DCs as Primary Care Providers in Managed Care

Managed care systems are set up with medical doctors as primary care providers and gatekeepers. Doctors of chiropractic, when included in a managed care plan, are specialists. AltMed, a company in the Chicago area, is trying to reverse those roles.

Michael Devitt, of Dynamic Chiropractic, in an exclusive interview with AltMed CEO James Zechman (JZ), and Richard Sarnat,MD(RS), president, reveals that the company has not only built such a model, but has a Blue Cross/Blue shield contract of more than 800,000 covered lives to test the concept.

MD: Tell us a little bit about AltMed. How did it originate, and what are its goals and mission?

JZ: Our mission was to integrate alternative medicine into the mainstream care. We felt this would be a much better model for patients. Dr. Sarnat and I came together and began working with HMO Illinois almost three years ago. They put together a program where chiropractors would act as primary care physicians (PCPs) on a capitated basis, accept the risk and treat patients using the full scope of their licensure in Illinois, which recognizes chiropractors as PCPs.

The goal was to create a better delivery system more patient-oriented towards wellness, while recognizing there are certainly appropriate times when medical care greatly aids the patient's treatment. We wanted the best of both worlds packaged in a managed care environment, which has not been done in this country.

RS: Part of what we're doing can be viewed as patient advocacy. As an MD, it greatly bothers me that patients are paying upwards of $20 billion out-of-pocket to access what they perceive are programs for wellness and prevention, programs where the allopathic model is weaker. What we do is mainstream it to the business community, which makes it reimbursable under the existing health care.

Managed care is a dominant player in most markets in this country, and yet chiropractic has been relegated as specialists. If you adopt an integrative medical system where the worlds of prevention/wellness and allopathic medicine are combined, it makes sense to run a trial and see how a medical system would perform with chiropractic as the entry point.

Over a decade ago, the World Health Organization stated that traditional medicine would not be the savior of the world's health problems because it's too costly, too high-tech oriented, and the side effects of pharmaceuticals are significant. It was the WHO's opinion that the way to properly treat the world's health care in a large perspective is to incorporate all of the most efficacious parts of the various traditional medical systems, i.e., ayurveda, homeopathy, herbs, Chinese traditional medicine and chiropractic; then scientifically document their efficacy.

Take the best of all worlds, combine them into a new system that is more effective and less expensive than what we have. That's our goal.

JZ: It boils down to the sum of the parts being significantly greater than the whole. We're combing the best of both aspects of the delivery system.

MD: Is this the first time that a managed care model with the DC as the primary care provider has been modeled and tested in the U.S.?

RS: To the best of my knowledge, this is a unique system. The idea of a chiropractor acting as a PCP at the entry point to an integrated medical model has never been tested.

JZ: Certainly in the Far East, where they don't have allopathic medicine, the alternative care practitioner performs the primary care function. But in the U.S., there is nothing like our system of delivering health care.

RS: I think it's obvious that the key to health and controlling costs is prevention. I would argue that the best thing that managed care does is screen for detection of early disease: a pap smear, a prostate surface antigen, a stress test, mammography, etc. But this is not prevention. I believe the alternative care world has a number of technologies which can aid at a truly preventative level and avert the disease which has not yet manifested in a full scope. And that's really the theoretical benefit of organizing the system.

We have everything from soup to nuts on the allopathic side. We're contracted throughout the entire Chicago metropolitan area with many hospitals, including university-based hospitals. We've contracted with approximately 2,000 allopathic physicians. We offer everything from allergy treatment to neurology, cardiology, pediatrics, etc., but the difference is the focus. Our beginning is prevention, not a piecemeal approach to the manifestation of disease. Many people seek alternative or complementary care as a last resort. It makes a lot more sense to use it as an entry point.

MD: Why a DC as the primary care physician instead of another alternative provider?

RS: Excellent question. Some MDs promote themselves as alternative providers. Anyone who's pharmaceutically based is the wrong choice. They also still don't have the added benefits of training and the techniques that an excellent chiropractor would have. On the side of alignment and adjustment, I think non-chiropractors are weak, so that's why that group doesn't qualify. Also, most alternative medicine MDs are not board certified. You have to have board certification to be a PCP in most managed care systems. It was through my interviews in the Chicago area that I found that most of them were not board certified, because of their unhappiness toward allopathic medicine. They left their residencies and sought a different type of medical education.

