In the 80s, the buzz word was stress; in the 90s, the buzz word appears to be managed care. We are all affected by managed care, and in the vast majority of instances, the word itself sends chills down most people's spines. We are all aware of the problems with managed care; however, as a team, we can make managed care work if we change our attitudes towards it.
The chiropractic profession seems to have been hit especially hard, with many managed care organizations not offering chiropractic services, or offering it only with a primary care physician referral, or significantly limiting treatment in one way or another, resulting in substandard care to the patient.
Typically, the relationship between the doctor and carrier is adversarial. The doctor feels that the carrier is limiting patient care to improve the insurance company's bottomline profits; the carrier feels that the doctor is just taking advantage of the goose that lays the golden egg. I do feel that for managed care to work, there must be a "win-win" mentality in the minds of both the carrier and doctor.
It is important to let the carrier know what chiropractors do. What we provide is a treatment-intensive approach to a variety of nonsurgical spinal conditions. Medicine for the most part is a diagnostic-intensive approach for the vast majority of the disorders we see in our offices. Some chiropractors over the years have increased the diagnostic aspects of their practice using high-tech diagnostic equipment. In a managed care environment, the diagnostics must be kept to a minimum and the treatment to a maximum to achieve harmony. In the vast majority of cases which chiropractors treat, a routine x-ray study of the region of chief complaint and a thorough initial evaluation should suffice.
One of the goals of a workable managed care approach is to coordinate all aspects of the paperwork. The initial patient intake form should be standardized so that the patient should not have to answer the same questions on each piece of paper they fill out. The form should travel with the patient.
The same holds true with the doctor. The doctor should have a standardized consultation format, standard examination forms, standard x-ray forms, etc. This would improve consistency of care, insure good quality control, and make it easy for the doctor to send copies of his records, as opposed to having to write or dictate a narrative.
The doctor should be schooled in a standardized format of keeping patient records so that the records can be read and interpreted by a trained carrier's representative. The doctor would be responsible for having the patient fill out outcome questionnaires so that the case could be better documented and thereby managed properly. This again would require little (if any) time on the part of the doctor.
Working as a team in the managed care environment would allow for better communication between the doctor and the employer when work-related injuries have occurred. Many times patients will tell their chiropractor that the employer will not allow them to return to work until they can perform all the duties they were capable of performing prior to the accident. Working as a team would prevent miscommunications which occur between the doctor and patient and will allow the employee to return to work sooner.
The managed care environment in the workers' compensation setting can approve certain types of orthopedic appliances which could be provided by the carrier to the doctor to be dispensed to the injured employee. There are a number of home exercise machines on the market which can provide excellent low back or neck rehabilitation without the high cost of a high-tech rehab clinic. These can also be provided by the carrier and dispensed by the chiropractor.
The chiropractor would be required to hold in-office workshops, or provide the patients with educational materials and videos to teach them how to use home care, proper lifting and bending techniques, proper posture, activities of daily living, etc. This would be a "win-win" situation for the patient, doctor, and carrier.
The managed care organization, being in a position to provide the chiropractic profession with a large volume of new patients, could develop a loyal team of doctors which work harmoniously with the best interest of the patient, the employer, and the carrier in mind. The relationship in the present environment is typically adversarial.
The fee schedule should be one which will help minimize overutilization and reduce the administrative costs of processing the claims, but still provide the care necessary for the patient who requires more care than the average injury would require.
This can be accomplished by having the reimbursement reduced over time. For example, the first 10 adjustments can be paid at $40 per visit; the next 10 would be paid at $35 per visit; the next 10 at $30 per visit, etc. This makes sense. The more familiar a doctor is with a patient's condition, the less time is necessary to treat the patient each visit. If a doctor is busy with many new patients provided by the managed care organization, the possibility of overutilization is reduced by providing less financial incentives for the doctor to overtreat. Why should the doctor treat a patient for $20 if the doctor can get paid $40 for the same service?
Statistics can be kept on each individual doctor to see how much care is being rendered for a particular diagnosis. If the doctor's statistics indicate that he sees patients for more treatment than 90% of the other doctors on the team, the doctor would be forewarned and may not be allowed to participate in the program the following year. This would be a tremendous safeguard for the doctor to avoid overutilization.
The carrier should also realize that they are part of the team, and should not overburden the doctor with things which really do not relate directly to patient care. Payments for care should be made within a reasonable period of time with a minimum of hassles. I foresee the future of reimbursement as a credit card type of system where the doctor would have money transferred to his account within 48 hours of the transaction. This would also fortify doctor loyalty to the carrier.
As far as the patient is considered, they will not be bounced around from one doctor to another. This would be a tremendous cost savings, and would allow for the development of a healthy doctor-patient relationship.
Since the chiropractor's expertise is the conservative treatment of back and neck injuries, the chiropractor is the logical choice as being captain and key player in the management of most nonsurgical spinal conditions. There are many benefits of working in harmony in the managed care environment. The ultimate result will be chiropractors achieving the respect and credibility which they so justly deserve.
David R. Reich, DC
Richmond Hill, New York
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