Chiropractic will certainly be targeted for practice guidelines by payers in the near future. As rapidly as outcome criteria are developed, expect them to be computerized by private review companies and Medicare's professional review organizations. Doctors have a reasonable concern about "cookbook medicine." Some medical societies and hospital staffs in self-defense will develop their own outcomes criteria for high-cost or frequently performed procedures and Diagnostic Related Groups (DRGs). The chiropractic profession should do likewise. If DCs want hospital privileges, they must define their own quality standards for diagnosis, treatment, and outcomes. The Michigan guidelines for hospital credentialing such as those developed at Detroit's New Center Hospital are a good first step, but much more specific treatment guidelines will be needed.
Trend #10 -- Ethics and Economics
Rationing of medical care is coming. Debate is increasingly public, by government and private insurance. Early discussions in Oregon set the tone for the debate. The question: should high-tech medicine get higher priority than health prevention and promotion? So far, prevention is winning. In Oregon and Alameda County, Calfornia, ethics commissions recommended priority be given to funding health promotions for women and children. The debate will widen to at least a third of the states in the next five years, and will reach the halls of Congress. Chiropractic professionals should be concerned that chiropractic treatment could be considered a low priority in any such rationing scheme.
Looking Forward
Chiropractic's future in the 1990s is promising. Demand is rising; so are chiropractic expenditures and DC revenues. Growing health consciousness by American consumers is well-aligned with the chiropractic philosophy of fitness and natural treatment. The aging of the population should swell demand for chiropractic services.
The 1990s will bring challenges, as well. The chiropractic profession could make a mistake to believe that the future of chiropractic depends upon overcoming the opposition of organized medicine and winning hospital privileges. These are symbolic battles.
From the forecast of The New Medicine, there appear to be three "make-or-break" issues for the future of chiropractic in the 1990s:
- Consumer satisfaction -- The real war between chiropractic and medicine in the 1990s is for the hearts and minds of American consumers. Their loyalty (and repeat business) will be won on effectiveness, quality, and service. The push for "outcomes measurement" must be met with both technical competency and service satisfaction by the chiropractic profession.
- Value to payers -- The growth of managed care and the decline of the self-pity market in the 1990s mean that chiropractic also must satisfy demands of the major health care purchasers: government, insurance companies, managed care plans, and self-insured employers. In business, these qualities are often summarized as "value." For the 1990s, the challenge for chiropractic is to provide value through cost-effective treatment, relief of symptoms, and maintenance of health.
- Scope of practice -- The chiropractic profession must resist the tendency to be limited in narrow legal definitions by state laws and insurance policies. The chiropractic profession must continue to expand the definition of the chiropractic domain to include fitness, nutrition, and health promotion. Chiropractic research should assess the appropriateness of chiropractic treatment approaches to other biomechanical problems. As a major provider of primary care, chiropractic needs a broad definition and domain to be successful in the 1990s.
Russell C. Coile, Jr.
Alameda, California