Silver Lining to the Managed Care Cloud?

Gerald Weis, DC, is president of the Cincinnati-based Chiropractic Choice, Ltd., recognized by the managed care industry as one of the premier chiropractic physician organization in the Midwest.

Dr. Weis is a provider for over 100 managed care plans, and serves as a consultant for 30 MCOs, hospitals, medical groups, and chiropractic groups.

Seventy percent of his chiropractic practice is managed care, and 80 percent of his patients are referred to him from a group of over 300 MDs.

Dr. Weis is also the producer and host of "Doctors' Health Tips," a cable TV talk show featuring prominent health care authorities.

DC: Dr. Weis, many chiropractors feel that managed care has been detrimental to their practices. Has this been the case for you, and if not, why not?

Dr. Weis: Great question. Actually, it's a little bit of both. In some cases, it's the best thing since sliced bread; in other situations it's very burdensome. The truth of the matter is that at this stage of the game, and with health care as it is today, it's the only game in town. So, you have an option. You can either choose to adapt to it, react to it and go with the flow, or go with a cash practice. I don't think the last option is very viable.

I think a lot of it depends on the attitude that you take about managed care. It's been said, "Your attitude determines your altitude." You can look at managed care as either a wonderful opportunity, or as a major problem. I think a very large percentage of chiropractors see managed care as the bogeyman that is going to the destroy the profession. I don't see that at all.

I think managed care is going to provide chiropractic an opportunity it's never had before: to become integrated into mainstream health care. It has certainly provided our office that opportunity. Chiropractic is a perfect fit for managed health care, because managed care is not interested in interprofessional bickering, turf battles, old prejudices, or political maneuvering. It's only interested in one thing: the bottom line. If you provide quality health care in a cost-effective manner, you get to play. If you don't, you're on the bench. It's that simple.

DC: What percentage of your practice income is from managed care sources?

Dr. Weis: About 70 percent.

DC: And how would you typify your practice income today versus that of a decade ago?

Dr. Weis: I would say our income has risen, but I'm working harder than I did 10 years ago. The gravy train is over for chiropractors. To have a viable, profitable practice, chiropractors have to work as hard as the MDs have been working. It takes a lot of hard work, long hours, and a large enough and skillful staff. Understand, we have to provide our staff with plenty of training. They are constantly going to seminars; they serve on various committees and in advisory capacities for many insurance companies. This is all part of the staff's learning experience.

Managed health care typically reduces your income and raises your overhead. So you have to develop a very lean, mean machine if you're going to survive. It not only forces you to improve your efficiency, but it gives you the opportunity for tremendous personal and professional growth, which ultimately benefits your practice.

DC: Tell us about your managed care organization.

Dr. Weis: I'm president of a physician organization called Chiropractic Choice. Sometimes they're called "clinics without walls," but it's a group of leading chiropractors here in the Midwest. We're now in three states, and we have 60 doctors in the organization. We're presently in a holding pattern. We've been growing so fast in numbers that we're slowing down a little bit to allow our management systems to catch up, but it's given us an opportunity to interact with not only managed care organizations (MCOs), but also the medical community and medical groups.

Take an MCO that has the choice of either contracting individually with, say 50 individual doctors, or with 50 doctors who have already formed a group. The doctors in the group are practicing under one ID number, have good geographical coverage, have a management system in place, the appropriate infrastructure, all the credentialing, have an operations committee that's working aggressively, and a staff working together as a team. Guess who the MCO is going to contract with.

That's the advantage of forming a group. The medical profession has been doing this for years. We're a little slow on the draw, but you'll find that throughout the country, there are a lot of chiropractors who are banding together, forming groups, and then contracting with the MCOs. You could call it the wave of the future, but actually we're in front of the wave.

DC: Can you give us some real-life examples of the kinds of relationships that your organization has with managed care organizations, and how that has carried over into your relationship with other providers?

