The Employer Holds the Key to the Doors of Managed Care

By Joseph J. Sweere, DC, DABCO, DACBOH, FICC
Most prognosticators of health care estimate that by the year 2000, three-fourths of Americans will be members of managed care organizations, as the result of contracts negotiated on their behalf by their employers. Since the failure of the Clinton health care reform effort, and with a strong conservative element in the U.S. Congress, it is clear that the federal government will not be playing a significant role in health care delivery issues in the near future. What this means is that the employer will retain almost total control over the health care arrangements they provide for their employees and their families.

If chiropractic is to retain a strong position in the care offered to HMO recipients, it becomes clear that doctors of chiropractic must develop positive rapports and trusting working relationships with the employers in their community.

How Can this Be Accomplished?

Chiropractors need to obtain the proper occupational related skills and be able to demonstrate to the employer that the chiropractic care and prevention services they are providing are an indispensable component of the success of the business. By doing so, the chiropractor can be assured of being named a preferred provider in any managed health care contract negotiated by the employer. Consider the following:

  • American businesses spend over 50 billion dollars annually on workers' compensation premiums. But this is only the tip of the economic iceberg, as it only reflects the direct costs (workers' comp. premiums). Add to this figure the indirect costs: hiring replacements for injured workers; training of new workers; inefficiency and errors of new workers; lost productivity, etc. (Most authorities consider the indirect costs to be from 8-12 times greater that the direct costs.)


  • Two of every three work-related illness or injury claims involve the neuromusculoskeletal system, many of which are preventable.


  • Ninety cents of every workers' compensation dollar is spent in the management of neuromusculoskeletal disorders.


  • Back injuries alone, when considering the direct and indirect costs, currently result in over $100 billion in losses annually.


  • Cumulative trauma disorders (CTDs) are rapidly becoming an epidemic among American workers.


  • There are more than 6 million businesses in America.


  • While there are approximately 650,000 licensed MDs, fewer than 2,000 are board certified in occupational medicine. Many of these physicians are not in private practice, and are employed by large corporations, assisting those entities in a variety of ways, including issues relating to pollution control, environmental protection, and product liability concerns. Most occupationally trained MDs have little interest or specialized skills in the clinical management or prevention of neuromusculoskeletal disorders.


  • Eighty-five percent of Americans work for companies with fewer than 100 employees; seventy-five percent work for companies with fewer than 50 employees. Small business is the largest business in America, employing the great majority of the workforce and will soon be responsible for the health care needs of up to 80 percent of our citizens.


  • Small and medium sized employers most often do not have an in-place "medical team" responsible for the health and safety of their workers. Almost none have a trained health and safety officer, occupational nurse, workers' compensation supervisor, human resources coordinator or personnel manager, and certainly not a specially trained occupational physician on their staff.


  • Small and medium sized businesses are heavily burdened by workers' compensation premiums and related indirect costs of work-related injuries.


  • For the above reasons, if approached properly, most of these employers are receptive to DCs who are properly trained to address their workers' needs. The DC can assist the employer in the development or enhancement of a health and safety program which has prevention as its highest priority, with optimal clinical outcomes for its injured employees as its second most important priority.

Wisdom and experience has shown the path to success is in helping others succeed. Never before in the history of American business has their been a greater need for appropriately trained, highly skilled chiropractors willing and able to provide ill and injured workers and their families exceptional care which returns them to health and restored function in a timely and efficient manner. More importantly, the DC with specialized training in occupational health functions to prevent reinjury, and better yet, prevents the injury from occurring in the first place. Accomplishing this objective can greatly assist American businesses in maintaining a competitive edge in the world marketplace, in addition to the elimination of immeasurable human suffering.

Specialized Training Available In addition to the pain and suffering endured by ill and injured workers and their families, billions and billions of dollars are lost to American businesses every year as the result of a less than efficient health care system, particularly in the prevention and clinical management of neuromusculoskeletal disorders.

Chiropractic has an unparalleled opportunity, but also a grave moral and societal obligation to assist American businesses and their workers by providing more effective and efficient health care services. Specialized training in occupational health is now available to the profession. During the past 10 years approximately 1,500 DCs have participated in the initial 120 hour phase of specialized postgraduate training in occupational health offered by CCE approved chiropractic colleges. Forty DCs have continued their training to become diplomates in the American Board of Chiropractic Occupational Health (ACBOH), which functions under the auspices of the Council on Occupational Health of the American Chiropractic Association (ACA-COH). Hundreds of these doctors currently enjoy contractual working relationships with one or more employers in their communities, established through health and safety programs in which the DC provides significantly more services than the traditional role of diagnosing and treating work-related injuries.

A Paradigm Shift in Health Care

This year America will spend approximately one trillion on so-called "health" care. In reality, it should be more appropriately named disease care, as probably 95 percent of the time the patient is ill or injured prior to seeking professional care, waiting until they are in an acute health crisis. During times of acute illness or health crisis, physicians often expertly and heroically intervene, however in many cases with dubious outcomes, limited success and with costs so great that our society is showing signs of rebellion. This rebellion has taken the form of "managed care" with cost containment and quality assurance as its greatest objectives. While managed care appears to have accomplished some success in cost containment, unfortunately to date, it has not shown indications of improved clinical outcomes. In fact, medical malpractice claim rates continue to escalate and public satisfaction with traditional medical care continues to erode.

