| William Whitney, DC, MA, is the author of the just published book, Healthy Back Building, presenting information to patients on back pain risk factor reduction, and how a biomechanically correct exercise program can lower one's risk. |
American health care is in the midst of a revolutionary change.
The quality of health care services is determined by researching even the most basic care to determine its efficacy and cost-effectiveness. No longer will procedures be performed just because they always have been done. Providers now must address what is best for patients with cost containment also a consideration. Since it has been estimated that only 15% of patients can be given a definitive diagnosis,1 medicine will have to answer to treatment efficacity as nonmedical providers are. These quality care issues alone highlight a major social transformation of American health care.
Consumer demand for types of services is another force in this health care revolution. A study published in the New England Journal of Medicine has found that about one third of the general patient population is seeking various forms of nonmedical care without a medical referral.2 This study reveals how the general public is switching from disease care to wellness/holistic care. This trend has occurred despite many of these non-allopathic services not being covered by traditional insurance.3
Meeting the demands of consumers in the areas of quality of care and choice in types of services has raised concern in the allopathic medical community. All fields of medicine will now have to answer to the consumer, justifying the types of care recommended. In addition, much of the "standard medical care" may be determined to be too costly and ineffective when compared to the "non-traditional" types of care.
Of course, the general public will ask the same of nonmedical services such as chiropractic, naturopathy, acupuncture, psychology, and stress management services. They want qualified, educated professionals, providing cost-effective quality care. These providers will have to answer to established standards of care based on scientific or clinical evidence.
In addition, it appears that competition may come from professional consultants in the fields of physical education/fitness, nutrition, and health education. A recent study done by Trends Research Institute, supported by chiropractic's own research group (FCER), forecasts a major health/fitness/nutrition revolution.4 Thus, we have a revolution among health care providers and consultants, with no clear winner in sight, except the general public's well-being.
At first glance, it's easy for chiropractors to say, "Let the competition begin." Never has chiropractic had more of an opportunistic time than now to serve the public. We are, and have been for many decades, "America's wellness doctor." We were the first health care professionals to have nutrition, and the belief in the holistic effects of optimal neurological function (treating subluxations) in its curriculum. Unlike osteopaths, we held steadfast to our belief in the functional effects of manipulative therapy and our basic philosophy in treating the body holistically. Additional wellness forms of care performed by chiropractors include exercise, public health concerns, behavior and lifestyle management.5
Unlike physical therapists, acupuncturists, herbalists, nutritionists, or fitness consultants we are licensed primary care doctors, able to diagnose, treat and refer when needed. Naturopaths are only licensed in about one fifth of the United States, and osteopaths have established themselves along with medical physicians as disease care providers. Historically, chiropractors have been experts in both disease and wellness care. Even our Mercy treatment guidelines designate chiropractic as the largest of the holistic-oriented professions.6
Problems of Concern
Despite chiropractic's advantages, the following issues need to be addressed. First, national chiropractic associations need to agree and implement a united plan of attack, so the battle is no longer within the profession. This will enable us to use our limited resources more effectively. The focus should be on researching and marketing our strengths as providers in a competitive health care environment.
Second, chiropractic treatment and research needs to focus not only on palliative care but on prevention. We can no longer afford the image of being just "back doctors." We need to continue to treat the patient as a whole, with preventive measures based on sound scientific theory and clinical evidence.
The last and most important issue is the need to be competitive in offering the public cost-effective quality care based on standards set and agreed upon by chiropractic as well as the general population (i.e., Mercy & AHCPR guidelines).
This is no easy task, but our patients deserve our unparalleled effort. If not, others will take over the wellness title and leave us behind. The competition has begun. How often have local hospitals or HMOs, advertised themselves as "Committed to Your Wellness," yet no chiropractors are on staff?
Some hospitals and HMOs are hiring professional prevention experts, including nutritionists, exercise physiologists, and lifestyle management specialists. Over two dozen universities in the U.S. offer graduate degree programs in wellness/health promotion,7 Arizona State, Georgia, Michigan, Texas, and Virginia Tech to name a few. Many of these universities offer doctoral degrees in wellness.
