When the seminal article on complementary and alternative health care by Eisenberg, et al., first appeared in the January 28, 1993 issue of The New England Journal of Medicine, the health care community was buzzing with speculation, skeptical distrust and outright hostility toward the study.
Some of the more outspoken critics dismissed the study as impossible, flawed at worst or misrepresentative at best. Many less vehement detractors were uncertain about the findings and, perhaps even fearing such a future trend, watched from the sidelines. Others who might be classified as "trend seekers" were already making plans to capitalize on the new information about consumer preference in health care and implement this demand into new and innovative insurance coverage products.
Only five short years later, in 1998, Eisenberg, et al., updated the study. What did it show? Should it now be taken seriously? Is the change in public attitude a trend and future demand by consumers for the new millennium? What should insurers, providers and the government do now that consumers have discovered and are utilizing a newfound strength (their vote and pocketbook) to make their voices known?
The findings in the 1998 study show that consumers spent more than $27 billion in 1997 out-of-pocket for alternative health care services. This represents a 45% increase from the original study in 1990. Americans made 629 million visits to alternative health care practitioners. Many of those visits were to doctors of chiropractic. The irony of this figure is that it represents more visits to alternative providers than to all primary care physicians (386 million) in 1997. The trend is expected to continue, and the value placed upon the services of chiropractors, acupuncturists and other less recognized and organized alternative health care practitioners will become more significant with each ensuing year.
The total dollar figure spent on alternative care represents approximately the same amount of money ($29 billion) spent by patients on all nonreimbursed physician services. Together these figures amount to $56 billion, which is the price tag and the value placed upon services that consumers are willing to pay. For insurers and providers, it represents the opportunity for the next millennium to provide these services, meet the needs of the consumer and reap the rewards of meeting consumers' demands.
In a weak attempt to meet this demand, medical schools are scrambling to introduce courses in alternative health care. A "new-age image" is being formulated by those entrepreneurial physicians and medical schools who see their market share decreasing. They want to say, "I can do it too." (Whatever your definition of "it" means.) Some insurers are offering alternative health care coverage more as a means to advertise and promote a new fad or concept than to actually and honestly implement the service. There will be groups popping up every day claiming that "integration," "alternative," "complementary" and "holistic" health care is delivered here.
One factor driving this movement is the economics of health care delivery. Many physicians are given a financial incentive to not refer patients. Others are duped into believing that a weekend course qualifies them to practice alternative care.
This is evidenced by the fact that insurance coverage of chiropractic services often has a PCP or gatekeeper in place to provide a "professional barrier" for patients to overcome to seek the care of a doctor of chiropractic. Still other plans mandate a huge co-pay or some other "economic barrier," attempting to create a financial disincentive designed to dissuade the patient from using the service while still providing the plan or insurer the ability to legitimately advertise the service. Still others offer the service and severely limit the number of providers who can provide the service, creating an "access barrier" for the patient, essentially denying freedom of choice.
These clever schemes worked when the consumer was unsophisticated and the confusion of managed care created temporary chaos. A window of opportunity existed for insurers and other plans toc learly confuse, confound and complicate what could have been an innovative coverage issue. To obfuscate real benefits, many plans now find themselves in a position of having to include certain benefits because of consumer demand.
What is happening with health care trends should become obvious to those reading the new millennium tea leaves. For those plans and insurers who truly want to break out of the box, there are viable concepts to consider incorporating into their benefit packages.
Recently, The New England Journal of Medicine reported that the American health care system is the most expensive and is riddled with problems and contradictions. John Iglehart, a correspondent to the journal, opined: "The American system is a work in progress, driven by a disparate array of interests with two goals often driven in conflict -- providing health care to the sick and generating income for the persons and organizations that assume the financial risk."
Managed care, which was supposed to control and curtail the economic spiral in health care, has been a dismal failure. Studies show that the government's annual bill for health care spending is $3,925 per person, which significantly exceeds every other nation. The government's expenditure for health care has been increasing, representing $507 billion (56.6%) of the $1.092 trillion spent in 1997, up from 40% in 1990.
If the current health care system is not working, could it be that we have continued to focus on a model which is no longer viable? Could it be that the trend toward alternative and complementary medicine is growing simply because the focus for the past 100 years has been on "disease" and "acute heroic medical emergency care," while very little emphasis has been focused on research targeting chronic conditions or a long-term wellness model? Could it be that if prejudice and bias were removed from the decision making and turf protection was not permitted to exist, the large dollar expenditures on musculoskeletal and neuromuscular conditions would be best treated initially by doctors of chiropractic?
The evidence is clear that the vast majority of these conditions are responsive and better managed by less costly, safe and effective, nondrug, nonsurgical chiropractic care. Yet barriers described above are put into place by almost every insurer which contracts for these services. They have failed to look at the economic benefit and savings to the system of cost shifting to a less costly, more conservative approach.
The cost savings of having chiropractic care as the "treatment of choice" would save the system millions and millions of dollars in unnecessary surgical intervention and the costs associated with drug reactions. Improper or inappropriate treatment and unnecessary surgery which simply does not work in many instances (see the AHCPR's Acute Low-Back Pain in Adults, Guideline #14), coupled with the high cost of increased disability, form compelling arguments to consider a new paradigm of how these types of cases are managed from the outset.
The system continues to be blinded by an antiquated model of health care driven by an outdated and nonapplicable economic concept in which each category of care is given its own individual budget. Attempts are made to ratchet the costs of that individual service down. The new process is recognizing that care is not driven by singular costs, nor is it rendered in a vacuum. If one care is utilized in a cost-effective fashion, the costs of other care will be driven down exponentially, because they are more expensive and/or unsuited for the conditions being treated.
If the economic significance of "most appropriate care" is coupled with the value of outcomes assessment (functional improvement), combined with the high degree of patient satisfaction already evident, those insurers who are looking to provide the value added edge in the next century will readily see the merit in these arguments.
Many insurers and health plans will wait until the consumer demands ring louder and more militant. Others will begin to implement these new concepts in a way that is carefully monitored; still others will see the creativity of incorporating chiropractic services as a direct-access service included in the basic premium package offered to their employees, policyholders and enrollees.
The alternative movement is not a passing fad. It is here to stay. Consumers will not be fooled by "alternative wannabes" who take a weekend course and claim expertise and knowledge of the subject. Consumers today are smarter, better informed and have access to more data to make an appropriate decision about their health. They are looking for "health care coaches" of tomorrow who will help them regain, sustain and maintain their health. The paradigm must shift from disease to wellness. It will not happen as long as the barriers to access remain in place.
The challenge for the health care industry is how to implement what is right without doing something wrong. Change will also need to occur within the provider community with a greater and greater acceptance of their responsibility and accountability in the delivery of health care. Providers of all types (and chiropractors in particular) who have the most organized, credible and sophisticated dominance of all the nonallopathic models, must become proactive and enthusiastically embrace the concepts of accountability, clinical relevance, outcomes, cost-effectiveness and patient satisfaction as the barometers by which their care will be measured. Only when credible evidence of the value of maintenance and wellness care is produced will the mode change.
Chiropractic has empirical evidence of the benefits for the concepts espoused by the chiropractic model. What is now needed is credible data to support those concepts. By participating in a process that is evidence-based, and by collecting data that is defensible, the movement toward direct access, increased market share and greater potential for a wellness paradigm will emerge.
Those insurers who see the void and need and proceed to fill it will emerge as the growth companies of tomorrow. What was unorthodox and alternative yesterday becomes the standard of care tomorrow. The changing complexion of health care should motivate, inspire and provoke those who are in control to fix it because it's broken!