Therefore, in greater numbers than ever, astute decision makers in business and health care management are moving away from the current "crisis-oriented" health (disease) care paradigm toward a paradigm where services are truly "health" related, and are predominantly preventive and proactive rather than reactive.

Preventative Services

Postgraduate occupational health training includes the following prevention related services:

  • Loss Source Analysis -- Assists the employer in identifying exactly who is getting hurt, when, where, how and what factors led up to the injury or illness.


  • Worksite Hazard Analysis -- Designed to identify high-risk work stations with critical incident techniques and to detect accident causation and recognize potential hazards, procedures and systems.


  • Educational Programs for Management -- Education and motivation of management and supervisory personnel. The importance of appropriate medical management of work injuries and labor-management relations and its effect on the incidence and outcomes of work illness and injury.


  • Educational Programs for Workers -- Education and motivation of workers in safety awareness, preventive and rehabilitative back schools, ergonomic training, self-care and wellness programs with emphasis on life-style issues, nutrition and stress management.


  • Worker Selection -- Assisting employers in identifying high-risk workers utilizing chiropractically oriented, highly effective pre-employment/preplacement physical screening examinations, D.O.T. physicals and drug and alcohol screening.


  • Ergonomics -- Assistance in the process of improving the safety, comfort and efficiency in the workplace to reduce injuries and improve worker health and productivity. Provision of on-site inspection and analysis of known high-risk work stations and identification of the sources of excessive stress, fatigue and other mechanical or environmental factors capable of producing occupational illness or injury. Assist management in the development of controls to reduce the encountered hazard(s).


  • Preventive Chiropractic Care -- Provision of treatment to workers with sub-clinical signs and symptoms prior to the condition becoming a full-blown workers' compensation injury claim. When possible, provided on-site to minimize workers time away from their place of employment.


  • Communications Skill Development -- Learn the unique language of occupational health professionals and the roles played by each of the members of the team of those responsible for health and safety in the workplace. The critical importance of timely, continuing and accurate communication between the health care provider, the employer, the injured worker and the third party payer.


  • Government Regulations -- State and federal laws, regulations and guidelines regarding health and safety issues, i.e., workers' compensation, OSHA, NIOSH, ANSI standards, the Americans with Disability Act, etc.


  • Physical Rehabilitation -- Designed to prevent secondary injury (reinjury) by facilitating maximum recovery, work-hardening and optimal restoration of strength, agility and endurance prior to return to the workplace.

Doctors of chiropractic are encouraged to contact the postgraduate division of their alma mater to encourage postgraduate training in occupational health. Those who have the foresight and diligence to recognize the role they can play as occupational health and safety coordinators will enjoy practice stability and a secure position in the future of health care. The trend toward safe, conservative, clinically effective and cost-effective health care is well established. DCs are invited to explore occupational health opportunities as a logical and highly viable and exciting option within the challenge of managed care.

A Challenge to Chiropractic Leadership Organizations

From the foregoing, it would seem logical that the chiropractic profession must immediately mobilize its organizational resources, strength and talent toward a concentration of occupational health education and industrial relations. For the entire history of its existence, the chiropractic profession and its leadership organizations have concentrated their educational message almost exclusively to the "general public." Obviously, this has resulted in some success as it has resulted in important continuous gains for the profession which cannot be discounted. However, in today's rapidly changing health care marketplace, the "public" is having less and less of a voice in their own health care options, with the decision making authority now residing almost exclusively with their employers. The ACA, ICA, FCER, and all state chiropractic associations and chiropractic colleges must play a major role in responding to this challenge.

Educational Resources Currently Available

The International Academy of Chiropractic Occupational Health Consultants (IACOHC) was founded in 1983 as a corporate, non-profit organization for the purpose of advancing the chiropractic profession in industry. The IACOHC is dedicated to fostering public health and safety through education, ergonomics, optimal clinical management and other measures.

One of its functions has been the establishment of a resource center which provides members and interested DCs with educational and training materials and products to assist their involvement with industry. Product examples include a 600 page starter pack for DCs working with traditional industrial workers and a similar sized starter pack for DCs working with sedentary and clerical workers, educational video/audio tapes, books, training manuals, slides programs, stretching and exercise programs, back school materials, ergonomic products, etc. The IACOHC also encourages and promotes postgraduate training programs on occupational health through its active cooperation and communication with CCE member chiropractic colleges. A quarterly chiropractic occupational health newsletter is published to assist DCs working (or interested in working) as consultants to industries. A speaker's bureau made up of experts within the field of occupational health and ergonomics also has been assembled. It provides educational programs for chiropractic associations and organizations as well as private corporate groups desirous of advancing their understanding and opportunities within the science of occupational health and safety. The IACOHC also has developed measures to aid in the establishment of industrial relations committees within state chiropractic associations. For further information, contact the IACOHC, Beth L. Auppl, executive director, at (507) 455-2524.

Joseph Sweere, DC, DABCO, DACBOH, FICC
Northwestern College of Chiropractic
Bloomington, Minnesota

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