What defines the standards of our care as chiropractors? Is it our ability to adjust? Or is it our ability to diagnose? Is it the standards set forth by our technique systems, or the standards set forth by our licensing boards? From the perspective of managed care programs - those people who actually control the money we earn - how we define our care as chiropractors is relatively meaningless.
Simply put, your standard of care is now being defined by the quality of your documentation. From the health care system's perspective, how you look "on paper" is actually far more important in determining the quality of your patient care than the strengths of your own personal practice emphasis. If you're the kind of doctor who says, "I get good results, but I'd die if someone saw my notes," listen up. I want to help you understand why the status quo has changed, and how you need to change along with it. It's the only way we're going to elevate our practices and elevate our profession for the coming future.
Let's start by analyzing three primary factors for the development of documentation as a new chiropractic quality benchmark.
Factor One: Rising Health Care Costs
Michael Moore has just made a movie about it. Politicians already are stumping on it for November 2008. We've all experienced the frustration of being both a provider and a customer of it. Of course, I'm talking about our health care system.
We're on the cusp of a change in American health care, although no one is sure what that change will be. Somewhere around 18 percent of Americans have no health insurance and the number is growing.1 America's HMOs already have announced their intention to raise premiums by more than 14 percent in 2008, the highest increase in four years.2 We have one of the most expensive systems in the world and costs continue to increase. The expense has caused rifts in the American labor market in manufacturing sectors like the automobile industry. It also caused chiropractors to sweat a bit last year over the possible passage of the controversial Senate Bill 1955. The bill was intended to make health care more affordable for small businesses by creating interstate networks that wouldn't have to guarantee services like chiropractic. Due to the increasing costs of chronic disease, some companies are even pegging what employees pay into health care based on factors such as their weight, smoking habits and cholesterol levels.3
Suffice it to say, controlling health care cost is everyone's concern. Consumers want to control costs so they can pay smaller premiums. Businesses want to control costs because worker benefits limit profits. Managed care programs are interested in any way they can decrease their payouts while being able to expand services.
Factor Two: Increasing Oversight
Whatever your opinion on best practice guidelines, one thing about these documents is certain: They aren't going away. In fact, the current atmosphere of guidelines and counter-guidelines make the days of the Mercy Guidelines seem simple. While the final chapter on practice guidelines isn't yet written, that hasn't stopped third-party payers from taking notice. The Federation of Chiropractic Licensing Boards (FCLB), the National Committee for Quality Assurance (NCQA) and the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) have things to say that are going to affect how you document. This is in addition to the treatment guidelines for managed care programs such as Blue Cross/Blue Shield (insurer to one-third of all America), which has its own practice parameters.
The number of parties with an opinion about how you take records has just multiplied. As a consequence, the level of interest in documentation standards by our state licensing boards is on an upward swing. The 2005 OIG report catalyzed an interest in greater scrutiny of chiropractic documentation so that we might avoid another embarrassing exposé of chiropractic standards of care. For example, one state's licensing board is going so far as to send a licensed DC to randomly review records of chiropractors. Those found not filling minimum documentation requirements will face sanctions. All parties with a stake in our practices are increasing their demand in the quality of our clinic documentation.
Factor Three: The Cost of Success
One could argue that the increasing demands of oversight can be partly blamed on our success; the government wouldn't write an analysis of our use of Medicare unless it believed the rates of usage and costs were significant. It's a circumstance that speaks of our arrival on the American health care scene. It's a situation similar to the way today's patients are changing in their attitude toward chiropractic.
While we're still struggling to broaden our patient base, I can say that I've seen a change in the expectations of our new patients. They aren't coming in as a last-ditch effort; they're coming in expecting results. They're coming in expecting to meet a doctor who has the same kind of credibility and authority that they'd find at a general practitioner's office, especially when it comes to working within the limits of their coverage, and winning the authorization of care that the patient needs. In some ways, that chiropractic wow factor is gone. No more Dr. Freelance when it comes to taking care of aches and pains. That era when patients loved their eccentric "alternative doctor" has ended for the bread-and-butter patients of chiropractic practice. We work for the patient now, and they're losing their patience when we can't figure out how to consistently win approval for their care and they have to ration their visits. That's not the doctor they're expecting to see.
