I have two questions after more than 20 years in practice: Can someone tell me what exactly is a cash practice and what is a wellness practice? And do these terms have the same meanings as they may have had in 1989, when I graduated from school? My impression is that currently, all practices are cash practices and all practices are wellness practices.
The reality is that health care is a consumable product, just as it is also an art and a science. There are many articles printed in news magazines that highlight the lack of solo medical practices and that physicians are now employees of major health care corporations. Health insurance companies argue that rising premiums are necessary to counter rising health care costs. This is important for the chiropractic profession because it is ultimately the patient who becomes burdened with higher deductibles and higher co-pays. So, even though many chiropractors accept or provide for private insurance, the actual insurance reimbursement is in fact minimal or none.
Getting back to the first question, it is the current reality that all practices are essentially now cash practices. With the patient paying much more than they had to in the past, it means they are more demanding of what they perceive as the benefit received from care.
As to the second question, because patients are aware of these costs, their reasons for being in our office are solely for wellness. The caveat is that they get to define what wellness actually is. It may be pain relief from an acute situation. It may be improvements in athletic performance. It also may be that their career creates certain stress, and doctors of chiropractic can allow them to function.
The buzzword in health care right now is effectiveness. It is not just the chiropractic profession that has to meet this standard. We are seeing similar challenges with diagnostic testing, such as mammography and PSA measurements. Now we are required to do more than document or take classes in "documentation." Medicare, a few years ago, did recognize what it considered failures of our profession in documentation. Some of the TPAs require it for benefit approvals.
The point is that the patients are more of the arbiters in this process because they perceive themselves as more of a stakeholder in the health care process than previously. They will decide for themselves if we are being effective and meeting their expected goals for care. Likely, this is not limited to chiropractic.
As a profession and from personal experience, we need to describe expected outcomes. Are our expectations a match for those of our patients? We need to offer them a reasonable explanation for their complaints and then ideas they may be able to apply outside of our offices. Less frequently I am asked if "something is out of place." I find greater patient satisfaction if I can tie in pertinent anatomical structures, and offer perspective on their pain and problems relative to an average group with similar complaints.
As someone who has been involved in strategic planning on many levels, both inside and outside the profession, I am well-aware that you have to be able to look to the future as you look at the paths previously taken. For chiropractic practices and health care in general, the burden is to be able to describe how we are effective in a particular case or within a set of particularly similar cases.
We have to be able to move beyond the current conventional wisdom of the VAS or function / symptom surveys. Measurement of findings such as range of motion or radiology need context. We need to look at expected outcomes and how we can define that they have been met.
A large part of the chiropractic profession has sought out and been accepted in many aspects of the health care community. At the most basic levels, our services are covered by many private and third-party insurances. We have made inroads and now see patients through VA facilities. Many chiropractic doctors receive referrals from medical doctors, and see MDs and nurses as patients.
In the meantime, in this age of corporate medicine and the "7-minute office visit," let us look at ourselves as offering patient-centered care. How we enable our patients to be in control of their problems is a good start to being perceived as effective. My premise is that part of an expected patient outcome is for them to leave your office with a good understanding and perspective of prognosis.
It is important for us to recognize the doctor / patient partnership and have discussions about creating and maintaining it. This is a crossroads moment for our profession, much as professional licensing was half a century ago.
Dr. David Kartzman, a 1989 graduate of New York Chiropractic College, practices in Corning, N.Y. Dr. Kartzman encourages readers to contact him with questions and comments regarding this article via e-mail: