The strategy is straight forward: co-opt physicians by the age old method of appealing to fear and greed. The fear is obvious; if you don't sign up, your competitor will, and all the patients will go to him. The plan doesn't have to appeal to the patients because their employer controls selection and will sell the patients to the lowest bidder. Then some plans offer capitation to the providers and the providers do their best not to see patients too often, thereby getting paid for less treatment. At the end of all this, the patient is the loser.
The patient who has been the centerpiece of physician attention since Hippocrates gets demoted to an unimportant piece of a bureaucratic puzzle, which is driven by an insatiable thirst for profit. To those professionals who object to the loss of clinical autonomy, the plans can respond by firing the doctor without cause. Yes, without cause. So, while the managed care companies can control provider income and drive some to bankruptcy, the chief executive officers make incredible salaries. Isn't there something wrong with this scenario?
The businessmen and women get rich at the patients expense as well as the doctors. This is what the corporatization of health care has achieved in a few short years. Nine of the biggest publicly traded HMOs are sitting on $9.5 billion in cash (Wall St. Journal, 12/21/94). HMOs use as much as 30 percent of every health care dollar for paperwork, advertising, multi-million dollar executive salaries and profits (Calif. Physician, 2/95). Some savings may come from cream-skimming. Sick patients are willing to pay for the right to see the doctor of their choice.
The primary mechanism is to deny care. For the sake of patients, it is our duty to work to change the present structure of managed care.
Gate Opening 1997
I have said my slogan for 1997 is "gate opening." I hope all state associations adopt this as well. Gate opening means:
- direct access to chiropractic care;
- no MD gatekeeper;
- guidelines developed by the chiropractic profession;
- professional accountability enforced by state boards.
Minnesota is a state with high HMO penetration. According to AMA News (March 13, 1995) 2,300 MDs have fled the state since 1993. Why? Managed care, managed care! Do you think that benefits managers select plans on the basis of quality? How can they when little research has been done on outcomes. They mostly choose because of price, not employee preference. The chiropractic profession must stand with the patients and criticize gag rules, "drive through" deliveries, the unethical conduct of underutilization, and the incentive to give less service and get more money. HMOs do not have ethics as their centerpiece, unfortunately.
Managed care is a movement away from medical professionalism toward a managerial professionalism. Health care is patient centered with the responsibility of doing what is appropriate for the patient, not unmindful of costs, but not driven, directed and dictated by costs.
According to the American Association of Health Plans, 400 anti-managed care bills were introduced in 1996, twice as many as last year. A spokesperson for Families USA, a group dedicated to health reform, stated she has never seen this amount of legislation activity in 20 years of work. Doesn't that say a mouthful.
I hate to embarrass our profession, but how many of these 400 bills were initiated by chiropractic organizations? Instead of internal warfare, we ought to address the economic issues facing DCs and their patients. How can we be the natural alternative to drugs and surgery, when we lack the political discipline to achieve fairness for chiropractic patients? Am I alone in my frustrations with the status quo of chiropractic associations? Gate opening is the goal; let's get going.
The Chiropractic Challenge
Instead of blaming one another, or using political spin to alibi for our legislative paralysis, I suggest we dig in and do the following:
- Since health status can be measured, let's utilize the tools to assess health status and show chiropractic contribution to patient wellness.
- Let's utilize outcomes and process measures to improve our services.
- When possible we should use explicit criteria to assess outcomes and processes.
- Expand our domain specific competencies so that our scope of care is evidence-based.
- Patient satisfaction is a critical component of outcomes since it recognizes biological uniqueness and addresses patient's fears and concerns.
- We must facilitate easy access to current information for our doctors.
- We must aggressively oppose economic disincentives.
When patients are assigned a small co-insurance or deductible, they reduced their use of medical services compared to patients without these requisites. Throughout our history, insurance companies have treated chiropractic physicians as third-class providers. The same services by an MD are priced at a higher level and without hassle. The DC gets less pay per same service, and is restricted to the number of office visits. These inequities must be ended once and for all.
Let's remember, chiropractic care uses one penny of the health care dollar, so there is no legitimate excuse for stacking the deck against us. The medical monopoly must not be allowed to deny patient's their access to chiropractic treatment. Gate opening 1997 -- how do you feel about it?
Arnold Cianciulli, DC, MS
Bayonne, New Jersey