As an Oregon physician and Western States chiropractic instructor, I have a unique perspective of our profession. I see the excellent quality of education that is provided the current chiropractic students and I understand the difficulties that a field doctor experiences in private practice.
I am also experienced in how managed care DOES NOT work for the chiropractic physician. In 1990, in a one-day special session, the state of Oregon drastically reduced the patient's access to chiropractic physicians and I lost 35 percent of my practice. In that one day, access was limited, through legislative action, to a 30-day or a 12 visit limit, after which point an MD must refer for further treatments. However, we were told that if we were under a Managed Care Organization (MCO), we would have full-attending physicians' rights; no need for MD referrals.
On paper, chiropractic was included in workers' compensation. In reality, it is a system that is designed to fail for the chiropractic physician and their patients. In two years of being one of 20 doctors in the Portland metropolitan area that was "approved" for Kaiser Permanente workers' compensation patients, I have received only two referrals, only because the patients had been insistent they be seen by a chiropractic physician. In both cases no true referral was made, but the patient was given a list of the doctors from which they could choose their own physician.
As a member of two MCOs with a limited provider pool (i.e., not all Portland chiropractic physician are included in these pools), I still have less workers' compensation patients than I did two years ago. Additionally, with contract re-negotiation, certain patient/employer groups which I treat could change and my provider group could be excluded!
Also, in order to maintain our status as "competitive," attending physician rights have been given up by some of the chiropractic negotiators. Therefore, my treatment plans are still under the supervision of a medical doctor. Managed health care means paying an expensive fee ($1000-$1600) to join, paying a $250-$500 yearly administrative fee to the parent organization (MCO), a yearly or biannual fee to the chiropractic administrators, accepting less than the 75 percentile, and in some cases, paying a percentage (5.5%) of what I bill, but not of what I collect. This is an insurance company's dream and a chiropractor's nightmare!
Prior to these changes, most of the Oregon chiropractic physicians were in disarray and very little was done in a concerted effort to head this off, even though it was known that legislation was coming. In a similar fashion, our profession is at the same crossroads, but on a national level. Unless we organize ourselves through political contributions, and mobilize and motivate our patients to contact their representatives and take a very pro-active role, we will get plowed under. This is certain! We must make sure our patients very simply, but very clearly, state that:
- They get results from their chiropractic physician which they do not get by the medical or physical therapy provider.
- That if a medical doctor will be acting as a "gatekeeper," they will not be getting any referrals to chiropractic physicians.
- They want free and unencumbered access to their chiropractic physicians.
Our scope of practice and the future of the profession depends on how quickly and how well we can act. When asked what he was doing, one of my colleagues told me prior to the Oregon workers' compensation debacle, "I haven't done anything. I'm just going to hope for the best." As evidenced by that Oregon DC, wishing and hoping without ACTION does not accomplish anything.
Joseph A. Cimino, D.C.
Portland, Oregon
Editor's Note: Below is Dr. Cimino's letter to Hillary Clinton, President Clinton's appointee to head the Health Care Task Force.
January 29, 1993
Hillary Clinton, Esq.
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Attorney Clinton:
I am writing with regard to the Health Care Reform Task Force. I would like to ask that you and your team consider how the upcoming changes will affect the patients' access to all health care providers.
The task you and the committee face is formidable. It will be a challenge to design a system that will be fair to the patients and fair to the health care providers. However, "fairness" was a main theme of the successful Clinton/Gore campaign.
I believe access to health care should be a right not a privilege and that the patients should have free and unencumbered choice as to the types of health care available.
For the last two years I have been operating under a managed care system with medical doctors as "gate keepers." This has resulted in a mushrooming of paperwork for myself and my staff, and many bureaucratic hurdles for my patients to negotiate in order to receive treatment. In three years, as a member of three managed care organizations, I have had only four referrals from medical doctors. This is in spite of research which support the efficiency and cost-effectiveness of chiropractic treatment.
In the latest edition of the New England Journal of Medicine, a 1990 study found that one out of three sought help from someone other than a MD for a serious illness, most paying "out of the pocket"; 70% did not tell their MD. Most of my patients are afraid to tell their MDs that their medical treatment is not effective for their problems.
As an instructor at Western States Chiropractic College and a practicing chiropractic physician, I have a unique perspective as to the state of our profession. Should you wish to speak with me, I would be happy to contribute my experiences and information with regard to the chiropractic profession and managed health care. Perhaps a more expedient source of information might be the American Chiropractic Association, headquartered in Arlington, Virginia.
As an American, I look forward to reform of America's health care system, but as a chiropractic physician it is with trepidation that I wait to see where in the grand scheme my patients and my profession will be placed.
Sincerely,
Joseph A. Cimino, D.C.