DC: The first question I would like to ask you, Mr. Bennett, is are the accusations and allegations made against specific chiropractors in Oregon, who have been charged, correct?
DC: Are there a significant number of chiropractors who have been abusing the workers' compensation privileges in Oregon?
Mr. Bennett: No.
DC: Why then, was SAIF so successful in almost eliminating virtually all workers' compensation privileges for DCs in Oregon?
Mr. Bennett: Well, SAIF wasn't the one that was so successful. Frankly, it didn't really occur in that venue. The way it occurred was business and labor under the leadership of our governor, Neil Goldschmidt, agreed to address workers' compensation -- the entire rates and benefits structure. He called together leaders of state labor unions and business representatives from some of the large business groups in the state and asked them to essentially follow a collective bargaining model and negotiate with an eye toward reducing rates or at least slowing the increase in rates to business. At the same time, they tried to revise the benefit package to get more benefits and money to the more seriously injured and try to deal with whether it was a real or perceived problem that there was a group of workers' who are injured but are getting too much for the injury -- the injury not being worth as much as they get. So, that is really what happened; it wasn't SAIF. Part of that review was what is going to be viewed as a reasonable level of medical care and a reasonable amount of money to be spent out of our workers' compensation system on medical care. Of course, chiropractors represent a percentage of that medical care, albeit a small percentage. One of the approaches that was taken was to establish a gatekeeper system, to move rapidly toward managed care and to move away from fee-for-service. Who is going to be the gatekeeper into the managed care and essentially what is left of the fee-for-service system, was what the debate was about. The one group that is universally accepted as gatekeepers are MDs. That was accepted by this group too. Then came the question: now who else? The answer was nobody. The osteopaths? They are a very small group in that state and are under the board of medical examiners, trained at the medical school, and for all intents and purposes, MDs. All other gatekeepers were eliminated, all other attending physicians, including chiropractic; chiropractors weren't targeted in that way, they were part of a subgroup that was eliminated. My job, as the lobbyist for the profession, was to get them re-included and that is what I did; they are now gatekeepers in the system with a limitation on the time of treatment.
Understand, there are two issues at work here, and this again gets to the fundamental problem for chiropractors in workers' compensation in this state, and I assume in other states. That is, the chiropractor's role as a primary care physician, attending physician, gatekeeper physician, and as the care giver and the therapist. One of the views in this state is that there is a conflict of interest where the chiropractor both prescribes and treats. Under the medical model in this state, for the injuries chiropractors would share or compete in with MDs, the MD refers along to a physical therapist or some other kind of therapeutic entity -- some sort of ancillary personnel. In the case of the chiropractor, they diagnose and they do the treatment. That is viewed as a conflict of interest and there has been a strong belief that is something that needed to be resolved in this state by the insurers and some policymakers. It has created some problems.
DC: What has taken place in Oregon within the chiropractic profession in the last few years to cause some of these events as far as the reforms and changes in the laws to take place?
Mr. Bennett: It is not in chiropractic; it is in the whole workers' compensation system. One of the things I think we have to be very careful of is not to assume this is based on chiropractic; it's based on other factors. One of them is whether Oregon's economy was being affected by high workers' compensation rates. Were we scaring off business? Workers' compensation rates in this state have been growing very rapidly. I can't quote you the numbers, but they have been growing very, very rapidly. Medical inflation inside of the workers' compensation system has been moving faster than the cost of medical care inflating outside of this system. Chiropractic is part of the medical care delivery system in workers' compensation. As changes occur there, chiropractors are affected.
The question continues to be are they ancillary or are they primary. We continue to debate that they are primary. Thus far, the legislature has agreed that they are primary, that there has to be an alternative care system other than the medical model -- the allopathic model. In that way, there wasn't really a monstrous loss.
These changes in our law are to reduce the cost of workers' compensation in this state approximately $150,000,000. That has to come from somebody, and it is proportionately coming from chiropractors. The biggest amount of it will come from MDs and a huge portion of it will come out of trial lawyers. There will be fewer and fewer trial lawyers working workers' compensation. Patients who are on long-term, palliative care, but the palliative care is not related to keeping them on the job or is not defensible clinically -- those cases are going to disappear. The other thing that happened is people would stay on those programs, not become medically stationary, and the cases were never closed which left a long-term tail on the case. Money was being reserved, essentially held out, and it was increasing the workers' compensation insurance system. It gets pretty complex; it is not as simple as a run at chiropractic. That is not what this is about. There is a realignment going on and a restructuring going on. Fee-for-service in Oregon is disappearing rapidly on all kinds of insurance. You are either going to be part of the solution or you're not; you are going to be out there on a cash only practice. That's fine. That is a perfectly acceptable alternative to participate in a third-party payor and government managed care programs. Managed care organizations that want to treat workers' compensation patients, which is virtually every managed care system coming into the state or in the state, like Kaiser, Blue Cross, Blue-Shield, etc., have to include chiropractors and chiropractors will be attending physicians inside that system. We are talking about a real big breakthrough in this state. It's the only state I know of where we are mandated into managed care now.
DC: Could this happen in the other states in the U.S. and, if so, what can the DCs do to protect themselves?
Mr. Bennett: Again, it is your perspective here. I happen to believe, that managed care, health maintenance organizations, provider organizations, HMOs, and all of those are the coming thing in health care. Certainly, as we look at national health care policy, that is where we are headed. Other states will see, to some extent, this kind of legislation as it relates to managed care coming into third-party payor situations like workers' compensation. Chiropractic has some very fundamental choices to make and it's whether they want to get involved in this type of health care policy or remain as kind of an alternative fee-for-service type of thing. The direction I have been given in Oregon is to make sure that chiropractors are part of that main medical delivery system, not under the MD but remain a parallel but equal. I would recommend that they look closely at what happened in Oregon and keep their eye on the prize; the prize is to be part of managed care. You are going to take some short-term hits on fee-for-service; everybody does. The chiropractors were not singled out. Understand, in Oregon, dentists were attending physicians and they lost; psychologists were and they lost; naturopaths were and they lost; none of these groups survived as attending physicians. "Attending physician" really only means that you can rate disability and certify time loss. You have to have chiropractors in your managed care organizations; that is really important to us.
