David N. Taylor, DC, DABCN

Multimed Center, Inc.

74 Main St .

Greenfield , MA 01301

dntaylordc@comcast.net

413-774-7501  

            JOURNAL OF THE AMERICAN CHIROPRACTIC ASSOCIATION, (19) August 2006

 Commentary:Health Care Industry Shaping Chiropractic’s Future By David N. Taylor, DC, DABCN

Abstract: The chiropractic profession is at a crossroads in the growth of the profession. There has been a great deal of change in healthcare, technology, society and business over the past 15 years. This commentary outlines some of the recent changes and proposes the core changes needed in this profession in order to claim its cultural authority and reclaim a pattern of growth.

 Introduction:

There is much discussion about whether Chiropractic should become integrated into our standard healthcare system. Is chiropractic mainstream or alternative? It is ludicrous to think that any health care profession would benefit society as an island unto itself. The question is no longer whether we should become integrated, but whether the profession desires to have a say in the matter. Well, while our profession continues its debate, society is determining the answers for us.

The future direction of the healthcare industry has been and is continually being determined by the government, insurance industry, and employers, along with and in consultation with the medical profession. The medical profession is looked upon as the cultural authority and is consulted regarding prospective changes in healthcare. The medical profession represents those groups that are integrated into the system. This includes physical therapists, optometrists, dentists, osteopaths, podiatrists, and to some extent it may include acupuncturist and other integrated complementary practitioners. But who represents the chiropractors? Sure we have our national associations who do a tremendous job in lobbying with our grassroots efforts. However, too often the chiropractors are not sitting at the tables for the discussion that impact our profession to a tremendous degree. Too often we are not invited and we are not represented. Why, you may ask.  Is it because the key players fear us? Hate us? Want to economically lock us out for their group benefit? I propose that it is more likely due to misunderstanding and ignorance of our profession. There is an ignorance of our profession because of a lack of integration. This lack of integration creates and perpetuates our own exclusion. The cultural authority therefore is forced to rely upon public information for their knowledge and impressions of our profession. To a great degree that means they rely upon the crass hucksterism of the newspaper, radio and yellow page advertisements that relay unsubstantiated and outlandish claims, which leave an impression of a void of professionalism. Many chiropractors do earn the respect within their individual communities. However, in spite of their successes, there is still a lack of cultural authority or even respect for the profession as a whole from the same individual patients who respect their personal DC.

It is time for the chiropractic profession to take an honest introspective look at itself. Authority is only awarded when professionalism is obtained through an earned trust by the patients, and society. It is only then that one can be looked upon as the trustworthy authority to be consulted on the matters that affect our citizens. This is the time for decisions to be made by every individual physician within this profession. It was the self interest of the practitioners in the late 1980’s and 1990’s that undermined the professionalism and public trust of the whole profession of chiropractic. There is no longer any room for self serving individual interests.

The fact that we participate in the third party pay system was the initial invitation for integration. Unfortunately, to some degree, this was abused and there was a failure to gain the trust of decision makers within the system. As a result the chiropractor experiences extensive reviews, precertifications, and artificial stop care limits. The lack of demonstration of trust in appropriate care has resulted in oversight by other practitioners. This has included reviews by nurses, MD’s, and now even DPT’s who have earned trust, respect, and gained professional authority via their integration.

The chiropractic profession has its own unique challenges, but it is also entwined in the national and local economy, politics and the healthcare industry and its ongoing development. However, many in the profession fail to recognize that science, politics, healthcare and the economy change over time and therefore the profession must change in response. As such, the chiropractic profession must look at the healthcare industry, the patients’ needs and desires, and evolve in response to the current demands. It is no longer 1895.  Society has changed and we must adapt to these changes. Chiropractic has endured through the past 110 years as a separate and distinct entity which has offered unique services and healthcare philosophy that were not offered by other healthcare providers. In addition chiropractic care has traditionally been more reasonable in price and cost effective in its applications. As a result patients were willing to pay cash, albeit a small amount, to obtain the services. The profession gradually became integrated into the healthcare and third party pay system; and it continues today. However, with this integration came increased administrative costs to support the third party billing. In the 1980’s this was not much of a problem. Doctors all increased their fees to cover the increased overhead costs and the insurers would reimburse 80-100% of our fees without much of a co-pay or deductible by the patients. Therefore the increased fees were not known or recognized by our patients, nor did they care. Their insurers paid the majority of the fees. This initially increased the reimbursement of the chiropractors to more respectable levels for the education, knowledge and skill. In the long term, it created greater integration of the chiropractic physician but it also put a greater burden on the practitioner to demonstrate the necessity and appropriateness of care.

