In a fee-for-service health care system, providers are reimbursed for the services they render. However, in a managed care system, services are deemed appropriate or inappropriate more strictly. As health care costs escalated out of control over the last 20 years, it became apparent that there was a limited amount of health care resources which could be affordably provided to consumers. Today, managed care organizations (MCOs) attempt to contain costs. This puts great strain on the ability of health care providers to get reimbursed for what they feel is reasonable and necessary care. This article describes how to identify what is reasonable and necessary care and how to justify appropriate reimbursement.
Discussion
First, the natural history of painful disorders of the spine if left untreated must be explored to judge the efficacy of interventions. What is the natural history of spinal conditions? Eighty-five percent of mechanical pain patients are better in six weeks.1 The 15% of patients that is likely to become chronic can be accurately identified with simple questionnaires early on.2-5 There is a high recurrence rate of pain, activity intolerances and disability.6-9 It should be pointed out that most of our patients should recover within the natural history.
It is often incorrectly presumed that since the vast majority (85%) of low-back patients recover quickly, a nonmanagement approach is most appropriate. The majority of the costs arise from the minority of the patients who are nonresponders. Those who do respond have a high recurrence rate of disability, symptoms and activity intolerances.1,7-9
Judicious allocation of limited resources is the key to optimizing outcomes in the delivery of health care services.10 Managed care organizations (MCOs) remain keenly aware of issues relating to cost effectiveness. However, the long-term success of an MCO will be determined by their ability to keep health care purchasers (i.e., employers), providers and patients satisfied with their services. Cost containment alone is not sufficient to achieve such customer satisfaction.
Value is defined as the ration of quality/cost.11 Therefore, quality assurance is an essential driving force of a long-term solution to the managed care problem. Providers who can demonstrate that their care improves outcomes involving pain, activity intolerances or disability will have less trouble getting reimbursed. However, if there is a dearth of objective documentation of patient progress with reliable, responsive outcomes and the patient's treatment outlasts the natural history for untreated patients, then reimbursement for services may be denied.
Screening is essential to prevention of chronic pain or disability.10 It is a prerequisite to prevention, because it allows allocation of limited resources to those most likely to benefit. Without such screening, an aggressive acute care program would be costly, since musculoskeletal pain (MSP) is so common and generally is self-limiting. A screening tool that reliably and validly identifies the high-risk patient is the best way to determine the minority of patients who are likely to benefit from more aggressive care.
It is clear that an MCO must limit resources (treatment visits/cost of care). Screening will enable greater resource allocation to the minority of patients most likely to benefit. Chiropractors need training in the biopsychosocial model, screening techniques, simple active care principles (i.e., McKenzie) for acute pain and outcomes management. Undoubtedly there will still be a subset of patients who are suffering or disabled after 4-6 weeks. Those patients require a more specialized rehabilitation/functional restoration/biobehavioral model.
Duration of symptoms3,4,8,12 Past history of numerous episodes5,8,13,14 Severe pain intensity3,5,8,9,14 Sciatica8,13-16
Psychosocial
Symptom satisfaction8,17
Anxiety3,4,17
Locus of control13
Depression3,4,8,17,18
Self-rated health as poor8,19
Job dissatisfaction8,20,21
Anticipation of disability six months into the future5
Psychosocial (fear-avoidance)
Belief that you shouldn't work with your current pain3,4,17 Belief that physical activity will worsen pain3,4 Belief that normal duty should not be performed3,4
Function
Light work tolerant for one hour3,4
Can sleep at night3,4
Disability
Physically demanding5,19
Any disability in last 12 months?3,4
Note: Less than 15% of our patients should receive care which outlasts the natural history. However, those that do should receive care which is reimbursable. Our history and examination should identify and document those risk factors as soon as possible.
What Treatments Are Evidence-Based and Can Therefore Be Defended Vigorously?19,22-34
Can Outcome Measurements Help You Defend Your Appropriate Care?
According to the Mercy document, if a patient does not have signs of objective improvement in any two successive two-week periods, referral is indicated.22 Outcomes are the surest way to demonstrate patient progress or lack thereof with your care. What outcomes are simple, inexpensive and time-efficient, yet are also reliable, responsive and valid?
1. VAS 2. Roland-Morris, Oswestry or Neck Disability Index (NDI) 3. range-of-motion measurements 4. strength/endurance measurements (i.e., Sorensen's back extensor endurance test)
How Do We Determine Appropriate Goals of End Points of Care?
According to AHCPR, the goal in treating back pain is to reduce activity limitations/intolerances due to pain.23 The "functional restoration" model also focuses on restoration of function, not just pain relief as a goal for care. Objective ways to capture information about such functional end points of care include:
The Future
Enlightened individuals are beginning to promote quality care and outcomes as a way to unite the benefits of chiropractic with the public's dissatisfaction with traditional options. Presently, PPOs, IPAs and PPNs with leaders such as in California with Casey Terribilini, Wisconsin with Steven Yeomans, Pennsylvania with Dick Erhard, Oregon with Dr. Larry Lubke and Florida with Dr. Joe Johnson, are joining the ranks of progressive payors. These payors include the workers' compensation boards of Alberta and Manitoba in Canada in facilitating the paradigm shift. Great Britain will soon be reimbursing for chiropractic care in their national health service. Networks from Maine to southern California will also be rewarding quality care with fairer reimbursement schedules and greater access to patients.
Conclusion
PPOs who can measure outcomes, classify patients and identify high risk patients can position themselves for aggressive competition in managed care. What is needed are providers who are prepared to practice in a quality assurance manner. Those same providers will benefit by being able to better defend all their care and market their practices effectively to attorneys, adjusters and medical doctors.
The chiropractic profession is poised to either prove that we are the most cost-effective front line for managing neuromusculoskeletal conditions or that we are inefficient overtreaters. We can create an international database and prove that we can beat the natural history of spine disorders and reduce recurrences.6-9,17,35,36. Data collection tools such as the CareTrak software (www.caretrak-outcomes.com) can serve as a vehicle for aggregating outcomes data collected from chiropractic centers throughout North America.35 Evidence suggests (and skeptics insist) that the natural history is difficult to influence.10,17,37 However, cost-effectiveness studies also demonstrate that early active intervention from a biobehavioral perspective shows promise for reducing the costs associated with chronic disability.38
Ultimately, small bands of chiropractors who commit themselves to quality assurance will improve customer satisfaction, reduce disability and cut health care costs. Working towards these goals will insure reasonable reimbursement for honest service and open chiropractors to larger number of patients.
References
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
