Chiropractic Integration into the Surgical Setting

Lisa Raines, practice administrator at the Texas Back Institute (TBI).

John Triano, DC, MA, TBI's co-director of conservative medicine, and director of the chiropractic division.

The Texas Back Institute (TBI), originally founded by orthopaedic surgeons, has expanded its conservative care department to include chiropractic. This new role for chiropractic is not only unique, but may hold insight into how DCs can better integrate into the managed care system.

In an exclusive interview, Dynamic Chiropractic spoke with Lisa Raines, practice administrator at TBI, and John Triano, MA, DC, co-director of conservative medicine, and director of the chiropractic division.

DC: Please explain how the TBI system works, and how chiropractic is integrated.

LR: TBI is a fully integrated, multidisciplinary practice under one roof and one system. We have surgeons; chiropractors; physical medicine/rehabilitation (PM/R) doctors; family practice physicians; DOs; PTs; occupational therapists; personal trainers; a full fitness center, and aqua therapy. We're a practice, that's the single most important thing. We are a single practice that is fully multidisciplinary.

DC: How are chiropractors integrated into that system?

LR: Chiropractors are integrated in the same way that any of the other specialties are. Through protocols, our patients are initially directed to the most appropriate provider. In conservative care, that can either be PM/R, family practice, or chiropractors. They are directed based on the needs of the patient.

DC: What is chiropractic's role with patients headed for surgery, or with postsurgical care?

JT: Before the patients go to surgery, chiropractors may be involved in three scenarios:

1) A patient may come into the system through the chiropractor. If the conservative care fails, then they would need a surgical consultation.

2) If a person comes into the system and is seen first by a surgeon, the patient will usually receive chiropractic, or other conservative care, in an effort to avoid surgery.

3) Every Monday morning, questionable surgical cases are brought in for review. All the doctors in the room form a consensus about the appropriate next step to take. Chiropractors are equal participants in that process.

DC: In practical terms, say there's a surgical candidate and the chiropractor doesn't feel the patient should receive surgery. What happens then?

JT: Well, the room is full of people who are conservative medical practitioners, chiropractic practitioners, and surgeons, and the clinical merits of the case are discussed. If the chiropractor can develop a persuasive argument, he can dissuade the surgical procedure; that has happened. The patient may be deferred for a trial therapy of chiropractic care if the patient hasn't already had it, or for the patient to receive a diagnostic procedure to confirm the pain generator, which is a very common event.

DC: How do the surgeons feel about chiropractors being involved in this surgical review?

LR: Let me answer it from the perspective of a new kid on the block. A year ago I came to the Texas Back Institute, and it was my first experience with a multidisciplinary facility. I came out of a market where chiropractors were not held in the highest esteem.

What I walked into was a practice where chiropractors are not only held in high esteem, they are true partners, and their opinions and their knowledge bases are used on a daily basis to further the quality of the group. I have yet to see a barrier between our surgeons and chiropractors that is insurmountable.

DC: You mentioned instances when a patient receives a trial of chiropractic care in an effort to avoid surgery. Would you know roughly what percentage of those patients never need to go to surgery?

JT: I want to be sure we were talking about the presurgical crowd.

DC: Yes.

JT: The people who end up being slated for surgery at TBI have generally already failed at least conservative medical care, physical therapy, and the like (injections, etc.). We're talking about a hardcore group of people, not the run of the mill back pain, leg pain groups. Off the top of my head, 25-30% receive chiropractic care which helps them to avoid surgery.

DC: What are the numbers of conservative care providers vs. surgeons at TBI?

JT: Let me give you the breakdowns. We have four chiropractors; three physical medicine/rehabilitation people; seven surgeons; one podiatrist; one part-time neurologist; two part-time family practice physicians; one full time occupational medicine doctor; one full-time DO; and a group of three psychologists (one full time, and two part-time).

DC: What is chiropractic's role for the postsurgical patients?

JT: It depends upon the type of surgery, and the patient's response to surgery. Most patients after surgery go through a postoperative rehabilitation program. If they are doing well in the rehabilitation program, then there is no chiropractic role.

However, a number of these patients have postoperative complications, or have difficulty with the rehabilitation process, and the chiropractor can play a very strong role in two ways.

First, in helping these patients reduce their postoperative pain, and the pain associated with complications from surgery. Second, in keeping the patient functional enough to continue the rehabilitation program so that they don't become debilitated, and can finish out the appropriate therapy. So they can play a very strong role.

