DCs as Primary Care Providers

Interview with James Zechman, Part I

By Editorial Staff
Editor's note: In the December 1, 1999 issue, we interviewed the CEO of Alternative Medicine, Inc. (AMI), James Zechman. AMI had contracted with Blue Cross/Blue Shield of Illinois, the state's largest managed care plan, to give its more than 700,000 enrolled members the option of having AMI's chiropractors as their primary care physicians. We esteemed this a coup for chiropractic, and awarded Mr. Zechman our "1999 Person of the Year."


As we only recently learned that AMI was selected by the American Academy of Chiropractic Physicians this past summer to become their exclusive national credentialing authority, we thought it time to check in with Mr. Zechman to see how his chiropractic primary care providers are fairing.

DC: When we last spoke, you were initiating a pilot program in the Chicago area to credential doctors of chiropractic as primary care providers. What has been the response to that program?

Mr. Zechman:

The theory behind the AMI pilot project is that our health care system, which is more of a disease care system, is not functioning at a very effective level. Patients often only access medical care to solve an acute medical crisis. This has proven to be costly, morbid and unsatisfactory. It is the reason the United States is ranked first in cost and 37th in health care quality by the World Health Organization.

Our theory was to accurately test a preventive health care system based on a non-pharmaceutical/non-surgical entry point. We specifically selected primary care chiropractic physicians to function as our entry point into the alternative health care system. We believe for a variety of reasons that primary care chiropractic was ideally suited to this task. The performance of our physicians has been very gratifying.

We are now concluding our 24th consecutive month of patient care delivery. Our patients, as evidenced by the annual BlueCross BlueShield HMO Illinois patient satisfaction survey, continue to be delighted with their care. Across the board, patients utilizing the AMI integrative health care model display a higher percentage of satisfaction compared to patients utilizing traditional Western (allopathic) medicine. This is the second year in a row we have scored higher than the traditional allopathic model.

Each year, BlueCross BlueShield HMO Illinois nurses conduct an onsite evaluation of the medical management team and their facilities. Our audit scores in the year 2000 were 100 percent on medical management and 97 percent on administrative management. Obviously, these are exceptionally high scores. Our feeling is that our selected group of highly credentialed primary care chiropractic physicians has distinguished itself as elite among our nation's health care providers.

Perhaps the most gratifying response has been from the national press and business community. The business community is beginning to realize the potential for improvement through more efficient utilization of health care dollars, and has embraced our model. We are in discussion with approximately 15 major self-funded employer groups in eight states. The first of these employer groups will be starting in Chicago January 1, 2001, with the Park District Risk Management Association and Exelon, the parent company to Commonwealth Edison. The reason these large employer groups have chosen the integrative AMI model is because of the credibility of our outstanding data.

DC: How do the results of your program compare to similar managed care plans that employ a medical doctor as the PCP?

Mr. Zechman:

Our model of true integrative health care delivery has out-performed even our own high original expectations. We're often asked if our clinical outcomes are statistically valid, or if our sampling is biased?" Our data is collected by BlueCross BlueShield HMO Illinois and given to us after their analysis.

We currently have data supplied to us by BCBS HMOI for the first 18 months of our program.

  • Compared to normative values in the greater Chicago area for all other allopathic IPAs, our network has reduced hospitalizations by approximately 60 percent over a 24-month consecutive period.

  • We have reduced outpatient surgery and procedures by approximately 85 percent over a 24-month consecutive period.

  • We have reduced pharmaceutical usage by approximately 56 percent over a 24-month consecutive period.

"We truly are the "best medicine of both worlds"...the prevention-oriented skills of well-trained chiropractic physicians and the crisis and emergency skills of allopathic physicians on an "as-needed" basis."

We have reviewed our enrollment and have found no difference in sex or age adjustment compared to the general demographics for the greater Chicago area. If anything, we believe we receive a negative sample bias for the following reasons:

  1. We have a much higher proportion of women of childbearing age than does the average IPA. The network average for allopathic IPAs is 36 percent. The AMI network enrolls over 52 percent. Women of childbearing age tend to be high medical users. Furthermore a disproportionate amount of our hospital admission days are due to normal labor and delivery in comparison to the network average. Of interest to note is that we have no C-section deliveries over a two-year period, as compared to a network average of over 22 percent.

  3. It was also reported by Austin in JAMA in 1998 that people who choose alternative medicine identify themselves as "sicker" than the general population. We would categorize most people enrolling with us as "medical failures." Examples are steroid-dependent asthmatic children who have been bounced from emergency room to emergency room and hospital to hospital, now much more evenly controlled without the use of steroids and strong pharmaceuticals. This again confirms our belief in the power of prevention gained from maintenance and supportive nonpharmaceutical care.

DC: Tell us about your model with chiropractors as primary care physicians.

Mr. Zechman:

Upon enrolling in AMI, patients must choose their primary care physicians. They can choose one of our chiropractors. This AMI physician will be the patient's only PCP. AMI is the only HMO in the country where it is mandatory for the patient to be seen within the first three months of enrolling. It is only by active prevention that wellness can be achieved and the medical crisis requiring pharmaceuticals or surgery can be avoided.

The average number of visits that patients make to AMI's PCPs is one every two to three weeks. This is in obvious contrast to the allopathic model, where the national average number of visits in an HMO to an allopathic PCP is one every 16 months. How well can that practitioner know the patient? Clearly, if you are visiting your physician only once every 16 months, with minimal or nonexistent prevention and wellness benefits, the cause is a medical crisis. Waiting to see a physician until disease is present adds costly tests, procedures and pharmaceuticals to the health care bill that could have been avoided through a strong and integrated preventive care program.