Today the practitioner is still charging the inflated fees, however there is ever increasing administrative requirements, increasing overhead expenses, and diminished reimbursement rates. Many contracted reimbursement rates today are the same or less than what we were charging in the early 1980’s. This has created the obvious problem of microeconomics with the outflow exceeding the inflow of cash.

In addition, most practicing DC’s have not had training in, nor were there known parameters of care, in appropriate clinical decision making, or documentation of such to optimize the quality of care and to substantiate the care. Therefore many chiropractic physicians began treating the insurance policies instead of the patients. This resulted in inflated care in number of procedures, frequency of care and duration of care.

Now and over the next year we will see increasing percentage of the charges being paid for directly by the patient. This will be due to increased co-pays, deductibles, stop care limits, and uncovered services. However, the patients are no longer in the habit of paying cash for healthcare services. Therefore the emerging situation creates an imbalance in affordable healthcare.  As the patient’s habits are forced to change, so must the chiropractic practitioner.

So the question remains. What is the future of the chiropractic profession? To answer this we must realize our uniqueness, our current level of integration, and the additional areas of integration that would be beneficial to make inroads. Finally we must look at our profession from a standard business and economic point of view.

Uniqueness:

The unique service of manual therapy that has been practiced mainly by chiropractic physicians is no longer a protected niche. The first 110 years were most fortunate to have a niche that created little interest from other healthcare practitioners. That is now diminishing. It has been estimated that between 1994 and 2010 there will be an 88% growth of per capita alternative medicine clinicians.1 Physical Therapists are all clamoring for manual therapy courses. They are being trained and certified in the same and additional techniques. The American Physical Therapy Association desires to have Doctor of Physical Therapy programs offered at all physical therapy colleges. Many colleges are offering online courses to provide current therapists with doctor degrees. The stated goal is to have all physical therapist to have doctors degrees.  In addition they are offering manual therapy certification courses in the core curriculum.  In 2005 41% of all college based physical therapy programs offered courses in “thrust type of joint manipulation”. In addition 51% of the remaining colleges had plans to add the program.2  There is projected continued growth in many of the non-physician clinician field. 3 Massage therapists are becoming more educated and their programs are improving. In addition there are increasing number of programs being developed at technical school, colleges, and an increasing number of specialty schools.  They are also being trained in increasingly sophisticated techniques.  In addition Massage Therapists are now making inroads into the hospital setting, even in areas where chiropractors are still being prohibited. They would love to perform manipulation if law would allow them to. Medical doctors are showing a newfound interest in manual therapy and are now attending weekend courses. Osteopaths are beginning to practice it more than they have in the past 20 years. Currently orthopedists, physiatrists, and physical therapists are forming cooperative relationships with the hospital outpatient rehabilitation departments to create spinal rehabilitation clinics that claim to offer the full spectrum of conservative and invasive care, including manipulative therapy. Suffice it to say that the uniqueness of chiropractic services has vastly diminished. If the profession does not act on this, then the profession will be in demand about as much as the inventor of the automobile was after Henry Ford began building the auto more efficiently and creating more accessibility to the general public.

The chiropractic profession must market itself as a true professional vs a manipulative technician. This should include the full capabilities as diagnosticians with a full spectrum of conservative care. It is the training in physical, laboratory, and radiology diagnosis that sets the chiropractic physician apart from physical therapists. It is the expertise in musculoskeletal diagnosis that differentiates the chiropractic from the medical physician.  The expertise in manipulative and manual therapy skills differentiates the profession from all other practitioners. The uniqueness of the chiropractic profession must be retained by virtue of the professions diagnostic and therapeutic expertise in the conservative care of musculoskeletal disorders. Although certain practitioners may expand their practice beyond this area into wellness care, or as primary care physicians in health shortage areas,[4] the profession must first be grounded with cultural authority as the experts in conservative musculoskeletal care with emphasis on the spine. The predicament of the chiropractic profession is analogous to the current competition in the global economy. It is no longer sufficient to provide a unique service. That service can easily be copied and provided at a more reasonable cost (in this case to the patient due to insurance coverage differentials). The Japanese learned how to copy the American products and produce them more reasonably. Now the Chinese and Indian economies are emerging and providing similar product manufacturing and services which copy the American and Japanese, but provide it more efficiently &/or economically. Just as the established companies must learn how to remain competitive, so must the chiropractic profession.

