I recently came across a column by Bob Lewis in the computer industry publication Info World. He writes a regular "survival guide" for information services professionals to stay afloat in a business climate characterized by its change-by-the-minute pace. He identified three marketplace factors that determine the success or failure of any new technology product:
- what it will do for its customers
- its affordability
- how much disruption it causes
Given the rapid changes and resultant chaos that occur in health care, consideration of these principles might be warranted for the business of chiropractic. For the sake of this discussion, let's consider widespread inclusion of robust, direct access chiropractic coverage benefits in public and private sector health plans as a "new technology product." With apologies to Mr. Lewis, I'd like to explore how each of the three factors might impact how well chiropractic as a separate, distinct, stand-alone benefit fares, as opposed to gatekeeping medical subspecialties.
What will it do for customers? The "customer" of health care is now distinct from the "consumer." There is a parallel in the computer world. The "consumer" is the person who uses the workstation, its software, and network paraphernalia. The "customer" is the person who makes the purchasing decision, i.e., the corporate IS manager.
In health care, the consumer is the patient. The customer is whoever pays the insurance premiums, which is increasingly the patient's employer or government agencies. Sometimes the customer and consumer are one in the same, but these days, more often than not, they aren't. Ideally, the interests of both consumer and customer should align, but again they often do not. The take home message for a new technology would be to determine the needs of both and tailor the pitch (and the product) accordingly.
From my vantage point within a state workers' compensation system, I frequently see isolation and adversity between chiropractors and businesses individually and collectively. Employers sometimes direct workers away from chiropractic services; chiropractors frequently fail to create opportunities for communication with individual business and the organized business community as a whole. Mostly, I see two perspectives that see nothing of value with the other. It's both a marketer's nightmare and a consultant's dream "job opportunity."
We chiropractors have done a fabulous job with informing and tailoring our services to our consumer-patients, but very little has been done to identify the market needs of those who are increasingly footing the bill: our customer-employers and agencies. Purchasers of health services often want things included like high quality care, convenient accessibility for the patient, and clear ways of delineating clinical "thresholds" (e.g., indications, conditions, end points of care). Individual doctors, county societies and/or state associations might find it enlightening to perform "customer" market surveys of corporate and agency decision-makers to better understand the customer's needs and expectations when it comes to shopping for health care benefits.
One medical director of a progressive insurer looking to expand coverage for alternative care recently suggested that the discussion needs to center around "insurable care" and "uninsurable care" rather than scope of practice, wellness care, provider types and patient choice issues. All providers and patients run up against both insurable and uninsurable care quandaries as it relates to any number of services that fall within respective practice scopes. The entire field of wellness and prevention care comes to mind. While a provider's perspective might take "an ounce of prevention" approach, the customer's perspective says, "Eating healthy is good prevention too, but no way is health insurance going to reimburse for produce purchased at the grocery store."
Demonstrating tangible value in anything other than condition-oriented care will need to occur for customers to move very far from this viewpoint. Because of their high costs, health care benefits are increasingly being slashed to minimum tolerable levels to keep them "affordable," which brings us to the next market factor.
Is the product affordable? Any new product is at risk of not being "affordable." The perception of added "value" is central in the customer's mind for determining affordability. If an existing benefit that is already purchased can substitute, any additional item is perceived as an add-on cost. For our services, cheap nonsteroidal medication and early return to normal activity are perceived as the major alternatives to uncomplicated musculoskeletal problems. Like it or not, most of our patients, society at large, and our own clinical documentation indicate that what we do most is care for people with back and neck pain. With incorporation of better medical and PT approaches in recent years, some of the cost and effectiveness margins chiropractic has had in the past appear to be shrinking. It's a competitive marketplace out there.
The challenge for us, of course, is not to simply discount our services to new lows to be attractive for managed care contracts. Unrealistic price-cutting has jeopardized survival for far too many doctors in recent years. Rather, we must be able to demonstrate the value and affordability of the service we provide.
High prices are just as risky. There are just enough of our colleagues submitting $8,000 to 12,000 bills for noncatastrophic injury care cases when others handle the same sort of thing for less than $1,000 that health care purchasers fear loosening up the reins on chiropractic benefits. Articles have appeared in some chiropractic publications that call for multi-million-dollar cost increases for chiropractic services in Medicare and workers' compensation. Are these affordability issues in the eyes of customers?
Guidelines, risk sharing (capitation), utilization review and pre-authorization represent some of the "products" the purchasers (customers) have come to expect from health care plans to keep the affordability issue in check. Research and clinical priorities for our profession should include finding answers to questions that customers are asking. How much care is enough? What are thresholds of care for common, insurable conditions? How does chiropractic care compare to the alternatives (both cheaper and more costly ones)? Which techniques and procedures offer the most outcome for the least amount of cost? Objective, evidence-based answers to these sorts of questions will help to counter the often arbitrary payer practices currently used to contain costs.
How much disruption does more chiropractic cause? Disruptive products in the computer industry are guaranteed losers, according to Mr. Lewis. Something that doesn't get along well with the "installed base" is the hallmark of a disruptive product. In the business of health care, I would argue that the "installed base" is "insurable, condition-based care." Although you and I would both argue vehemently that this represents exactly the wrong incentive for an effective health care system, changing Western society's fundamental health care paradigm is unlikely to be accomplished by doing battle with a few claims managers or medical directors at insurance companies.
The challenge I see for chiropractic in gaining meaningful long-term market share and influence is to develop a seamless migration path from the current installed base to a better health care financing paradigm. Chiropractic professionals would seem to be poised to offer insight and leadership for such a task. However, given our profession's history of survival by rugged individualism and our legendary ability to circle the wagons and shoot inward, I suspect the work involved in constructing such a seamless migration path will be substantial. Such a path will require partnerships with business, government and other CAM providers, as well as traditional care providers and third-party payers.
So what's the point? We should not expect that the world sees things the way chiropractors do by default. For robust, direct access chiropractic health care benefits to become the default position of health care's customers (i.e., employers and agencies that pay most of the premiums), chiropractors may want to start by looking at the world through the customers' eyes. What is the tangible value of better chiropractic covered compared to the customers' current practice? This cannot be answered with philosophical belief systems using our proprietary internal syntax. Instead of trying to convert the uninitiated, perhaps we should begin to ask questions about the customers' needs and expectations and explore ways to incrementally "custom-tailor" what we can do for them.
Preventative dentistry got a foothold in health care through:
- conducting long-term longitudinal research studies documenting the value of regular dental care;
- communicating the value of preventative dentistry in a way meaningful to the customer (e.g., pitching the value of a nice smile, not a physiological model of bacterial by-product infiltration of tooth enamel and how decay disrupts the dental pulp healing processes);
- establishing affordable clinical care thresholds (such as two preventative visits per year), delineation of effective, cheap self-care strategies, and;
- clearly delineating between insurable and noninsurable care.
So as a health services researcher and policy wonk, what makes me an expert on creating a business formula for chiropractic's future? Absolutely nothing. I'm just borrowing from an old, well-worn marketing principle that Mr. Lewis passed on to his readers in the computer industry: Make buying from you easy. Usability for the patient-consumers and value-affordability for the employer/agency customers are part of that formula. It's much more than just a message.
