To further carry on our dining metaphor, members of the health community are trying to get their place at the dining table. The allopathic community has had the lion's share until this point. They tip the waiter to get the quickest service, best seats, and choicest cuts of meat. But the owner of the restaurant has announced that there is going to be a whole change in waiters, seating arrangements, and portions served and that everyone will probably have to get by with smaller portions so that the multitudes can be fed.
Chiropractic physicians have for years had to settle for crumbs falling from the master's table. When more and more insurance carriers began to pay for chiropractic care, our emaciated frames started gaining a little more weight. We got a little stronger and healthier. But some of the diners got gluttonous. If seeing a patient (and getting paid) for 12 visits was good, seeing the same patient (and getting paid) for 12 months was even more tasteful, but unfortunately not satiating. The gluttons got larger and spread. Their size made them more visible and this apparent wealth and prosperity lead leaner less prosperous doctors to follow their practice techniques or to associate themselves to get a few crumbs left over from the feast. Of course, this is not only a phenomenon in the chiropractic field. It is found in almost every other field from eye surgery to dentistry.
Now there is quite a bit of elbow jostling going on between the MDs, PTs, and DCs trying to get more room at the table and a larger piece of the pie. But the whole thrust of the new approach to health care management is to get everyone lean and mean. The fashionable buzzwords, managed care, indicate a trend towards decreasing numbers and kinds of treatments, not only for chiropractic doctors, but for all health care providers. In this environment, conspicuous consumption just will not be supported. To be fair, the health care system in toto is bloated and overweight. As doctors who have for almost a century advocated prevention, we have exhibited a fair degree of responsibility in managing costs and avoiding overutilization. We have also demonstrated a high level of professionalism and care in treatment of patients and avoidance of injuring patients, witness our lower malpractice rates compared to MDs, especially those performing physical care, such as orthopedists and neurosurgeons. But like the small ketchup stain on a perfectly white tablecloth, the bad eggs stand out in relief. Our profession should have zero tolerance for abuse and fraud.
The Crash Diet
For many doctors, business as usual is going to have to stop. I have reviewed records where patients presented initially with sprain/strains, were treated, under the same diagnosis, for three years. The staff were frustrated and confused that the insurance company started refusing to pay. Let's face it, if our loved one were going to a doctor on a daily and every other day basis for three years for a simple sprain/strain and was not any better (per the SOAP notes), we wouldn't pay.
Doctors who want to keep a place at the table are going to have to do several things. Documentation is going to be a sine qua non to even be invited to be at the dinner table. Our MD colleagues are great at this and are already in this mode. One specific area we can improve is in history taking. The reports that most orthopods, neurologists, and neurosurgeons generate are complete. They detail the history of the injury, allergies to medications, past surgeries, what the person does for a living, how much they smoke or drink, and on and on. Compare these to the run of the mill chiropractic report. Although we are supposed to be the holistic alternative, chiropractic reports tend to focus just on the car wreck or the fall. They tend not to get into peripheral issues such as the person's psychological make-up, family situations, etc. Utilization review doctors usually do a much better job of emulating our medical counterparts.
We must understand that if we are serious about wanting to occupy a portal of entry position in this system, we must do more than adequate jobs of diagnosis and then, based on the diagnosis, must be ready to refer the patient out if they have problems which are outside our scope of practice. Nothing will get you removed from the dinner table quicker (and straight into court for malpractice) than missing a diagnosis and continuing to treat a patient in the face of serious symptoms and lack of improvement. Doctors must also begin learning how to classify patients and defining prognoses better. The days of displaying a grave expression in the report of findings room and declaring that you "found the pinched nerve," and telling the patient it may take 40 or 50 visits are, I feel, going the way of the $5.00 adjustment.
A Lean, Mean Adjusting Machine
Chiropractic has limited itself to manipulation as its primary treatment method. There is a move within our profession to push for limited use and prescribing of pharmaceuticals appropriate to the kinds of problems we treat (i.e., use of anti-inflammatories, pain killers, muscle relaxants, etc.) This unfortunately has been a hot debate within our profession. Whichever way you come down on this issue, you must understand one vital thing. Patients will usually go to the doctor that can do the most for them. Until recently, we ruled the roost on manipulative therapy, and rightfully so. Editor/Publisher Donald Petersen Jr. recently reported on "orthopaedic manipulative therapy" and the Journal of Manual and Manipulative Therapy in his "Report of My Findings" (Dynamic Chiropractic, September 12, 1993). Mr. Petersen notes that this journal is a product of physical therapists. It also states that under the definition given in that magazine, those performing this therapy are "... responsible for making a clinical physical diagnosis and for deciding on the suitability of a patient by observing precautions and recognizing contraindications."
If it is not apparent where the PTs and OTs are going, does the phrase portal of entry mean anything to you? And osteopathic and allopathic physicians are showing renewed interest in manipulation (in part, thanks to the positive press that chiropractic research has generated). If you had your choice of going to a physician who could do surgery, admit, and treat you in a hospital setting if need be, deliver babies, prescribe drugs, send you to a PT, and do manipulations, or go to someone who was limited by law to just doing manipulations, where would you go (assuming the standard of manipulative skill was the same)? And who would you choose for a family doctor, i.e., someone to take your kids to when they break a leg, or your wife when she needs hormonal therapy, etc. Would you rather go to a restaurant that just served ham sandwiches or one that had a salad bar, all kinds of foods and drinks, and full service?
Dog Eat Dog, Survival of the Fittest
What I am trying to point out is that managed health care increases competition for patients and for inclusion into health care organizations like HMOs and PPOs. You will start to see more medical doctors advertising. As doctors are limited to getting less and less from each patient, we will start to see more territorialism. This is speculation on my part, but it makes sense that this will happen. If we as health care providers are able to give pain killers and adjust, we are going to be more competitive with PTs for example (should they begin manipulating) than if adjusting is all we have.
I do not want to upset those doctors who are hole in one doctors or "straights."
If you can make a living by maintaining a purely cash practice, then great and more power to you. There is no one I know that would want to force you to practice any other way. But I don't think it is fair to actively oppose other doctors who want to have more therapeutic options, should they choose to employ them.
In 1995, we will be celebrating a century of chiropractic. Yes, we have helped people and continue to do so with our hands, and for some, hands alone. The nature of life is change and I believe that change is in the air for us and our profession. The bakers and servers of this new health care pie are going to be telling diners that they have had enough to eat a lot sooner than was the case in the past. If we are to remain a vital force in the health care system, if we are allowed to continue to dine at the health care dinner table, we are going to have to learn how to eat less, be more cautious of how we eat, and zealously guard our plate.
John Raymond Baker, DC
Beaumont, Texas