RS: Your average homeopathic doctor -- and really, this is true for all of these people -- does not really practice what we call primary care in the managed care setting. They have what I would term strictly outpatient medicine. In many cases, they chose homeopathy, naturopathy, alternative-complementary medicine to get away from mainstream medicine. They may not be able to really practice a scope of medicine in a broad fashion that's required of a primary care physician.

Having said that, I should mention that the same thing is true for some chiropractic physicians. Because we're starting this model, and because we intend to test and document it, does not in any way mean that we think all chiropractors are ready to jump into a managed care system and act as a PCP. On the contrary, I'd say the majority of chiropractors in their current practice patterns are probably not ready.

JZ: AMI excels in working with the "Blues" and working with the managed care environment. We organized our network and the credentialing criteria that we developed on a proprietary basis. Bringing chiropractors who had not been involved in managed care "up to speed" in those practice protocols and parameters, for lack of a better term, is something we're very good at.

MD: What type of criteria do you use for credentialing chiropractors?

JZ: Every practitioner in an IPA for HMO Illinois goes through NCQA-type credentialing as a primary care physician. There's all kinds of guidelines that they need to address: chart review; UMQA review; peer review; site visits by HMOI; nurses on their facility; signage; and OSHA regulations. There's a litany of issues they go through that we help them get up to speed.

The important thing is understanding the rules and regulations of NCQA, the credentialing criteria, and how to interface with the managed care organization. This is something Dr. Sarnat and I have done for a number of years. We've worked with them and helped develop oversight criteria, and it's important that we bring chiropractors into the managed care arena at full stride.

RS: If you were to interview most chiropractors in your community and ask if they are a part of any PPOs or managed care organizations, a certain percentage of them will say yes. If you ask how they became a part of that PPO, they will say that some insurance company mailed them a form; they filled out the form, put their name, address and a copy of their license, accepted their fee schedule, and that was it. That's all it took for them to join a PPO.

By contrast, the chiropractors that we have functioning as PCPs in a managed care setting have successfully met the NCQA criteria equal to their MD counterparts. These people have spent hundreds of hours looking over correct charting, the correct way to set up the office, having the right fire extinguishers and exit signs, etc.

JZ: It's a minimum six-month process going through the various review committees at the "Blues" or any managed care organization that's NCQA-accredited. They have to go through each step of that process successfully.

RS: It's for the protection of clients and patients. When we roll out a system and say our chiropractors are credentialed equal to their MD counterparts, we go to a large employer group and tell them we have the exact same product you're already using, except we're expanding the world times two in a sense. We give you the alternative/complementary world integrated with the world you already have at no extra cost. That's very powerful, because they have a certain assurance of what they're buying in terms of quality care. That's what makes the program so unique.

MD: So it's a benefit to patients, employers and DCs who are part of the group.

RS: Absolutely. We're not trying to exclude anyone. We recognize this is a long process. We want this to be open to everyone. We want the chiropractic colleges to learn from what we're doing and incorporate what we're teaching into their educational programs. We're in close contact with Dr. James Winterstein, president of the National College of Chiropractic. We're in contact with people on the state and national levels. We're trying to really expand and open this as quickly as we can, but in a careful fashion so that the quality remains the same.

MD: Aside from the NCQA criteria, how else does joining AltMed benefit a chiropractor?

RS: Joining AltMed opens your practice to the mainstream business community and how the current insurance companies are functioning in a way that's otherwise not open in your practice.

JZ: It allows DCs to maximize the usage of their licensure. Right now, any chiropractor licensed in the state of Illinois who's not acting as a PCP is not utilizing the licensure to its fullest extent. Looking down the road, there are significant economic opportunities by opening up their practice to primary care in a managed care environment that cannot be minimized.

The classic battle between allopathic medicine and chiropractic has been who's the "real" doctor. The states have recognized that they're both real doctors. One of the significant benefits is our programs afford chiropractors a platform to show the world that they are qualified, that there is a public demand for their services as PCPs, and that it's a better way to keep people healthy. That's the study we are in the process of conducting. We will collect and publish our data. Then we'll be on the cutting edge -- no pun intended -- of changing how health care is delivered in this country. It's very exciting.