DC: How has chiropractic fared traditionally in Oregon legislation?
Mr. Bennett: It has done fairly well. Traditionally we have been able to beat back any attacks on the scope of practice. Oregon has a very, very broad scope of practice instituted years ago and we have been able to protect that. Most of the things we supported or opposed have been successful. We have generally been able to have our way in the workers' compensation system. Use of a special session, using the collective bargaining model made it a little more difficult. We didn't have quite the control we would have in a regular session. It is a very smart political maneuver by the governor, big business, and insurance in this state. It essentially isolated everybody in compensation. A regular session is a different process than a one-day special session, believe me. Traditionally, we have done well with the legislature.
DC: How else is this new workers' compensation law different than it was before?
Mr. Bennett: It is a new system. We had a system that really was weighted on the workers' side in Oregon, that really the worker had fundamental rights to care, treatment, everything. That has been severely limited and it is not going to be as easy to get care and treatment under the new Oregon system. The rights of workers to go into a hearings and court process have been severely limited or changed. It is going to change the focus of what is going to be considered an industrial injury in this state. People are going to be expected to live with, in the worst sense, the outcome of an industrial injury in this state. Industrial disease -- we don't even know what has happened to that in this state. Industrial disease is different than immediate injury. We may have lost it all. That's a real problem.
Frankly, this was a special session activity. We are going back into regular session in January and the whole thing can be thrown out then. This is not set in stone. It is so complicated that for the legislature to vote on it in a one day session is like a political maneuver. I think we will go back to policy in January and we will really start changing it again. A lot of this just isn't going to work. We are going to have people laying out there in the street. It just has some real severe problems. That is why I think any kind of panic is a mistake right now. Part of the thing when you deal with politics is you have to go through the process; it takes time. It does not have a beginning or an end. You just move from one station to another. It is a highly uncertain situation.
DC: Do you personally believe that chiropractic in Oregon was under attack and if so, by whom?
Mr. Bennett: Yes, I think it was under attack. I don't think it was under quite the attack the way I hear it often described. There is a group that believes the first dollar spent on chiropractic, is a dollar wasted. We also have had some problems in Oregon, perceived and real, with fraud and abuse in the system. Some of it also is in the area of utilization where there are some real questions about some of the cases. I have seen them, where they bring in the case by the box-load, just boxes of paper on a chiropractic case. I think observers of the system would agree there were some problems but certainly nothing to write home about.
Chiropractic was also singled out for civil racketeering action by the State Accident Insurance Fund (SAIF). No other profession had that attack.
Chiropractic had maybe some problems that had not been resolved and some real confusion. Part of it is practice management. There are some practice management techniques out there that I think get people a little bit confused about practice and management. I've heard of one called "No Cash out of Pocket," which is a system where a patient has a deductible and doesn't pay it or, in fact, makes money back. I don't fully understand it, but it isn't right. Chiropractors have been more public about practice management. Everybody has practice management seminars, but I'll tell you, at the end of the last session we were facing some very tough bills. We killed some of these bills in our last session. In a Western States Newspaper there was a big ad that said you could earn $100,000 your first year out of chiropractic college. What kind of message is that? That was circulated widely in the legislature. We had a local chiropractor offering a seminar that was just outrageous in its promises. This went on for months during the most critical discussion of chiropractic's role in workers' compensation. We were discussing the question "Are chiropractors rip-offs? While we were saying no, at the same time, we had a chiropractor here offering a practice building seminar that just made some promises that may or may not be accurate, but they would make people who don't understand a little nervous. Most chiropractors said "Oh my God," and talked him into withdrawing from the seminar, but it's that kind of stuff that gathers an attack.
This profession has not been good at policing itself. In reality or in perception. We doubled our licensing fee two years ago. I think there is a move afoot now to double it again, and give all the money to the Board of Examiners to increase their investigation and legal powers. We doubled it once. This isn't a group sitting on its hands here. We are the ones that set up a protective peer review system under our Board of Examiners. I mean we are really trying here to establish policing. But it's hard. Did Oregon DCs contribute to their own demise? I don't know. We have had some problems but nothing that any other profession hasn't had.
We can't go into a denial system, we have to agree we have problems, and we have to deal with them. MDs have what I call the "Marcus Welby Syndrome," which protects them from all attacks. If Marcus Welby had been a chiropractor we would have that. So we have to be cleaner. We have to be like Caesar's wife, and that is really important if you are the underdog trying to gain appropriate recognition and authority in health care.
DC: Is there anything else that you might want to add that you would say to the DCs across the nation, who would like to better understand what has happened in Oregon?
Mr. Bennett: What happened in Oregon I think, is the vanguard of a national trend. That is a move away from fee-for-service toward managed care. It has been underway for a long time. We have a program currently in front of Congress to set up an insurance program to where health insurance, will be health insurance and essentially move away from a workers' compensation type system. That's what is happening in Oregon right now. But, along with that you've got to keep very close track of position and you have to look at long term vs. short term issues. Don't get trapped in short term issues. There are a lot of chiropractors in Oregon who have mentally fixated themselves on the short term effects on this thing, and are ignoring what is going to happen in two years. So you have to mix with pragmatism too. The main thing is to keep your eye on managed care. I really think that's where the future is.
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