I want to spend a minute mentioning the complications. The early complications are often associated with co-morbid conditions, conditions that existed in conjunction with the lesion that caused the patient to go to surgery; sometimes they are subsequent true complications of the debilitating effects of surgery. In those patients, chiropractic care has demonstrated the ability to be very helpful in resolving the problems, or substantially reducing their problems when they are unable to recover through standard physical therapy and other methods.

LR: Let me add that the senior surgeons are cognizant of the manipulable lesion, especially for low back pain, and just as recent as yesterday, in a physicians' meeting, it was discussed in depth about the need to properly identify and manage those lesions prior to either a new surgery or repeat surgery. That's actually become part of the process.

DC: Are there gatekeepers at TBI? How are the cases managed, and who manages them?

LR: It depends on the patient's entry point. If the patient comes as a referral for a surgeon and the surgeon then sends the patient to a chiropractor because that was a better pathway, then the chiropractor would manage the case. Many times, we'll get a surgeon who has a long-term patient who may have been here for 10 years; the surgeon has become the gatekeeper, as it were. It truly depends on what is going on with the patient.

DC: Why are TBI and the parent company, MedPartners, beginning to include chiropractic?

LR: I believe that they see chiropractic's value. MedPartners is always looking for opportunities to deliver quality health care in an environment of increasing costs and decreasing reimbursement, and particularly with the TBI model. We've proven that we can give great continuity of care by having a system that's fully integrated. MedPartners needs those types of systems to be effective across the nation.

DC: Most of the chiropractic profession probably isn't aware of MedPartners. How big is MedPartners, and what's their influence in managed care market?

LR: MedPartners is the largest physician management company in the country. We have about 13,000 physicians. A huge portion of our physicians are in the California market. The Mullikin group was purchased by MedPartners, so they have an excellent basis in capitation managed care. Their Eastern operations, to a lesser degree, haven't seen those markets move yet. And their central markets are a mixture of capitation and good old-fashioned fee-for-service, or discounted fee-for-service.

DC: Given the type of relationship that you have here with TBI and chiropractic, where do you see chiropractic's involvement in managed care and in these kinds of fully integrated relationships going in the future?

JT: I think that's a function of a couple of things. It's a function of is the preparedness of the chiropractic profession to take on the challenges and the opportunities of managed care. So far, we've heard a tremendous amount about the negative effects of managed care, and I'm absolutely certain that there are. We certainly are not feeling them here at TBI in the chiropractic division. Perhaps the biggest thing for people to understand is that a managed care patient is still a patient who needs chiropractic services, and that it would be nice to be paid for those services; that there are ways within managed care to be paid.
The reality is to demonstrate value, and here we've demonstrated a value to the system. My personal practice is over 51% managed care. I am seeing a good, solid, busy practice with patients of all different case mixes, including postsurgical, presurgical, radicular pain, neck, low back, thoracic and some extremity problems, sports injuries, etc.

The point is, if one develops a strategic alliance, one can find a means of having a good practice, and an income and/or salary that is at or above the national averages as published by the American Chiropractic Association. There's nobody at TBI that is below the national average chiropractic incomes from prior to the managed care era.

So it really is a matter of picking your strategic alliances, preparing yourself, doing your homework, and making the system work for you: you'll be providing a valued service in a system of the future. It's not the only system, but it's an alternative practice profile to the past solo practice of yesteryear.

DC: Assuming chiropractors become part of such systems, where do you see it all going?

JT: Well, if chiropractors demonstrate the value that they talk about, then I see them being absorbed and integrated as a part of the health care team to the extent that they're willing to play. If we want to take over the system, I think that's a mistake, and it will do nothing but destroy our opportunities. If we want to contribute as a member of the team, and we've shown that we can be responsible, accountable, and offer value in increasing the positive outcomes from patient care, there's a broad vista for contribution to this health care system. The system needs what we have to offer. It doesn't need some of the games that a few chiropractors play.

DC: Based upon the success at TBI, and that being a demonstration of integration of chiropractic, do you see MedPartners expanding across their network?

JT: I'll ask Lisa to speak to this too, but MedPartners has definitely taken notice of TBI's experience to the extent that it is leaning very heavily on TBI as an organization to provide recommendations about the appropriate or best practices in spine care. TBI's voice carries weight, and is being listened to within the organization. I think that there is a future for that, and I think MedPartners is rationally sitting back and paying attention. I will tell you this. The president of MedPartners is personally aware of who the chiropractors are at TBI, and what they have experienced and contributed to the advancement of spine care.

LR: To reiterate what Dr. Triano has said, they are watching us; at the same time they are supporting and funding us to move towards having the ability to "cookie-cut" our system, as it were. They like what they see here, they see the value of it, and they want to see it tried and true in other practices.

DC: Thank you Ms. Raines and Dr. Triano.