- Some joined because they thought they would be the only provider in their community and would get all of the covered patients.
- Some joined based on the promise that they would be one of a few providers in their area, and would therefore see many new patients who would transfer from nonprovider DCs.
- Some joined just to keep their patients from transferring to HMO provider DCs in their area.
- Some joined just to get on the provider list, because they were told that if you didn't join, you might be locked out for years.
The recent Supreme Court decision has at least addressed some of the issues surrounding practices used by the managed-care industry against providers.
DCs and other providers in 21 states can rejoice in the fact that they can't be locked out of a specific managed-care plan in their state. Sadly, for the chiropractic profession, this is too little too late. Similar to several of the initial strategies used by the managed-care companies in the early days, the issue of only using a limited group of providers is no longer attractive to the HMOs. While once a negotiating tool used to grind out the lowest reimbursement rates, the chiropractic managed-care industry has now matured into an oligopoly (a market with few vendors requiring a large investment to enter).
Reimbursement rates have settled into ranges based on reduced "bids" initially accepted by those DCs who first joined the managed-care plans. Chiropractic reimbursement rates continue to be depressed by those most willing to accept the least amount per visit.
To make this point more clearly, consider this: In the beginning of managed care, many DCs accepted lower payments based on the hope of gaining more patients; fear of being locked out; or a desire to keep the patients they had. They compromised the amount they would normally expect to be paid based on the hope, fear and promises prompted by the HMO in question. It is safe to say that many, if not most, doctors who first joined managed-care networks were overly motivated to do so, and therefore accepted reduced payments based on these expectations.
Opening their doors to "any willing provider" only enlists the support of DCs who currently hold the same motivations of hope, fear and promise as those who began the downward spiral of chiropractic reimbursement rates in the first place. AWP laws make it easier for managed- care organizations to act in their own interest. They are able to identify and quantify the number of DCs willing to accept their reimbursement rate, and make an educated guess as to how much lower they can go.
If they have a high provider-to-covered-lives ratio, they have some room to reduce their reimbursement rates - possibly. If not, perhaps they will hold the line for now.
What the insurance laws still fail to accomplish is to give some kind of bargaining equality to the providers. Doctors of chiropractic are caught in this "take it or leave it" position when dealing with any managed-care company.
Only when they scream loud enough and make threats (or file lawsuits) do the managed-care companies begin to believe that they are somewhere near the lowest reimbursement rate they can currently offer. This only postpones a potential reimbursement rate decrease that could be coming next year.
What I am still looking for is some kind of legislation that gives doctors the right to actually negotiate in good faith. The legislation must function within laws that address collective bargaining, but there should be a way to accomplish this.
Managed care has effectively turned the science, art and philosophy of chiropractic practice into a commodity; every DC is the same as the next, and every patient is given the same amount of chiropractic care for the same coded complaint. DCs are allotted a specific amount of money per case to address the needs of their patients, and managed-care companies keep as much of this money as possible. There is almost no consideration given to the cost of running a chiropractic practice, increases in living expenses or improved outcomes.
The current system is similar to a remote town with only four gas stations. As soon as the four gas-station owners realize they have the market cornered, they can charge almost anything they want. If people want to continue driving, they will pay the higher prices. Price increases will become common, until drivers get so angry that they decide to do something about it.
Health care providers need some kind of adjustment to the current situation; one that will place them on equal footing with the managed-care companies with whom they are currently contracting. Without an adjustment, managed care will remain a one-sided game that DCs cannot win.
DMP Jr.
Click here for more information about Donald M. Petersen Jr., BS, HCD(hc), FICC(h), Publisher.