I don't know why we do it, but when the world around us undergoes dramatic transformation, we chiropractors seem to circle the wagons and start firing inward, mostly at the scouts who are reporting what they've seen on the other side of the hill. It's true that sometimes the messengers bring back bad news, and sometimes they have personality defects as bad or worse than some of our own. But do we really need to use censorship, deceit, fear-mongering, or character assassination to express legitimate disagreement? It seems to me that getting a hold of information (even if you don't like some of it), careful assessment of it, open and reasonable discussion about it, along with coordinated strategic planning and hard work might be the best tools to use to cope with many of the tight spots we're in. Or could it be that without a "Darth Vader" (like the AMA, managed care, or a chiropractor with a different perception of scope of practice) we just have no purpose in life?
In my job, I have the task of routinely dealing with many different people with varying beliefs and opinions about health care issues. I do "health policy and research," which means that I must read lots and lots of stuff, talk with hundreds of people, synthesize everyone's interests and opinions, and put together the best case I can for a reasonable policy about something. One of the many things I've learned is that policymaking is undergoing change. New rules and strategies are coming about for making physician reimbursement determinations. Chiropractors have never before held seats at the policymaking table. Oh, they have attended meetings, given testimony, and such, but when the public goes home and the doors are closed, there has never been formal representation of chiropractic in the inner sanctum. I've heard chiropractors talk about this aspect of government decision making like its some meaningless, bureaucratic process, or that its just one of the ways that the AMA continues to try to contain chiropractic. All we need is another law, or another TV commercial and it will all be better. There may be some partial truths in those statements, but in fact this is the level of government (and business for that matter) where all of the implementation of laws and regulations takes place; it is where the world of health care decision making standards are being developed.
An evolving process of reviewing scientific literature, obtaining clinical input and coming up with health policy recommendations is being used. Some relatively new formalized protocols and "explicit" methods have been developed to address practice variation, clinical uncertainty, and the needs of society. The process has been termed "technology assessment," and I've put together a little talk and have presented it all over the state of Washington to anyone who will listen: chiropractic societies; medical societies; medical and chiropractic managed care organizations; attorney general conferences; insurance companies, etc. The talk doesn't have a lot of answers, but it points out some of the questions being asked of doctors these days and offers some strategies for dealing with the situation.
Recently, I gave this talk at a small seminar that was co-sponsored by a multidisciplinary spine care interest group in Washington state, the International Chiropractors Association, and the World Chiropractic Alliance. Wow! I got letters, calls, ridiculing and all kinds of stuff from a bunch of chiropractors who didn't even go. They wanted to know what I was doing "supporting" such groups.
I gave essentially the same talk right around the same time to a different, much larger group of doctors at a program sponsored by an apparently evil, but very successful chiropractic managed care network in the state. Holy doodle! I'm written up in chiropractic newspapers, ridiculed, accused of questionable integrity, from the some of the same people who were sponsoring the other talk, but just like the pundits on the other side, didn't bother to go to this one. Gee, and I did both of these for free, on the weekend on my own time, buying my own gas, because it is really, really important, in my opinion, for all chiropractors to understand what's happening in the "mysterious" world of health policy. I'm the first chiropractor who has ever been hired into such a position, developed for chiropractic. As a chiropractor, I feel a sense of duty to fill my colleagues in on what's going on. DCs, left out of the system for so long, need to learn about what happens here; especially what changes are taking place and what the rest of the world is doing about it so that they are not left behind again, and again, and again.
But you know what's even more interesting? When I've given this kind of talk to attorneys, insurance companies, medical managed care organizations, and medical groups, all I get is thanks. This is despite the fact that I bring them the horrible news that the feds, important think tanks like RAND, and scientific reports are finally starting to shed some light on the value chiropractic methods can have for people and, based on technology assessment processes, how this kind of evidence is going to impact how they do business. This is despite the fact that I'm speaking to them as a representative of a government agency, not a chiropractic trade association. This is despite the fact that much of what I'm telling them, flies in the face of many of their long standing beliefs and biases. But when chiropractors so much as hear that you've talked to another chiropractor they don't like, you're an evil conspirator. Are we immature or what?
There is an awful lot of misinformation around these days. Things just aren't black or white. The current Romulan du jour seems to be managed care. Yes, it has taken the health care market by storm, and yes there are financial rip-offs of doctors going on, and yes, there are some poorly administered MCOs out there that are way more interested in the bottom line than they are in reasonable clinical care, provider members' well-being and efficient management strategies. But there just might be an alternative to full frontal assault.
Myth: Managed care will destroy the chiropractic profession. Fat chance. No one loves managed care (except maybe for some executives or stockholders of MCOs), but it's nothing more than a private sector response to market forces. U.S. health care costs now account for 1/6 of our gross national product, up from about 1/20th in 1970! That is a really, really big deal. The idea behind managed care is to make doctors share in the financial risk so they won't order unnecessary tests and perform unnecessary treatment. It's a challenging and complex situation, and a relatively young one. What is the problem? Managed care is a "new technology" and there is not enough good competition out there yet. It's administration heavy. However, it is still new and is primarily being driven by market forces. What is needed is innovative new managed care approaches and smarter companies to give the current start-ups some serious competition. And the "value" of service will sort itself out over the coming years (value represents a balance between quality of care and cost).
