Managed care plans are grinding chiropractic PPOs down to as little as 14 cents per member per month (PMPM): anything under 70 cents leaves very little for the DC after administration costs. Finding themselves in a losing situation, the only solution for the chiropractic PPO is to reduce the utilization of chiropractic services down to a point of ridiculousness. (One wonders if they should have accepted the contract in the first place.)
We have the worst of all worlds:
The DC tries to tell the chiropractic PPO they need more visits to care for the patient.
The chiropractic PPO has already signed the contract with the insurance company. So, in an effort to service a bad contract, they force the DC to UNDER-utilize.
The patients are getting substandard chiropractic care and begins to believe that chiropractic (as administered by the DC hampered by his PPO) CAN'T help them.
And the insurance company tells the patient that the amount of treatment is adequate according to the chiropractic PPO!
Add to all of this the fact that almost every DC in the United States has paid good money to join at least one chiropractic PPO that NEVER brought in one new patient. On the contrary, the DC is now getting paid less for treating some of their old patients.
With the bitter taste of managed care's realities still in your mouth, let's look at how we got here. Health care has been out of control for many years, predominately driven by excessive medical technology, over use (dependence) of drugs, and medical morbidity and mortality. Employers, government, and the public are finally not willing to take it anymore. The current state of Canadian and American health care is in itself an indictment against the medical philosophy.
In answer to public demand, business is stepping in with the hope of reforming health care and making a profit along the way. The incorporation of federal guidelines into the implementation of managed care provides a great deal of savings on health care. Curiously, very little of that savings has been passed back to the consumer.
Driven by fear, providers are ready to accept almost any agreement and pay significant dollars in hopes of not being left out. The pendulum has flown past a reasonable position and is now taking its vengeance on all providers. DCs are having to undergo the same "spanking" as the medical profession, even though the vast majority did not contribute to the problem.
But when we finally stop griping and complaining, we will be ready to deal with reality. Managed care is not going away.
In case you didn't hear it the first time: managed care is here to stay. Yes, it will continue to reinvent itself time and again over the next few years, but the "good old days" of the 1980s are gone, never to return.
Now what?
Now you do what chiropractors have done for the last 100 years. In the words of Clint Eastwood, portraying the Marine commander in the movie "Heartbreak Ridge": "You improvise, you overcome, you adapt."
There are a few chiropractic PPOs that have learned to do just that. They have taken the time to see what health care was asking of chiropractic. They have balanced (as much as possible) the demands of managed care with the needs of the DC for the ultimate benefit of both the patient and the payer.
One PPO organization (having spent over seven years working with a small group of DCs) has seen its members adapt to the new health care environment to the point that most of them will no longer have to obtain pre-authorization before beginning a treatment program.
Having worked their way through the managed care maze, they are beginning to grow very rapidly. Their DCs (numbering approximately 130) are accessible to over 750,000 covered lives. While not all patients in each health care plan utilize chiropractic care, the DCs in this PPO see an average of 15 new patients from the program.
It can be done. Nothing has stopped chiropractic so far: not political medicine, not orthopractic -- nothing. Managed care is just another hurdle.
As Mick Jagger once sang:
"You can't always get what you want. But if you try sometimes, you just might find, you get what you need."DMP Jr., BS, HCD(hc)
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