When Factors Combine
What do we get when you combine a health care environment looking to cut costs with an increased interest in the consistency of chiropractic records, with increased patient expectation? Let's explore just one possibility.
The pressure to cut health care costs has placed such pressure on businesses that coverage programs are responding with their own coverage guidelines. This is where the rubber meets the road for evidence-based health care. Health care administrators are attempting to control and influence uses of procedures and diagnostic tools based on outcomes studies in the literature and payment trends from patients' pay programs.
However, there also are the outcomes studies conducted by the health insurance plans themselves. Various provider networks have begun to track the results of a particular procedure for a particular diagnosis. This tracking even includes the direct input of patients in satisfaction surveys, where the patient reports their own outcomes in order to corroborate the records of the charging physician. We can't assume that clinical trials and literature reviews are going to determine which practices managed care programs are going to consider "best." If they can cut payouts and increase their profitability by building their own database, why would they rely on the tectonic movement of scientific research? They already have the data themselves, and you'd better believe they're already starting to analyze it.
Which brings us back to the three factors discussed: How will managed care analyze the efficacy of chiropractic if we don't give them the data they need to analyze? For example, what if we haven't detailed the co-morbidities that may slow a patient's progress, how will they know that our outcomes should take longer than average? How will they know to authorize continuing care and pay us for it? This is where the future starts to look grim for those who cannot prove the quality of their care through documentation. Increasing oversight means the red flags start to appear sooner than they used to. Increasing patient expectation means that the patient already is looking for another provider. And thanks to our inability to fully document the case, the payer program can easily justify cutting its costs by cutting our ability to see the patient. Can we see why documentation has become an ultimate criterion for standards of care?
Technology Improves Quality Standards
The gains that chiropractors have won through the past 40 years of political advocacy and research are vulnerable. We have to be able to see how individual chiropractors are going to prove the value of chiropractic with the only barometers the current health care system can interpret (e.g., how long did it take the patient to get better and how much did it cost?) It's a gauge that requires thousands of points of data which we have the responsibility to provide. So much responsibility, in fact, that I believe these data (read our documentation) will decide whether chiropractic is determined to be worthwhile for the long haul by health care bureaucrats.
We're fortunate enough to have reason for hope in this complicated time. Clinic management technologies have moved us far beyond spine-centered travel cards with little room to note anything but segments adjusted. We now have the ability to move through detailed patient workups that prompt a plan of care that is intelligible to the patient's other doctors involved in their health care and the patient's pay program. We have digital tools that can help us secure a quality of documentation that proves our standards are above board no matter who is looking over our shoulder. Rather than losing ourselves in the details of what managed care wants from us, technology can fulfill those demands, allowing us to practice with a level of efficiency (and a fully documented one at that) which we didn't believe was possible.
We do need to admit there's a problem, however, and be open to the possibility that a solution may only be found in the benefits of the digital clinic and adoption of electronic health records. The elevation of our profession is waiting for it. And so are our impatient patients. If documentation is going to be the benchmark on which we're judged, let's have the best tools at our disposal to finally prove this profession called chiropractic works for once and for all. They're not going to be able to limit a chiropractor who's empowered by the digital clinic of the future.
References
- Number of uninsured growing. American Medical News. Accessed July 16, 2007. Available online at www.ama-assn.org/amednews/2007/07/16/gvca0716.htm.
- HMOs propose highest rate increase in four years. Accounting Web. Available online at www.accountingweb.com.
- Lee D, Berggoetz B. As waists expand, paychecks may shrink. The Indy Star. July 1, 2007. Available online at www.indystar.com.
Click here for previous articles by Steven Kraus, DC, DIBCN, CCSP, FASA, FICC.