But just because it is a type of change, is complex, and has economic impact, some DCs want to pick up their toys and go home where they can sit on the sidelines and throw rocks at the big ugly beast -- like that's really going to fix all of the health care problems in the United States. Managed care needs real innovation, competition, and quality, not character assassination of proponents or messengers -- and it needs chiropractic.
Some shape or form of "managed care" is going to persist. The latest satisfaction studies show consumers (our patients) are very happy with it! At a minimum, they are happy enough with it to choose plans with the lowest premiums, and avoid spending more out-of-pocket money for their health care than they have to. And, guess what? The government and the health care industry are finally starting to acknowledge and incorporate manual approaches to spinal care into mainstream health policy making and planning! If we choose to opt out of managed care, don't worry, someone else will fill the void. We have worked for 50 years to create a patient demand for our services. Sure, cash practices worked really well when office visits were cheap, patients paid out-of-pocket for all kinds of health services, and there were only 8,000 chiropractors in the country. I question whether 50,000 of us could really give up all insurance and participation in the mainstream and still see the majority of us flourish. Adaptability and maintaining options is important. Some will do fine in cash practices, some political innovation such as medical savings accounts will crop up, and a range of managed care programs will continue to evolve.
Reality: Ignoring or resisting managed care will not make it go away. In fact, it just might make us go away. Organized medicine has been trying to keep us out of the health care delivery system for ages. When the new one evolves, wouldn't it make them happy if we just disappeared of our own accord? When the modern health care marketplace finally settles down, and quality/value oriented, fully integrated MCOs finally become the norm, I want direct access to chiropractic services included in them. When multidisciplinary centers of excellence are established with protocol and evidence-based triage, I want the spines of their patients to routinely be evaluated by doctors of chiropractic without an MD gatekeeper making all the calls. When the paranoia and greed in some of the existing networks is supplanted by common sense, I want DCs involved in the process. When inefficient administration involving ridiculously excessive weekly or biweekly pre-authorization and ongoing auditing is replaced by efficient incentives and provider support and education, I want us as part of that system. Some of these MCOs need to be bought out and/or subjected to stiff competition. Its going to be rough for everyone for the next 5-10 years. But its going to be a lot rougher for chiropractors if they choose not to be involved in constructively influencing and shaping the evolving system from the inside.
Wouldn't it be amazing if organized chiropractic could be on the cutting edge of assisting in the resolution of an important public health concern? If we deliberately positioned ourselves as resource and problem solver for an important social issue? And if we could do it based on track record, scientific evidence, and mature, calculated participation that we help to set up? What a feature length Disney-like fantasy that is. (I really hope my friends have noticed that I have used cinematic parallels this time out, successfully avoiding any contact with any sports or jilted-romance metaphors). Isn't it natural for chiropractors to be on the cutting edge of cost-effective alternatives? Isn't it appropriate for DCs to rally behind the cause of appropriate use of diminishing health care resources in our society? Doesn't it make sense to be offering to participate fully within the first newly evolving health delivery paradigm this country has seen since 1914?
Health care futurist Russell C. Coile Jr. wrote the book Revolution: The New Health Care System Takes Shape1 in which he offers strategies for providers to consider as the managed care juggernaut plows through the system. His views were so insightful that the American Medical Association purchased and supplied each member with a copy. Mr. Coile has certainly taken notice of chiropractic. He published an article in the last issue of Topics in Clinical Chiropractic2 outlining what the health care industry is likely to do regarding chiropractic, and devoted an entire issue of his market forecasting newsletter (Health Trends) to chiropractic.3 His predictions? Chiropractic will be fully integrated into mainstream health care, but considerable scrutiny and pressure will be placed on chiropractors to demonstrate effective clinical and economic outcomes. His recommendations for chiropractors?
- Align with these paradigm shifts and see substantial acceptance of the profession as an important "minimum health benefit."
- Focus on the current obvious market need of efficient and effective management of low back conditions, but don't let go of the need to be accepted as primary care. The strategies to use to accomplish this: standards, clinical guidelines, and infiltration into and participation with integrated managed care systems.
The current version of managed care per se is probably not the answer, but it certainly can be one of the vehicles by which we can carry ourselves into KGB headquarters. We may not have all of 007's miraculous gadgets and accoutrements, but we really ought to be able to harness some of the confidence, strategy and attitude to work it from the inside. Bond, Dr. Bond, where are you when I really need you?
References
- Coile RC. Revolution: The New Health Care System Takes Shape. Knoxville, Tenn: Whittle Direct Books, 1993.
- Coile RC. Chiropractic health care: the second century begins. Top Clin Chiro 1995; 2(2):22-30.
- Coile RC. Chiropractic treatment: an alternative becomes mainstream. Health Trends 1995; 7(9): 1-8.
Robert Mootz, DC, DABCO, FICC
Olympia, Washington
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