Clinical competency - These words hold the key to unlock the door to more referrals from other health care providers. Prove you have the clinical competency an orthopedist or general practitioner can trust, and you'll achieve a practice that doesn't have to fight so hard for authority in your community.
Now, as true as these words are, we wish they weren't. How long do we have to offer effective solutions to the conditions that often leave MDs scratching their heads, before we're recognized for the good that we do? "Why do we still need to prove ourselves?" some might ask. Our profession is always debating the rise and fall of chiropractic utilization rates and wondering how we're going to fit in the future. Have we really hit a critical mass of consumers to be legitimized by the mainstream? These questions just never seem to go away.
Until questions over chiropractic clinical competency are put to rest, controversies over our wax and wane will remain because we will lack one important keystone to increased utilization: referrals from the health care gatekeepers in our communities. Now is the time to prove our clinical competency. The perfect environment is being set for chiropractors to prove their clinical competency for the following reasons: (1) Chiropractic enculturation is slowly growing in key areas. (2) There are an increasing number of multidisciplinary growth centers. (3) Medical mismanagement of NMS conditions isn't slowing. (4) The cost-effectiveness of chiropractic continues to be documented. (5) Quite frankly, employers need us.
Let's look at each of these five factors and see how the right clinical technology can help us use these developments to make our demonstration of clinical competency more effective.
Five Factors
Increasing enculturation:When it comes to chiropractic market use, my home state of Iowa defies stereotypical trends and stands as witness against those who say that our current utilization has topped off. The chiropractic utilization rate stands at 22 percent in Iowa, the highest in the country. This is in spite of us having one of the largest amounts of chiropractors in practice, per capita. And when adjusted for regional costs of living, the cost of chiropractic is no lower than anywhere else. Iowa is proof that no state is stuck hovering around 10 percent utilization.
Iowa poses a unique and optimistic example due to chiropractic's stability and reputation in the Midwest. Simply put, chiropractic has been accepted and used for multiple generations by a wide swath of Iowans. In some rural areas, DCs continue to represent the only licensed health care practitioner within a convenient driving distance. The history and geography of Iowa have been fruitful enough to create utilization that is twice the rate of most places in the U.S. This stands in contrast to other locations where there is a high density of chiropractors in an urban area with inflated costs of living, among a population that has scarcely used chiropractic care for more than two generations. The unique position of Iowa is strong evidence that utilization can grow and chiropractic can become a larger part of the cultural landscape, given time and the proper environment.
Increasing interdisciplinary growth centers: What other factors lead to greater regional enculturation, aside from the generational trust? How about interdisciplinary management of patients at the federal level? Each year, more and more chiropractors and chiropractic students are taking advantage of the Department of Defense's inclusion of chiropractic in the Veterans Administration and are completing rounds and clinical rotations in VA hospitals. Many of the young MDs present to witness patient outcomes under chiropractic will go into a private practice having experienced cooperation and co-management of patients with chiropractors as a completely normal, though novel, part of health care. While it might take at least a decade for us to begin to feel the effect of this seismic health care shift, the positive potential of this situation is there. Rather than emerging into private practice with ignorance or suspicion for chiropractors, these MDs will represent bridges to a greater interdisciplinary cooperation.
Medicine is still mismanaging:It is a chiropractic truism that MDs mismanage the conditions that chiropractors consistently help most effectively. Eighty percent of all back pain cases are still heading to the MD as a first option. That is enough patient visits to keep chiropractors busy for the next half century. Studies continue to show that medical management of musculoskeletal pain is still more expensive and that outcomes aren't improving even though expenses are going up. This situation continues to remain ripe for the advancement of chiropractic as a way to effectively manage this societal burden.
Chiropractic is still cost-effective: With the advent of scalable data systems that can examine treatment codes, patient outcomes, and treatment costs, the proof of our economic effectiveness is literally in our hands. That makes it that much closer to being in the hands of influential policy makers. I draw your attention to a previous column of mine that tells of how two Maryland doctors are using data from their own clinics for one-on-one negotiations with Blue Cross/Blue Shield. These clinicians are effectively embedding themselves in the health care culture of their community through the strength of their own evidence behind their treatment protocols.