AMI was founded to correct this philosophical imbalance. Of course, we do utilize allopathic physicians when appropriately educated. AMI has over 2,500 allopathic physicians under contract in the greater Chicago area. However, these allopathic physicians all act as referral specialists. In our model, pediatricians; OB/GYNs; family practitioners; and internal medicine doctors are all labeled as "specialists." They only see patients when our chiropractic PCP issues them a referral. All referrals generated by AMI are co-managed with one of AMI's medical director MDs.

We believe this is the only rational choice: to create a true prevention-based health care system as opposed to an after-the-fact disease care system. It is this system of truly integrated medicine that precludes the need for restrictive guidelines and disruptive oversight of chiropractic care. We believe once you identify quality - the rest takes care of itself. We do encourage co-management with our MD medical director for all complex cases and require MD specialist's referrals on a disease-specific basis. However, all routine cases (example, those involving throat cultures, CBC, SMA-20, routine office x-rays) are initiated by the chiropractic PCP without any required consultation of the AMI medical director MD.

We have no limit on the number of visits, treatments or procedures. Anything which takes place within the doctor's own office is unencumbered. Should more complex medical workup or treatment be required, co-management with the AMI medical director is initiated by a telephone call from the PCP. The patient's care is then discussed. In complex cases, the chart may be faxed to the AMI medical director as necessary. An appropriate differential diagnosis will then be formulated, and a suitable workup or treatment regimen will be undertaken.

To the best of our recollection, we have never disallowed any form of in-office treatment desired by the chiropractic primary care physician. We have, however, redirected what we considered to be inappropriate allopathic workup or referral after discussion with one of AMI's medical directors.

Clearly, our experience demonstrates that with proper prevention, maintenance high cost disease care can be significantly minimized, and for many conditions, completely avoided. We truly are the "best medicine of both worlds"...the prevention-oriented skills of well-trained chiropractic physicians, and the crisis and emergency skills of allopathic physicians on an "as-needed" basis. This is our vision of our country's future health care system.

DC: What do the doctors participating in the program have to say about your model of care? How do patients feel about it?

Dr. Zechman:

For the most part, our primary care chiropractic physicians are very gratified by their experience with the AMI program. Only one provider has dropped out of the program over the first two years. However, working in the role of "gatekeeper" in a classical HMO model is no more fun for chiropractic physicians than it is for allopathic physicians. The HMO classical gatekeeper model has its strengths and weaknesses. I believe the national trend away from this model toward an open access PPO model speaks for itself. Nonetheless, our physicians have performed to a very high level as indicated by our outcome data and our patient satisfaction surveys.

Many of our providers have told me of their great pride and sense of achievement in fulfilling the highest level of credentialing and performance in the chiropractic profession. I also am aware that they have received numerous awards and recognition from the highest levels of their own profession within academia.

We feel very fortunate to have had the opportunity to work with such excellent providers. I am glad they are being recognized for the truly outstanding job that they have done. AMI's primary care chiropractors are showing the world what the profession has always believed since its inception: Chiropractic has an ability to impact a person's health in a very profound manner. We are personally very gratified that our model is truly integrative - using the best that allopathy and chiropractic has to offer, and making such a dramatic impact nationwide.

Although our company is small, our impact on a national basis is quite large. We are actively moving the marketplace in the right direction. We know our patients are overjoyed that they can access full range of CAM modalities as core- covered benefits. Unlimited chiropractic assessment and treatment; acupuncture; analysis of nutrition; exercise and diet; and nonpharmacological means are readily available without restrictions or referral. Fortunately, AMI has proven that this should continue as an effective model for optimal health.

DC: How do the results demonstrated in your program translate to the average employer?

Dr. Zechman:

The AMI program is being geared toward large self-funded employer and governmental groups. The true payer of health care is, in most cases, the employer. Managed care organizations and insurance companies merely act as middlemen, to organize and deliver health care or to pay claims. Thus, the real decision maker in the process is the payor or employer.

By nature, these decision makers are good businesspeople. They understand the present health care system is failing to control health care costs, and are looking for answers to address this problem. While all of the readers of this magazine certainly understand the problem and perhaps, "the solution," clearly mainstream business is only beginning to realize the true cause of increasing costs and decreasing productivity.

We know, of course, that if 75 percent of all disease is aggravated or caused by stress, then clearly stress management is indicated. We know, of course, the value of regular maintenance and supportive care to avoid medical crisis, but our company has finally proven it. Employers are extremely interested in our model because of the credibility of our data. They can look forward to a more efficient delivery of care to avoid the costly downstream effects of pharmaceuticals, procedures, hospitalizations and surgery.

Even more crucial than improving the bottom line of their health care dollar is its direct effect on lost productivity, i.e., reducing absenteeism. Dollar-for-dollar absenteeism, whether it is caused by accident, stress or illness, is more costly than the health care dollars spent to correct these issues. For this reason, AMI has tremendous promise for the mainstream business community.

We are most excited by the unique opportunity this gives us to again scientifically document cost offsets in a more rigorous fashion. Our future data through the self-funded corporations will give us data that can measure the unit of the individual employee itself. Thus we can once and for all document cost reductions employee-by-employee, episode-by-episode, and not have to rely on comparisons of normative models. This, in our mind, is the final hurtle to be overcome to obtain national acceptance by the scientific community and medical establishment at large.

What employer wouldn't want to decrease health care cost and absenteeism, while improving employee satisfaction and enhancing its overall effectiveness of business operations?

That is why this year, AMI has made every option available to the mainstream business community via the complete menu selection of HMO, PPO, executive optimal health, and workers' compensation products.

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