There is a motive to my theme. I will draw a parallel to addiction and managed care. How are managed care and addiction alike? It is not hard to see the similarities. Doctors join managed care IPAs with high expectations that they will increase market share and income because of this wonderful affiliation, and promise raised by the managed care companies based upon the "covered lives" they have under contract. The lure is strong: "Come, doctor, join this 'exclusive' network and be the 'only' DC for miles around to provide chiropractic care for ABC company."
So, you join and agree to the contract language. You are joyful and thankful that you were selected. You now wait for your practice to explode. But it doesn't happen quite like that. Instead, you agree to a fee that is lower than you ever would have thought possible in the year 2000. You assuage that misgiving with the thought of the tremendous new volume of patients that will help defray the lower reimbursements: kind of like fast-food marketing - selling millions of hamburgers for a small profit, rather than competing with high-priced restaurants that only a few can afford.
You begin to accept a few patients, then more and a few more, until before you realize it, you are "hooked" (dependent) on the managed care company to provide you with patients. You realize too late that for the first time in your practice you do not own your patients - the managed care company does!
Then comes a letter telling you that your fees will be reduced even lower. Your first reaction is, "I'm out of here." But you realize that you are in so deep that if you leave, so will a percentage of your practice; in many instances a large percentage. You begin to realize that you are addicted. Panic sets in. You perspire, you shake, and suddenly the symptoms of managed care "withdrawal" manifest. You know you simply need a "fix," but you say to yourself, "I will just get through this one time and then I'm out of here."
The "fix," unfortunately, is to accept the new contract, lower fees, and more constraints upon you dispensed by the managed care group. You realize this is not the right thing to do, but your "withdrawal" symptoms are so strong that you feel you need to just get over this one more time and then you will "break the habit." The cycle continues, and you again come to your senses and realize that you are in a never-ending downward spiral - with no hope or help in sight.
What do you do? If you leave this network, you are told there are several doctors waiting to fill your spot, and admonished, "Don't let the door hit you on the way out." If you don't take the contract provisions, as onerous as they are, you will be on the outside looking in with no possibility of help, no managed care temporary fix to get you over the practice jitters, and no game plan on how to survive.
Perhaps I have over-dramatized the addiction, but it does draw one's attention to the conundrum that many doctors of chiropractic are facing. On one hand, they know they are in a bad relationship with their managed care networks (not all of them); they know that if they leave, they will have serious problems, because slowly and insidiously the managed care contracts have eroded the patient base, to the point where the doctor does not have many or any patients who truly belong to the office.
Most of your practice today is comprised of patients from a managed care group that can, in a heartbeat, decredential the doctor, put another practitioner on "the list," and erect barriers to this group seeking your services - and there you are, no longer able to take care of the patients from XYZ company. Fears manifest: fears of losing patients; of being left out; that Dr. X down the street will sign up; that you have not established a relationship with your patients to the degree that they will demand that you remain in the network; and the fear that you will not be able to "make it" in private practice without the patients directed from the managed care groups.
How do you 'fix' this, short of continuing to be an addict of the managed care company? Remember that not all companies are bad, however, those that attempt to create a situation in which you have "no choice" or "no options" are to be considered harmful to the health of your practice, and are not healthy for it or you. Differentiating the affiliations you make in your personal and practice life, will ultimately determine the significance of whether your relationship becomes one of dependency and addiction, or prosperity and a restoration of self-worth. It is important for every doctor to make that determination for his or her future.
How do you finally "kick the habit" and remain free of the addiction? The answer is not easy, but it is possible to achieve. It is a decision that must be made by each doctor; no amount of group therapy or discussion can break the habit for you. This support system can help, but in the end, each doctor must kick the habit individually.
You must look at your practice and identify the kind you want. You must be willing to convert your practice and build a patient base, by forming strong bonds with patients and providing the value needed to sustain those relationships. You must seek out those managed care programs that are not dangerously limiting to you as a health care provider and that reimburse a fee that is reasonable for the care rendered. You must be willing to walk away from a bad relationship, and determine that walking away is the lesser of two evils. You must be willing to draw that line in the sand and say, "Enough is enough." You must be willing to take these steps irrespective of the fears that haunt and gnaw at the inability to be the doctor you were trained to be. You must be willing to do this, because, in the end, addiction will only lead to more addiction - and ultimately to death or destruction.
I write about this because of the despair and hopelessness articulated by many DCs in my travels across the country. I see the analogous message of despair echoed by those who are addicted and want to be helped, but do not seem to be able to find the strength to do what it takes to break the habit.
Who would deliver the chiropractic care if there were no chiropractors to meet the demand? How would the consumers who are driving the market react? Would they simply say, "Okay. No chiropractic? That's fine. I will do without"? Or would they begin to put pressure on their employers and insurance companies to meet the benefits promised?
Wouldn't it be nice if there were an opportunity to simply take stock of your individual situation and make a determination that you want to practice and be paid a fair fee for a fair service? Wouldn't it be nice if the care you rendered were based upon clinical necessity rather than the economic returns for the private owners of the managed care organization? Wouldn't it be nice if chiropractic care was not deemed to be such an expendable service and allowed to be given away, bargained away, or priced away based upon the model currently in play by some groups?
All of this can and should be able to be resolved, but it will not without a commitment from every practitioner. There must be a re-evaluation of the participation in those plans designed to prevent honest practitioners from having the opportunity to practice with pride, treat without obstacles, and retaining the dignity of being a health care professional. First, the individual must understand and acknowledge that he/she is in an abusive relationship that is not healthy, diagnose the best possible course of action in order to correct the cause, and take that action step, however painful or uncomfortable it may be initially, to rid oneself of the addiction.
Only in this way can each professional chiropractor rise above this incredible quagmire that has crept over us - much like the first addictive line of cocaine. It may be time for you to break the habit of addiction and return to society as a rational, reasonable practitioner who is unafraid of being challenged to support your clinical decisions; enthusiastic at reporting patient outcomes; encouraged by the potential market share growth a well-managed contract can provide; and optimistic about tomorrow, because you know that you no longer are dependently addicted, but rather, self- actualized.
At this moment in the history of our health care movement, many doctors have succumbed to their unfortunate predicaments by taking the path of least resistance. To regain personal and professional control, you must recognize the problem, realize the consequences, and realistically determine your best course of action. The first step is to come to grips with the fact that there is a problem.
Louis Sportelli,DC
Palmerton, Pennsylvania
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