Dr. Eileen Hearn, also a CCCLA graduate, is a Qualified Medical/Disability Evaluator and Industrial Disability Evaluator.
This is a three-part series: Part II, "Utilization Review, Outcome Assessment and Functional Analysis -- What Role Can They Play in Building the Chiropractic Practice of the Future," will appear in the November 4, 1996 issue; Part III, "Wellness Care -- The New Health Paradigm," will be published in the December 2, 1996 issue.
Managed care and the realities of cost containment have made a significant impact on the practices of almost all doctors of chiropractic. Managed care organizations, the brainchild of insurance industry experts in partnership with the best minds of Wall Street, have reshaped the health care environment and are forcing all doctors to learn the language of cost-effectiveness and outcome assessment. The freedom and autonomy that we once enjoyed and held sacred as the birthright of the doctor-patient relationship have been challenged and often undermined as decision-making power has been usurped by administrators and claims reviewers. How chiropractors should respond to this challenge is the source of acrimonious and often destructive debate within our profession.
Strict adherents to the purist philosophical tenets of chiropractic are urging an affirmation of the subluxation-based model of practice. Lifetime care for the correction of the vertebral subluxation complex on a cash payment plan is the model they propose. They point to the historical fact that chiropractic existed before anyone ever dreamed of managed care, HMOs, PPOs, or even insurance companies for that matter. Seminars exhort us to return to the basics and forget about the hassles of insurance and managed care. Though there will be selected instances in which some doctors of chiropractic, either through force of their personal charisma or temporary good fortune of being in the right place at the right time, will succeed with their subluxation/cash practice strategies, most will fail as fewer and fewer patients are capable of paying out of pocket for services that their managed care plans fail to cover.
It is my belief that we must learn how to secure our place in the managed care environment by promoting the cost-effectiveness of what we are trained and best-suited to do. Furthermore, we must use this place of recognition and credibility to advance ourselves as champions of an emerging model of health care efficiency -- a wellness model -- that is a critical building block of true health care reform.
It is clear to students of health care policy analysis that managed care is simply a euphemism for cost containment. There is nothing particularly caring about the decision-making process of a managed care organization. MCOs are creations of the same corporate world that bankrolls pharmaceutical research, development and marketing. It is no accident that these creatures of Wall Street are being engulfed in the same merger and acquisition fever that has seen media and financial conglomerates cannibalizing smaller competitors as they seek to establish monopolies in their fields of interest. What choice do chiropractors have in the midst of this storm of change?
To some extent the temptation to find a safe refuge in a cash practice that can withstand the turmoil of an unfriendly third party payment system is quite understandable. We believe that this component of a chiropractic practice can serve as a bridge between today's managed care model of disease intervention and tomorrow's model of wellness care. But hold that thought for the time being. First, let's consider the present day facts that must shape our plan in the here and now.
With the failure of legislation aimed at implementing national health insurance in 1994, we are seeing the disappearance of the fee-for-service, indemnity insurance products. The allopathic paradigm has proven to be unsustainable in an era of diminishing resources and budgetary restraint. Health care service in the United States is strictly marketplace driven. It is not the result of a comprehensive health policy.
The decision-making process about who is going to receive what services and who will pay for these services has shifted from the doctor to the managed care organization. The determination of what services will be paid for and who will be authorized to deliver them will be based on studies of cost-effectiveness that are being conducted by large clinics and teaching institutions. They will rely on RCTs (randomized clinical trials) and some meta-analysis of smaller studies, usually with multidisciplinary groups. Unfortunately, many of these studies that are either under way or in the planning stages are excluding chiropractic altogether.
Most doctors and patients will agree that there has been a degradation of the doctor-patient relationship, and a loss of autonomy for all doctors. MCOs have succeeded in altering the prevailing agency relationship from the historical situation in which the doctor possessed the knowledge and authority for decision-making and the patient chose to: (1) comply with the doctor's advice; (2) seek some type of alternative care; or (3) forego professional care and hope for the best with self-medication and benign neglect.
MCOs now have intervened with their guidelines and experts who make business decisions that affect the care-giver role of the doctor and the recipient role of the patient. The financial risk for care has been shifted to patient and provider and away from the TPP. This change in the decision-making process can compromise the health of the patient. It undoubtedly has affected the financial well-being of the providers of care.
The fact that practice management experts have trained physicians to practice in a style that is designed to maximize their incomes has been a mixed blessing. Their input has fueled a drive toward maximum utilization of physician services and may have created an environment ripe for backlash by the insurance industry. It may also have alienated a significant number of health care consumers.
Decisions regarding the shape of the chiropractic practice of the future should anticipate that managed care criteria are likely to become the basis for utilization standards for both workers compensation and personal injury. The soon-to-be enacted Kennedy-Kassenbaum health insurance reform legislation will enable insurance companies to pool their databases and create accurate indices of patients and providers. Even cash practice may not shield us from the eyes of claims reviewers and industry experts.
I believe that we should take a proactive approach to proving our case as chiropractors. When we direct our efforts toward the restoration of normal function and the capacity to perform the activities of daily life, our method of care is better, safer, faster and more cost-efficient than any other form of professional treatment. Comprehensive consideration of the costs of various forms of health must take into account, not only the costs of actual treatment, but also the cost-effective reduction of the rate of recurrence, disability and dysfunction.
The trend toward care in non-institutional settings will benefit the flexible chiropractic practitioners who strive to strategically market their practice, communicating effectively with other health care professionals, and developing rapport with patients that builds long-term relationships based on trust and high quality service. Our lobbying efforts should target the administrators of managed care organizations, elected officials, and patients themselves. Our patients can be our best advocates for inclusion in their health plans.
Health care reform is an issue in search of a champion. Is our profession willing to step forward as a true champion in crafting a policy that does the most good for the most people with the least damage to the pocketbooks of the special interests that hold de facto veto power over any effort at reforming current policy.
Can we as chiropractors make a credible case for our inclusion in a system that will insist on cost effectiveness of treatment and will use outcome assessment measures as scientific tools to determine the allocation of resources? If there is to be a future for our profession, the answer must be a resounding YES!
The good news is that much of the current research strongly supports chiropractic treatment as the best care for the management of musculoskeletal conditions. From the literature that has considered the efficiency and cost-effectiveness of chiropractic treatment much hope can be drawn.
Research on the appropriate utilization of chiropractic care for musculoskeletal conditions provides us with much ammunition to fight for our right to be included as doctors of choice for ailments that relate to the structure and function of the neuromusculoskeletal system. By effectively communicating to the consumer public and our professional colleagues our ability and willingness to do the job -- faster, better, safer and less expensively than any other credentialed health care provider, we can assure ourselves the foothold that is necessary to expand into a wellness care model. For it is here, that the proactive self-care philosophy that lends itself to cash practice/maintenance and preventative care model can be successfully and sustainably implemented.
Dean Goodman, DC
Eileen Hearn, DC