In this paper I briefly summarize how to improve the quality in chiropractic health care, explore the most common causes of the problems, and discuss the most important obstacles to improvement. Our profession must recognize the crucial role that visible and effective leadership might play in accomplishing this goal, and the potential sources of such leadership.
Patients may suffer harm from health care, regardless of its source (medical or chiropractic) when the following types of quality problems arise:
- Patients do not get beneficial health services.
- Patients undergo treatments or procedures from which they will not benefit, with overuse issues.
- Patients receive appropriate services, but those services are poorly provided.
The subject of health care quality was generally ignited by a series of heated public debates. Point-in-fact: Proposition 44 recently came on the ballot in California (which, in my opinion, wrongly places chiropractic licensure issues in the hands of government control/intervention), and is targeted at chiropractors and fraud. Those issues-at-hand are not for catapulting any discourse into the realm of public policy with a set of governmental specific legislative and administrative recommendations. Will the profession see, as a result, drafted proposals or organizations of physicians and hospitals suddenly announcing their concern and pledging to help the government? Congress created the Agency for Health Care Policy and Research (AHCPR), charged with investing in research on the effectiveness of health care services, and developing practice guidelines to assist providers in improving quality. Medicine challenged its guidelines with respect to the efficiency of chiropractic care and published its own guidelines! Hence, little improvement has been documented.
Chiropractic must consider its biggest obstacles within the delivery of health care to bring about major quality improvement, and discuss the vital role of chiropractic leadership in achieving this goal. The biggest obstacle is then perceived as the traditional medical model of care that serves as the "gold" standard in care today, and is so vastly different from a practice perspective, and from the chiropractic model.
The Problem with Quality and Its Common Causes
Why do we have so many problems with quality in a profession replete with such resources and talent? There are many reasons. For example, the profession continues to be so mired in its historical internal discordances that it misses its opportunity to assume any leadership.
But more importantly, a significant lack of technology exists in chiropractic. Patients are actively participating in their care and expect their doctors to "do something" about their complaints. Patients are also infatuated with technology, often believing that whatever is the newest must be the best. It is therefore often difficult and time-consuming for us to convince patients that the best treatment for them may be to avoid tests, procedures, and pills. Technology available to the patient in managed care makes it difficult for the chiropractor to order a procedure, such as an MRI, without a medical referral from a generalist who does not understand the neuromusculoskeletal condition beyond that of a strain. And what of the so-called medical specialist? Recently, I had an orthopedist report to a patient that a superficial lipoma (fatty tumor) was the result of the muscle "leaking" its fluid into the soft tissue after trauma. Of course, this was a contested workers' compensation claim that a new attorney referred to me. Naturally, I withdrew from the case.
Most businesses have strong and consistent financial incentives to improve the quality of their products and services. The same does not happen so uniformly in chiropractic health care. We have seen our "contracts" whittled down to a virtually nonexistent fee-for-dollar or per diem cost. The latter refers to that umbrella policy of lumping all services into one fee-for-service reimbursement.
Chiropractic Leadership Role
The cumulative impact of these barriers makes it highly unlikely that a widespread movement toward substantial quality improvement in chiropractic health care will occur. For such movement to occur, new circumstances must emerge.
I believe that one of the avenues to achieving such a new development is bold and visible leadership. Leaders can show how to improve quality to unprecedented levels and attract followers to achieve similar goals; they can focus attention on all of our quality problems - expressly for the sake of improving quality, rather than attacking quality problems selectively; they can identify quality improvement as among the highest-priority issues and keep constant emphasis on it; leaders can take responsibility for marshaling resources, and forcefully articulate the harm that occurs at our present level of mediocre medical-based health care.
We see few signs that our colleges are prepared to expend much effort on health care issues outside the realm of education. Perhaps academia will produce leadership in chiropractic health care quality in the future, but this direction is not indicated, because it fails to educate chiropractic students in business. work opportunities. Too many of our young DCs are leaving the profession to seek alternative methods of supporting their families and paying off their high student loans.
Many share the common frustration of having witnessed the steady erosion of the delivery of health care. There are those of us that can lead a major improvement effort to recapture a significant measure of the lost quality in chiropractic health care delivery.
The only other place from which effective leadership can spring is among those doctors who provide health care directly to patients. Quality improvement on a substantial scale requires a major investment in one's profession and unity in group chiropractic practices. It simply takes a few resourceful, good men and women.
Nancy Molina,DC
San Juan Capistrano, California