MD: From a patient perspective, what benefits can you see the average patient receiving in having a chiropractor as a PCP rather than an allopathic physician?

JZ: There are significant differences. A recent study showed that a significant percentage of adult Americans have participated in alternative medicine this past year. That participation, or the vast majority of it, has been done on an after tax dollar basis. They're paying for this out of their pocket. Some of these people are intimidated about telling their allopathic doctors that they're seeing a chiropractor. So the coordination of care is not there for the alternative medicine patient.

Our program allows free access, flow and dialog between the alternative medicine practitioner and his or her allopathic counterpart to benefit the patient at no additional cost. In terms of quality of patient care, that is a tremendous advantage.

SR: The article that Jim was referencing was the Eisenberg study from the New England Journal of Medicine, originally published about five years ago. An update in the last six months showed that the trends have only continued to increase, so we know the marketplace wants alternative medicine and complementary medicine. (Editor's note: See "Alternative No More," DC, Jan. 1, 19991, for a review of the new Eisenberg study.)

I can tell you from visiting venture capital groups over the last year or two that everyone in the country knows this is a major change that's going to take place within the medical health care delivery system. The whole question in the board rooms of large companies is, what's the best model? How do we achieve it? How do we integrate it? How do we test it?

I always joke that we're running the world's largest clinical trial. We're taking an entire metropolitan area of a very large city and comparing our outcome studies, our costs, our results, to every other managed care system in the city of Chicago with the same underwriter, namely HMO Illinois. When our group of people get a better product, they end up in the hospital less than other people at a reduced cost with less morbidity and less side-effects. Their pharmaceutical usage is down; and when surveys show their satisfaction with the product, the company and their physicians are higher, then you've created a better mousetrap. That's really what this is all about.

JZ: I met with a large employer group several weeks ago. The group talked about how our program will help reduce absenteeism and loss of productivity. The group did a study on loss productivity for for people on sick leave, and it was in the hundreds of millions of dollars. They thought that if they could cut into that by 10 percent. What a spectacular savings that would be. And if the people are healthier, they're going to be more productive during their entire career.

SR: This is really what managed care is all about. The construction of all managed care is based on the assumption that by making it available to everyone, if you have the correct system, your health care costs should decrease and the outcomes should improve. But that's never been found to occur with Western medicine, which is why obviously the system is incomplete. It needs other components to truly bring it to fulfillment.

MD: What has been the response from the chiropractic profession in your area?

JZ: When we constructed the network, we kept a low profile and selected one practitioner for every 10 square miles of the metropolitan Chicago region. We worked with them, got them credentialed and up and running; then the word started to get out. Once we had a contract with HMO Illinois, National College of Chiropractic put out an article about our program in Outreach, their alumni newsletter. We've probably received 75-100 calls from DCs wanting to join our network. I think that there is no shortage of interest from the chiropractic community to get involved. They're just trying to figure out how to do it best.

MD: How do the DCs feel about the responsibility of being a PCP in your network?

RS: One of them, when we signed her up, said, "This is what I was trained to do. This is why I became a doctor. I'm finally getting the chance to use the full scope of my license." These are the things that they said to us during training, so I think they're enjoying their role as PCPs.

We also interviewed a number of chiropractors who were not credentialed, who did not become an active part of the first network and realized that their scope of practice as they're currently practicing was too narrow to really be a PCP. We truly need people who practice primary care, who see a wide range of problems and are comfortable treating these things, and have a strong pathophysiological basis in their understanding of medicine. Those people are not the norm in the chiropractic community right now, but I'm quite sure will be in the future.

MD: Have you experienced any problems with the medical profession?

SR: I haven't had any negative feedback from anyone. The primary care chiropractors make referrals to their MD specialist counterparts. There is open communication back and forth. At this point, I don't think that on a one-to-one basis there's been any problems.