Integration:

When there is not a niche, there is competition. When there is competition one must compete through either improved quality or lower price. Since the fees have already been beat down, the profession has no choice but to improve the quality of care. That would include increased patient relations, improved manual technical skills, increased knowledge, and improved outcomes through decreased frequency &/or duration of care. This will also necessitate the chiropractic professional becoming educated in all the different parameters and techniques of conservative care. The profession will have to expand beyond the basic high velocity low amplitude manipulative techniques. The chiropractor has to become the cultural authority in manual therapy. That means knowledge, experience and utilization in the many different chiropractic, physical therapy, osteopathic and medical manual therapies, treatments, and techniques. It means that the chiropractic professional will have to know the optimal use of each treatment for the best outcome. The chiropractic professional should know the optimal utilization of all passive and active therapies and when to make the transition. The Doctor of Chiropractic should not be competing with the non-physician professionals or the Doctor of Physical Therapy. They should be integrating as the leader in the field and directing the rehabilitative departments at the hospitals instead of competing for patients with these departments.   Future clinicians will have to be equipped not only with the knowledge and skills needed to provide their unique services, but also with the ability to collaborate with the wide range of practitioners and there must be uniformity of high quality of care.[5]

The chiropractic profession has in fact already become partially integrated into our healthcare system to the point that it is now sharing parallel problems with our optometric, podiatric, dental and yes our medical colleagues as well. Our history of independence actually puts our profession at an advantage. I optimistically believe that chiropractors are more creative and better prepared to deal with adverse business conditions than our medical colleagues, who have been able to utilize their control over the healthcare system to economically insulate and protect them.  However, the continuation of entrepreneurialism in the chiropractic profession without professionalism, high moral and ethical standards, and patient centered care will result in further alienation from the healthcare system.  The average medical physician might see their plight as dire due to integrated oversight and control systems constraining them. The real difficulty for them is that they do not have the experience of dealing with trying economic conditions that are out of their control. They do however have the advantage of being fully integrated, with continuing strong influence and cultural authority in the decisions made which effect all healthcare professions. This reveals the importance of integration and collaboration.

Patient centered collaborative care must be the primary directive of every practitioner. There can no longer be different treatment recommendations for similar injuries contingent upon the insurance. The care recommendations must be made on the basis of what is the most efficacious care for the particular patient in order to obtain the best outcome in the most expedient manner. The consistency of treatment expectations must improve. This must include the collaboration with other practitioners within the healthcare system in order to provide the optimal outcome. The chiropractor must become more educated in appropriate collaboration. This must start at the level of the colleges and universities and continue through internships and residencies. Established practitioners must learn to communicate with the other practitioners in a manner of mutual respect and confidence regarding the care within our own offices as well as the care rendered in other practitioners offices for the benefit of the patient.  Once this is established, then the profession would be able to improve the public trust and confidence, resulting in further integration and progressive improvement in cultural authority. It should be noted that the medical schools are now integrating complementary or alternative medicine ( CAM ) into their educational process with the intent to provide the information seamlessly integrated into the curriculum as a whole, vs a separate course.[6] This will result is a graduate medical physician that will be more likely to seek out a knowledgeable CAM practitioner that they can confidently collaborate with. However, let the practitioner beware. The medical students are also being trained in proper evaluation of the efficacy and safety of CAM therapies.⁶  Those practitioners not practicing evidence based care will be castigated, and isolated.

Evidence based practice and subsequently value based practice will be necessary to maintain market share and further integration. Generation of evidence based “Best Practices” and implementation of these into practice would aid in accomplishing improved, consistent quality evidence based care. It will also allow establishment of data that can hopefully manifest the value of chiropractic procedures when compared with other procedures.   The current available evidence is being utilized by the payers regardless of the professional’s desires. Discussions with adjusters and decision makers often reveal that they are more familiar with the current literature than many practicing physicians. In order to prevent misuse of the scientific literature the chiropractic profession must become evidence based experts and integrate into the health care system  as the trusted authority in musculoskeletal care

Economics

The economic worth of all types of care is currently being evaluated by payers and government. Medicare is currently investigating linking fees to “pay for performance measures”. The innovation of utilizing value based measures such as Quality Adjusted Life Years (QALY) with cost measures will enable comparison of treatments from different disciplines that is understandable to the health economist. Fortunately this often works in favor of the chiropractic profession. However consistency of this within the profession has not yet been attained and recent overutilization has skewed the statistics.

