be a challenge. Wellness and prevention may well improve a person's lot in life, but deciding who should pay for it will be the source of consternation for many providers, especially those of us with holistic leanings. Most health-care insurance is indemnity-based, which means everyone pays a little to cover rare but expensive needs for the few. As insurance coverage is called on to handle everyone's regular needs, it doesn't make business sense. In the old days, high deductibles provided incentives for patients to interface directly with doctors on costs of care. Today, per-treatment copays play a similar role. I expect more innovations in health-care-financing products to evolve in the coming years.
Regulatory inflexibility is another external issue chiropractors and their patients must confront. In general, once laws, regulations and policies get made, they are hard to change. More and more, evidence-based practices are being reflected through evidence-based policy-making. Doctors will increasingly find that getting new procedures or gadgets covered by insurance will require higher-quality research studies demonstrating both effectiveness and value. Purchasers and regulators are increasingly fed up with high-cost "advances" that provide only a marginal gain. A new drug that works the same as an existing one, but only has to be taken once a day instead of twice, may not be seen as a good value, when it costs $100 per month more per patient - and those resources are getting redirected from prenatal or elderly care, for example.
Can Chiropractic Make the Shift?
We must make some cultural shifts to stay competitive and valued in the future. I see several goals chiropractors should embrace for this to happen.
I think the chiropractors of the future should be among the most evidence-driven providers out there. They also should be among the most patient-centered of providers, offer the most efficient, high-value services of any provider, and be one of the "go-to" resources for health-care issues in their communities. Unfortunately, no one else has the slightest interest in making us that - so we'll have to do it ourselves.
Robert Mootz, DC
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