These students are trained for workplace and hospital jobs, and possibly in the future, managed care positions. Their job description duties to promote holistic health include assessment, education, and counseling on topics such as nutrition, exercise, smoking cessation, weight and stress reduction, among others. In addition, they will have university supported research to maintain their effectiveness.8 The competition among wellness specialists will be fierce; now is the time for us to compete with all our resources. Chiropractic needs to be proactive in positioning ourselves to provide the public with quality wellness care. We must emphasize the cost effectiveness of utilizing chiropractors who are both disease and prevention care specialists.
Care and Prevention
Regardless of whether chiropractors wish to be accepted by the insurance/managed care companies or not, we will all need to focus on effective wellness care. It is a trend that many (if not most) Americans are willing to embrace. In working with insurance carriers, it is important to understand primary and secondary prevention.
Primary prevention works to prevent a condition before an injury occurs; therefore, insurance companies cannot be billed for this service (i.e., maintenance chiropractic care, or non-therapeutic exercise). Yet, secondary preventive measures work to prevent recurrence of a condition and can be billed if it is an effective and established form of treatment (risk factor reduction, or prescribed exercise).
Our Mercy and some workers' compensation treatment guidelines9,10 recommend preventive services to help combat the recurrence and development of back pain: services, I might add, which can help chiropractors boost their income from managed care and their patients. Yes, even some managed care companies11 would like you to advise your patients on preventive services.
The Mercy and AHCPR guidelines9,12 classified risk factor reduction (life style adaptations) and exercise as valuable forms of therapy. Yet, these forms of treatment also serve a dual purpose as a form of secondary prevention. I personally classify these forms of care as "preventive active care," since this "treatment" can be a form of both secondary and primary prevention. As wellness providers, we need to shift our emphasis onto lifestyle management and secondary preventive care. Rather than concentrating solely on relieving back pain or enhancing neurological integrity, patients need a complete (primary and secondary) preventive approach to back pain and health promotion.
With this information, chiropractors will have more to offer in the field of wellness, making us more competitive, competent, and patient oriented. We as a profession will be perceived as unique in that we provide cost-effective care for back pain, yet haven't given up on our holistic approach to optimal health.
At this time, the choice is still ours. Do we work towards our goal as the leading expert in wellness care, or just hope that after the dust settles from our current health care revolution, chiropractors are accepted solely as back pain specialists? Please, let's not hesitate; we should strive to maintain our image of "wellness expert" and maintain our competitiveness in the treatment of back pain.
Chiropractic is in a position to prosper from the current health care revolution. We should give our fellow Americans what they want: quality disease and wellness care.
References
- Waddell. Bailliere's Clinical Rheumatology. 1992;6(3):523-57.
- Eisenberg, et al. New England Journal of Medicine. 1993;328(4):246-52.
- Blevins. Policy Analysis. 1995; Dec.,15:1-36.
- Seater. Dynamic Chiropractic. 1996; Dec. 2:14,21.
- Coulter, et al. Sociology of Health Care. 1996; 13A:95-117.
- Guidelines for Chiropractic Quality Assurance and Practice Parameters. Proceedings of the Mercy Center Consensus Conference. Aspen Publications, 1993;183.
- Ball State University, Institute for Wellness. List of U.S. University graduate programs in Wellness/Health Promotion; 1996.
- Ball State University, Institute for Wellness. Institute's Description; 1993.
- Guidelines for Chiropractic Quality Assurance and Practice Parameters. Proceedings of the Mercy Center Consensus Conference. Aspen Publications, 1993;118-123,183.
- State of California. Title 8, Division 1, Chapter 1, Article 7, Section 70, Treatment Guidelines for Low Back Problems, 1996; 22.
- Perillo. ACN-HP/SW Provider Newsletter. 1996; 3(2):1.
- Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Dept. of Health and Human Services. Dec. 1994, 14:50-51,53-57.
William Whitney, DC, MA
Antioch, California
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