Chiropractic care is affected by the ongoing changes in all of the healthcare industry and this is particularly compounded by the unique and often uncontrolled or externally controlled economics in the chiropractic profession.  The whole healthcare system is in crises with the daunting challenges of the uninsured-underinsured, workforce shortages, unacceptable medical errors and inappropriate utilization, compliance demands, decreasing reimbursement, and medical liability[7] Healthcare is the only trillion dollar industry in the United States and is the largest expenditure of the gross national product, but the World Health Organization ranks the health care in the US at only 37^th. The chiropractic profession is often looked at by the cultural authorities as the fall guy for the extensive costs. Taking into account the total expenditure on chiropractic (reported at less than 1%), the assertion is often ridiculous. However, the few cases of overutilization and abuse are usually held out as examples of the low level of standards of care in order to further diminish access and reimbursement for chiropractic services. This has created further narrowing of the profit margin over and above the tightening of the budget as a result of the round of cuts to general healthcare reimbursement. Therefore the chiropractic professional is finding it necessary to be creative in their ability to provide services in a manner that allows them to be cost effective while still making sufficient profit to maintain their balanced budget. Friedman points out in “Flattening of the Earth” that all industries are finding the need to be more cost effective and more efficient. Many are now accomplishing this through outsourcing and offshoring.[8]  The chiropractic profession must realize that it is in fact an industry and must also take advantage of cost efficient methods in order to remain competitive. There is a known need for efficiency throughout the healthcare system and all hospitals and doctors offices and clinics have to deal with this. Outsourcing is one method of controlling costs, creating increased consistency and efficiency of the tasks. Although the chiropractic profession is a service-oriented industry, there are ways of outsourcing tasks. The clinics and the small solo practitioners can outsource transcription, billing, payroll, marketing, mailings, and just about anything that is not direct patient contact.  Even some patient care can be hired out on per diem basis. This type of management would allow restriction of payroll to only profit oriented service personnel.

Open unimpeded access to chiropractic care has always demonstrated to be of benefit to the chiropractic profession. This was noted during the early heyday of insurance reimbursement for chiropractic care, prior to the controls of managed care. It was also noted to those who served at “Ground Zero” helping the rescue workers at the respite centers in New York City following the 9/11 tragedy. All those who participated noted the stark contrast from their controlled access environments which they left at their home practices. Sharma showed that the most important factors for choice of a chiropractic physician over a medical physician for patients with low back pain included the following:

1.      Higher income bracket

2.      Confidence in the abilities of the particular chiropractic physician to treat their low back pain

3.      Lack of trust in medical physicians

4.      Opposition to prescription drugs

5.      Patient satisfaction with previous chiropractic care

6.      Favorable attitude in self directed care and active behavioral involvement in the care

7.      Oswestry disability scores of <40, or lower disabilities

8.      They were often uninsured or had a positive attitude in the identity of the payer.

The patient’s attitudes and desires however were found to be less important when financial issues arose. This came into effect when the study group found that Insurance coverage for chiropractic services was often more limited than coverage for medical care. Although 75% of those with private coverage had chiropractic benefits, most had coverage restrictions, including visit or dollar limits. Therefore, even when the fees for chiropractic care were less than medical care making chiropractic care less costly for the uninsured, the limited benefits made the care more costly for insured patients.[9] Some policies are now being issued with coverage for physical therapy, acupuncture, and homeopathy that exceeds the limits on chiropractic. This will surely result in directing patients to other practitioners based on the above criteria.