Dr. Weis: Chiropractic Choice has contracts with 20 MCOs. We are interacting and have developed working relationships with some of the leading medical groups in the area. Again, they're interested in providers who have a degree of sophistication, understand the workings of managed care and can, most importantly, demonstrate their positive outcomes.

The providers of the present and the future who can demonstrate their cost-effectiveness and demonstrate positive outcomes will get the gold. If you can't demonstrate it, you don't get to play. It's not enough anymore that you and I know we're good providers. We have to be able to prove it. A solo practitioner cannot afford to do that from a pure economic standpoint. The only way you can afford to do that is by banding together, pooling your resources, and then using the proper infrastructure and management systems.

DC: When you talk about the 20 contracts with the MCOs, some people would suggest that those contracts are causing chiropractors to sell their services too cheaply.

Dr. Weis: Nobody's picking on us exclusively. We're just part of the food chain. They're picking on everybody. That's the real world. That's managed care.

There is a silver lining in the managed care cloud. It's down the road, but it's there. I have a friend whose favorite saying is, "Chance always favors those who are in motion." And I've got news for you. If you're not in motion in the health care environment that we're in right now, you're in trouble.

Managed care is about seeing larger number of patients fewer times, not a fewer number of patients for longer periods. As you get more involved in managed care, you find it's a mindset. When you really buy into managed health care, the focus is, "In how few visits can I get this patient well?" It used to be, "How high can I have my case visit average?" Now it's, "How low can I have it?"

That's part of the real world, and to continue to be one of the players and be invited back to play, MCOs look at your utilization profiles. Managed care companies have a profile on all of us. I consult for over 30 managed care organizations and medical groups, and I have seen these profiles. I can assure you, they are there. They're watching us very closely.

DC: When you talk about these profiles and the desire to have a lower number of visit profile, do you feel that is infringing upon the quality of care that you provide?

Dr. Weis: No, because at the same time we're striving for that, we're also surveying all of our patients for satisfaction. We're also monitoring, using measurement tools, our success rates and everything that we do. We're now able to prove it, not only to ourselves but also to the MCOs and to the medical physicians who as gatekeepers referred the patients to us in the first place. In managed health care, chiropractors are recognized as specialists, not as PCPs (primary care physicians). The medical PCP is at the top of the food chain, determining which specialist gets to eat. Chiropractors need to know that, and need to react to it.

DC: Sometimes in the chiropractic profession, we don't always see ourselves the way other people see us. When you talk to insurance representatives and people in the managed care world, what do they see as chiropractic's role?

Dr. Weis: A specialist. Like I said, I consult for over 30 MCOs, I interact with hundreds of insurance executives. I have yet to meet a managed care official who thinks that a chiropractor is qualified to be a PCP. It never even crosses their mind. However, as we continue to become involved in the managed care environment and prove our cost-effectiveness in the treatment of neuromusculoskeletal problems, the ones I talk to appear to be very receptive to the concept of having chiropractors serve as the portal of entry and as gatekeepers for neuromusculoskeletal problems.

That is a very viable and saleable opportunity for chiropractors. I feel that should be our niche. I think that's where we should be expending our resources, not trying to be a primary care providers, because very few outside of our profession feel we're qualified to be that. The managed care industry and the marketplace ultimately determine everything; the marketplace does not for a moment consider us to be PCPs.

DC: What would you consider to be the negative aspects of a chiropractor working within managed care?

Dr. Weis: Lots more paperwork; more accountability; loss of our autonomy. Some of us don't don't like that because we have to answer to somebody. My response to that is, "Everybody else has to, why shouldn't we?" We've been very fortunate until now. So there's more accountability, more paperwork, decreased fees, and higher overhead; those are some of the negatives of managed care.

But I'll tell you a very positive aspect of managed care in our practice. I saw managed care coming down the pike about 10 years ago, and in the last eight years, I've been really focused on positioning our practice for integration in managed health care. As a result, 80% of our new patients are referred by MDs. We ask every patient referred by an MD, "Have you ever been to a chiropractor?" The range is between 30-50% who have never been to a chiropractor; they would never have even thought of going to a chiropractor had not their MD said this is where they were going.

