The Truth about "The Trouble Ahead"

I have been following the debate about managed care in the
chiropractic profession, the medical profession, and the
public/political forum. The discussions are often distorted by a
lack of understanding, misuse of terms, and "hardening of the
categories," to the extent that meaningful discourse is
sacrificed.

The past several months have seen a series of articles from Arnold
Cianciulli, DC, in this and other chiropractic publications. The
point of view Dr. Cianciulli brings to these pieces is clearly
anti-managed care, which is all well and good. Both sides need to
be heard. I have always been struck by the lack of comprehension of
managed care. The most recent "Maturity" column in Dynamic
Chiropractic (April 10, 1995) moved me to express a contrary
opinion to balance his view of health care reform.

I do not see myself as an apologist for managed care. Not
everything is rosy in the future of health care, but change is
taking place. Change is sure to continue in spite of deprecations
from the likes of Dr. Cianciulli. I do participate in a number of
managed care organizations, both as a provider and as a manager, so
I think I know whereof I speak.

In "The Trouble Ahead" Dr. Cianciulli asserts: "Few people can deny
that American doctors and hospitals provide the highest quality
medical care anywhere in the world..." By what measure? By the
measure of per capita spending, number of surgical procedures
performed, and MRI scanners, maybe the U.S. is best. But if your
quality measures include life expectancy, infant mortality, or
nutritional status, the quality of U.S. health care suffers in
comparison to most of the industrial nations, and even some of the
less developed countries.

I'm reminded of Detroit automakers in the '60s who were convinced
that "quality" was equated with big, heavy, chrome and tail fins.
Volkswagen and Toyota however identified quality quite differently
and proceeded to take over a hugh share of the automobile market.
If Dr. Cianciulli's view of quality in medical care holds sway with
the chiropractic profession, I fear DCs will suffer the same fate
as Detroit.

Dr. Cianciulli cites statistics showing the prevalence of CT and
MRI scanners in the U.S. versus other countries. Do three to six
times as many scanners in the U.S. make us three to six items as
healthy? I don't think so. Dr. Cianciulli posits that the goal of
"industry" (actually the purchasers of health care, not just
industry) have a "motive ... to reduce expenditures for health
care." Nowhere in any segment of the health care reform debate has
anyone even suggested that spending levels be reduced. Even the
wildest single-payer advocates recognize that health care costs
inevitably rise. The financial goal, if any actual targets have
been set, consists of reducing the rate of growth in spending and
improving the efficiency of the system. The goal of managed care is
to increase value for health care dollars spent.

Dr. Cianciulli complains that savings in managed care (HMOs in his
example) are illusory, achieved on a "one time" basis and by
"cost-shifting." May I suggest that market forces are a far more
powerful determinant of value than any preconceived notion of
quality held by Dr. Cianciulli? Detroit iron, anyone? The growth of
managed care proceeds not because of some sinister agenda on the
part of the medical-industrial complex, but because customers
search for, recognize and purchase based on their own
determinations of value. Health plans that can offer high quality
health care and demonstrate cost containment will displace more
expensive and lower quality products.

Dr. Cianciulli goes on to say that the Group Health Association of
American (GHAA) "vigorously opposes direct access for chiropractic
physicians..." A quick phone call to GHAA Senior Legislative Aide
Vernon Rowan revealed that there is no policy at all in GHAA
regarding access to any specialty. GHAA does observe that HMOs with
effective gatekeepers are often more efficient, but not because
chiropractic is excluded. GHAA opposes managed benefits (e.g.,
insurance equality laws), but isn't opposed to chiropractic.

I realize that Dr. Cianciulli is a national chiropractic leader.
His work with the ACA and NCMIC is commendable. His experience is
to be revered. I find much to agree with in his columns, and
perhaps in face-to-face conversation we would agree more than
disagree. Chiropractors are not effective on the "inside" of a
medical gatekeeper. Portal of entry access is the only way to
integrate into managed care. Many MCOs already know this. Certain
specialties, ob/gyn, for example, do not require referral from a
gatekeeper. A woman knows when she needs a PAP smear or when she's
pregnant, and she doesn't need a PCP-gatekeeper referral.
Chiropractic patients know when they need a chiropractor and don't
need a PCP referral either.

I agree with Dr. Cianciulli that DCs need to work within managed
care to assure access to chiropractic services. But the way to
achieve that integration is not to demand inclusion because it is
our right. Managed care recognizes a good deal when it sees one.
Providing appropriate and cost-effective health care which
satisfies patients and is administratively congruent with MCO
operation can virtually guarantee success in the current and future
managed health care market.

In its infancy, the chiropractic profession was dependent:
dependent on its defiant leaders; dependent on its loyal patients;
dependent on dedicated practitioners. As the profession developed,
it achieved a measure of independence: freedom from persecution,
prosecution, and in the heyday of third-party pay, financial
independence. As we mature it becomes increasingly apparent that
chiropractic must exchange independence and isolation for
interdependence with the rest of the health care enterprise. We
need not compromise our values, but build on them and capitalize on
our strengths: unique service which is clinically effective,
economical, and very patient friendly.

Given these values and an understanding of health care economics,
the health care world becomes a much less frightening place, and
the proper place of chiropractic it it becomes much clearer. Here I
think Dr. Cianciulli and I can agree. Dr. Cianciulli's column is
appropriately titled, "Maturity," which to me reflects the reality
of interdependence and the necessity to prepare ourselves
individually and as a profession to bring the benefit of our
services to those who need it.

Charles A. Simpson, DC, DABCO
Cornelius, Oregon