Today, one in ten Americans use chiropractic services; that will increase with the aging of the population. The arithmetic is simple. Today there are approximately 33 million Americans over the age of 65. In 20 years -- only a generation -- there will be 60 million, almost doubling in size. By their sheer numbers, the elderly will propel the upward growth of all medical services across the spectrum of health care delivery. Older Americans represent nearly 13 percent of the population today. That percent should climb to 15 percent by mid-decade. New patterns of demand will impact areas like South Florida, Iowa, Arkansas, and other states with high percentages of the elderly. Older Americans are surviving the acute episodes of chronic diseases -- the heart attacks, strokes, mastectomies -- and recovering to high-health lifestyles. These age groups have substantial disposable income and will be investing in their own health. The aging of America will push demand upwards for medical and chiropractic services, and impel a closer working relationship between the DC and the MD for care of their older patients.
Trend #5 -- New Diagnostics
Medicine and chiropractic may become more like engineering and less like art in the 1990s. Enhanced imaging devices and new diagnostic software will assist MDs and DCs to pinpoint potential diagnoses, comparing patient symptoms with computerized profiles. There are dozens of medical applications for artificial intelligence in development and testing now, which will come to market in the 1990s. New biomedical software will drive the computerization of medicine and chiropractic, stepped down to PCs, not mainframes. Computerized Axial Tomography (CAT) and Magnetic Resonance Imaging (MRI) scans will be transmitted via computerized images for remote consultations. Computerized patient history profiles will identify future health risks.
Advances in imaging in the 1990s will include 3-D imaging, holography, and body-field mapping. MRI will become commonplace. Even small, rural hospitals will have mobile access to MRI. Many of the new diagnostic tools will be expensive, but doctors in private practice will use them widely despite cost factors. Fear of malpractice will continue to shadow chiropractic and medical treatment in the 1990s. By one estimate, 40 percent of diagnostic testing may be unnecessary. The pattern of "defensive testing" is likely to continue unless states act to cap malpractice awards and establish mandatory arbitration processes.
Trend #6 -- Techno-Therapy
The 1990s will be a techno-cornucopia for medical science and chiropractic treatment. The growth in medical knowledge will continue at a geometric rate. In the treatment of orthopedic conditions, artificial joints will find a widening audience, as the the backs, knees, hips, and tennis elbows of Baby Boomers will age. Even spinal transplants may be attempted in the 1990s. The high cost of treatments such as bone marrow transplants, often $100-150,000 per case, may lead to rationing and the imposition of age thresholds. More likely, future health insurance policies and managed care plans will simply exclude transplants from coverage. That could make transplants a market commodity available only to the affluent.
Lasers will continue to transform surgery into painless, bloodless practice. Improved spinal surgery techniques will result in shorter lengths of stay and greater patient satisfaction. Even surgical robots may be used in health applications. Robot MDs or DCs are not entirely science fiction. Surgical robots are being experimentally utilized in neurosurgery. A prototype surgical robot has been in testing at Memorial Hospital of Long Beach for three years.
Trend #7 -- Consumerism
American expectations for health and medical care are rising, and many are disappointed in the current system. A survey conducted by the Harris polling organization for the Harvard School of Public Health, recently reported in the Health Management Quarterly publication, that an astonishing 91 percent of Americans were dissatisfied with their medical care. This compared with 56 percent of British and 89 percent of Canadians who were satisfied with their medical care delivery. Major corporations like Chrysler are calling for fundamental reform in the U.S. health system, such as the Canadian model. So are unions and grassroots consumer organizations like California's Health Access.
The malpractice crisis will continue. According to a Medical Economics 1987 report recently cited in Dynamic Chiropractic, 1 in 5 MDs and DOs is sued for malpractice annually, compared with 1 in 23 DCs. The bad news for both professions is that 43 percent of MD/DC claims and 55 percent of chiropractic claims result in financial settlements.
Trend #8 -- Re-regulation
No wonder DCs and MDs have a "siege mentality." Chiropractors and physicians are the target of increasing regulation from public agencies and private insurers. The sanctity of the doctor-patient relationship is ended. Health professionals have lost their absolute control of treatment decisions and must now seek payer approval for every significant expenditure. Third-party review organizations will intervene with pre-authorization approvals, concurrent review, and post-treatment audit of DC and physician performance. The change is permanent. DCs and physicians may continue to bill for individual treatments in the fee-for-service mode in the 1990s, but only with the prior approval of an anonymous reviewer at the end of a toll-free telephone number.
For medicine, national physician prices will be set by imposition of the Harvard Research Based Relative Value Scale (RBRVS) system for Medicare reimbursement. Chiropractors are already working under fee limits by Medicare for chiropractic treatment. The re-regulation trend could get worse. What's next? It may be in-office quality assurance and utilization review. This is the last unregulated bastion of MD and DC judgement, and it may not last beyond 1995.
Russel C. Coile, Jr.
Alameda, California