Chiropractors as Primary Care Providers

Editor's note: In the December 1, 1999 issue, we interviewed the CEO of Alternative Medicine, Inc. (AMI), James Zechman. AMI, which was founded in 1997 by Mr. Zechman and Richard Sarnat, MD, had contracted with Blue Cross/Blue Shield of Illinois, the state's largest managed care plan, to give its more than 700,000 enrolled members the option of having AMI's chiropractors as their primary care physicians. We esteemed this a coup for chiropractic, and awarded Mr. Zechman our "1999 Person of the Year."

As we only recently learning that AMI was selected by the American Academy of Chiropractic Physicians this past summer to become their exclusive national credentialing authority, we thought it time to check in with Mr. Zechman to catch up on AMI's activities. Part I of this interview appeared in our February 12 issue.

 

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DC: Pretend for a moment that I'm a patient. I've never seen a chiropractor. Today is my first appointment with an AMI provider. What type of care will I receive, and how is it different than what a typical managed care plan offers?

Mr. Zechman: Patients that go to AMI's primary care chiropractors experience an entirely different form of primary care delivery than in a traditional allopathic model. The traditional allopathic model does not require routine maintenance and supportive visits. Our model does. As we have already discussed, it is mandatory to be seen within the first three months, and it is typical to be seen at intervals of four to five weeks thereafter.

Our primary care chiropractic physicians access and evaluate all facets of the patient's life: physical, emotional and spiritual. Our physicians attempt to make recommendations that will truly alleviate the root cause of disease, which has not yet manifested on the allopathic radar. This can be accomplished by the many and varied options open to our physicians.

Typically our physicians incorporate many modalities: the chiropractic adjustment; acupuncture; homeopathy; herbal medicines; traditional Chinese medicine; ayurvedic medicine; mind-body stress management techniques; and advice on supplements, nutrition and diet. Clearly, most of these areas lie outside the experience of the traditional allopathic physician. The American public has been clear in survey after survey that one of the most disappointing parts of allopathic medicine is the lack of knowledge of alternative treatments by its physicians.

AMI's primary care chiropractors, by contrast, are knowledgeable in these various fields. As discussed earlier, we do not dictate how an individual practitioner practices medicine. We allow our credentialed primary care chiropractic physicians to practice in the manner they feel is most appropriate and comfortable. Physicians have their own strengths and styles. We allow them to proceed in an unencumbered fashion. We merely provide support and direction on a consultative basis when medically necessary. This is what we mean by integrative care.

Of course, integrative medicine also includes traditional Western medicine. So when medical crises do emerge, such as acute appendicitis, a compound fracture, or an acute myocardial infarction, appropriate allopathic measures are employed. The only difference is that to aid in the recovery process, we incorporate as much nonpharmaceutical and surgical intervention as possible. From their initial visit, our patients are immersed in AMI's model of wellness and prevention.

DC: What are your plans for taking this model of care and expanding it to the national level?

Mr. Zechman: AMI's model has clearly met the challenge of credibility. Our network has met the highest NCQA standards recognized by all managed care entities and health care purchasers. We believe achieving such a "gold standard" has placed AMI in a unique position to benefit both the company and the chiropractic profession as a whole. Having successfully accomplished this, we are now expanding our products to meet the needs of our growing and evolving market and client base.

Our future is intensely focused on continuing growth via PPO products delivered to large self-funded employer groups and local, state and federal employee/payor programs. The reasons for this include:

• The client/patient barrier to entry is much less for our PPO program than the HMO product. We are asking the patient to make a less drastic jump into the "unknown."
  


• The physician "hassle factor" of conducting business in a PPO arena is much less than that of the HMO product.
  


• The reimbursement to our providers is potentially much greater in the PPO project than the HMO environment. Historically, our PCPs have been paid a higher rate than any family practitioner, internal medicine physician, pediatrician, etc. nationwide. We did this because we believe the cost offsets outcomes would more than equalize the increased fees paid to our physicians up front. However, in the HMO model, the bulk of the cost savings reverts back to the managed care organization, instead of the provider, the patient or the payor. We believe this is less than ideal.

Philosophically, our preference is to enhance the revenues of our providers commensurate to their good works, and those of our large, self-funded employers. We achieve this not by restricting care, but by increasing access to effective models of prevention.

It's an economic benefit for our network providers to participate with us. We pay existing marketplace fees for services, plus a year-end bonus. The bonus is a percentage of the cost offsets achieved by the self-funded employer. To the best of our knowledge, AMI is the only PPO that pays nondiscount fee for service and a year-end bonus based on performance.

