We Get Letters

A Managed Care Perspective

As the director of provider relations for one of the nation's largest chiropractic networks, I'd like to comment on some of the opinion and ideas expressed by your distinguished panel regarding chiropractic's future and the question of integration or isolation (see "CCE Panel Looks at Chiropractic's Future," Feb. 27, 1995).

From the standpoint of representing chiropractic to the managed care industry, I found that Dr. Allenburg's cogent summary points out the challenges facing this profession as it enters its 100th year. Chiropractic does need to be part of managed care. It offers too many benefits not to be included in all aspects of health coverage. The real issue is what role can chiropractic play and how will it be promoted to payors, physicians, and patients.

Dr. Grassam points out the problem chiropractic could have if it goes too far with integration. The health care community is not looking for alternate MDs: they already have that alternative with osteopaths. The health care industry is moving toward more restricted access that is controlled by a gatekeeper. While many in the profession would like to see chiropractic designated as such, or at least as a portal of entry, that designation is not usually extended to chiropractors under most states' scope of practice laws. It is not likely that many states will act any time soon to change that situation either.

Drs. Clum and Williams are right to assert that the profession needs to maintain its unique identity, but more importantly, it must find ways of reaching out and working cooperatively with other health professionals within the managed care system. It has been my experience that most chiropractors have formed informal relationships with local allopaths when referring patients for second opinions or treatment. Now that chiropractors are being accepted into many of the managed care systems, they now have an opportunity to become part of the treatment team.

The premise of managed care is to contain costs through aggressive case management. By limiting the number of patients entering the system, by limiting or requiring pre-authorization for the number of procedures and therapies performed, and by decreasing the level of reimbursement, managed care companies believe they are being fiscally responsible. These organizations are not looking to add more doctors or render more services. Rather, they are looking to substitute one group's services for another. If chiropractic is to be successful it must establish its place in the system. Much of the recent resistance to chiropractic is not from a lack of clinical acceptance. Chiropractic is seen more as a financial threat to those who are scrambling to maintain their patient base. The system will reward those doctors that provide the most efficient (doing things right) and effective care (doing the right thing). While some professional bias may remain, those that can consistently demonstrate that quality of care is achieved, as measured by cost and outcome, chiropractic will always have something to offer. The real issue facing plan administrators is not so much the total cost of care, but whether or not there is any real value to the care authorized and paid for.

As a health care economist and project manager at the Colorado Prevention Center, a local medical research institute affiliated with the University of Colorado's Health Sciences Center, I have been actively involved in the design of research projects to document the efficacy of chiropractic care. One study, funded by the FCER, is to objectively measure and compare the rate of physical improvement between chiropractic and medical treatment for chronic cervical pain patients. This interdisciplinary study will assess both immediate and long-term effects from both forms of treatment. Other research projects are planned that will evaluate the outcomes from electrical stimulation therapy. In the future, these types of studies can be done jointly with the results being published in nationally recognized peer reviewed journals, ensuring greater exposure and acceptance of the clinical findings.

Chiropractic is on the threshold of widespread public acceptance. Many of the major managed care companies are actively seeking a chiropractic partner that can deliver services in a manner similar to that of medical providers. This profession has developed its own distinctive competence as neck and back specialists, and must not try to be all things to all patients. By focusing on our primary mission, we can expand our reach to those patients previously unfamiliar with chiropractic. This has been everyone's goal for the past 100 years.

Peter Caplan
v-p, marketing & provider relations
Managed Chiropractics
Denver, Colorado

Dear Editor,

I read with some interest the article, "Associate Doctor Syndrome" by Dr. Wipf in the March 27, 1995 "DC".

I would first like to congratulate Dr. Wifp on building a practice to the size that he has a large number of associates to deal with. This is wonderful for both him, and chiropractic in general. In reading his article it became very clear that he has never been an associate, nor did he have any student loans to contend with.

The comparison of Dr. Wipf's clinic system to the residency program of the armed forces is ridiculous. In the first place, working as an associate is not a residency: It is a job. Therefore none of the lending institutions will allow forbearance of student loans. It should be noted that if you do get forbearance, interest continues to accrue and is added to your principle. You also only have so many years to pay back your loans and that time frame shrinks with forbearance. This makes the loan payment even larger.

If working in his clinic is a residency exactly what are you board certified as when you complete your two years?

The rest of the article appears to complain about associates only lasting two years and then wanting to go out on their own. I do not see where this is a problem for the schools to address. This appears to be a business problem peculiar to Dr. Wifp's clinics.

In the medical group practices in this area, the doctors are each part owner of the practice. This obviously gives them more incentive to stay. The scenario presented by Dr. Wipf is that of a job. As with any job that I ever had, when you reach the end of your ability to earn and there is nothing left to achieve, or you are not allowed to achieve more, you leave to find a bigger challenge. It is evident that in Dr. Wipf's clinic system, it takes a new graduate two years to either become bored, or to achieve the highest earning level possible. He has taught them well to want more, but when they leave to seek higher levels, his is upset that another resident has completed his term and is gone.

Isn't that the purpose of a residency? It is not however the purpose of running a profitable practice. I believe that Dr. Wipf tries very hard to teach his employees the proper way to build his practice to the $100,000 level. I also believe that Dr. Wipf is smart enough to realize that this problem is his problem and not that of the entire profession.