The needs of employers: While our health care system is large and cumbersome, its infrastructure offers a strategic point at which chiropractors can exert more influence. Employers still remain the largest purchasers of health care plans, and their productivity is still negatively impacted by workdays lost to low back pain and other conditions. Ninety billion dollars a year is the conservative estimated cost for low back pain in the U.S., not taking into account the actual time lost in productivity from days off, or out-of-pocket expenses. Much of the legwork for making chiropractors choice gatekeepers for low back pain has already been completed. We need to convince more employers of the economic benefits of having chiropractors as the first line of treatment in getting American workers back to work in less time, and with less expense.
Of course, none of this is really news to you, especially if you're a frequent reader of this publication. You've heard these facts, many of which have been documented for years. Yet the promise of larger access to the health care pie always seems to lie just around the corner. We definitely don't need another government report to say how recommended we are for certain musculoskeletal conditions, if those conditions aren't going to walk through our door and sign up for care.
What we do need is an army of general practitioners who realize that not every migraine or low back pain sufferer is going to spontaneously get well, or want to commit to a lifetime of painkillers and muscle relaxants. We need a critical mass of GPs who understand how chiropractors think, how we work and how many of their musculoskeletal pain patients deserve a chance to get adjustments, exercises and rehab with attention paid to their functional needs and quality of life. Furthermore, we do it in a more unique and comprehensive manner than physical therapists since we actually diagnose, can offer more, and have diagnostic testing orders available to us for immediate and practical management.
While these five factors create an environment for a potential breakthrough for our chiropractic future, this potential won't be realized without us proving our clinical competency.
Show Your Competency
Simply put, we can't expect to have a critical mass of GPs who understand how chiropractors think and work without first exposing a critical mass of GPs to how we think and work. The currency traded in health care communication is the record of the patient interaction, the patient management plan, and the doctor's thoughts behind why and where the doctor is doing what they are doing. Unless we're actively trading this information with MDs for patients they manage, the lines of communication will remain down. Your patients' MDs will have very little exposure to your clinical competency. They can't know you're competent if they don't understand why you're doing what you're doing. And secondhand patient quotes from your patient education about the importance of the nervous system probably aren't going to cause a professional breakthrough. It hasn't yet. I've heard practice-management gurus belching, "One spine at a time" and "Bring the miracle of chiropractic to the world" for the past three decades. They still are only seeing 7-8 percent of the population in their area. If we truly want to increase the chiropractic market share, we need to utilize certain tools within technology to make it happen faster.
The Right Technology
In a previous column, I asserted that the reason why chiropractors don't seek more referrals from GPs and other MDs is because they are afraid. We're afraid of rejection, we're afraid of criticism, and we're afraid to open our practices to that kind of scrutiny. We're afraid to show our records and management plans because in many places they're still small enough and lack enough detail to fit on a travel card.
What would your communication be like, however, if you could produce pages of quality and meaningful patient data from your exams? How would your communication improve if your records could chart and graph the patient's pain patterns, trends in progress and setbacks in their functional abilities? Would your patient's GP understand what you do better if they saw the details of your postural and neuromuscular analysis, and how these values changed and even improved through your care? Just think: You might replace your fear of rejection with confidence in your care plan. You might replace your avoidance of scrutiny with an embrace of interdisciplinary respect. And believe it or not, if you get yourself the right clinical technology, you could do all of these things in a few minutes or less.
All the ingredients are here; our health care environment is ready. With electronic health records and the right kind of meaningful digital documentation, we have infrastructure to do it and make it rewarding. The only thing we lack is the willingness of chiropractors to prove their clinical competency and start the communication process. Will you join me in making chiropractic part of the health care of the future? Are you ready to lead by being an early adopter of proven technology that lowers your overhead, increases your bottom line, and helps garner referrals from MDs to finally increase chiropractic market share?
Click here for previous articles by Steven Kraus, DC, DIBCN, CCSP, FASA, FICC.