So what it's doing is opening up a whole new market share for chiropractors. That's awesome. The profession is always talking about trying to expand our market share. The way to do it is to use managed care to become integrated, build up a large referral base from MDs, and the market share will just explode for you.

Having the MDs refer patients gives us instant credibility. We don't have to try to sell ourselves. It gives us an opportunity to see people on an even par with the MDs; as a peer.

DC: In summary, what would be some of the other positive aspects of managed care?

Dr. Weis: I think the real opportunity is the opportunity for chiropractic to become integrated into mainstream health care.

Here's some advice to chiropractors to get involved. It's later than you think. My model works best for chiropractors who accept the fact that they will be perceived as specialists and not PCPs. If you buy into that, then it will work for you because the medical PCPs who used to be at the bottom of the food chain are at the top of the food chain under managed health care, and they determine who gets to eat.

Case in point: We have a very large medical IPA here in Cincinnati. It has over 500 MDs in it, and the primary care providers in that group have formed what they call a "pod." A pod is a group of 6- 15 medical care providers. These pods may still be in their separate offices, but they work together as a team; they're geographically close to one another. They are now in the process of selecting the various specialists to whom they will refer all their patients, so if you are chosen by that pod to be their specialist, then you will receive all the referrals. The patients from that pod will go where their primary care physicians direct. This would not happen were it not for managed care. If you're not plugged into managed health care, you don't get these opportunities. So my advice is quit fighting it. It's bigger than all of us, and it's not going away.

Get involved in managed health care. Become active, involved and knowledgeable. Go to the seminars in your area; not just chiropractic seminars on managed care, but also medical seminars in the hospitals. Look around. Subscribe to the American Medical News and Medical Economics. Read all the managed care articles in chiropractic publications; read your newspaper; and keep a running list of articles you've clipped out on all of the latest changes, mergers, affiliations, etc., on managed care.

Find out what's going on in your community. Subscribe to the business newspapers, because managed health care is now a business. We used to be in the practice of getting sick people well; now we're in the business of getting sick people well. You have to apply business principles to your practice to survive in managed health care. That doesn't mean you're less of a doctor. Actually, you're a better doctor. The more involved I am with managed health care, and especially with Chiropractic Choice, the more I realize its tremendous opportunity for personal and professional growth. It's just a tremendous growing process.

You mentioned the positive aspects of managed care for DCs.
I think there's a lot of people out there with back problems and spine problems that chiropractors never have the opportunity to see. By proving our effectiveness, and working in a relationship with MDs, we now become the doctors of choice for neuromusculoskeletal problems; that makes up a large percentage of health care problems in the United States. I think that will help the profession. Forming groups helps to prove our effectiveness, and working with MDs develops interprofessional relationships that on an individual basis we didn't have before.

DC: You mentioned that you saw managed care coming 10 years ago. What do you see coming in the next 10 years?

Dr. Weis: Lord only knows. I don't know, but whatever it is, I'm going to be ready for it because I'm in motion. The work that we're doing now will position us for whatever comes next. I know some of the "experts" in chiropractic say that managed care is a passing fad, don't worry about it, it's not going to hang around. They may be right, but guess what? If they haven't been in motion and they haven't positioned themselves to be ready for that next level, they won't be part of that either.

DC: Is there anything else you'd like to pass on to the profession?

Dr. Weis: I feel that this is a unique opportunity in the history of our profession for acceptance and integration into mainstream health care. I think in the next very few years, our country is going to experience the most dramatic and perhaps traumatic changes ever witnessed in the health care delivery system. And I think that for those chiropractors who are willing to expend the time and energy necessary to integrate into managed care systems, this will open the floodgates for medical referrals. We'll all discover that this is truly an incredible time to be a chiropractor.

Editor's note: All readers are encouraged to send, fax or e-mail their comments directly to Dynamic Chiropractic, rather than to Dr. Weis, so that they may be shared with the entire profession.