Chiropractors and cattle ranchers have a lot in common these days. Like all doctors, DCs have faced the corporate control of medicine, and have been either domesticated or disenfranchised. Reimbursement is decided by contract with corporate vender networks and payers on one hand, or on the other hand, paid in cash, or barter, such as with sides of beef.
"How low can chiropractors go in charging for their services?" is a question often asked in editorials. Shouldn't we all be angry at the large, national networks that market our services, since it has become apparent that corporate health care payers expect to deal only with equally large corporate provider networks? Well ... sure! Why not be upset, when it becomes apparent that one is simply a commodity? Yet there is nothing keeping chiropractors from starting their own tribal uprisings, and competing with these firms - nothing but money and time, that is.
Tribal uprisings have not worked well for the MDs. Physician-owned HMOs, or physician-hospital-owned networks, have been folding up like Japanese fans. I call it the "Tecumseh effect" after the native American chief who tried to organize a number of tribes to chase the white man off the land. It seems that every issue of an industry publication, e.g., Health Affairs, has a case study of "what went wrong" with some ill-fated physician HMO.
The scenarios sound like this: Doctors were ticked-off at managed care, and a few champions among them organized a physician-controlled/owned network/corporation with or without a hospital. Fast-forward to when the group bids too low on capitated contracts and goes broke, or rewind to the moment when the leaders realized they had been financially devoured internally by their own lawyers, accountants and consultants.
Managed care is not working well. According to Modern Healthcare, a General Accounting Office report about a year ago said that Medicare HMOs were paid 13.2 percent more in 1998 than they would have been paid under a fee-for-service model. So, what's the point? Yet, according to Russ Coile's Health Trends, employers are bracing for increases of eight to 12 percent in premiums for 2002. Add that to the exploding mandates and costs for pharmaceuticals, and ponder the chances of managed care organizations paying doctors of chiropractic more for their services.
What we get paid as chiropractors is crucial, much like the relationship between food and starvation. But in the long run, it may not be the most important issue. Job satisfaction could be that issue. When daily, physical contact with people in pain becomes repugnant and cheap, then what?
A study of Massachusetts doctors, conducted in conjunction with the Robert Woods Johnson Foundation, compared findings from surveys taken in 1986 and 1997. It found that doctors surveyed were significantly and increasingly less satisfied with "most areas" of practice. In 1986, only 20 percent agreed with this statement, but by 1997, it had grown to two-thirds of respondents.
HealthLeaders magazine recently included a feature article, "The Sad State of Health Care Staffing," predicting a worsening of the shortage of hospital nurses, therapists, and radiologists and anesthesiologists. Low pay was a major reason for the shortage, but it was not the primary one. The grueling hours, paperwork, the intimidating oversight from governmental and payer bureaucrats were the stresses that were driving professionals out of health care.
A survey reported in Medical Group Management Update, conducted by the firm Merritt, Hawkins and Associates of Dallas, indicates that 38 percent of physicians over the age of 50 plans to retire within the next three years, and 12 percent plan to seek jobs in nonmedical settings. That means that of doctors over the age of 50, about half plan to be out of medicine in the next 36 months. When asked if they would choose medicine as a profession if starting out today, 50 percent said that they would not.
Victor Frankel, Nazi holocaust survivor and psychiatrist, once said that the ultimate freedom for humans is the ability to choose their own attitudes. That was easy for him to say. He should have tried to practice under the forces of managed health care for a while. But he was right, you know. Reimbursed or not, chiropractors had better learn to like what they're doing. Nobody can take that away from us but us.
John Hanks,DC
Denver, Colorado
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