I have been reading your publication since graduation in Dec. 1987 and rarely have I read something to make me write. Maybe it is seeing one of my classmates writing an article complaining about the system he built. Maybe it is because I have a monthly student loan payment of $1,300 for the next 14 years. I do know that private practice has been much more fun and is much more challenging than any job I had prior to becoming a chiropractor. If Dr. Wipf truly views his clinic system as a residency program, he should be ready to graduate his residents and find new ones on the rotating two-year basis that he has established.

Lance Sikorski, DC
Robinson, Illinois

Editor's note:

I was pleased to see the article by attorneys Ladenheim and Sherman (vol. 13,#5) on "independent contractor/associate." I hope a large number of host doctors take heed.

As the article was brief and the problem very significant, I would like to expand on the IC/associate situation.

Ladenheim and Sherman are correct. There are many doctors in chiropractic-land who believe that because they put a header on a document that says, "Independent Contractor," the title validates the contract. Sometimes this is naivete and sometimes it is chicanery.

Over the years illegitimate documents have been repeated so many times that the doctors employing other doctors have come to believe that documents are legitimized by intent.

It must be understood that the IRS see independent contractor as a red flag. And further, the IRS has been particularly aggressive because they view the average IC agreement as a thin deception to avoid collecting withholding taxes and FICA.

For years, many consultants have tried to figure ways to legitimize a true IC relationship. It sounds easy but it is not because of the prejudice of the IRS, mostly.

I would like to offer a solution that high priced legal help says will work. To begin with, abandon the whole concept and name independent contractor, and call the relationship something else. I propose that the IC become a subleasee and sign a subleasee contract (commonly found wherever boilerplate contracts are purchased). This legal classification, subleasee, allows a legitimate relationship between doctors. This "not an employee," status will pass the test of the IRS called form SS-8 and Employment Tax Regulations; section 31.3121(d)-1(c).

In addition, a subleasee is responsible for the entire lease payment of the office should the host doctor default. This may seem like an additional risk to the subleasee, and it is, but it further legitimizes the subleasee relationship as something other than an employee.

As one who has wrestled with this whole "independent contractor" conundrum for years, I hope this helps chiropractors avoid the wrath of the IRS.

I would appreciate Ladenheim and Sherman commenting on the legality of my suggestion.

John Whitney, DC
Roswell, Georgia

"... how do you know that you want to be a chiropractor if you have no idea what a chiropractor does?"

I have never written a letter to MPI, but I feel I must respond to Dr. Dana Lawrence's letter in the 3-13-95 issue. I respectfully disagree with some of his comments.

I have a practice in a town with one of the five largest universities in the U.S. Often students call and ask me about chiropractic as a career. A good 90 percent of them have never been to a chiropractor. Upon questioning, most are investigating chiropractic because they have heard that you can "be a doctor and make good money." My argument is how do you know that you want to be a chiropractor if you have no idea what a chiropractor does, aside from the monetary concerns?

These are the students that will have a harder time getting the big idea of a "chiropractic life style." A "chiropractic life style" is probably as multidefinitional as a subluxation seems to be at present, but as a second generation doctor of chiropractic (and also a practicing attorney), I doubt that these would be the kind of people that would go to jail for practicing as some of our founders have done. I doubt that some of these could really grasp onto the idea that the body can heal all kinds of things by itself, and that chiropractic is a excellent means to achieve that goal. I doubt that these people would keep practicing chiropractic if they won the lottery. I wonder how many people in the orthopractic movement had ever had the benefit of adjustments before entering chiropractic school.

Because we are still considered "alternative medicine," we have to walk our talk much more than those in other health care occupations. How often have you had a patient ask, "How often do you get adjusted, Doc." Are you exercising regularly, not smoking, etc.? I remember my father 30 years ago telling me that cancer prevention was probably as simple as modifying one's diet and outlook, but that it probably wouldn't catch on because there wasn't any pharmaceutical dollars to be made from nutrition. I was extremely healthy as a child and didn't have to go to a medical doctor for anything until I was 14 (and I had no vaccinations, either). You see, chiropractors were touting preventive health care long before it became in vogue in the current medical and health care circles.

I don't know if this answers what a chiropractic lifestyle is, but I know I'm proud to be a doctor of chiropractic.

Marcy Halterman, DC, JD, DACAN
College Station, Texas

Dear Editor:

As we are all aware of, it is a very exciting period for chiropractors all over the world as we celebrate our 100 year anniversary this year.

I'm writing this letter to you on behalf of this special celebration to inform you that in our office is a beautiful, gold mirrored mural on our reception room wall of engraved pictures of our forefathers who founded and developed chiropractic, D.D. and B.J. Palmer. Also are engraved etchings of some of the more well-known schools of chiropractic, Life College and Palmer College, the "Tree of Life," and the "Lasting Purpose" emblem just to name a few. There and many other engravings, dates, and sayings that make up this mural and we have a pleasure to look at it on a daily basis to remind us of how our lives, and the lives of our families, friends, and patients, have benefitted from the philosophy, science, and art of chiropractic.

We would like to share this mural with you and with your readers. It inspires us and it also intrigues our patients and gets them interested in learning about how chiropractic was founded and developed. Believe me when I say that the photo does not do this mural any justice.

This is our contribution to the centennial celebration and we would just like to share with your readers how much we appreciate chiropractic and how we remember those who made it possible for us to give, to love, and to serve in the chiropractic way of life.

Sami Makool, DC
Dearborn, Michigan