But the two industries are very dissimilar. Doctors aren't farmers and patients aren't potatoes. The nuances of health can be elusive to anyone that has been in the profession for decades, much less a recent MBA graduate. The prevailing policy for most managed care companies appears to be: "Do what seems like it will save money until too many people get upset."
When managed care first arrived, doctors flocked to see who could get on the panels first. No one wanted to be left out, so very few questioned what the reimbursement schedule would be. Once in, a DC's practice changed to accommodate the managed care patients. Once the managed care patients became a large portion of the DC's income, the managed care company could easily add restrictions or reduce reimbursement. Doctors didn't want to complain for fear of losing 60 percent or more of their patient base.
Today, the chiropractic profession has two "scopes of practice." The first is state statutes that govern the actions of all doctors of chiropractic with all patients; the second is a de facto "scope of practice" - one created by the managed care companies to replace the one established by the state.
Rather than allow doctors to practice according to the needs of the patient, managed care companies are:
- denying necessary and appropriate chiropractic care;
- denying necessary and appropriate adjunctive care through "global fees";
- relegating chiropractic to little more than "simple low back" or "sprain/strain" through the use of "uncomplicated" examination codes; and
- homogenizing chiropractic care through flat-fee arrangements.
Because of the restrictions placed on health care providers by antitrust laws, DCs are not able to band together to demand "fair chiropractic care for a fair price." The only resort left to the profession appears to be lawsuits, our ever-present, immensely expensive, time-gobbling alternative.
But maybe there is another way...
Perhaps our chiropractic state licensing boards have a role to play to insure that managed care contracts don't violate state statutes. As agents of the state government, they could do several things:
- Ask the state insurance commissioner to request and review managed care contracts to see if they are in compliance with state statutes and administrative law. This may require a face-to-face meeting with someone from the insurance commissioner's office to get that official to understand the issues, especially where payment equality between providers is a concern.
- Based on reviews of the managed care contracts, ask the state attorney general's office for a ruling on whether the managed care restrictions impede the state's scope of practice and appropriate patient care. It may take a little bit of work to find a state attorney willing to look at this issue, but it would be well worth it.
- Talk with other chiropractic licensing boards to see what's working and where.
- Network with national chiropractic associations already wrestling with these issues.
- Ask your board's attorney to bring these issues before the next meeting of the National Association of Chiropractic Attorneys.
Our chiropractic state licensing boards are tasked foremost with protecting the public; that includes protecting the public from illegal and dangerous restrictions on health care. The boards are also responsible for helping to define our scope of practice. Managed care companies cannot be allowed to set their own scope of practice in place of the scope established by the state.
There are many ways to attack a problem. The only time you really lose is when you stop trying.
Donald M. Petersen Jr., BS, HCD (hc), FICC(h)
Editor / Publisher of Dynamic Chiropractic
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