We are philosophically against discount affinity programs and any contractual relationship that would limit access by the patient to a chiropractic physician for a "token" number of visits per year. We will not participate in either of these types of plans.

Our belief is that a minimum of 20 visits is required to impact the lifestyle choices that account for 75 percent of the etiology of disease. How can this possibly be achieved in one or two visits?

To expand our model nationwide, our new principal marketing officer, Linda Eldridge, has been extremely focused in six geographic regions. AMI has a selective network of key executives throughout the U.S. that function at the highest level of the business world. We work from the top down to contact government agencies, large unions, and self-funded employer groups.

I mentioned that we have approximately 15 companies in eight states in various stages of our sales cycle. In the Chicago area alone, we have four new clients that will begin PPO products this year. Our need to identify competent, properly credentialed providers goes hand-in-hand with our ability to generate sales in these major metropolitan areas.

Our goal is to create significant impact in several high-visibility markets: to change the delivery of health care forever. AMI is totally committed to the scientific documentation of our outcomes, and will continue to publish our results, regardless of outcome. Every chiropractic physician, no matter where he or she lives or practices, can participate in furthering this health care evolution and revolution. Anyone with significant contacts to the CEO, president or health benefits manager of any large self-funded corporation, union or government agency should contact Linda Eldridge to coordinate a presentation. The more high-profile clients AMI can interface with, the greater the visibility and impact of our program on the national level. Each client further enhances our database and makes the final statistical results ever more credible. We invite your readership to be proactive in this regard, and to contact us in any way we are able to help them.

DC: AMI was selected to be the exclusive national credentialing authority for the American Academy of Chiropractic Physicians last summer. How is that relationship going, and how does it tie in with your future goals?

Mr. Zechman: AMI was very gratified to have been selected by the American Academy of Chiropractic Physicians (AACP) as their national delegated credentialing authority. We are actively credentialing physicians nationwide on their behalf. Both paper credentialing and onsite visits have already been conducted. The AACP has notified each of its members of their formal relationship with us and has encouraged them to participate in the program as a means of distinguishing themselves and to enhance future business opportunities. It is our hope that other larger chiropractic academies will follow suit recognizing the unique credibility that AMI's credentialing program and medical management model encompass. Recently Richard Sarnat,MD, president, and co-founder of AMI, was asked to provide testimony to the White House Commission on Alternative Medicine. Dr. Sarnat is intending to provide testimony specifically aimed at credentialing criteria for CAM providers in the up-and-coming spring sessions. Dr. Sarnat has been in constant communication with various members of the commission discussing AMI's experiences and philosophy.

It has never been our objective to define what the chiropractic profession should engage in or how it should define itself. It is not our judgment call to decide who, where or when broad scope of practice will be embraced. However, we believe all doctors of chiropractic should practice in the manner in which they philosophically believe and are legally empowered.

However, for those physicians who wish to enter the mainstream managed care and business world in order to offer the public the freedom of choice of chiropractic and its full scope of benefits, AMI has created a vehicle for this to be accomplished.

It is important to understand AMI does not actively do any network development or recruitment. We do not have a network development staff position at our office, nor are we anticipating one in the future. We merely respond to our client and member needs in order to produce results.

It is our personal belief that until chiropractic embraces national standards for primary care practice, which mimic those standards required of MDs and DOs, chiropractic physicians will be considered "nonprimary providers" relegated to musculoskeletal issues only. Our goal is to provide a vehicle for the chiropractic profession to go "mainstream"; not to redefine it, or to limit the choice of any practitioner to practice in the way he or she chooses. Our goal is to allow the public the freedom of access to the type of medical options the individual patient desires and deserves. While we appreciate the right of chiropractors to practice in the philosophy they choose, it would be selfish of chiropractic not to allow the public mainstream access to its full scope of services.

As our outcome data illustrates, we have a health care system that is drastically crippled. We believe chiropractic is one of the central solutions to fixing that system.

We also believe there is a short window of opportunity for the profession to claim its rightful "place at the table." Already, we are seeing scientific journals and studies of practitioners with other licensures who take minimal courses on adjustment, who also claim they can achieve similar or better results than chiropractic physicians who study for four years or more. Many physicians and providers are now scrambling to join the CAM bandwagon. However, the typical "physician in transition" eager to join this bandwagon probably does not have the experience and skill set necessary to do so effectively.

Our greater fear is that the chiropractic profession will continue to be so mired in its historical internal discordances that it will miss this golden opportunity to assume world leadership. AMI only wants to provide the vehicle to enable the leaders of the chiropractic to stand up and claim their rightful place.