William H. Dallas
Research is more than merely an academic exercise. It is the key ingredient in establishing chiropractic's role in an evolving health care system -- and chiropractic research is carried on primarily at the colleges.
Health care has changed radically in the past 25 years. In 1980, the medical profession basically controlled the system. Even though reimbursement came primarily from third-party payers, decisions about payment were dictated by the medical profession. Any influence by the financial executives of insurance companies was minimal and subject to medical veto. Today, most decisions are based on financial consideration first and clinical second.
A public backlash about the bottom line being more important than the health of the patient is already evident. Some change in policy will occur as the managers feel pressure from subscribers and competition from other companies, but the financial managers will likely retain control. Herein lies the opportunity for chiropractic to make a stronger statement than ever before.
Some in chiropractic claim that "it works," and that's all there is to it. There was a time when this approach was effective due to the market configuration. Chiropractic competed with medicine on a patient-for-patient basis, with insurance playing a secondary role. As insurance programs restricted options, patients insisted on coverage for chiropractic care. Although insurance companies offered nominal resistance, most relented under pressure from chiropractors, patients and legislators. Besides, the issue wasn't cost of care, it was medical opposition to chiropractic inclusion. As a consequence, over 40 states passed insurance equality laws, resulting in the closest to a level playing field in chiropractic history.
Since that high-water mark during the mid-eighties, a steady decline in chiropractic coverage has occurred. A marketing survey conducted by a firm retained by Western States College in 1995 reveals major shifts in reimbursement patterns for chiropractic care. Reported is a significant reduction in insurance claims paid from 44% down to 32%, and a corresponding increase in out-of-pocket payments. Other data show that approximately 10% of Oregon chiropractors' revenue comes from managed care, as contrasted with 62% of insured patents being covered by managed care.
The key question today is, "How much does it cost and how soon will it work?" Medical opposition to chiropractic now has a distinctly economic flavor, replacing the old scientific argument. Managed care organizations are beginning to assemble enough data to assess cost effectiveness for most therapeutic interventions and procedures. Data is retrieved from their claim files, information which will be supplemented with results from clinical research involving prospective outcome studies and controlled clinical trials.
Until 1994, no chiropractic college had received federal funding for chiropractic research. Late in that year, with money appropriated by Congress through the Health Resources Service Administration, Western States Chiropractic College received more than $80,000 for a three-year prospective study to compare outcomes between allopathic and chiropractic treatment of low back pain patients. Other college have since received grants for studies in chiropractic.
By the time this article is in print, we expect a chiropractic research center will be funded by the Office of Alternative Medicine and ensconced on a chiropractic college campus. This center will serve as a focal point for all colleges to apply for grants to investigate chiropractic health care and its efficacy and applications.
Even though this is news to cause hope, the money provided is inadequate to develop the proof necessary to achieve a competitive position in a system filled with experienced players. Thousands of seasoned researchers in the health sciences covet every available research dollar. Chiropractic education has approximately 50 people who have the necessary minimum credentials to have a chance of receiving serious funding.
If we are to flourish as a discipline, our 60,000 field doctors must recognize the critical need for the profession to enhance our research capability. Only a few colleges are sufficiently staffed to meet this challenge. Others are in greater need of financial support and encouragement from their alumni.
There have been many times when chiropractors have banded together to accomplish gains for their patients and the profession through political means. All of that work has successfully taken us to this place on the road of professional progress. We must now address the issues generated by that success. Your colleges need your support -- moral, political, and financial.
We have established that chiropractic is the most cost-effective care for the treatment of low back pain. Though some think that's enough, chiropractic has a much larger role to play in the health care delivery system. If we are to assume that role, supportive data and research on chiropractic's efficacy are essential.
William H. Dallas, DC
President
Western States Chiropractic College
Portland, Oregon