These findings clearly indicate the underlying demand for chiropractic care that is being interceded by financial constraints of the patients. These financial constraints are exacerbated by increased cost to render chiropractic care today due to the partial integration into the third party pay system and its associated administrative costs including increased need for personnel and equipment, longer waiting periods for payment and then decreased reimbursement with the managed care contracts. In addition the scope of practice is shrinking, as a result of the shrinking insurance reimbursement and non-coverage restriction. Therefore in spite of state law, the insurance industry is determining chiropractic scope of practice through their economic control.  It also indicates that the better-educated patients are making the choices for chiropractic care, but their preference becomes secondary to financial output.

This manifests the problems that arise when there is a lack of understanding or respect for the profession along with insufficient representation by the profession with the payers. Initial inroads have been made here, but this needs to be significantly expanded. Perhaps dual DC & MPH program paths might provide the pathway to prepare doctors to take on these roles.

Conclusion:

The chiropractic profession faces the same challenges as other health care providers with the decreased reimbursement, changing patient payer types, changing patient and payer expectations, and diminished profit margins. The options available to adapt to the changes in the healthcare system include the same options that other providers and other industries have. However, the occupational latitude of the chiropractic physician is limited when compared to some other healthcare practitioners and there is still a need for further integration to open up additional occupational options and patient populations such as in research, academics, or salaried employee of hospitals, governmental organizations, clinics and payers.

It is most important that chiropractors remain a cost effective alternative. In order to accomplish this, the practitioners need to become more consistent in evaluating progress and response to care, documenting their clinical judgment and obtaining more consistent quality outcomes. They also need to address the current and future economics of the healthcare industry, which is now following the course of many other industries. The diminished profit margin necessitates improved management of office resources. This may include outsourcing many of the tasks and having remaining staff trained in multiple job duties in order to decrease payroll and run a more efficient office. However, the conundrum is that the cost effectiveness alone will not allow chiropractic to be further integrated into our health care system. The artificial insurance limits are being set regardless of the quality of care or cost effectiveness of care. The low cost alternative care is only important to the self-pay patients. However, because of financial constraints and insurance alternatives, what may be viewed by a health economist as cost effective, is being viewed by the patient as being an expensive alternative. This is the bubble that the profession must push through and survive in order to gain the public trust and move the profession forward toward integration and authority. Education of the patients is important. However, those experiential practitioners who desire to rely solely on education of their patient base and to restrict their practice to subluxation base are also limiting their exposure to the <10% of the population who currently consult and trust their chiropractic physician and are willing to pay limited amounts for the care. In effect this limits the growth of the profession. It limits it from any further integration, and it restricts the profession from becoming the cultural authority for manual therapy. Finally, it leaves the other 90% of the population without valuable chiropractic care.

Regulatory bodies in their actions affect the economic status of every chiropractor. Our licensing boards were formed as a result of extensive effort of our colleagues who preceded us. It was the intent of these doctors to create a cultural authority for the profession along with consistency and quality of care to benefit the patients. Some state boards are now having a hard time dealing with the governmental demands, politics and the unsubstantiated, sometimes extensive care of the doctors.  The boards must not function on an island of government. They must not forget that they are not there as a vehicle of the insurance companies to create “witch hunts”. They are a representative of the profession with the fiduciary responsibility to balance patient protection, regulation and licensing to assure care is meeting minimum standards.

Cooper et al found that nonphysician clinicians (nurse practitioners, physicians assistants, nurse-midwives, chiropractors, acupuncturists, naturopaths, optometrists, podiatrists, nurse anesthetists etc) had regulatory prerogatives that correlated with the number of practitioners in each state.4 However, he also points out the fact that chiropractic appears to be different than the other nonphysician clinicians in that it is shrinking in scope due to insurance restrictions and shrinking reimbursement. If we looked at chiropractic in particular, we find that the scope of practice, degree of restrictive licensing, and legislative power does not appear to correlate with the number of practitioners within the state. Instead it appears to correlate with the unity of the profession and the degree of leadership of the state society. Some states with many DCs have restrictive licensing due to self-interested leadership or lack of one voice to speak for the profession.

There is great potential for the chiropractic physician to increase their market share of patients to fill an emerging void of medical physicians[10] that is currently being filled by international medical graduates and other nonphysician clinicians of different types. However, the profession must face the realities of the healthcare industry, the competitive marketplace, the internal clinical problems within chiropractic, and the internal self imposed political limitations. It must dedicate its future to becoming the cultural authority in conservative neuromusculoskeletal care and manual therapy. It is time for the chiropractic profession to decide whether it will make history or be history. The responsibility is ours.