We certainly are creating "ripples" within the managed care profession. We've made waves within the medical profession locally. Other managed care IPAs are certainly quite aware of our existence. I'm sure they're somewhat threatened by us and are trying to figure out exactly how to deal with us. But that's more of an economic business "turf" battle. As far as physician-to-physician relationships and patient care, I would say there's no negative fallout at all.

We may have 2,000 allopathic physicians under contract, but we carefully select these 2,000 people. There are always going to be physicians that we lean toward and physicians that we won't utilize as readily. We take all this into account, which is another part of why the program works. These people are all in a sense pulling in the same direction.

JZ: They're on the same team and all for the benefit of patient care.

RS: And that's where it should be. That's what physicians are supposed to do. We're here to help the patient and provide a service to them.

MD: What plans do you have for expanding AltMed?

RS: I think the first step is the documentation of what we're doing in Chicago. Fine-tuning the system, so to speak, so that we achieve the outcomes that we want. Once we've done that, it's very easy to duplicate the same system in any major city.

JZ: The learning curve to put a program like this together is significant on the AMI side. We're ready. We're poised to maximize that learning curve by expanding into other cities.

We are going to expand as MCOs discover us, react to us and ask for our help in organizing a network and a primary delivery system on their behalf that's quality-oriented and fully integrated. Once you spend the time to develop a product, you get the right product for all the right reasons. The second one follows, and the third one follows even quicker. We're in stage one. We have developed the product; it's out in the market, we're getting feedback, and things are happening rather rapidly for us.

MD: How long will it be before the data that you're collecting will be published or available?

RS: Part of NCQA regulations is that we're always gathering data. The beauty of managed care is that both the management systems that we have in place have to keep track of expenditures. By tracking outcomes and expenditures, all of the data is already there. It's gathered and reviewed every three months. We can start reviewing data on a quarterly basis, but I'm sure it will truly be a year before we have really good concrete things.

I think a lot of credit has to be given to Blue Cross/Blue Shield of Illinois. This is a unique program. Everyone sort of views the Midwest as being provincial and behind the times. Yet we find it's Blue Cross/Blue Shield of Illinois that has taken an extremely creative and courageous step to test a different model and see if it works. We don't think it's a great jump for us to envision that we can leapfrog from Blue Cross to Blue Cross company in various cities and states as they request us to do so. We have to give Blue Cross a lot of credit here in Chicago. Having the foresight to make this happen is a significant event as far as I'm concerned in the history of medicine.

MD: What's the biggest challenge that you see facing AltMed?

JZ: Managing growth. We do anticipate this to be very successful. Every state has different rules and regulations. You have to do the regulatory work to get up and running properly, so there are significant barriers to entering that we've learned about through development of this company. We've learned tremendously from what we've already accomplished and because of that, we're ready to embark on that next step.

MD: What can the chiropractic profession do to help ensure the success of a plan like AltMed?

RS: There are so many answers. I think it would be helpful for the chiropractic profession to engage in open dialog and keep the channels open with the movers and shakers of the chiropractic world on a political and education level. We try hard to include all of these different groups of people into what we're doing. The lack of response can sometimes be frustrating. We're bringing something unique to chiropractic. To some doctors, I'm sure it's threatening. They've never really dealt in managed care; they don't understand risk pools; and they don't understand large employer groups. This is what mainstream business and medicine are about today. We just want to bring the chiropractic world up to the 21st century and integrate them into this.

JZ: We like to think we are the guys wearing the white hats. That really is an objective: bridging the gaps, helping people get over whatever was in the past. We're looking to build upon that with the help of the chiropractic community, MCOs and the allopathic delivery system. We like to think of ourselves as the center of the wheel where we can help coordinate the effort among different factions to make the system better. In the past, it's always been viewed as if one side wins and the other loses, but that is so narrowminded and counterproductive to what the physicians are supposed to be concerned about. Let us bridge those gaps and take politics out of the arena. Let's get people the quality care that they deserve.

MD: Thank you, Dr. Sarnat and Mr. Zechman, for participating in this interview.

Editor's note: AltMed's website is www.altmedinc.com.

E-mail for Dr. Zechman, CEO: jzechman@altmedinc.com

E-mail for Dr. Sarnat, president: rsarnat@altmedinc.com

To speak to the doctors directly: (847) 433-9946.