Is it ethical for a DC to be a member of an HMO which uses MDs as gatekeepers who decide when and for what condition and how often a DC may treat a patient who is a member of the HMO. Let's evaluate the following situation.
A patient with a long history of headaches goes to her primary care gatekeeper. Under her employer's previous medical program, she visited numerous MDs for her headaches but received little help. At the suggestion of a friend, she tried a DC and was very satisfied. However, her employer switched to an HMO and the HMO does not allow for direct access for chiropractic care. The patient's MD gatekeeper initially resisted the patient's request for chiropractic treatment. After continued failure, he reluctantly okayed three office visits. The DC began care, but realized the prescribed three office visits were seriously inappropriate. The DC concluded a CT scan of the upper cervical spine was warranted. The MD gatekeeper refused to allow any diagnostic imaging.
Given the managed care system is rooted in an economic model that sees health as a commodity, as well as a human service, it follows that those who pay for care dictate how it is or isn't provided.
Is it ethical for a DC to treat this patient for three office visits without the CT scan that the DC deems necessary? The following facts need to be considered:
- The MD is not educated in the discipline of chiropractic.
- The MD lacks experience and skill in the practice of chiropractic.
- The MD is a member of a profession which has a history of opposition and persecution of chiropractic.
- The MD is licensed by the medical board, not the board of chiropractic.
Questions to be answered by the DC: Is it right for the patient to be denied proper chiropractic care? Is the care rendered a deviation from the appropriate standard of care? If the DC follows the MD's treatment plan, does the DC increase his potential liability? What does the malpractice carrier say about this scenario? In the final analysis, does substandard chiropractic treatment prescribed by an MD, unqualified in the practice of chiropractic, appear to be in the patient's best interest. Would you like to be cared for in the same manner?
It is my opinion that any DC who submits to MD prescription without the application of individual professional judgment, places the patient in possible jeopardy as well as exposing himself to increased risk of negligence. It is a breach of ethics to manage patient's within this fashion. I have declined membership in an HMO in which my primary care/direct access role is not honored. I suggest you strive for direct access in the managed care system as our colleagues in some jurisdiction have achieved.
Arnold Cianciulli, BS, DC, MS
Bayonne, New Jersey